It's not about drunks or too many patients: resolving the A&E crisis involves first recognising the real causes of the problem, writes Aidan Gleeson.
The events of the past week have been hugely significant for the health service and, in particular, for emergency medicine. Years of denials, finger-pointing and some spectacular blame game tactics, culminated in a Prime Time programme which documented the appalling experiences of many acutely-ill patients who required a hospital bed.
It is unfortunate that the persistent cries for help from emergency department staff and patient interest groups over the past 10 years were repeatedly ignored and that it took covert camera work to bring this unacceptable situation to a head. Tánaiste Mary Harney was right when she declared in recent weeks that there was a national crisis in emergency departments.
However, that announcement came too late for many patients who, in the final minutes or days of their lives, had to endure the indignity of their medical and nursing care being delivered in full view of all and sundry. Why has this been allowed to happen? It can be explained by ignorance, complacency and an unwillingness to accept ownership of the problem. It was somehow perceived as "an A&E problem" and not one which reflected major deficits across the whole health service.
An example of such came from a hospital chief executive three years ago, who, after I complained vociferously to him about overcrowding, responded with the immortal words, "But Aidan, that's emergency medicine". He could not have been more wrong. Lest we forget, all patients are entitled to receive timely and appropriate medical and nursing care in a proper and safe environment from staff who are not overly stressed or overworked, whether they are in an outpatient clinic, a hospital ward or an emergency department.
Now that we have finally had an acknowledgment that this situation cannot continue, we need effective, evidence-based change, and a zero tolerance of patients waiting on trolleys for any significant period. There are no quick solutions, but half the battle is in having a proper understanding of the problem. Despite what has repeatedly been said by those who have no recognised expertise in emergency care, this is a "Bed access crisis". It is not a crisis of patients presenting to emergency departments who should be with their GP, or of drunks who should be sent to a gulag on Bull Island for the night.
Yes, these are issues for emergency departments, but they are not at the heart of the problem and are largely ones that we can deal with ourselves, so long as we are properly resourced to do so.
That view is supported by extensive international research on emergency department overcrowding. The known solutions to emergency department overcrowding lie in five elements:
1. We must increase bed availability. This will require a combination of more efficient use of existing beds, ensuring that there are no patients occupying a hospital bed unnecessarily (the elderly and chronic young sick "medically fit for discharge" group) and increasing the acute bed stock.
Improving efficiency not only involves looking at different ways of doing things, it also requires giving healthcare staff the facilities to do their job.
The elderly currently comprise 11 per cent of the Irish population, but that will rise to 14 per cent by 2016.
We cannot meet their needs at present and, unless drastic action is taken to cater for their acute and chronic care needs, the present situation will only deteriorate further.
Ireland has one of the lowest number of acute beds per head of population of OECD countries, with the result that, not only are we failing to meet the needs of patients with emergencies, we are floundering in our ability to deal with our elective workload.
Even Government-commissioned reports support this view. Despite the initiative of the National Treatment Purchase Fund, where 42,000 public patients have been treated privately since 2002, many public patients still wait more than a year for treatment.
One can only imagine how much worse the overall situation would be if those patients had not been taken off our public waiting lists. St Luke's Hospital in Kilkenny is repeatedly cited as the shining example of what can be done locally to eliminate trolley waits and they deserve tremendous credit for their achievements.
However, St Luke's success has not just been the fruits of better working practices, as it also required a 25 per cent increase in bed numbers.
In addition, the hospital does not have the medical and surgical tertiary referral workload of the major urban teaching hospitals. Finally, and contrary to popular argument on the need for change, all of this occurred under the terms of the present consultants' contract.
2. Bed occupancy in many acute public hospitals is unacceptably high, running at 98 per cent in some institutions. It should be no more than 85 per cent, as anything more causes the service to be inherently inefficient and crisis management ensues.
3. There needs to be a better balance of elective and emergency work in public hospitals. Simple mathematics, based on a knowledge of the average number of emergency admissions to each hospital and their average length of stay, can estimate the number of beds needed for acute care. One should then ensure that there are enough additional beds on site for elective work, with these beds being used solely for that purpose. This would allow for proper scheduling of elective cases, thereby preventing repeated cancellations.
4. Emergency department overcrowding must be accepted as a hospital problem. We must give emergency admissions a higher priority in healthcare, rather than their traditional poor relation status.
5. The final requirement for success is that of good change management. The health service is a mass of negativity at present, despite a tremendous amount of good work being done, day in, day out, by many people across the country. It is vital that Ms Harney and the HSE have a strategy that engenders high morale among the 100,000 health service staff, and they must ensure that individual contributions at all levels are valued and recognised. That will be their greatest challenge.
Aidan Gleeson is an emergency medicine consultant in Beaumont Hospital, and a council member of the Irish Hospital Consultants Association.