MEDICAL MATTERS: We need good practical ideas for our struggling health services and here is one. It concerns frequent flyers. This is the new term being used to describe patients who are repeatedly re-admitted as emergencies to acute hospitals and lie on trolleys to the increasing embarrassment of the nation, writes Tom O'Dowd
A recent UK report identified nearly half a million such patients who had at least three emergency admissions in a year. These admissions cost the UK National Health Service £2.3 billion or 2.5 per cent of the £90 billion it costs to run its system. If we extrapolate to Ireland, we are looking at €275 million or half our capital budget. Thus it is a problem worth examining and doing something about.
Frequent flyers are usually over 65 years, poor and suffering from chronic cardiac (angina and heart failure), respiratory (asthma or chronic obstructive pulmonary disease) or diabetic conditions. They frequently come from under- doctored areas and many have multiple conditions.
Conditions such as heart, respiratory and diabetic diseases account for half of the GP workload and three-quarters of time in a hospital bed. The management of these conditions does not require the latest drugs or diagnostics. They are bread and butter medical diseases that can be managed at home or in the community.
Their turning up at hospital leads to time on a trolley while waiting for a bed. If the patient has already been admitted three times in the year, it is likely that they will not have the confidence to go home and will try to spend as long as possible in the hospital. These are the ingredients of bed blocking.
GPs don't necessarily know that their patient has been admitted as an emergency. The first you may know is the patient turns up with an even longer list of drugs than previously. The next is a long story about days on a trolley but once they got into the hospital inner sanctum how lovely the nurses were "and the doctors too of course".
They are surprised that we do not have a letter from the hospital with a list of their tests and diagnoses. Thankfully, we can often work backwards from their list of drugs.
So why don't GPs just keep these vulnerable people under tight surveillance, see them every week or two and keep them away from the humiliation of the hospital trolley?
It is a tall order. The frail elderly are often clustered together in an area having aged together with their GP. They may require a lot of home visiting as well as surgery visits. Their spouse may also be fragile with one propping up the other. A decent visit may take an hour if both need attention.
Surprisingly, the GP may not be the best person to keep the ill from the hospital.
An experiment in Cornwall with community matrons is showing great promise. These are specially trained nurses who work with GPs and with a defined caseload of chronically ill patients. They visit regularly in a planned fashion, liaise with the doctor or specialist nurse in the hospital.
Cornwall has 30 community matrons and they have cut emergency admissions by half with a saving of over £1 million in hospital costs. Anyone who has called the ambulance service here knows their skill and expertise.
We have a developing para medical ambulance service in Ireland which can be extended to keep the patient at home rather than admittance to the nearest hospital.
The one thing that is clear is that it is possible to keep patients out of hospital and in their own homes for longer periods. There are a variety of schemes that need to be adapted for our healthcare system in Ireland.
GPs are wary of schemes however. We have come through an era of pilot schemes which are a series of non-sustainable, cobbled-together deals that dug someone somewhere out of a hole. That someone was seldom the patient who is usually left high and dry after the scheme has run out of money.
The HSE has a stated commitment to primary care and we hope it comes up with a resourced, planned, sustainable approach. The area of frequent hospital re-admissions of patients with common conditions is an opportunity for what is called a quick win for everyone.
Doctors and nurses are ready to experiment with ways to help the sick spend time where they want to be - at home.
The full report is at www.drfoster.co.uk
Dr Tom O'Dowd is a practising GP and professor of general practice in Trinity College Medical School.