'It's worse here than Baghdad in the 1980s'

What's the solution to the A&E crisis? People working at the coalface talk to Eithne Donnellan, Health Correspondent

If Dr Gerry Lane, an A&E consultant at Letterkenny General Hospital in Co Donegal, ever meets the actor Brendan Gleeson he will kiss him on both cheeks.

The kisses won't be to congratulate him for his performance in any of the multitude of films he has appeared in, they will be to say a big thank you for powerfully portraying the sense of anger and frustration felt by patients and relatives, as well as hospital staff, at the inability of those in charge to change a system that sees people having to put up with intolerable conditions in A&E units daily.

"He put it so much better perhaps than I could ever verbalise . . . that was raw human emotion coming from a deep well inside him and there are hundreds, thousands of people with the same well of emotion," Dr Lane says, referring to Gleeson's appearance on last weekend's Late Late Show when he denounced the Government's ineptitude for failing to get to grips with the problem. "A baboon could sort this bloody thing out," he said.

Gleeson, who has had personal experience of elderly relatives in A&E, expressed his disgust at the way many elderly patients in particular were being treated there. Dr Lane agrees conditions are awful and confesses what he has encountered in A&E here is worse than what he saw in Baghdad when he worked there during a previous conflict. "It's worse than Baghdad was in the 1980s. I have never, ever had to treat a patient on the floor before, you know, somebody comes in out of an ambulance, they are really really sick, no trolleys, no chairs, I have to lie them on the floor on a blanket. I've never actually had to do that before. I've had to do it five times in the last year."

And apparently he is not unique in having to do this. He has talked to colleagues who have also had to look after patients on the floor. Not surprisingly, Dr Lane spends "an extraordinary amount of time apologising to people".

"I'm back in the country four years now and there is a culture of acceptance to this problem. As a father of four, as the son of two elderly parents and as a professional I feel our culture has to change."

He says three things are required to make a difference. These, he argues, are adequate bed capacity - some of this should come from additional beds being provided as well as smarter use of existing beds; a zero tolerance culture towards anybody spending a night on a trolley; and targets must be set for the maximum amount of time patients spend in an emergency department. He suggests this should be four hours.

Angela Fitzgerald, who has been given responsibility by the Health Service Executive for sorting the mess and chairs its new A&E taskforce, which meets for the first time next week, says all hospitals will be given such targets next year. She agrees it is absolutely unacceptable for people to have to wait hours on end on trolleys but says it will take time to sort the problem. Tackling it, however, she insists, is the HSE's number one priority.

Dr Lane says people need to be moved on from A&E quickly as studies show patients then do better. He points to Australian research published this month (see panel) which links excessive time spent in A&E with increased mortality rates.

The A&E overcrowding has now reached a stage where not alone can patients who are sick not be treated with dignity, but those who are dying are similarly neglected. One such case was highlighted earlier this month at Dublin City Coroner's Court. It was told an elderly woman died on a trolley in a nurses' tea station at the Mater hospital after waiting four hours to be seen by a doctor. Dr Eamonn Brazil, an A&E consultant at the hospital, told the court Nancy Lucas (74), of Woodhazel Close, Ballymun, should have been seen within an hour by a doctor but because the hospital was so under-resourced, she was not seen until her family brought it to the staff's attention that her condition was rapidly deteriorating.

"It is inexcusable what happened," he said. He doubted the woman's life could have been saved if she had been seen earlier but she could have been made more comfortable.

Dr Lane says Dr Brazil was apologising for a dysfunctional system. He adds that while in Letterkenny Hospital staff move heaven and earth to find a bed for anyone on a trolley who has a terminal illness so they can spend their final moments in privacy with their family, "the tragedy is we are not always successful . . . it's awful, awful, awful".

DR LANE HAS seen from experience that things can change. He worked at the Mater Hospital in Belfast when it had large numbers of patients on trolleys. But the problem was solved. The solution was extra beds, making existing beds work harder,changed work practices which saw patients who had been seen by a GP going directly to an admissions unit, and a zero tolerance attitude to people on trolleys for long periods. He believes the Republic can change too but he says the problem will never really be fixed and finished with. "It will be a continuous process of fixing, evaluating and making further interventions."

Angela Fitzgerald says the HSE is realising this. She says while it removed more than 1,000 patients whose discharges had been delayed from the main Dublin hospitals last year by placing them in step-down beds, nursing homes or giving them home care packages, the acute hospital beds they left were quickly taken up by other elderly patients who, after being treated, had nowhere to be discharged to.

As a result there are still around 400 patients in acute hospital beds in Dublin that don't need to be in them. She says extra step-down beds will have to come onstream regularly.

Another 250 private beds are being sourced to discharge these patients to, the Taoiseach Bertie Ahern told the Dáil this week. Sourcing extra beds like this is an exercise that will have to be repeated again and again, Fitzgerald believes.

Joe Hoolan, an A&E nurse in the midlands, says people cannot appreciate how bad things are in A&E until they experience it for themselves.

"You cannot deliver safe care to huge volumes of people when you don't have the time, the space and the resources. You are constantly prioritising what is the next most important thing you have to do. You are dealing with high volumes of people and the danger here is the most urgent case might get missed because of the stress and strain that both the nurse and the department are under and that could be catastrophic for the patient," he says.

"As a nurse in A&E it's a real sickener listening to the HSE and the Tánaiste saying that things are getting better, that there are real improvements, and yet you have just left a completely overcrowded department with people waiting for their third or fourth day for a bed," he adds.

Earlier this week the head of the HSE, Prof Brendan Drumm, said the A&E taskforce set up two weeks ago was already having an impact. A strange comment given that the taskforce hasn't met yet. Dr Lane, who is a member of it, said its inaugural meeting would be on Tuesday.

Hoolan reckons the Government knows what needs to be done to solve the crisis but isn't biting the bullet. The answer, he says, was in its 2001 health strategy, which promised 3,000 extra hospital beds, a large number of primary care units and thousands of extra beds in the community. However, Hoolan says it seems the plan has been "shelved".

A major problem which needs to be sorted if the A&E logjam is to be broken, according Dr Michael O'Tighearnaigh, a GP in Rathmines, Dublin, is the inappropriate use of emergency departments. "They are full of people who shouldn't be there. A lot of people walk in for trivial things and clog up the system and they continuously get away with it," he claims.

He believes these people should get a severe rap on the knuckles but instead of being penalised they are never even prosecuted if they don't pay their €60 A&E charge.

ANOTHER BUGBEARFOR him is people walking into A&E off ambulances. People are using them as taxis, he says. The long queues in A&E for beds affects how he goes about his work. He admits a patient has to be really sick now before he would send them to A&E.

"I find people do not want to go or wonder if they can pay to get around it . . . One of the things I would often do is defer people going into A&E at night with something like a suspected fracture." He would give them painkillers and tell them to sleep in their own bed and go to A&E at 6 or 7am when things might have calmed down.

"Sometimes you'd be forced into taking risks and saying to a patient to try a prescription but if that doesn't work after a day or two to go to A&E and you would give them a referral letter. At the end of the day that is a risk. It's not good enough and you are depending on the patient taking on board what you said about going to A&E if they don't improve."

He also recognises that the problem of delayed discharges has an impact on A&E. He claims this is because families know if they take an elderly relative home "the health board will dump the person with them and be gone" without providing the supports required for the elderly person and the carer. Primary care is also a problem. "I suspect if you doubled the number of beds in Dublin hospitals the problem would still be there because the Government won't fund primary care properly." The HSE has been talking about setting up a GP out-of-hours service on Dublin's northside for over a year but there's still no sign of it.

Overall Dr O'Tighearnaigh says the mechanism of A&E itself is probably fine: "It's the before and after A&E that are the problem areas." And he is not confident the problems will be ironed out. "It needs strong management with balls but we have a bunch of administrators that are toothless and gutless. Nothing has changed since Mary Harney took over," he said. He doesn't agree with Gleeson that a baboon could sort it out, though he asserts it's not rocket science.

Fitzgerald says there are plans in the short term to provide admission lounges in hospitals to give some comfort and dignity to patients who have to wait long periods for beds. Hospitals have been asked to submit proposals on how they could provide these. Different hospitals require different solutions, she says, and the A&E taskforce will work with them on this. For example, she says, Letterkenny and Wexford hospitals do need more beds, whereas in Dublin hospitals existing beds could be used more efficiently if the problem of delayed discharges was overcome. She says the problem is extremely complex. "I think we have challenges, there is no doubt, but I would be confident we can make significant inroads."

Dr Lane says he looks forward to using his taskforce membership to advocate for those who this week he asked to leave their trolleys and sit on chairs to make way for others.

Does he see the problem continuing? "I have an aspiration it won't - I have a fear it will."