Emergency staff work hard enough – it’s the system that’s not working
Government needs to focus on recruitment and bed capacity to solve crisis
The step change in trolley waits will only come when we have adequate hospital beds for patients. Photograph: Alan Betson/The Irish Times
It has been difficult to hear the Taoiseach focus his efforts to improve long waits for patients awaiting beds in Irish emergency departments (EDs) on the overstretched emergency doctors and nurses. However, we need to see this for what is it, an attempt to divert attention away from the much bigger problems of inadequate bed capacity and staff recruitment and retention in Irish healthcare.
People in Ireland are not happy with access to healthcare, especially access to a hospital bed and the wait to be seen in outpatient departments. Delays are long, particularly if we don’t pay extra – either out of pocket or via private health insurance – to increase our access to emergency care on weekdays (in some areas) and to elective care everywhere.
This is particularly visible to me as a consultant in emergency medicine in a public hospital. Personally I find working within the two-tier system difficult, but over my years in practice, that’s been the way it is in Ireland.
The ED in a public hospital is the part of our system that is blind to health insurance status. People come for care all day, all night, every day of the year. Priority is always given based on clinical need rather than ability to pay extra.
I, and all professionals in general practice and public hospitals, spend endless hours trying to negotiate a way through the public system for patients who need urgent care.
The obstacles are significant.
All of us doing on-call at night, in addition to working during the day both on weekdays and weekends, know that it’s getting busier
The Irish hospital system does not have enough beds. On the frontline we always knew this, but it was good to see it confirmed when the Health Service Capacity Review in Ireland 2017 recommended many thousands more beds. The progress on increasing bed capacity is extremely slow.
The aim is to increase beds by 600 up to the end of 2019. Why are we being so unambitious? Has there been a decision not to invest capital into acute adult bed stock and staff it? Are we hoping the need will go away?
Given our increasing population and the ageing demographic, the need will not go away. The step change in trolley waits will only come when we have adequate hospital beds for patients.
I agree with the Taoiseach that our health service is set up to work differently on weekdays than at night, on weekends or on bank holidays. This is what Government designs and resources. It is not because those working those anti-social shifts need to work even harder.
Most patients seek care within office hours. Indeed, in the past Irish people did not expect to access much health care outside of these hours. We have changed. Our expectations of emergency care access have changed.
In response, what emergency deparments want for patients has changed. Patients come to ED when they have a health crisis (and the definition of a crisis always belongs to the patient) or inevitably when solutions are not available elsewhere. For the ED to manage those patients coming in (we have had 1,064,053 attendances so far this year) we need to be able to access diagnostics and other professional care all the time and we need to be able to get patients out again. We treat and discharge about 75 per cent without needing a hospital bed. Huge effort and time goes into this and there is no evidence to suggest care within an ED is unnecessarily costly. For the remaining 25 per cent of patients, we need to move them onto a hospital bed for further care. This is a major block within the public system.
Outside of ED, the health sector delivers emergency care with on-call staffing. This is the way it is set up. This arrangement rises to the challenge for the patient with a truly emergent need, and extraordinary efforts to get it right for patients are made every day and night by those on shifts and those on call. But the system is not set up to keep less urgent care moving all the time. All of us doing on-call at night, in addition to working during the day both on weekdays and weekends, know that it’s getting busier. We are up and working at night (after the day) much more than we were in the past. But yet, despite this, progress through a hospital admission and back to home or into community care does slow down outside of weekdays every day of the year, and especially with back-to-back bank holiday weekends over Christmas and New Year. Changing the Monday-Friday model for delivery of healthcare will need patients to want and insist on it, and then for Government to plan, engage with staff and resource it.
Medical (and nursing) recruitment is international. Doctors move country and continent for professional training. As an employer, the Irish health sector is not attractive. The work is arduous, the support structures inadequate and, in my own experience working as a consultant in emergency medicine in an overcrowded Irish ED for the last 20 years, the feeling of letting patients down is pervasive. A shift working as a doctor or nurse on the floor in an Irish ED is extremely challenging. Consultants put enormous efforts into recruiting, supporting, training and mentoring young doctors to encourage them to stay in the Irish health service and also to keep patients safe.
The numbers of consultants in emergency medicine has crept up to about 100 now. We cover 29 EDs, (most of them for 24 hours a day, every day of the year) and many other minor injury units. This improves the quality of emergency care, resuscitation, senior decision-making, technical skills, admission avoidance, training, supervision, planning within ED and the greater health care. However, there are too few of us to provide hands-on, out-of-hours care to the level we know patients need. We need more consultants in emergency medicine covering fewer EDs with increased breadth and depth. This needs to be an attractive and sustainable way of working (every hour working in ED is intense) and we cannot work in isolation. The entire health system – general practice, diagnostics, hospital beds and community care – should be set up to deliver as much care as we can afford, at the time the patient firsts needs it.
The Irish public health system needs to become a great place to train and work for Irish and international doctors. At the Irish Association for Emergency Medicine’s annual scientific meeting in October, emergency medicine professionals again discussed problems and solutions to overcrowding, but we also emphasised what is good. We appealed to our medical diaspora and reminded them about how remarkable emergency medicine is and how good healthcare in Ireland can and should be. I hope the far reach of the Taoiseach’s comments does not further hamper our efforts to get doctors to come and work in Ireland.
Finally, a thank-you to all those organising their Christmas around their shifts in emergency departments, and, for all those who will need our care during the festivities, can we please ask for your support in changing emergency healthcare in Ireland for the better?
Emily O’Connor is a consultant in emergency medicine and president of the Irish Association for Emergency Medicine