Sir, - Alison O'Connor (The Irish Times, November 16th) gets to the nub of the problem when she states that simply throwing money at our health services will not work and will not bring about sustainable health gain.
As a general practitioner trying to work the system on behalf of patients, I see two things clearly about the public healthcare system: first, my referral is not counted in the statistics on waiting lists, hence my patients join an unofficial list in order to get on the official waiting list. Secondly, once patients are in the system it is difficult to get them out and back to their GPs. The routes to a waiting list are crowded by patients being internally referred by the hospital itself, by others referred by accident and emergency departments, and finally by those referred by general practitioners. Admissions from accident and emergency are swamping planned elective admissions from other departments and from GPs.
Once in the system, patients cannot get out of it because, while the system is nominally consultant led, the junior doctor actually seeing the patient has neither the authority or experience to discharge the patient. Communication between doctors both in hospital and in the community is poor; hence many patients arrive at my doorstep with the often unanswerable question: "Well, what did they say about me at the hospital." Kicking to touch, I reply: "Well, what did they do to you?" Then I try to build up a picture of what has actually gone on.
Outpatient departments are a black hole in the Irish healthcare system. Patients on their waiting lists sometimes die from their complaints but equally others get better and of course others find the money to go private. International literature indicates that on balance one new patient should be seen for every two returning patients. The figures for Ireland are nearly four returning patients for every new patient.
I have seen data which shows one new patient being seen for every seven old patients in some Irish hospitals, which means that some outpatient departments are full of patients seen many times already. Indeed general practitioners are currently reluctant to refer patients to some consultants who never discharge patients back to them. This means that such specialists are virtually servicing a chronic patient load and have ceased to consult in the manner in which their training and contract demands. Information systems exist to identify such expensive time-wasting, but are not in use in Ireland.
The Minister is currently holding the line with health boards on budgetary control. He now needs to extend this to individual hospitals which in turn need to extend it to individual departments. Gate-keeping needs to be strengthened and placed in the hands of experienced clinicians in the community and activity in outpatients needs to be measured and actively managed. Once patients get into hospital it is almost impossible to keep control of costs. Devising strategies to keep patients out of hospital is a good and obvious place to start reforming the health services. - Yours, etc., Dr Tom O'Dowd,
Professor of General Practice, Trinity College, Dublin 2.