The Minister for Health, Micheál Martin, may dislike the word 'crisis', but it is the only one to describe the state of our health service, writes Dr Muiris Houston, Medical Correspondent
Sylvia (51) has had rheumatoid arthritis for a number of years. Within the last year, she has developed arthritis in her hips, which is seriously affecting her mobility. She finds it difficult to get out, and even moving around her small council home in west Dublin is hard because of the pain. As her exercise tolerance decreases, her weight increases, leading to a vicious circle of pain, insufficient exercise, weight gain and more pressure on her already diseased hips. Sylvia, who is separated, is a public patient and is entitled to a medical card.
In January of this year, Sylvia's GP referred her to an orthopaedic specialist in Tallaght Hospital with a view to arranging a total hip replacement. However, three weeks later, he received a letter back from the hospital saying it was unable to accept any new orthopaedic referrals. Attempts to have her assessed in a hospital outside the catchment area for Tallaght have failed.
Her GP despairingly refers to Sylvia as "one of the patients on my 'personal waiting-list'. I am absolutely snookered with this woman. She is in limbo. Because I cannot even get her on a hospital waiting-list, she cannot access the National Treatment Purchase Fund [for which a patient must be at least one year waiting on a list for hospital treatment]. She appears in no health service statistic, even though I have come up against an absolute barrier in advancing her treatment".
Sylvia's family doctor is upset, but battle-hardened by cases such as hers, which represent the reality of the Republic's public health system in 2003. "If only she could get €3,000 from somewhere, I could get her operated on privately," he says ruefully.
This week saw the perennial crisis in the health service reach an unprecedented level. A lengthy statement from the five premier hospitals in Dublin - the Dublin Area Teaching Hospitals - on Tuesday outlined the effective loss of 600 of their normal complement of 2,800 beds. Some 250 will be closed because of inadequate funding from the Eastern Regional Health Authority, while 350 are already out of use because they are occupied by (mainly) older people who are medically fit for discharge but who have nowhere to go in the community.
More than 20 per cent of the capital's already scarce acute treatment beds will now effectively be decommissioned. Added to the 104 beds already closed by the Mater Hospital in the last two months, the closure last week of a 25-bed ward at Crumlin Children's Hospital, and the decision to severely curtail elective admissions at James Connolly Memorial Hospital in Blanchardstown from yesterday as a result of bed closures, it is clear that the already stretched acute treatment facilities for public patients in Dublin are being decimated.
This is not a view shared by the Minister for Health, Micheál Martin. In a robust defence of his stewardship of the health service in the Dáil on Wednesday, he rejected allegations of a crisis. Referring to the word "crisis" being used with "gay abandon", he said: "Language is cheap. I have heard the word crisis used to describe the health service for the past five or six years."
However, the language of the Dublin teaching hospitals' statement was stark. Nor was it the kind of language one usually associates with senior managers and consultants in these hospitals. The statement referred to delays "in the treatment of the sick with consequent unnecessary morbidity because they cannot get into hospital - including disability, deformity and pain (with reduced quality of life)". It said that financial pressures will lead to "potential delays in the diagnosis of medical conditions and in the performance of necessary operations".
On Tuesday, The Irish Times published details of an Irish Patients' Association management survey which makes clear that, even before the 250 beds and 14,000 treatments are lost in the coming months, the slowdown in health service funding is already beginning to bite. The Mater Hospital recorded a year-on-year drop in planned admissions of 34.5 per cent during March. The James Connolly Memorial Hospital admitted 28 per cent fewer patients for planned surgical and medical work.
Accident and emergency admissions at the Mater are up 8.3 per cent compared with this time last year.
The Irish Patients' Association survey - based on figures compiled by the Eastern Regional Health Authority - found one statistic of particular concern, which was consistent across all Dublin hospitals. This was that the number of return attendances to accident and emergency departments had increased by 9.4 per cent in the first quarter of 2003 compared with the same period a year ago. A sensitive indicator of extreme pressure on hospital facilities, it suggests that doctors are having to discharge patients they would rather admit. The best they can do is see them again in the casualty department within days in the hope that a deterioration in the patient's condition turns then into "absolute" candidates for admission.
And if the thought of being the victim of such a game of admission roulette does not convince you of the real crisis in our health service, consider these figures. A new category of "other emergency admission" is beginning to emerge out of limited statistics of what actually happens when a patient needs hospital care. This is the unfortunate patient who has managed to be seen by a specialist in the outpatients department and for whom admission is deemed the most appropriate course of action. Typically, it could be a person with unexplained anaemia (low blood count) or someone with unexplained stomach problems. Because of the decreasing likelihood of getting anyone into a hospital bed, this person languishes on a waiting-list. However, unlike the person waiting for an operation for the repair of a hernia or the removal of varicose veins, the diagnosis in these patients is not yet definite. Both hospital consultants and GPs have told The Irish Times that such patients are now regularly deteriorating to the point where they become true emergencies.
Worryingly, patients with unexplained anaemia and abdominal pain end up diagnosed with cancer and other serious illnesses - which have avoidably worsened, sometimes to the point where the condition is no longer curable. Such an outcome has no place in a developed health system.
A north Dublin GP, working in an area of relative deprivation, explains some of the situations he and his patients regularly face: "For a patient with sinister-sounding headaches, which could be a sign of a brain tumour, I am forced to refer to the accident and emergency departments of the Mater and Beaumont Hospitals. The earliest I can have such a patient seen in the outpatients department is 18 months after I refer. Unfortunately, within the last year, one such patient, who waited a year to be investigated, turned out to have a malignant tumour on her spine".
He points out that despite the best efforts of hospital doctors, there is no alternative but to refer every acute patient through accident and emergency, even when the GP has made a diagnosis of serious illness. "The days of ringing a hospital colleague, explaining the situation and having a patient assessed in the following week in outpatients has gone," he says. "The system is so badly stretched that all they can offer is the A&E department."
In a letter to yesterday's Irish Times, Dr Peter Conlon, consultant physician at Beaumont Hospital, said of the planned bed closures: "If these cuts go ahead they will result in the effective closure of one quarter of Beaumont's bed complement. A 10 per cent shortfall in hospital funding is likely to result in a 25 per cent reduction in bed capacity."
Dr Conlon concluded that, having become used to 20-25 patients waitingin casualty overnight, "I fear we will have to get used to 50 or 60 patients waiting on trolleys each evening".
This fear will become a daily reality once the darker evenings of October descend upon us. Infectious illnesses traditionally level off during the summer; however, come the autumn and winter months, people with chronic disease, such as asthma, bronchitis and heart disease, fall victim to a range of viral and bacterial illnesses. Because of their poor underlying health, such patients can deteriorate to the point where they must have acute, intensive hospital treatment. With the level of bed closures outlined this week, it is no exaggeration to say that people's lives will be directly threatened.
It is not unreasonable to ask why the considerable amounts of money poured into the system by Micheál Martin over the last three years do not appear to have made a difference. The reasons are complex: poor management, a multi-layered bureaucracy, the generally acknowledged failure of the Eastern Regional Health Authority and, not least, the difficulty in following a clear trail between money put in and frontline services emerging at the other end.
Prof Niamh Brennan and her colleagues on the Commission on Financial Management and Control Systems in the Health Services have identified what they call "two major structural weaknesses in the health service": no single institution or person is responsible for day-to-day management, and there is a lack of clear accountability throughout the system.
These conclusions have strengthened the belief of the Minister for Finance, Charlie McCreevy, that he is simply pouring good money after bad. At a purely accounting level, he is right. But the point that seems to have escaped the "ultra-reformists" in Cabinet is that you cannot reverse 20 years of chronic underfunding with three years of largesse. Nor can you turn a monolithic structure, such as the health service, around in a short period of time, no matter how worthy the reform package is. In fact, most management gurus accept that you have to invest money in the change process itself if you are not to make a bad situation even worse.
Is there a crisis in the health service? Yes, there is, and it has become worse in the last week. What is to be done? In the short term, money can be invested to reopen closed beds and to shore up the system while much-needed reforms are implemented over the next three to five years.
To do anything less is to abandon people such as Sylvia who depend on our public health system to deliver a basic service when they experience genuine medical need.