MEDICAL MATTERS Christine O'MalleyIt is a difficult and frustrating time for all of us who work in the frontline of patient care in our acute hospitals. Every day is a struggle.
Our sickest patients are on trolleys in A&E because the hospital wards are full. Patients' operations are cancelled because no bed is available, so the public surgeons cannot do their work. The public purse then pays a second time for a private surgeon to operate, through the National Treatment Purchase Fund.
Meanwhile, our Dublin hospitals are being turned into nursing homes, with up to 400 elderly patients at a time who no longer need hospital treatment but who cannot be discharged because there is nowhere appropriate for them to go.
To the outside eye, it might appear that acute hospitals are inefficient and that Irish families are less caring than in former times. A closer look tells us otherwise.
Irish acute hospitals have been constantly increasing in efficiency and productivity. In 1980 there were 17,665 acute hospital beds. Some 543,698 inpatients and 8,377 day cases were treated. Through the health cuts of the 1980s and 1990s, wards were closed across the health service.
Yet, in 2000, with only 11,832 acute beds, Irish acute hospitals treated 548,834 inpatients, an average of almost 1,500 patients per day. In addition, 319,837 day cases were treated, representing a very significant increase in overall throughput.
The improvements in productivity are almost certainly due to innovations such as surgical day wards, and new investigations and treatments. Unfortunately, health planners and policymakers seem to have drawn the conclusion that reducing beds makes hospitals more efficient. Even as money flowed into the health service in the late 1990s, the number of acute hospital beds was being further reduced.
It has not been possible to get full value for the money spent on appointing more hospital consultants due to the lack of acute hospital beds. Because, of course, the unit of function in our hospitals is a bed, meaning wards with nurses and doctors.
At the same time, other institutions providing hospital care have been reduced in size or closed.
The 1968 Care of the Aged report identified 13,594 elderly patients in care in a variety of public institutions. For a significantly larger population in 2001, there were just over 10,000 elderly patients in public institutions. This means that the number of public beds available to the elderly free of charge has fallen by 25 per cent. Families, who in former decades would have been offered a publicly funded place for their elderly relatives, are now expected to pay crippling private nursing home charges.
Because of these policy decisions, there are now not enough acute hospital wards for those needing hospital treatment, and insufficient elderly units for those needing long-term care. There is nowhere to go now except the A&E department of our acute hospitals.
It is against this background that the Hanly Report should be considered. Under Hanly, acute hospital care would be delivered in 12 or 15 "centres of excellence". The remaining 25 hospitals would have no doctor on-call at night and would close to acute admissions, removing a further 3,500 beds from the acute hospital network. The new super-hospitals would need over 1,000 beds each, simply to maintain the existing acute bed capacity. This would require a massive capital programme which does not appear to have political commitment.
Does the private sector hold the answer? Unlikely. While it takes some pressure off the over-stretched public system, it does this for a limited range of clinical conditions.
Irish private hospitals do not treat emergency admissions such as patients with heart attacks, strokes or broken hips. These patients are too complicated and too expensive to treat. They need higher staffing levels of nurses and doctors, based in the hospital. The costs are high and unpredictable.
As a result, the State carries the main burden of hospital treatment for patients with private insurance, through the 20 per cent private beds in public hospitals.
And yet, public money funds 100 per cent of the capital costs of private hospitals and provides revenue funding through the National Treatment Purchase Fund. Subsidising private hospitals is not good value for money and diverts public money and attention from the needs of the public hospital sector.
In contrast, increasing the capacity of our public hospitals is expensive but valuable. Emergency admissions are the routine of work in the public hospital, accounting for almost 75 per cent of all inpatient admissions. All cases regardless of complexity, cost or ability to pay are treated.
Improving our hospital service will not be quick or cheap but it can be done. The private sector is not the answer. The answer lies in revisiting hospital care of our elderly by the State.
The balance of beds must come from a sustained and major investment in our public hospitals.
Dr Christine O'Malley is a consultant in geriatric medicine at Nenagh General Hospital.
Dr Muiris Houston is on leave.