An analysis of 10 hospitals nationwide effectively backs arguments of Government, the medical and nursing bodies on why problems in A&E persist, reports Martin Wall
A Government report on tackling problems in A&E maintains that progress will require reforming and developing medical services in the community. It will also need changes in how hospitals and their emergency services are managed, the report, by consultants Triba Secta, says.
It recommends establishing acute medical units in hospitals, developing new nurse-led systems in A&E for dealing with patients with minor injuries, and creating new one-stop facilities in the community in an effort to keep people out of the acute sector as much as possible. One-stop facilities would cater for a variety of patients' medical needs.
However, the report's authors criticise aspects of the management of hospitals and call for significant changes in the governance arrangements. The report was carried out for the Government and senior healthcare management.
It says that the decision-making processes between management and clinicians in hospitals is frequently unclear. It also maintains that few hospitals had clinical directorate structures.
It says that "most organisations relied on medical boards to progress clinical and operational matters".
"It was considered throughout the review that this mechanism was no longer adequate to oversee clinical governance. Without strong accountability structures within the hospital environment, it is difficult to see how all aspects of governance delivering best patient care and safe outcome and maintaining financial balance can be assured," it states.
The Tribal Secta report, which involved an analysis of 10 hospitals nationwide, effectively backs separate arguments of Government, medical and nursing bodies on why the problems in A&E persist.
It supports the Government's assertion that current work and operational practices in the health services play a significant role in creating the difficulties in A&E which lead to unnecessary queuing and waiting times for patients.
However, the analysis also endorses the view of the Opposition, medical and nursing bodies that the current A&E difficulties are frequently the legacy of the sharp public sector cutbacks of the 1980s and 1990s.
It says that not only did these cuts reduce the capacity of hospitals, but that, as a result, the traditional GP/consultant relationship was eroded.
The report states that on any given day up to 300 patients can be waiting on trolleys around the State.
The consultants maintain that while Ireland is not alone in experiencing such figures, the "sometimes catastrophic consequences this situation has on patients, carers, staff and organisations across the State" should not be underestimated.
Much of the assessment of the causes of the problems in A&E set out in Tribal Secta's report is common sense and reflects analysis carried out over recent years.
It states that a lack of consistent development of services outside of hospitals is a primary cause of the volume being experienced by the acute sector.
It argues that as a result of the lack of development in community services that there is "disproportionate focus on acute hospitals".
The consultants say that there are insufficient numbers of GPs and primary care teams available and that they are unable to access acute services such as tests and observational facilities.
It proposes that there should be new one-stop facilities in the community where patients could receive tests, diagnosis and some forms of treatment without having to enter hospital.
It proposes that acute medical units be developed in hospitals and that GPs should have access to the observation/short-stay facilities established in these units.
Within the A&E unit the report proposes that advance nurse practitioners be involved in a "see and treat" service which would deal with patients with minor injuries.
It says that the idea is for the development of a fast-track system for those with minor injuries to speed up treatment and discharge. It points out that at busy periods it is often this group who end up waiting for excessive periods of time in A&E.
The report also proposes that consultants have an input into the triage system for assessing patients to ensure rapid discharge of patients from the emergency department.
The consultants also found variable access with emergency departments to tests which may be deemed to be in the domain of other specialities - such as exercise stress tests being the provenance of cardiology for example.
The report proposes that there should be "clear categorisation of diagnostic facilities required by the emergency department to manage patient flows and clear protocol with other departments to ensure access".
It suggest that the emergency department should have priority slots for diagnostic support.
The consultants also found that the balance between elective and emergency workloads across the majority of hospitals was out of kilter.
It calls for clear separation of services and facilities for planned procedures to avoid repeated cancellations and appropriate use of theatre time and facilities.
The report's proposals are likely to generate a mixed reaction within the health sector.
However, a number of senior figures in the healthcare sector have stated recently that the proposals for one-stop shops in the community sounded suspiciously like the recent facility established by the VHI in south Dublin to which GPs objected. The major questions over such centres are likely to be who would own, finance and operate them.
Hospital consultants are also likely to have grave reservations about any plan to abolish medical boards in hospitals and are expected to seek clarification of the status of the recommendations with the HSE and the Department of Health.