There’s a not very subtle blame game about the overcrowding crisis in hospital emergency departments (EDs) going on between the Department of Health and its minister, the HSE, hospital managers and consultant doctors. Each has their own agenda; each is defensive about their own roles, turf and responsibility. Of course this has been going on for years, and it’s one of the reasons why our health service is deficient in some respects, and very expensive in others.
As the situation in EDs deteriorated and the numbers on trolleys climbed, the blame game was especially evident this week in the calls from Minister for Health Stephen Donnelly, followed by an instruction from the HSE to hospital managers to get consultants on-site at weekends. The doctors responded by pointing the finger at the lack of resources – not enough staff, not enough beds.
Actually, they both have a point. Rates of discharge of patients from hospitals slows dramatically at weekends, leading to the system becoming clogged up – with no spaces becoming available in wards due to the lack of discharges, there are no beds for patients admitted to hospital through the emergency departments, and so they end up on trolleys or in chairs waiting for a bed. Typically, hospital consultants are not rostered for work at weekends, and even though lots of them come in to see patients, discharges still plummet on Saturdays and Sundays.
The hospital authorities have been told to move to a seven-day roster for the coming weeks in order to speed up weekend discharges. In conversations this week, the example cited by everyone to me has been Waterford Hospital, where trolley numbers are typically zero, or not much above it. How can Waterford do it, when some other hospitals have dozens of patients – 54 in Cork on Friday, 33 in Limerick – on trolleys?
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Senior health officials point to the agreement with the consultants in Waterford to work seven-day rosters, and that is undoubtedly a factor. But there are other factors at play, too. One of them is a collaborative relationship between the doctors and the management that appears to be lacking in many hospitals. Several people, at local and national levels, mentioned the role played by Grace Rothwell, the general manager of Waterford. Clinical staff actively work with her, patient by patient, clearing patients out of acute beds as quickly as possible. This doesn’t happen everywhere. Individual talent and performances matter.
Better management and better relations with consultants at other hospitals would certainly improve performance and reduce the number of patients on trolleys. “Consultants must have absolute independence in clinical decisions,” says one person who knows the health service inside out. And nobody disputes that. But outside that, this person suggests, they must allow themselves to be managed to achieve greater efficiencies. That isn’t always the case. In some places, it is rarely the case. One senior health official almost shouts, relaying a statement from consultants in one hospital complaining of an emergency in trolley numbers that was reported on the evening news some time back. “There are 52 consultants in the hospital. How many were in the hospital at that time? Two!”
But to suggest that the problem in EDs would be solved if consultants would give up their Saturday golf game is nonsense. As the consultants’ organisation, the IHCA, pointed out this week, the winter plan for this year required an additional 51 emergency medical consultants; none of these have been appointed on a permanent basis, and only 20 locums are in place. At every level of the health service, people say it is desperately in need of more doctors, more staff and more beds. They can’t all be wrong.
[ Hospital overcrowding: there are two answers to this perennial Irish problemOpens in new window ]
One GP who runs a large practice observes that changing consultants’ hours and other such work practice issues – more diagnostics, etc – will give you marginal improvements. “But there’s a huge structural issue. Our population grew nearly 10 per cent in five years,” he says. “It all comes down to beds and staff.”
“The truth is you can run hospitals better and use existing capacity better and you’ll still need more beds,” says one person in a senior health service role. That seems about the size of it.
A few further points are worth making. The first is that hospitals all over Europe are experiencing similar – and in some cases worse – squeezes because of the continent-wide coincidence of Covid, RSA and flu. In much of the UK, the health system is under dangerous pressure. You rarely hear that in many news reports.
Also, there will be pressure on the health system at this time every year. To have a hospital system that was not stretched in January would be mean having a much bigger system that was partly idle for much of the year.
Secondly, the sight of the health minister begging doctors to work weekends is testament to the political weakness in relation to managing the health service that is not invented by this Government but has not been changed by it either. A new consultants’ contract will help a bit. But it will hardly be a radical reform of the system. The power of interest groups – consultants, nurses and so on – and their determination to defend their role and privileges remain features of the Irish health landscape, even if they’re rarely remarked upon.
Finally, doctor shortages will reach crisis point as need expands and many GPs retire in the coming years. It’s bonkers for the taxpayer to be funding the medical education of thousands of doctors, nurses and other medical professionals every year, and then watch them head off to Australia or wherever. This is combined with the corresponding morally dubious practice of replacing Irish doctors by poaching medical professionals from developing world countries. Surely the question of requiring some years’ service in Ireland by health professionals in exchange for their very valuable training must come on the agenda at some stage.