Sir, – Dr Brendan McCann (January 15th) generously acknowledges the contribution of general practice in preventing emergency admissions to hospital. He makes the widely accepted point that primary care is cheaper than hospital care. The King's Fund health research charity has calculated that seeing a GP costs £31, attending an emergency department costs £114 and the ambulance that takes the patient there costs £235 a journey.
While these are UK prices, they are likely to bear up here in Ireland. I look forward to the time when our ambulance colleagues can triage appropriate patients into well-equipped primary care and out-of-hours centres as we need more options for urgent care that is not yet an emergency or may never become one. This would be an appropriate healthcare experiment for our system to plan facing into next winter. There is a large health services research literature developing on urgent and emergency care and all of which points to problems in the broad system rather than in one area. Merely fixing one area will not do it. – Yours, etc,
TOM O’DOWD, MD
Professor of General
Practice,
Trinity College Dublin,
Dublin 2.
Sir, – There has been much discourse in recent days regarding the crisis on trolleys. The Trojan work carried out by all of the staff of emergency units throughout the country during the increased pressure and congestion of the last weeks has undoubtedly saved many lives.
The needs of patients who are acutely unwell, who will not recover without the aid of medical intervention, who are beyond the scope of what general practice can deliver, are best served by our colleagues in emergency departments throughout the country.
The levels of congestion, peaking at over 600 on trollies in previous weeks, is as a result of a logjam in the system, the occupation of hospital beds by those who are medically discharged but for whom the appropriate step-down or home supports are not available. Increased resourcing would help alleviate this to some extent. Of course, better homecare packages and a robust and responsive Fair Deal scheme would help.
But what of those presenting acutely unwell? Acute injury due to some form of trauma is hard to prevent. The congested lungs of inefficient hearts, the strokes that arise from gradually accumulating clots dispersed by abnormal heart rhythms, the wheeze and breathlessness of clogged and damaged airways, the damaged toes and retinas of diabetes, the pale, pulseless limbs arising from hardened arteries are the acute manifestations of chronic poor health. At this stage of their illness patients appropriately arrive into the acute medical service, sometimes via emergency departments but ideally through acute medical assessment units.
General practice within a functional primary care framework is where chronic diseases are prevented, or if they exist already, their worst effects are mitigated. Resourcing general practice and primary care, concentrating on chronic disease management, gives us the best chance of reducing some of the burden on the hospitals, but more importantly saving patients the shattering distress of trolley-based care.
We recognise that this will take years and perhaps even a decade to have an effect but as well as trying to solve this year’s crisis we must look to the future and invest now in reducing unplanned admissions.
Like the arbitrary threshold which determines a “crisis in trolley numbers”, the acute catches the attention. Concentrating on the chronic is required if we are to stem the erosion of dignity, health and resources. – Yours, etc,
Dr DARACH Ó CIARDHA,
Irish College
of General Practitioners,
4/5 Lincoln Place,
Dublin 2.
Sir, – The debate on the emergency department overcrowding crisis in the letters page has generally been very informed and constructive. However some of the comments made in yesterday's Irish Times expose a conflict of opinion that highlights the different views that hospital-based specialists and community-based generalists have on the health system.
It is generally accepted that different levels of analysis can yield different perspectives. Our hospital colleagues are excellent at focusing on diseases, illness and obvious disabilities and providing care for those issues in an isolated problem-orientated fashion.
In general practice we deal more with complexity and uncertainty. We utilise the knowledge we have of our patient’s medical, family, social and psychological history that is developed by having a trusting, ongoing relationship with the individual to provide personalised, patient-centred care.
The paradox of primary care is that while specialist care for individual diseases might be rated a higher quality than general practice led-care, overall patient outcomes are much better and more equitable with a lower spend on resources if a GP is the principal doctor.
It has been well proven in many reputable studies over the last two decades involving millions of patients on both sides of the Atlantic that increasing the number of GPs servicing a population reduces the death rate in that community. It also reduces the rate of out-patient attendances, emergency department attendances and, with the rare exception, in-patient admissions. The data also confirms that if a patient can get to see their own personal GP, it accentuates these benefits.
Having a specialist knowledge of diseases and illnesses in the absence of a personal knowledge of the patient increases the chance that the decision-maker will admit the patient to hospital.
There is a lot of US data on the numbers of unnecessary inpatient deaths annually due to medical errors. These are predominantly due to medication errors in emergency departments and acute admissions. No doubt the stresses that our health system is currently being exposed to will increase the chance of such a negative event. Shouldn’t we be trying to reduce these risks to our patients? – Yours, etc,
Dr WILLIAM BEHAN,
Walkinstown,
Dublin 12.
Sir, –The vast majority of front-line staff in the National Ambulance Service and Dublin Fire Brigade have already received a significant level of formal and on-the-job training in addition to the professional experience gained since qualification and, as a result, they already have the training required to refer patients to the most appropriate care pathway (primary care/GP, self-care or emergency department) but are simply not permitted to do so by ambulance service management.
Married to the protocols issued by the regulators for pre-hospital care (the Pre-Hospital Emergency Care Council), National Ambulance Service and Dublin Fire Brigade staff are left with very little option than to bring the vast majority of patients to an emergency department.
What is needed is for the protocols issued by the Pre-Hospital Emergency Care Council to change their emphasis from transporting patients to “discharge” or “refer to appropriate healthcare provider” where appropriate and for ambulance service management to empower and give confidence to their staff to make the most appropriate decision for the patient.
Several volunteer organisations such as St John Ambulance and the Order of Malta have trained the public and their members to refer or transport a patient to an emergency department only if necessary. Despite the lesser experience and qualifications of the majority of these volunteers, this approach has served those unlucky enough to need their assistance for over 100 years.
Perhaps the professionals can take a leaf from their book? – Yours, etc,
BRIAN SMITH,
Clondalkin,
Dublin 22.
Sir, – It is right to raise the issue of positioning of ambulance stations as a crucial factor in the delivery time of sick patients to our hospitals and a perusal of the Pre-Hospital Emergency Care Council regional maps of this issue will show that a poor turnaround time is not unique to the west of Ireland. It is wrong, however, to presume that the quality of healthcare can be the same in rural areas compared to large urban areas and this gap will widen as many new treatments, as in stroke care, for example, become a reality .
I remember this debate in Leeds with the closure of a rural Yorkshire emergency department whereupon my mentor remarked that “if you live up the dales, you live up the dales – beautiful scenery, no traffic, little crime but not as good healthcare”. It’s time we stopped being disingenuous to the public. It is simply not possible to deliver many time-dependent high- tech treatments to rural areas efficiently or at all. It’s not popular to say so, but it is a fact. – Yours, etc,
RONAN COLLINS, MD
Rathgar, Dublin 14.