If you were minster for health, what would you do?

tallaght01

So, assuming sensible allocation of resources, what kind of changes wowld you like to implement if you were suddenly made minister for health?

Mine would be:

Improved access to primary healthcare, whether that's through lowering the threshold for medical card entitlement, or by "nationalising primary care" (The latter may not qualify under the rule about sensible resource allocation).

More A+E frontline staff. If we don't have enough staff to sensibly staff A+E departments, then we should have, so I'd increase the number of medical school places.

Tied in with the above, I'd introduce a grade of healthcare professionals, who can put in cannulas, take blood, do ECGs and catheters in A+E and the wards. A kind of Physician's Assistant Lite role. This would free up our doctors to do more clinical work, withouth dumping the load onto nurses.

Much more ambulances on the roads....those guys are seriously run ragged.

Set up special clinics for those with the least access to healthcare (especially asylum seekers and those with addictions, who traditionally have very poor access to healthcare). In the same way that fostered children have a "health passport" in the UK, with accompanying yearly/6 monthly health checks, I'd bring this in for the children of asylum seekers and those with addictions, children in care, children with mental illness.

More community services for those who need them (as opposed to the current situation where there's community support for people who should really be in hospital).

Much more healthcare involvement with overseas health issues. I'd allow our doctors to go and train doctors/nurses in developing countries, while retaining their pay and benefits in Ireland.

I could go on, but they're the basics.

So, what would everyone else do? I'd be intersted to see the differences in what different health professionals and the public write.

ImDave

I haven't really been in a hospital since my work experience in TY (good six/seven years ago), but has there been implementation of such technologies as PACS in many hospitals around Ireland? Not likely to be top of the agenda with regard to the health service in general, but I would imagine it would substantially increase overall efficiency.

tallaght01

ImDave wrote: »

I haven't really been in a hospital since my work experience in TY (good six/seven years ago), but has there been implementation of such technologies as PACS in many hospitals around Ireland? Not likely to be top of the agenda with regard to the health service in general, but I would imagine it would substantially increase overall efficiency.

Damn right.

But apparently it's not been rolled out all over Ireland, which is mental.

ZYX

My 2 main items would be:

• A serious hospital closure plan involving about half of hospitals in the country. These are wasting huge resources with the only benefit of having hospitals close to people. We have to decide do we want good hospitals and have to travel to them or do we want the generally poor secondary care hospitals we have now but close to us.

• All health care professionals to be audited to a much higher standard. For example any doctor should be able to get info on any other doctor. eg what is so and so doctors waiting times, how many patients does he see a week, how much of drug X does he prescribe, how does this compare to similar doctors.Most of this info is easily and cheaply available. It would also aid hugely in CME.

Prime Mover

Whats really missing is an overall strategy. Does anyone know the current one? Maybe I missed it. It just seems to be one half-assed notion after the other.... co-location is falling apart, there are now more med students on the way but no postgrad places for them, the consultant contract is negotiated apparently but the money is being withheld because nothing has changed, over 70's got medical cards but then they are taken back off them... etc etc.

It's like a big money-burning ship being randomly steered around the Atlantic with all the frontline slaves down in the the engine room and the administration up in first class.

At least Fine Geal have put forward some sort of strategy with the Dutch model. I know it's not perfect but it seems like a reasonable plan.

JuliusCaesar

Prime Mover wrote: »

Whats really missing is an overall strategy. Does anyone know the current one?

Yes. It's Harney's strategy of a two-tier health system. Building private hospitals on public land to cream off the money-making planned surgery, and leave the chronic medical conditions, care of the elderly who can't pay for long-term care, psychiatric conditions, & real emergencies to the public service. (You'll notice the Beacons etc just do minor surgery). Basically, the USA system.

If I were Min for Health, I'd

1. seperate out the Health and Social Welfare functions of the Health Service

2. Ensure that there were enough long-stay beds for care of the elderly etc to free up acute beds for acute cases.

3. Put in many many more respite beds, to ease the burden on carers

4. Implement Vision for Change!!!! I'd also remove psychiatric wards from general hospitals - it is not a proper environment for those who are not physically ill, and who need to get exercise/go for walks as part of their therapy. I'd also de-medicalise a lot of psychiatry and institute a lot of skills training, stress management, early intervention for psychosis. At present, the bulk of the mental health clients are institutionalised - even if they are living in the community.

5. Most importantly to ensure equal access as recommended by the WHO - an insurance based Health system; everyone working pays it. You might not need it now, but you may when you're older or for your kids.

I don't see why nurses can't cannulate / take blood etc. I remember speaking to a phlebotomist one time who'd been a hairdresser in her previous job....her phlebotomy training took two days and then she was let loose on the wards. )

More staff......but that's a non-runner at the moment. (A newly built 15 bed unit paid for by the HSE can't open because they cannot recruit staff - yet another waste) I could go on......

sam34

one of the things i'd like looked at is the mental health commission.

it is costing the country a fortune!

now, i think the new mental health act is a good thing. the old one was archaic, in breach of the european convention of human rights, and unsatisfactory for a variety of reasons.

the advent of tribunals, automatic external reviews for those detained against their will, is of benefit to patients, and is inherently a positive thing.

but...... they cost a feckin fortune! each tribunal panel consists of a consultant psychiatrist, a barrister and a lay person. each patient has a solicitor appointed to them. each patient is also seen by an external consultant psychiatrist. all these people get paid and get travel expenses. a conservative estimate is €4500 per tribunal.

now, when you consider that many people who are admitted on an involuntary basis will be in hospital for more than three weeks, this means that those people will have 2 tribunals. €9k.

it's huge money.

i dont know how many invol admissions and tribunals were heard in ireland last year, but the costs i've heard were in the millions.

another really frustrating thing about the commission is that whwnever you ring them for advice on a procedural issue (under the act they created) they will not give you a straight answer. they invariably say "seek your own legal advice". now, when you consider that their employees (barrister, psych, lay person mentioned above) will be the very ones adjudicating on your actions, this is baffling. it surely cant be outside their remit to clarify what correct procedure is prior to us doing something, rather than after it, and thus causing untold hassle for staff, patients and their families.


i am in no way saying that patients shouldnt have these reviews.

i just think it could be done in a more practical and cost-effective way. there are other areas of psychiatric care that need teh money so badly.

of course, like the best hurlers, i am on the ditch! i dont have any practical ideas about how to cut costs.

but i needed to rant today!

Dr Galen

Jesus where do i start??

We're in a pretty awful mess even without a "credit crunch" but here's some of the things I'd think about...

1) Proceed with a proper hospital rationalisation plan has already been suggested. We have far too many hospitals dotted around the country, that don't actually do very much and refer huge amounts of patients annually for relatively routine surgeries and treatments.

2) Borrow a sizeable sum circa 300 million from the market. Savings made from the planned hospital closure scheme in the future would help service this debt along with charging the health insurance companies an increased levy as a proportion of treatment costs. Also selling lands freed up by closing hospitals etc even at todays depressed market prices would again help out.

3) Invest heavily using the borrowed money in the following
a) round the clock primary care - GP, community nursing, health promotion initiatives, providing proper diagnostic services to GP's and physio/OT/Dietician services. This will lift the current pressure on acute hospital services and A&E. Freeing up hospital admission days over things like cellulitis, chest infections etc etc.

b) As Tallaght01 suggest take a long hard look at ambulance and emergency health care services. Completely de-mrege ambulances from fire services across the country. Use 10 million or so of the borrowed money to bulk buy ambulances, jeeps, cars and motorcycles. Equip wih essential equipment. Train and hire a number of the new advanced paramedic grades, and staff the new ambulance service with these guys, some nurses and some docs. Group the new ambulance service according to geographical area, using population, size and call out statistics to manage resources. Oh and give me a shiny fast new bike, a jacket that says emergency nurse specialist and a flashy blue light on my helmet!!

c) In our new proper sized hospitals, invest the money needed to provide at least 6 day week 8am-8pm services. Not the current all shut down at 5 and close for the weekend nonsense.

4) Use tax breaks to encourage private investment in elderly care, both residential, day-care and independant living type units for those older people needing supervision and assistance without needing full-time nursing home care.. Impose strict regulations over minimum standards of care. Private enterprises availing of tax breaks will be obliged to provide minimum numbers of beds/places for people from less well off social backgrounds.

5) Examine the HSE as an organisation. It appears large numbers of staff within the HSE are middle management admin. Using whats left of the borrowed money, pay off these staff using whatever means necessary. Start at the top, work down, anyone without a proper job description goes. Bear in mind, some admin support will be required in the newly expanded primary care sector and the new ambulance services so some sideways type movement would be possible for those affected.

6) Expand the roles of nurses particularly to include cannulation, catheterisation etc etc. Provide the courses needed if red tape gets in the way. Do this in bulk in conjunction with the private sector companies that do this sort of thing, thus securing a discounted rate, much like what we did with the driving tests.

7) Let NCHD's, especially interns concentrate on being doctors and not glorifie paper pushers or cannulation machines. Introduce proper shift patterns for all doctors, ensuring our doctors are not working 72 hour shifts as is normal now.

I could probably go on but I'll stop now and let someone pull my ideas to shreds!

7)

taram

1. More respite for carers, and more education for them on how to actually care (seen a lot of people be given a brief talk by their PHN then sent on their way), they need help in coming to terms with their new role, what respite is available, groups in the area that can help, and espically keeping an eye on young carers that perhaps have a burden of younger siblings to care for too, they need all the help they can get.

2. Cheap, available contraceptives of all types, none of this reliance on the pill and condoms, we need longer term strategies like coils, implanon being attractive and available.

3. More encouragment of vaccinations, and more warnings about the symptoms of diseases like measles, mumps, meningitis etc. A friend shrugged off what was obviously mumps until a already very ill friend was hospitalised because of it.

4. More weekend hours for GPs, more late hours for GPs, more GP services in general, perhaps a reduced fee card for full time students or children under 16.

5. A little offtopic, but healthy eating/living classes in schools, with super basic cooking skills taught. And ofc, proper sex education.

tallaght01

two of the recurring themes that I'd like to ask about.....

1) Closing smaller hospitals: Fair enough. Lots of their services can be centralised. But how do we overcome the fact that closing them leaves a lot of people a long way away from an A+E department.

2) Longer GP surgery opening hours: If the GPs are working nights and weekends, will the public have to pay more to see them out of hours? Who would staff these extra hours?

taram

tallaght01 wrote: »

2) Longer GP surgery opening hours: If the GPs are working nights and weekends, will the public have to pay more to see them out of hours? Who would staff these extra hours?

This wouldn't work in some small surgeries, but there are plenty out there with a few doctors, they could take it in turns to do a full Saturday, or a late Thursday evening, not talking very late or more than one late night a week, maybe 8 oclock finish, just so people who work during the day can still get to a doctor. Services such as SouthDoc here in Cork are no good to a large chunk of people, the doctors have no history for me, so why should they prescribe me a night's worth of abused drug X etc? On the flipside, if I need something routine like bloods or injections, why should I have to go to a strange doctor half across the city (would have to walk or pay for taxi) only to pay through the nose just because it's 5.30 and my GP closes at 5 o'clock?

sam34

taram wrote: »

6. Make a kind of sanitorium, but use for medium-long term, hands off care, such as recovering psych patients, respite care, eating disorders, all the bits and bobs that don't need acute care in a hospital, just need a bed, supervision, counselling in some cases, and minor medical care/dispensing of medication.

the psychiatric services are trying to close down the old institutional/asylum buildings, not reopen them or create new ones.

for far too long psychiatric patients were shut away from "polite society" , thus causing them to be hugely stigmatised.

someone with anorexia who requires hospitalisation will usually be medically compromised, so i'd want them on a psych ward attached to a general hospital, not in one of the long grey buildings on the hill.

more money should be pumped into psychiatric community services, but i dont think what youre suggesting is in any way appropriate.

taram

sam34 wrote: »

the psychiatric services are trying to close down the old institutional/asylum buildings, not reopen them or create new ones.

for far too long psychiatric patients were shut away from "polite society" , thus causing them to be hugely stigmatised.

someone with anorexia who requires hospitalisation will usually be medically compromised, so i'd want them on a psych ward attached to a general hospital, not in one of the long grey buildings on the hill.

more money should be pumped into psychiatric community services, but i dont think what youre suggesting is in any way appropriate.

I mean towards the end of their care, obviously if they need medical care they should be in a hospital, but often wards in hospitals are stigmatising too. It'd be more of a halfway house between being in a hospital environment, but not being in a community facility yet. Ideally with facilities like art classes, music rooms, counselling and other remedial facitilies, but they can be given their medication/food in a supervised manner under medical staffs care and sleep in the facility. Sorry if I was unclear, half asleep posting is bad for me

sam34

JuliusCaesar wrote: »

4. Implement Vision for Change!!!! I'd also remove psychiatric wards from general hospitals - it is not a proper environment for those who are not physically ill, and who need to get exercise/go for walks as part of their therapy. I'd also de-medicalise a lot of psychiatry and institute a lot of skills training, stress management, early intervention for psychosis. At present, the bulk of the mental health clients are institutionalised - even if they are living in the community.
QUOTE]

taram wrote: »

I mean towards the end of their care, obviously if they need medical care they should be in a hospital, but often wards in hospitals are stigmatising too. It'd be more of a halfway house between being in a hospital environment, but not being in a community facility yet. Ideally with facilities like art classes, music rooms, counselling and other remedial facitilies, but they can be given their medication/food in a supervised manner under medical staffs care and sleep in the facility. Sorry if I was unclear, half asleep posting is bad for me

i really dont think this would be a good idea.

i think patients who require psychiatric admission should be admitted to a psych ward in a general hospital.

they often have multiple medical co-morbidities, for starters.

they are often commenced on high doses of meds and need monitoring.

patients needing rapid tranquillisation may run into respiratory difficulties, and need access to medical care.

what about ect, and the need for GA.

and lets not forget that the majority of psych nurses are not generally trained.

this is not something that the medics/surgeons realise/fully understand.

the nurses cannot therefore be expected to provide care for med/surgical issues on a psych ward.

having all these issues going on in a building that is removed from a general hospital would be, imho, irresponsible and dangerous.


many psych wards in general hospitals have gardens and exercise areas for patients, so thats not an issue.

even if tehy dont have gardens, patients can walk the hospital grounds. (some may need to be accompanied by family/staff, but still the facility is there)

likewise, are and music and relaxation can be provided in a general hospital just as easily as in a dedicated psych hospital, and in fact they frequently are.

i cannot think of one good reason to herd up psychiatric patients and send thmn to what would essentially be an asylum, no matter what fancy rehabilitation/recovery type name you give it.

taram

Okaies so Sam34, have edited my post to reflect what you've told me, thanks, not familiar with psychiatric treatment here, I'm only familiar with bulimia at the end of recovery, the hospital distressed her, but she wasn't well enough to go home, or could afford private care. There was a need for a middleman there.

sam34

taram wrote: »

Okaies so Sam34, have edited my post to reflect what you've told me, thanks, not familiar with psychiatric treatment here, I'm only familiar with bulimia at the end of recovery, the hospital distressed her, but she wasn't well enough to go home, or could afford private care. There was a need for a middleman there.

well i kinda agree with you, in that psych admission for bulimia is always less than satisfactory, no matter where the setting.

very few bulimics would be admitted, in the public services anyway.

in my posts i was largely referring to "traditional" psych patients, such as those with depression/bipolar/schizophrenia/other psychosis, who amke up the majority of psych admissions.

anyway, my brain is addled now, i'm off to bed.:pac:

Traumadoc

Closing peripheral hospitals will increase mortality ( its about 1% for every 10km journey travelled in the UK)

I work in a larger center that will receive these patients. In typical HSE fashion , no thought has been put into the consequences of closure of smaller units.
I have yet to see a cost benefit analysis. No extra beds will be provided. More people will be forced to go private and the state will have to pay for more private treatments as they run down the public service.

( some of these units accident and emergency departments see nearly 40k patients which is the same as tallaght in 2000 or as many as SVH or Connolly now).

norrie rugger

I would remove the nurses from Admin roles.
Why is a degree qualified nurse spending her time on the phone/at a desk?

I would also remove the nurses from clinics. Example is an orthopaedic clinic, why is there 4 nurses calling patients into see a doctor.
All they are doing is handing the file in the door. These people should be caring for patients.

Allow GP's to advertise their services, this would create competition and you might get GP's opening later to get an edge over the others etc.

A&E units around the country, not hospitals. Close the smaller hospital and leave a dedicated A&E. If this occurs though, then the beds removed from the hospital have to be sourced elsewhere in the central hospitals

JuliusCaesar

sam34 wrote: »

patients needing rapid tranquillisation may run into respiratory difficulties, and need access to medical care.

what about ect, and the need for GA.

and lets not forget that the majority of psych nurses are not generally trained.

I think what you meant to say is the majority of psychiatric nurses are not general-trained

There is a place for 'liason psychiatry' instead of having segregated facilities, to have psych pts in a general hospital - but equally, given the research on the effect of environment on mood; effect of exercise -outdoors on grass vs hospital carpark or treadmill in gym (never mind effect of sight of outdoors on wound-healing) (don't have refs here, but will dig them up if anyone interested) there's a good case for either improving the environment of general hospital or moving psych pts to somewhere more conducive to recovery. Meds are useful, I'd be the last to deny it, but we also need to treat psychologically.

norrie rugger

tallaght01 wrote: »

so I'd increase the number of medical school places.

I would want that too but I think that there would have to be a change in the application process.

The minumum subject standard needs to be addressed.
Why is a kid who did Ag-Ec, Home-Ec (or what ever subjects they do for easy points) etc given the same treatment as a kid who did all the sciences.
There are too many private schools that tailor the courses to maximise points and not tailor the courses to the pupils natural ability.
But the CAO system is really for another day and another forum

sam34

JuliusCaesar wrote: »

I think what you meant to say is the majority of psychiatric nurses are not general-trained


LOL, sorry, it was late at night and i was tired!

There is a place for 'liason psychiatry' instead of having segregated facilities, to have psych pts in a general hospital - but equally, given the research on the effect of environment on mood; effect of exercise -outdoors on grass vs hospital carpark or treadmill in gym (never mind effect of sight of outdoors on wound-healing) (don't have refs here, but will dig them up if anyone interested) there's a good case for either improving the environment of general hospital or moving psych pts to somewhere more conducive to recovery. Meds are useful, I'd be the last to deny it, but we also need to treat psychologically.

i think the way to go would be improving the psych wards in a general hospital setting. i think a move to a purely psychiatric facility would be a huge step backwards to the "madhouses" era, in the eye of the public, but also for the patients themselves.

given adequate room and resources, there could be quite nice psych wards.

(slightly aside, but i worked in one of the real old institutions for two years... it was in an idyllic location, all you could see around it was greenery, mountains and lakes. the gardens were huge, - i'm not good at estimating no of acres, but a walk round the perimeter would take well over an hour.) but the patients were confined to small fenced-in areas, of roughly 7 metres squared. totally ridiculous, considering the expanse of beautiful gardens outside the fence. i often wondered why they were given such a small area - i bet it was something to do with the amount of money allocated for fencing :mad: )

Prime Mover

norrie rugger wrote: »

I would want that too but I think that there would have to be a change in the application process.

CAO and graduate places have been added recently but no allowance has been made for onward internship/post-grad training. Whats the point in training doctors for export?