How would you solve the trolley crisis

Qualitymark

If you were Minister for Health (also Minister for Finance, also Taoiseach), how would you solve the trolley crisis, and indeed the crisis in our hospitals and health care?

Please don't treat this as a question for smart-alec responses. I'm asking seriously. The country's health system is in crisis: if you had the power, how would you heal it.

Mods: I'm posting this in After Hours because I don't see a forum for doctors, nurses and other health workers - if there's a more appropriate forum, please move it.

Dozen Wicked Words

Reopen all the closed beds, reintroduce all the care hours taken from people living at home. There's 2 things for a start.

Roselm

Dozen Wicked Words wrote: »

Reopen all the closed beds, reintroduce all the care hours taken from people living at home. There's 2 things for a start.

Where would you take the money from to staff the beds and care hours?

steddyeddy

Go through the HSE and get rid of all the human flotsam and jetsam that call themselves admin. That should free up a few mill.

Dozen Wicked Words

Roselm wrote: »

Where would you take the money from to staff the beds and care hours?

Raise taxes.

Atlantic Dawn

Its a case of solving the problem of those ready to leave hospital but are still there taking up beds rather than coming up with a solution to new patients arriving. 5 or 6 massive 1000 bed hotels with basic medical facilities should be built around the country to handle these people.

steddyeddy

Lainey Wide Straw wrote: »

Me too. I had a whole piece ready on fixing wonky wheels and collecting them from car parks more often.

For the health service; the waste needs to be examined, beds reopened, staffing etc but it costs money. We will all have great ideas but nobody in the job has been able to fix it yet. Real life and our musings can vary greatly. A few million won't fix it.

In my brief time working in the lab there I seen countless incompetents who couldn't be fired and knew it.

suicide_circus

Getting rid of the trollies would be a good start

Harry Palmr

Tricky, how much of it is money and how much maladministration?

I'd put a health levy on all off licence sales of 10% of retail. That should rustle up some money quickly enough and it would be spent on primary and step down care facilities so to free up hospital beds.

All consultant golfing leave would be cancelled as well.

Mr. Incognito

Build a 500 bed new hospital out near the red cow which could be accessed quickly from the M50 and the motorway.

BigCon

Dozen Wicked Words wrote: »

Raise taxes.

Cut welfare

mfceiling

Too many people in hospital from their own stupidity.

I had kidney stones last year and was sent to A+E in St James. The amount of junkies there was unreal. Coming in from an ambulance even though they were capable of walking and abusing the receptionist (and the paramedics who brought him in).
There was an obese kid in a wheelchair who had his knees strapped because of the strain on them. This was made worse by his dope of a mother bringing him cans of coke and bags of hunky dorys from the vending machine.
Chain smokers on ventilators because they wouldn't stop smoking.
Alcoholics in bits because they wouldn't stop drinking.

Meanwhile genuinely ill people and the elderly lie on trolleys trying to hold on to whatever tiny piece of dignity they have.

But to answer your question...I have no idea.

kneemos

More two Euro coins.

Wibbs

Go through the HSE like a strong dose of laxative and remove all the waste, the quangos the duplication and the like. Make GP's a stronger line of treatment, rather than the "send anything beyond a sniffle to casualty" that they can be. I'd even go as far as to have a separate line/area for obvious drunks and drugged individuals in the casualty dept.

tayto lover

We have hospitals within a 50 mile radius of Dublin with most of their wards closed i.e. the Louth County Hospital in Dundalk and Our Lady's Hospital in Navan. Open these again and employ a few more nurses and doctors or transfer them from existing duties. They can also transfer some of the admin to these hospitals to cut down on expense.

Harry Palmr

Mr. Incognito wrote: »

Build a 500 bed new hospital out near the red cow which could be accessed quickly from the M50 and the motorway.

A billion quid and 10 years later the plans would still on the drawing board.

gizmo555

Wibbs wrote: »

Go through the HSE like a strong dose of laxative and remove all the waste, the quangos the duplication and the like.

I always remember in this context the benchmarking committee, tasked with comparing public sector employees with their private sector equivalents and from that to recommend appropriate salary levels.

In the HSE, there was a cohort of several hundred middle managers for whom it wasn't able to make any comparison, because it couldn't understand and these people were unable to explain what their roles were.

steddyeddy

Also they spend well over what they should for lab equipment and resources.

Sh1tbag OToole

I would hire 1 apprentice carpenter for each hospital to start making beds.

If there is nowhere to put the beds then get in a few builders, supply them with a cement mixer, cavity blocks, cement.

I get the feeling that it might not work because there is a little-known law hiding somewhere that states that even for a flatpack shed to be put on hospital ground a lengthy consultation period is required involving D4-based consultants on at least 400,000 a year and they're not allowed to show up to the consulting room in anything less posh than the latest model Mercedes CLS

The Randy Riverbeast

Put down anyone who is not going to get better or needs more than a week in hospital. Also have random ward cullings. Then charge more to stay at the hospital, this will cause the poor to die off.

Username here

Username here wrote: »

FFS, I thought this was a thread about shopping!! I need coffee.

Do you mean when you want to get a trolley, but have no euro coins to put in the slot?

Hate that.

PirateShampoo

I would remove the wheels from said Trolleys.

Sir Osis of Liver.

An admission charge of €10 to A+E without exception would solve it.

FalconGirl

Get tougher on our alcohol culture for a start. Have drunk tanks in the city centre. Too many people with alcohol related injuries clogging up the A&E.

Also have a massive clear-out across the public services. Far too many non-performing there. That should save some money in salaries and pensions. Govt grants to bodies such as the IFA need to be reviewed. The money is there somewhere, the Govt just are not ballsy enough to tackle these issues.

Also they need to take a hit and cut their losses on IW. Its a black hole. Write downs to major players need to be investigated thoroughly. Anglo wrote off €1.3bn from their asset sales and the inquiry is collapsing. The tax payer cannot afford to be taking hits.

Greed kills down the line and we are seeing the results of it in our hospital crisis. Major reform needed.

Harry Palmr

One solution is open main doctors surgeries 24 hours a day in the larger towns and cities - no charge for a consultation.

Charge anyone who turns up at A&E under their own steam 100 euro if they do not need immediate critical medical help.

FortySeven

Raise nurses wages, employ a large team of forensic accountants to go through the HSE books and identify wastage. Eliminate said wastage. Start a modernisation program and build new, modern facilities, twice the size than they need to be for the future demand. Tear up contracts preventing under performing workers being fired and take the compensation hit, it would be cheaper than furnishing these incompetents in employment.
Reduce admin and give funding decisions to medical staff. Reduce executive wages.

Provide a comprehensive home care network, this will free up beds from OAP residents who neither need nor want them.

Introduce a sensible drug policy to stop criminalising addiction and use the funds saved on overdoses, amputations, prison costs, garda investigations and spend it on treatment centers and social programs. This will free up many beds and wasted resources.


Introduce universal healthcare to remove overpricing by gouging insurance companies.

Scrap deals for overpriced drugs and buy generics where appropriate.

Legalise cannabis and earmark all tax returns from sale to the health service.

Pretzill

We need to go back to the old system of community health centres - not just GP facilities but local places were cuts and uncomplicated sprains and breaks can be dealt with, blood tests etc. To free up some of the a&e queues.

Further to that more reinvestment is needed in hospitals which have lost crucial services. You can't treat counties of people in one regional hospital. More triage nurses in existing a&e's. Cut out some of the admin and jobsworths - open up those empty wards - more investment in mental health services - more investment in primary healthcare and care in the community - more vetting of nursing homes - more emphasis on recovery - more emphasis on cleanliness - more nurses - more specialised doctors - basically more needs to be done and more money needs to be found -

But it would be an added tax I'd be willing to pay if it meant we had universal healthcare for all.

Avatar MIA

Ah, the HSE.

Embargo lifted recently and took on a load of new staff they didn't need.

How do I know this. One of my direct reports who wouldn't have been worked off her feet recently left to take up an admin post. She left the HSE within 3 months.

It was boring and actively told to slow down. She said she had to cover another person's absence and her own duties and stilll had everything covered by lunchtime.

I know this can come across as PS bashing and is only anecdotal, but is what it is.

The nursing sector and admins have huge power, they also have great unions and PR. This is not going to be fixed any time soon.

Throwing money at it hasn't and wont work. Raising taxes to spend in the HSE is simply missing the real problem.

Going through the HSE 'like a dose of salts' would have the HSE closed down overnight. Would make the Blue Flu look like a picnic.

kazamo

Harry Palmr wrote: »

One solution is open main doctors surgeries 24 hours a day in the larger towns and cities - no charge for a consultation.

Charge anyone who turns up at A&E under their own steam 100 euro if they do not need immediate critical medical help.

Do they not do that already.
i got charged a few years ago for attending A&E without a doctors referral.

corner of hells

steddyeddy wrote: »

Go through the HSE and get rid of all the human flotsam and jetsam that call themselves admin. That should free up a few mill.

As a former HSE contractor , I was left wide eyed and shocked by the amount of waste in one of their sections.

Money was literally thrown away, even for my dopey sense of awareness it was stunning. Laziness beyond belief .

I do remember years ago years ago hospitals seemed to be left to thief own devices , employing their own management , thief own tradesmen, matrons for running and training nurses and looking after thief own cleaning , catering etc.

Maybe it might be worth looking at again.

jimdublin15

I think Blindly spending money or pumping cash into the system is not the answer, It needs understanding that it can't change overnight and changes will take time to get results.

So at the top level close management to set correct policy,leadership and focus, also spending increase on first line staff to save costs down the line. It as a system also needs the understanding that preventive care is costly however it's better to spend on prevention than deal with costly problems down the line.

I would like to see more nurses and no more temps ! With that we also need more GP's working longer hours or overlapping hours to better serve the public and overall a better quality of work from GP's as a front line service. To many people go to A&E as they can't see the GP, the GP has no time or the GP is too focused on covering him/her self. Let's be honest we have a major knock on problem from this of people simply being in A&E wasting nurses and doctors time. A&E Doctors should send them back to the GP's, however this is not done because of the fear that it might go wrong in that 1 in x 1000000 cases. But surly that's better than stacking people on the floor/chairs and trolleys and waiting for them to die.

Alternatively have a 24/4 (Thursday - Tuesday) or even 24/7 for major city A&E 's GP post based inside the A&E's who do a 10/15 min consult on all walk in cases sending the ones that need to take an aspirin or a simple prescription home, correctly and speedy weeding out the wasters would significantly reduce the pressure on the A&E. And charge anyone with a medical card who is found to be wasting A&E time. Edit: Just to note I know A&E's do work with a triage system but this would add the additional quick resolve layer.

risteard7

steddyeddy wrote: »

Go through the HSE and get rid of all the human flotsam and jetsam that call themselves admin. That should free up a few mill.

Yes too many walking around with clipboards on 50k plus.

Hey OP,
As per your request, I've moved this to the health sciences forum, I've notified the mods that it's been moved.

Posters who are following over from AH need to bet in mind the change of charter before posting.

Thanks.

deandean

Introduce bunk trollies, 2-up.

steddyeddy

corner of hells wrote: »

As a former HSE contractor , I was left wide eyed and shocked by the amount of waste in one of their sections.

Money was literally thrown away, even for my dopey sense of awareness it was stunning. Laziness beyond belief .

I do remember years ago years ago hospitals seemed to be left to thief own devices , employing their own management , thief own tradesmen, matrons for running and training nurses and looking after thief own cleaning , catering etc.

Maybe it might be worth looking at again.

The lab I was in paid 3.3 times what they should have for some supplies. There was also cheques paid out yearly for services that the HSE didn't use anymore.

I said it before and I'll say it again. There's a lab assistant working in a large Dublin hospital who's unqualified to work there. He got the job because of his aunty. No one will bat an eyelid until a test is performed wrong and a patient gets the wrong results. When that happens I'll have a copy of the letter I sent to the HSE about it.

Qualitymark

Atlantic Dawn wrote: »

Its a case of solving the problem of those ready to leave hospital but are still there taking up beds.

Friends of mine with several interacting chronic illnesses had to stay in hospital a fortnight every time they went in for tests - because three or four consultants had to consult together on their case every time. If the consultants had daily consultations with all the other consultants, rather than once a week, this wouldn't happen.

mfceiling wrote: »

The amount of junkies there was unreal…

So I hear. A lot of that is from the drugs being illegal, so they're sold by criminals who cut them with all kinds of poison and people who take them get infected wounds and are made ill by the poisons. Also, addicts have to recruit new users to sell to, if they're to make the money to buy their own drugs. Decriminalising drugs and bringing all addicts into the care of the State seems to have worked in other places. But not just "legalising" them and leaving the chaos to work itself out.

But I don't know if drug users are the major cause of problems in the health system.

How did Britain do it when they started their National Health, and was their health system in an equal state of chaos?

Are there examples of other health systems that have been rescued from chaos?

Harry Palmr

Qualitymark wrote: »

How did Britain do it when they started their National Health, and was their health system in an equal state of chaos?

Are there examples of other health systems that have been rescued from chaos?

and here is the biggest challenge of all - you cannot switch off the health services and start again.

Once the initial structure takes hold and stabilises layer upon layer is accumulated as the system becomes less and less about the patients and more about the system and those who work within it (or maybe better put - work it).

Qualitymark

I'd be interested in seeing people like Atul Gawande and those he's studied taking a look at the Irish system and telling how to fix it. And perhaps those who know best how to fix it are those who work inside it, and have worked elsewhere in health systems that work.

corner of hells

mfceiling wrote: »

Too many people in hospital from their own stupidity.

I had kidney stones last year and was sent to A+E in St James. The amount of junkies there was unreal. Coming in from an ambulance even though they were capable of walking and abusing the receptionist (and the paramedics who brought him in).
There was an obese kid in a wheelchair who had his knees strapped because of the strain on them. This was made worse by his dope of a mother bringing him cans of coke and bags of hunky dorys from the vending machine.
Chain smokers on ventilators because they wouldn't stop smoking.
Alcoholics in bits because they wouldn't stop drinking.

Meanwhile genuinely ill people and the elderly lie on trolleys trying to hold on to whatever tiny piece of dignity they have.

But to answer your question...I have no idea.

Qualitymark wrote: »

So I hear. A lot of that is from the drugs being illegal, so they're sold by criminals who cut them with all kinds of poison and people who take them get infected wounds and are made ill by the poisons. Also, addicts have to recruit new users to sell to, if they're to make the money to buy their own drugs. Decriminalising drugs and bringing all addicts into the care of the State seems to have worked in other places. But not just "legalising" them and leaving the chaos to work itself out.

Identifying small sub groups in a society and pointing a finger at them is unfair whether responsible or not for their health issue.

To put things into perspective we have about 24000 opiate addicts at different levels in their addiction i.e. iv injecting , stable on methadone , detoxing off methadone and so on A.That group is a tiny percentage of what uses our health services.

Vorsprung

You could write a book on this topic. This is as long a post and apologies if I repeat myself/go off on a tangent.

jimdublin15 wrote: »

I would like to see more nurses and no more temps ! With that we also need more GP's working longer hours or overlapping hours to better serve the public and overall a better quality of work from GP's as a front line service. To many people go to A&E as they can't see the GP, the GP has no time or the GP is too focused on covering him/her self. Let's be honest we have a major knock on problem from this of people simply being in A&E wasting nurses and doctors time. A&E Doctors should send them back to the GP's, however this is not done because of the fear that it might go wrong in that 1 in x 1000000 cases. But surly that's better than stacking people on the floor/chairs and trolleys and waiting for them to die.

We'd all like to see more full time nurses working. Unfortunately,they can get better conditions abroad, including but not limited to better pay, education prospects and less restrictive scope of practice. Improve their conditions and they will stay.

Regarding getting more GPs working, we need that anyway due to our ageing population. Again, recently qualified GPs are moving abroad for the same reasons as nurses. In addition, thanks to the FEMPI cuts of a few years ago, GP incomes have taken a tumble, acting as a further disincentive to work here. 4 GP mates of mine (out of about 14) who have qualified in the last 2 years are now abroad.

I think your assessment of why people attend ED is a little oversimplistic, and to be honest isn't the root cause of ED overcrowding. I should have a sense of some of the issues, I've worked for long enough in them, both adult and kids. If a patient attends ED (regardless of whether they've been referred by a GP of not), they're seen by an ED doctor and then my an inpatient team if an admission is felt to be warranted. Only if an admission is confirmed by that team does a patient become part of the trolley count. So regardless if patients are "time wasters" or not, they don't really affect the "trolley crisis". What does affect the number of admissions is the lack of senior decision makers (ie consultants) in hospitals available to see patients in EDs. There was a presentation at last year's Irish Emergency Medicine meeting at which the benefits of increased ED consultant presence on the shop floor were outlined. Interesting that the hospitals where this doesn't happen make the papers more often than others. A few stats include:

Less unplanned returns to the ED (upto 30%)

Increased discharge rates (upto 22%)

Reduced hospital admissions (between 11-25%)

Reduced hospital length of stay (upto 10%)

Fewer missed diagnoses

You'd wonder what the stats would be if you put you a medical consultant in addition to an ED consultant. You'd wonder further if the tests/scans were available as routine for hours outside 9-5. I've worked in a large Dublin hospital where I've had to refer patients for admission at 6pm because I cannot get the CT scan they need because radiology is closed. They then languish on a trolley for upto a few days (at a financial cost to the hospital and at a comfort/social cost to the patient) until they get the scan, at which point they can be discharged. ****ing madness! For elderly patients, being in hospital is probably the worst thing for them. Moving care back to the community is important (where appropriate), as is putting in place appropriate outpatient facilities so they that they can be followed up where needed. A good example of where this works well is in St James' in Dublin, where the geriatric team admit a number of over 65s each day directly under their care. It saved something like 18000 bed days in its first year, by getting the patients the early multidisciplinary care they needed, keeping their hospital stay short enough that they didn't develop hospital acquired infections, and seeing them back reasonably quickly for medical/physio/OT follow-up.

Regarding GP referrals to EDs, unfortunately it's sometimes to the only way to get tests/scans/specialist reviews sorted. In some parts of the country, GPs can't get a simple ultrasound scan through the public system. They need to be referred to the local hospital for it. It's not the GPs' fault, merely a manifestation of a malfunded system. Acute Medical Units were held up as a solution, and while they do work in some places, their effect is variable.

As to why people attend ED, some of it has to do with an inability to see their GP same day, but be in no doubt that plenty of people bypass their GP completely. A recent NAGP survey showed that people are waiting longer to see their GPs.

The bottom line from my point of view is that the system is geared towards being reactionary, as opposed to ensuring a quality provision of chronic disease management. And where necessary, having investigations quickly available to primary healthcare providers. This takes money, balls, and ultimately funding into primary care/GPs. Programmes such as childhood vaccination and antenatal care work well in Ireland because GPs are resourced to do it. They need to be resourced to provide more care. It's an upfront investment but it will ultimately take pressure of hospitals. Equally, hospitals need more consultants. Why hasn't any of this happened? Because the government has spun things in such a way that it be publically unpopular to give more money to either group.

jimdublin15 wrote: »

And charge anyone with a medical card who is found to be wasting A&E time. Edit: Just to note I know A&E's do work with a triage system but this would add the additional quick resolve layer.

Define "wasting time". Very hard to! You could charge a co-payment to medical card holders for both ED and GP care, say a fiver or tenner per visit . I personally don't think that's too unreasonable.

jimdublin15

Vorsprung wrote: »

You could write a book on this topic. This is as long a post and apologies if I repeat myself/go off on a tangent.



We'd all like to see more full time nurses working. Unfortunately,they can get better conditions abroad, including but not limited to better pay, education prospects and less restrictive scope of practice. Improve their conditions and they will stay.

Regarding getting more GPs working, we need that anyway due to our ageing population. Again, recently qualified GPs are moving abroad for the same reasons as nurses. In addition, thanks to the FEMPI cuts of a few years ago, GP incomes have taken a tumble, acting as a further disincentive to work here. 4 GP mates of mine (out of about 14) who have qualified in the last 2 years are now abroad.

I think your assessment of why people attend ED is a little oversimplistic, and to be honest isn't the root cause of ED overcrowding. I should have a sense of some of the issues, I've worked for long enough in them, both adult and kids. If a patient attends ED (regardless of whether they've been referred by a GP of not), they're seen by an ED doctor and then my an inpatient team if an admission is felt to be warranted. Only if an admission is confirmed by that team does a patient become part of the trolley count. So regardless if patients are "time wasters" or not, they don't really affect the "trolley crisis". What does affect the number of admissions is the lack of senior decision makers (ie consultants) in hospitals available to see patients in EDs. There was a presentation at last year's Irish Emergency Medicine meeting at which the benefits of increased ED consultant presence on the shop floor were outlined. Interesting that the hospitals where this doesn't happen make the papers more often than others. A few stats include:

Less unplanned returns to the ED (upto 30%)

Increased discharge rates (upto 22%)

Reduced hospital admissions (between 11-25%)

Reduced hospital length of stay (upto 10%)

Fewer missed diagnoses

You'd wonder what the stats would be if you put you a medical consultant in addition to an ED consultant. You'd wonder further if the tests/scans were available as routine for hours outside 9-5. I've worked in a large Dublin hospital where I've had to refer patients for admission at 6pm because I cannot get the CT scan they need because radiology is closed. They then languish on a trolley for upto a few days (at a financial cost to the hospital and at a comfort/social cost to the patient) until they get the scan, at which point they can be discharged. ****ing madness! For elderly patients, being in hospital is probably the worst thing for them. Moving care back to the community is important (where appropriate), as is putting in place appropriate outpatient facilities so they that they can be followed up where needed. A good example of where this works well is in St James' in Dublin, where the geriatric team admit a number of over 65s each day directly under their care. It saved something like 18000 bed days in its first year, by getting the patients the early multidisciplinary care they needed, keeping their hospital stay short enough that they didn't develop hospital acquired infections, and seeing them back reasonably quickly for medical/physio/OT follow-up.

Regarding GP referrals to EDs, unfortunately it's sometimes to the only way to get tests/scans/specialist reviews sorted. In some parts of the country, GPs can't get a simple ultrasound scan through the public system. They need to be referred to the local hospital for it. It's not the GPs' fault, merely a manifestation of a malfunded system. Acute Medical Units were held up as a solution, and while they do work in some places, their effect is variable.

As to why people attend ED, some of it has to do with an inability to see their GP same day, but be in no doubt that plenty of people bypass their GP completely. A recent NAGP survey showed that people are waiting longer to see their GPs. One of many reasons for this is that government is providing less and less funding for primary care. A properly resourced primary care sector is absolutely key, but by no means the only piece of the puzzle.

The bottom line from my point of view is that the system is geared towards being reactionary, as opposed to ensuring a quality provision of chronic disease management. And where necessary, having investigations quickly available to primary healthcare providers. This takes money, balls, and ultimately funding into primary care/GPs. Programmes such as childhood vaccination and antenatal care work well in Ireland because GPs are resourced to do it. They need to be resourced to provide more care. It's an upfront investment but it will ultimately take pressure of hospitals. Equally, hospitals need more consultants. Why hasn't any of this happened? Because the government has spun things in such a way that it be pubically unpopular to give more money to either group.



Define "wasting time". Very hard to! You could charge a co-payment to medical card holders for both ED and GP care, say a fiver or tenner per visit . I personally don't think that's too unreasonable.

Wasting time, I would have a soft start on this with anyone who should have been seen by local GP/Nurse.

I would if i was you not apologize to anyone for the long post as it is simply a complex topic that sooner or later unfortunately directly or indirectly will affect most of us and I think we do agree that it's mainly a reactive system, and we need to have a better or more focus on the proactive quality and holistic care across the multiple avenues so to speak. It would cost but save costs in the long run.

Indeed as you point out plenty of route causes and breaks in the system this is not a case of just a single issue or a few quick fixes and certainly no 1 fix solution will resolve this, but we need to start with an issue and when we have and it brings other issues to light we need to continue addressing them.
This takes direct leadership and care from the top down and that's something I think the HSE has.

Not that I know all the answers thankfully, would make my head hurt and I would not claim to know all the solutions either :-)

corner of hells

Vorsprung wrote: »

You could write a book on this topic. This is as long a post and apologies if I repeat myself/go off on a tangent.



We'd all like to see more full time nurses working. Unfortunately,they can get better conditions abroad, including but not limited to better pay, education prospects and less restrictive scope of practice. Improve their conditions and they will stay.

Regarding getting more GPs working, we need that anyway due to our ageing population. Again, recently qualified GPs are moving abroad for the same reasons as nurses. In addition, thanks to the FEMPI cuts of a few years ago, GP incomes have taken a tumble, acting as a further disincentive to work here. 4 GP mates of mine (out of about 14) who have qualified in the last 2 years are now abroad.

I think your assessment of why people attend ED is a little oversimplistic, and to be honest isn't the root cause of ED overcrowding. I should have a sense of some of the issues, I've worked for long enough in them, both adult and kids. If a patient attends ED (regardless of whether they've been referred by a GP of not), they're seen by an ED doctor and then my an inpatient team if an admission is felt to be warranted. Only if an admission is confirmed by that team does a patient become part of the trolley count. So regardless if patients are "time wasters" or not, they don't really affect the "trolley crisis". What does affect the number of admissions is the lack of senior decision makers (ie consultants) in hospitals available to see patients in EDs. There was a presentation at last year's Irish Emergency Medicine meeting at which the benefits of increased ED consultant presence on the shop floor were outlined. Interesting that the hospitals where this doesn't happen make the papers more often than others. A few stats include:

• Less unplanned returns to the ED (upto 30%)

• Increased discharge rates (upto 22%)

• Reduced hospital admissions (between 11-25%)

• Reduced hospital length of stay (upto 10%)

• Fewer missed diagnoses

You'd wonder what the stats would be if you put you a medical consultant in addition to an ED consultant. You'd wonder further if the tests/scans were available as routine for hours outside 9-5. I've worked in a large Dublin hospital where I've had to refer patients for admission at 6pm because I cannot get the CT scan they need because radiology is closed. They then languish on a trolley for upto a few days (at a financial cost to the hospital and at a comfort/social cost to the patient) until they get the scan, at which point they can be discharged. ****ing madness! For elderly patients, being in hospital is probably the worst thing for them. Moving care back to the community is important (where appropriate), as is putting in place appropriate outpatient facilities so they that they can be followed up where needed. A good example of where this works well is in St James' in Dublin, where the geriatric team admit a number of over 65s each day directly under their care. It saved something like 18000 bed days in its first year, by getting the patients the early multidisciplinary care they needed, keeping their hospital stay short enough that they didn't develop hospital acquired infections, and seeing them back reasonably quickly for medical/physio/OT follow-up.

Regarding GP referrals to EDs, unfortunately it's sometimes to the only way to get tests/scans/specialist reviews sorted. In some parts of the country, GPs can't get a simple ultrasound scan through the public system. They need to be referred to the local hospital for it. It's not the GPs' fault, merely a manifestation of a malfunded system. Acute Medical Units were held up as a solution, and while they do work in some places, their effect is variable.

As to why people attend ED, some of it has to do with an inability to see their GP same day, but be in no doubt that plenty of people bypass their GP completely. A recent NAGP survey showed that people are waiting longer to see their GPs.

The bottom line from my point of view is that the system is geared towards being reactionary, as opposed to ensuring a quality provision of chronic disease management. And where necessary, having investigations quickly available to primary healthcare providers. This takes money, balls, and ultimately funding into primary care/GPs. Programmes such as childhood vaccination and antenatal care work well in Ireland because GPs are resourced to do it. They need to be resourced to provide more care. It's an upfront investment but it will ultimately take pressure of hospitals. Equally, hospitals need more consultants. Why hasn't any of this happened? Because the government has spun things in such a way that it be publically unpopular to give more money to either group.



Define "wasting time". Very hard to! You could charge a co-payment to medical card holders for both ED and GP care, say a fiver or tenner per visit . I personally don't think that's too unreasonable.

Very informative post.

blackbird 49

kazamo wrote: »

Do they not do that already.
i got charged a few years ago for attending A&E without a doctors referral.

If you are lucky enough to have a medical card or a doctor's referral there is no charge, otherwise there is a E100 charge,

Geuze

No increase in overall exp.

Abolish job-for-life in PS.

Lay off excess admin staff.

Move to a one-tier healthcare system., either all insurance, or all tax-financed.

If we go for all tax-financed, like the NHS:

then abolish tax relief on health ins and medical exps
only public activity in public hosps
only one waiting list in public hosps
much less people expected to buy PHI
raise the speed of public hosps
waiting times reduced to UK rates, i.e. 18 weeks
if needs be, consultants paid per procedure, accepting that they are greedy, to drive down waiting times
improve public hc so much that people don't buy PHI

pay hosps per procedure, not by block grant.

screamer

It can't be fixed without spending money. The the Hse was never and will never be reformed it's just a big juggernaut caught up in red tape.

As for the hospitals I've spent many a stay in them as a teenager as a public patient and from what I saw the hospitals are full of people who need appropriate care in purpose built care facilities. The public wards were full of geriatric patients that there was nothing much wrong with them some were convalescing some had dementia some were just old and infirm and God help them stuck in hospitals when they needed to be in nursing homes.
But they had nowhere to go the district hospitals full couldn't afford private nursing homes and family not able to take care of them.

I also think that there are many people who visit emergency departments who could be taught to administer treatment themselves for illnesses they have. I don't mean life threatening things but there is an over Reliance on medical intervention and I think people are treated like idiots as if we can't learn how to do things.

Hospitals are like tetris keep moving the beds as quick as you can but when it fills up there's nowhere to move them and out come the trolleys and the politicians with fake apathy and pathetic excuses and empty promises.

Qualitymark

Vorsprung wrote: »

4 GP mates of mine (out of about 14) who have qualified in the last 2 years are now abroad.

How much did the State pay towards their medical education?

I should have a sense of some of the issues, I've worked for long enough in them, both adult and kids.

Just the kind of person we need answering this question.

What does affect the number of admissions is the lack of senior decision makers (ie consultants) in hospitals available to see patients in EDs. There was a presentation at last year's Irish Emergency Medicine meeting at which the benefits of increased ED consultant presence on the shop floor were outlined. Interesting that the hospitals where this doesn't happen make the papers more often than others. A few stats include:

Less unplanned returns to the ED (upto 30%)

Increased discharge rates (upto 22%)

Reduced hospital admissions (between 11-25%)

Reduced hospital length of stay (upto 10%)

Fewer missed diagnoses

You'd wonder what the stats would be if you put you a medical consultant in addition to an ED consultant.

Is this said to politicians in a formal forum and in formal presentations?

You'd wonder further if the tests/scans were available as routine for hours outside 9-5. I've worked in a large Dublin hospital where I've had to refer patients for admission at 6pm because I cannot get the CT scan they need because radiology is closed. They then languish on a trolley for upto a few days

This is lunacy - hugely expensive machinery and highly qualified staff being under-used because of 9-to-5-no-weekends working hours.

In some parts of the country, GPs can't get a simple ultrasound scan through the public system. They need to be referred to the local hospital for it.

In France, there are public laboratories in suburbs where you go in to get all kinds of medical tests done; you then bring your tests to the hospital with you if you need to go. You can also walk in off the street to see a consultant - you don't have to be referred by a GP. Not to mention the cost; a friend went to a lung consultant, who diagnosed the fatal disease that had been missed by Irish doctors; the visits cost €55 for initial visit and a fraction of that for subsequent visits.

The bottom line from my point of view is that the system is geared towards being reactionary, as opposed to ensuring a quality provision of chronic disease management.

The whole of this country's thinking is reactive. We don't sit down and work out what will make the best society; we wait for an emergency and stick a plaster on it.

Define "wasting time". Very hard to! You could charge a co-payment to medical card holders for both ED and GP care, say a fiver or tenner per visit. I personally don't think that's too unreasonable.

Only trouble with this is that it will quickly rise to €20, then €40… politicians paid ballooning salaries have no idea what it's like to live on a small amount.

screamer wrote: »

politicians with fake apathy and pathetic excuses and empty promises.

Nothing fake about politicians' apathy!

locum-motion

corner of hells wrote: »

As a former HSE contractor , I was left wide eyed and shocked by the amount of waste in one of their sections.

Money was literally thrown away, even for my dopey sense of awareness it was stunning. Laziness beyond belief .

I do remember years ago years ago hospitals seemed to be left to thief own devices , employing their own management , thief own tradesmen, matrons for running and training nurses and looking after thief own cleaning , catering etc.

Maybe it might be worth looking at again.

Last edited by corner of hells; Yesterday at 12:17. Reason: change thief for thier .

Need to get back out editing again; you missed at least three thieves!

Vorsprung

Qualitymark wrote: »

How much did the State pay towards their medical education?

Probably paid most of it. Same as most nurses, OTs, physios, engineers, teachers that we're exporting. Set a system up for retention and we'll have less of it..

Qualitymark wrote: »

Only trouble with this is that it will quickly rise to €20, then €40… politicians paid ballooning salaries have no idea what it's like to live on a small amount.

Hard to predict. I think the principle of co-payments is sound though, and when general practice gets completely slammed this winter with under 6s (if it hasn't been already saturated), I wonder if this is going to come onto the table, particularly with the GPs negotiating a new GMS contract over the next few months (may not reach completion with the election coming up).

hytrogen

Atlantic Dawn wrote: »

Its a case of solving the problem of those ready to leave hospital but are still there taking up beds rather than coming up with a solution to new patients arriving. 5 or 6 massive 1000 bed hotels with basic medical facilities should be built around the country to handle these people.

There's a shell of a structure in Urlingford that would be a good start for this! NAMA-Mia!

Kurtosis

Geuze wrote: »

No increase in overall exp.

Abolish job-for-life in PS.

Lay off excess admin staff.

Move to a one-tier healthcare system., either all insurance, or all tax-financed.

If we go for all tax-financed, like the NHS:

then abolish tax relief on health ins and medical exps
only public activity in public hosps
only one waiting list in public hosps
much less people expected to buy PHI
raise the speed of public hosps
waiting times reduced to UK rates, i.e. 18 weeks
if needs be, consultants paid per procedure, accepting that they are greedy, to drive down waiting times
improve public hc so much that people don't buy PHI

pay hosps per procedure, not by block grant.

The dangers of a fee for service model of funding is it can incentivise supplier-induced demand, i.e. the more tests or procedures carried out, the more a hospital will be paid regardless of whether they are necessary or appropriate. Any funding system has to carefully considered and balanced to avoid unintended consequences and introducing perverse incentives. Look at the recent example in the UK where some CCGs are offering money to GPs who reduce the number of patients they refer to hospital (link here).

Qualitymark

What about paying hospitals per cure?