The current hospital / A&E crisis

Are you speaking from experience?

Because you have no insight into either position, is the obvious answer.

Are you speaking from experience, have you worked in either/both an Hospital/GP Clinic?

I might think I know what it is like working in IT, but as my experience is limited to working in Hospitals and health Clinics, I know that even though I occasionally sit at a computer, I really don’t have any insight into what being an IT worker is like.

I think it's probably multi-factorial and not out of any malice/laziness despite what the public seems to think about General Practice.

1) GP caseloads have ballooned to unsustainable levels due to inadequate supply of new doctors and addition of free GP care for paediatrics. This is the cause of people not getting an appointment with GP for ages. Appointment times reduce to try get as many people seen in a reasonable timeframe, but that means less time to spend with the patient and as a result a GP may be afraid of missing something & send to ED to be sure.

2) Patient expectations have increased that a diagnosis is correct and immediate. Consequently GP practice has become more litigious and this leads doctors to practice defensively. Eg- I'm 99% sure this is a benign chest infection but I'd feel more reassured if i had a chest x-ray to outrule a focal pneumonia

Ultimately I think GPs are scapegoated. In a normally functioning system a GP should be able to refer to ED if they want a second opinion about something acute or want more investigation to reassure both doctor and patient. It's no different to me calling cardiology to read an ECG if I'm unsure about it.

Obviously community access to diagnostics would help a lot but would need centralisation of practices and a lot of investment

There isn't.

When someone presents with infection we may do a couple of tests to assess not just the infection itself but the patient's overall health in the context of that infection. For example if a GP sends in a kid with a vomiting & fever, and they've dipsticked their urine and confirmed a UTI I might do a full blood count and CRP to help me differentiate is it likely to be kidney (more severe) or bladder (less severe), and I might do a U&E to tell me if they're dehydrated. It might be that the infection bloods show it's not severe, but that the U&E tells me they're quite dehydrated in which case I'd admit for IV fluids even despite a seemingly small infection. If it does look like a severe infection, I would take a blood culture to exclude sepsis which needs to be incubated in a lab for 36h.

Our infection blood tests also help us determine whether an infection is more likely to be bacterial (more severe) or viral. These however are lab blood tests that don't have a point-of-care machine that could be used in a general practice.

I've worked in emergency departments and feel very lucky to be able to do bloods or imaging to reassure myself about a clinical decision or guide my management, or to be able to pick up a phone and speak to a specialist team for advice. Even if ED is backed out the door I don't begrudge a decision made by a GP to refer- they're making the best decision based on the information available to them at the time.

I know most would be glad to access community investigations to save referring, but to do this we need infrastructure and we also need far more GPs. Taking bloods from a kid for example would require an additional nurse to help and can take up to 20-25 min which means less people that can be seen in that day.

In a large Dublin A&E yest where not a wink of sleep was had due to some prisoner wailing for food. 4 Gardai there all night, minding 2 clowns.

Then a well-heeled, well-spoken lady also screaming harassment at one of the workers for not letting her visit her ma in A&E. Garda could have easily told her to jog on but didn't.

Seems to be a lot of internal politicking going on earwigging on convos. Surgeon who accepted me was explaining to a Junior lad about how to play the game as the CT team didn't want to take me on. So he had to convince them in a roundabout way by leaving vagueness that might prompt them to cover their own asses.

Seems like it's fucked from every which way.

Undersubscribed as in qualified Drs did not wish to apply to specialise as GPs. The unfilled places, which is not as assumption, you can look it up, are not dependent on leaving cert points as entry to a GP scheme occurs after graduation, not after secondary school. There are currently just under 1000 Drs in the GP training scheme at the moment, 285 were taken in this year, again, these figures are available to view if you look them up. There are currently 25% more inhabitants in Ireland since 2002, the highest population since The Famine, I doubt anyone envisaged such growth 20 yrs ago.

In relation to points, this has always been mentioned as an issue with intake into health care courses, the points are so high that Universities are getting book smart students rather than students suitable to be Drs, it was one of the reasons why the HPAT was introduced. It is not ideal that LC results alone decide whether a student gains entry, but for now it is possibly the best indicator of whether a 19yr old will be able to complete the 6 yrs of extensive learning that it takes to graduate as a Dr. Entry requirements/points apply to most undergraduate courses, it is understandable why the requirement for a course like medicine would be among the highest given it’s popularity with top students. It is also worth baring in mind that there is now a graduate entry option into medicine in UL, so LC points is now not the only means by which people who wish to become Drs can gain entry to medicine.

When you say gaining financially, who are you referring to? The ICGP, who are responsible for training GPs are trying to increase the numbers on their schemes to meet demand, working GPs are buckling under the pressure, most have closed their lists to new patients because they are at their limit, there are Practices advertising GP jobs who have not received any applications, many can’t retire or sell their Practices because there is no one to take their place. The IMO are warning the government that GP levels are dangerously low and that Drs are emigrating rather than staying to work as GPs. I’m struggling to see who you think is gaining financially from this situation.

The Government chose to expand the med card scheme and GP care for children and are ploughing vast amounts of money into the Health system, if they wanted to save money they would cut back med cards and have patients pay for GP visits, not expand it. I don’t see how limiting GPs helps the State financially, and certainly problems with healthcare are going to be a major issue at the next election so it is in TDs best financial interest to try and improve access, not hinder it if they want to try and keep their jobs.

GP training spots are at their current number due to a number of reasons- the primary one being government funding. It’s the department of health that that decides how many training placements in each of the schemes it will fund and this will be mapped to long-term workforce planning (will there be a GP job at the end of the scheme to fill). That is the primary limitation.

Other factors to consider is training infrastructure- you need to find teams to place these new training spots on and appropriate training sites. It’s generally up to the HSE and training bodies to make sure there’s adequate trainee supervision and a balance of trainees and skill mix in a team.

The problem with GP training as with most training in Ireland is that there’s no long-term workforce planning so the HSE/DoH either doesn’t know or is will fully ignorant to the staffing needs of the health service going forward and how it will achieve that

Its actually pathetic to listen to the FFG ministers this week trotting out the same old excuses over and over. They must have a laminated sheet with what they are allowed say. They wont answer any direct questions. All the experts are saying that hospitals are running at a very high capacity throughout the year and cannot handle any surge whatsoever without resorting to trolleys. The solution is simple and all the experts agree - more beds, more staff. These ministers are embarrassing themselves with their guff. They were warned about this in July and did SFA. It will happen again next winter, guaranteed.