What exactly is the problem in the HSE?

maninasia · 06-01-2015 05:20PM

The 'system' as such should largely be broken down into individual units (hospitals) or hospital groups, which operate in a public or private capacity under their own management structure. They should then compete for patients and get funded on a service per patient model. A universal insurance system can help to cover insurance premium gaps for poorer folks.

Yes there are some problems that can go with such a model, but improved service due to competition and private investment would be a vast improvement on the current situation. The playing field will be a lot more transparent and hospitals will succeed or fail according to their overall performance, in the main.

Also I would suggest the culture of the blame game and the idea of 'management' and 'consultants' and 'foot soldiers' would need to be broken down and changed to one where people see themselves as part of a bigger entity (hospital/dept) working towards a common goal.

Also it's very clear that the current system is a shambles IT wise, get a chipped card for each patient, and stick the records on a central database, it's not that hard in this day and age.

treecreeper · 06-01-2015 06:32PM

i have always felt that the groups, units of care should be broken down. i suggest 'small injuries' clinics, alcoholic and drug addicts and problem solving clinics, (places to rest overnight after a binge and see someone next day but not in the main A'E services, these should be attached to the psychiatric hospitals or other) the step down facilities have been needed for over a decade and ignored.
the community care and primary care with 'visions' have all been known for decades and nothing done about it.
when you lop off transport to hospitals from various smaller towns and villages no wonder there is an outcry against shutting smaller hospitals.
the hse cannot have it everyway.
if we do not sort the problem its not going to go away!
the system is now 'unattractive' for any professional to work in, and dangerous.
we have a dangerous health service provision yet top medical colleges and research units at the universities, the result being educate and emigrate. madness.
we have a high elderly population but its known they fare better and want to be in the community
what happens now is all the public health nurses time is taken up with the baby clinics, i see it. and the elderly who need care are not getting it, they should be equal in health.
the children and babies now will be getting free gp services, this will not have impact to the pubic health centre where the mothers and babies go for all sorts of things, -everything, you would think irish mothers have not been having babies for centuries.
its a waste of resources.
and money
the community element is going, when everyone feels the state should care for just about everyone.
the elderly are being shoved away as soon as they can be got rid of into mass dying homes where they await their time in passing.
the window of use has decreased from babyhood to about fifty after that we begin again at the babyhood stage and the rest prepare for the massive institutions where we ditch the mothers and fathers.
community care should be just that.
its the one big issues with the hospitals and not being dealt with.
its too expensive to keep people in these institutions, small community places should be funded at far less expense and far better emotionally and physically not to mention morally.
IT is a madness, with one co ordinator of services doing the payroll for all her workers BY HAND for three weeks out of every month.
what country works like this ?
all have an electronic pay slip and all patients an electronic data information number.
all patients should have a duplicate of the doctors letters, test results etc.
we in Ireland have to apply for these, through our gp who have to request them and then to get any other information you either have to beg for it or get it under FOI>
can you blame the doctors for not knowing up to speed data when the patient cannot bring a folder with him/her and behave like adults, not some kind of demigod looking after eggits.
we are people who are ruled by medics and we all should be in this together, including including the elderly in the framework, not as expendible but part of community.
end of rant!

Vorsprung · 09-01-2015 10:30PM

I find ED overcrowding particularly sickening. Lots of reasons for it, and it is a hospital problem rather than an ED problem in many cases.

Lots of ED consultants being interviewed in the media, and I wonder if things would be a little better if some of those ED consultants actually spent time on their respective shop floors instead of on the radio/TV. An inconvenient fact that is being ignored.

One of many, many reasons.

treecreeper · 09-01-2015 10:40PM

anyone understand 'human rights law' and how one goes about taking a case against the HSE under this, because all else has failed in a case very close to my heart, they say after failing to get justice for health care there is a way to europe, well where do i find any links to how to process this please.

echo beach · 09-01-2015 11:30PM

Vorsprung wrote: »

Lots of ED consultants being interviewed in the media, and I wonder if things would be a little better if some of those ED consultants actually spent time on their respective shop floors instead of on the radio/TV. An inconvenient fact that is being ignored.

One of many, many reasons.

The people waiting in A+E will already have been seen and it has been decided they need to be admitted and probably need further tests.
A radio or TV interview only takes 10 or 15 mins and by drawing attention to the problem may well do more good than standing around looking at a sea of people, most of whom are medical cases and not the people an ED consultant is best placed to help.

As you say there are many reasons for the problem but the HSE seem convinced that the main factor is delayed discharge. The general manger of Letterkenny hospital says this isn't an issue for them with only 2 or 3 patients awaiting step down beds when there were up to 37 patients waiting for admission. Something doesn't add up.
I see a lack of provision in primary care, especially in the evenings, at weekends and over the holidays when patients are left to out of hours services staffed by doctors who don't know the patients, their history or their backgrounds. Sending patients to hospital becomes the default option because there aren't the resources to provide the regular home visits needed to safely treat these patients in their own home.
A 'flying squad' of GPs and nurses who would visit the patients at home 2-3 times a day and who had direct access to out-patient facilities for tests and x-rays might relieve some of the pressure without using up acute beds.

Vorsprung · 10-01-2015 12:06AM

echo beach wrote: »

A radio or TV interview only takes 10 or 15 mins and by drawing attention to the problem may well do more good than standing around looking at a sea of people, most of whom are medical cases and not the people an ED consultant is best placed to help.

Firstly, I suppose I'm referring to certain consultants who are on the radio a lot of the time.

Secondly, lots of studies to show that ED consultant presence on the floor reduces inappropriate admissions and discharges. I don't know that those papers specifically deal with medical patients.

echo beach wrote: »

As you say there are many reasons for the problem but the HSE seem convinced that the main factor is delayed discharge. The general manger of Letterkenny hospital says this isn't an issue for them with only 2 or 3 patients awaiting step down beds when there were up to 37 patients waiting for admission. Something doesn't add up.

Different in different places. I hear it's a particular problem in Beamount. How someone in the HSE decides that it's better value to spend around a thousand euro a night on an acute hospital bed instead of 1000 euro a week on a nursing home bed is beyond me.

echo beach wrote: »

I see a lack of provision in primary care, especially in the evenings, at weekends and over the holidays when patients are left to out of hours services staffed by doctors who don't know the patients, their history or their backgrounds. Sending patients to hospital becomes the default option because there aren't the resources to provide the regular home visits needed to safely treat these patients in their own home.

Agree 100%. Timely access to diagnostics and adequate funding to manage chronic disease instead of increasingly infrequent tertiary reviews constitute some of the issues that need to be addressed. No doubt there's an up front cost but I can't but imagine that the savings in the long run would outweigh that initial cost.

Same could be applied to hospital inpatient teams, I remember having to refer from ED to an inpatient to get a CTPA, wastage is incredible!

Apologies for bringing it down to money but it's the only language the HSE speak.

treecreeper · 10-01-2015 10:33AM

those who have severe illness and disease who are already living in the community in their own homes do not get to see any medical staff day in day out and i know two individuals, yearning to stay in their own homes, who are not that elderly being 63 never ever have a visit from a nurse even. the problem seems to be understaffing and a demographic of other needs within primary care clogging up the works.
if the nurses have a catchment area of young families and a centre that is permanently taken up with baby issues, then the elderly, very sick etc do not get the services they need.
the money goes where the need is, and its children first.
this is alarming. there is simply no balance at all.
one nurse covering for the chronically ill for instance and that alone would mean that she can concentrate on that group.
its about how one manages particular areas.
there is also community committment which is fast eroding. an article about a pensioner cycling two hours to get her pension in a rural area says it all - where are her neighbours?
there isnt enough senior or consultant A'E doctors on the floor of the department, leading to unsafe decision making.

echo beach · 10-01-2015 09:33PM

Vorsprung wrote: »

How someone in the HSE decides that it's better value to spend around a thousand euro a night on an acute hospital bed instead of 1000 euro a week on a nursing home bed is beyond me.

What you are leaving out of the sums is the fact that as soon as a person moves to a nursing home the acute hospital bed gets filled with another patient so the only way it saves the HSE money is if they close that bed. Otherwise they will have to pay for two beds instead of one.
All the figures are averages. The average cost of the acute hospital bed may be 1000 euro but the patient awaiting discharge costs a good bit less than that because they aren't getting active treatment. Replace them with a seriously ill patient and the cost will be greater, as will the stress on already stretched staff. The reality is that it suits management and staff to have a certain percentage of beds taken up with those who aren't very sick, either awaiting discharge or waiting for tests or waiting for a consultant's opinion. I've had occasion over the years to visit a variety of wards in various hospitals and notice that about a third of patients (nearly always 2 on a 6 bed ward) tend to fit into those categories.

bleg · 11-01-2015 11:07PM

The problem is that the HSE faces a so called "wicked problem."

http://en.wikipedia.org/wiki/Wicked_problem

A wicked problem is a problem that is difficult or impossible to solve because of incomplete, contradictory, and changing requirements that are often difficult to recognize. The use of term "wicked" here has come to denote resistance to resolution, rather than evil.[1] Moreover, because of complex interdependencies, the effort to solve one aspect of a wicked problem may reveal or create other problems.

treecreeper · 11-01-2015 11:13PM

wicked or evil....who suffers...and thats why whether wicked or evil someone should try and divide it all up and sort the bloody mess.
people are dying cos of the mess.
people are facing some sinister forces within management which means care for them is being denied.
and far worse, whole generations, usually the elderly are dumped at the mercy of people who are either wicked or evil

echo beach · 12-01-2015 02:52PM

bleg wrote: »

The problem is that the HSE faces a so called "wicked problem."

http://en.wikipedia.org/wiki/Wicked_problem

In some respects it is a 'wicked' problem but I'm not sure it fully fits the description. Nobody seems to have much difficulty recognising the requirements, and they don't change that much except to increase in volume at certain times.

czipownik · 09-05-2015 10:05AM

Why don't we decentralize the public health service in Ireland? Just dismantle the HSE and build contract/tender based system like in Poland for example. This way, poor performers like the maternity in Portlaoise are simply rooted out, i.e. no contract renewal at beginning of next year.

Polish system is opened to both public and private entities (health centers, hospitals, practices). Every procedure all the way from organ transplant down to GP consultation has its unit price on the list generated by the ministry of health. Publicly insured patient have their user and login into internet website where they can follow all procedures performed/attended.

I think the problem here in Ireland is that the HSE is a black whole or well without the bottom. Plenty of beaurocrats, administration, complex reporting structures, no trasparency in the event of medical misconduct/mistakes.

Having contract system in place, allows to track what pricing level can be achieved for each procedure = competition.

adamshare01 · 09-05-2015 11:22AM

Management and administration

SpaceTime · 09-05-2015 12:40PM

There are a few big problems:

1) Administration where instead of recruiting people to positions based on merit, they're being advanced to management based on their length of service. This isn't really a viable way of recruiting good management.

They also don't seem to understand the difference between "management" and "administration". They're two related but totally different skill sets.

Confusing the two creates a problem for both patients and medical staff.

2) The two tier system (and I think this is a big thing).

Ireland has a public/private hybrid health system. So we take most of the patients who are likely to demand high levels of customer service out of the public system and leave it full of people who are more likely to be passive about how they're treated.

In the NHS or other public systems, everyone from the local solicitor, the journalist, the GP, the local MP to the unemployed former construction worker are all sharing the same system. If something goes wrong, you will absolutely hear about it.

So, we've basically created in Ireland a system of "working class" vs "middle class" healthcare and rigidly stuck with it come hell or high water despite our claims to be more 'classless' than the UK.

To make it even worse, it's not even a fully private system. Instead we have a barrier fee to keep the two streams separate in the same hospitals.

3) A culture that has come from the concept of free charitable hospitals where patients were 'the poor'.

Unfortunately, I think there is a culture that pervades the whole public system here (especially aspects of the voluntary hospitals which are almost totally state funded) that patients are some kind of charity cases instead of customers of a public service. I don't get that sense in the NHS system but I do get it in some Irish hospitals.

People are being expected to accept whatever they get and be lucky to get it because they haven't 'paid' (other than heavily through their income tax and paying 23% VAT on everything for their entire lives).

Like it or not, that attitude definitely exists.

I was really, extremely annoyed with how my own grandmother was treated by non-medical staff in a major hospital in Dublin. She had terminal cancer and literally had no bones in one of her leg (replaced by steel bars).

The medical staff were really nice, but the administration staff kept calling her in for non-existent appointments and making her wait for hours and hours on hard chairs for absolutely no reason when the woman literally could hardly get herself out her own hall door with assistance.

I remember on one particular day we spent 7 hours in a waiting room for absolutely no reason. They discovered they'd lost the files and had a bit of a mix up. "oops!"

There was also no thought put into thinking about how they could possibly do things without calling her in.
A lot of the consultations were pointless and could have been conducted by phone. A lot of the blood samples could have been collected by a community nurse or a GP.

They also couldn't seem to manage simple things like doing several simple things on one day. Instead they'd call her in maybe on a Monday, then a Tuesday and a Friday for appointments that seemed to be about chats about nothing or to collect a simple blood test.

Every one of these appointments meant that a very sick, very old lady was sitting on a hard chair for hours and that family members had to take time off work or try to work from laptops in waiting rooms.

Another relative of mine is using the same hospital, and is quite ill with a form of cancer and it's similar. They seem to run clinics where they just call about 100 people in at the same time and them expect them to wait all day for a simple consultation.
It's like they just couldn't be bothered making proper appointments and expect 'the plebs' to just file in and wait.

While the facility is modern (thanks to state money) the attitude is still as dismissive as ever.

On the other side of it, I was over in St Luke's in Beaumont (Radiotherapy facility) which is basically a single facility for both public and private patients and it was like the difference between night and day.

They couldn't have been nicer or more efficient if they tried.

The admin team were fantastically helpful, genuinely had an interest in what they were doing and how the patients were doing and even made a big effort to actually come over and greet people by their first name and have a proper chat when they arrived.

It just shows what is possible!

I am 100% convinced that all of the problems in certain hospitals are coming from a management and institutional culture that needs to be tackled very aggressively.

4) Culture of non-transparency

This has to be tackled and tackled very aggressively too.
It's completely unacceptable in a system that makes life/death decisions that there is a culture of trying to suppress reports and gag staff.

Did we learn absolutely nothing from the institutional abuse scandals of the past?

Big vested interests and bureaucracies will protect themselves.

Sorry this is a bit of a long rant but the HSE REALLY annoys me!

SpaceTime · 09-05-2015 12:50PM

I'd just add one of the things that shocked me the most was how they had no single point of contact for patients in that major Dublin hospital.

My grandmother who sadly passed away a couple of years ago and my other relative who is currently battling an incurable type of cancer have had this experience.

They arrive in and basically it seems that nobody is looking after them. Each aspect of their case is being dealt with in a very remote, technical way by very good medical staff, but nobody seems to be visibly coordinating anything.

For example, she was sent for radiotherapy at another hospital without much explanation. She had no idea why she was having radiotherapy or what it was achieving!

She thought it was curing the cancer, when it was actually palliative and nobody had told her that very clearly until the radiation oncologist directly treating her was a bit surprised she didn't realise this.

The other hospital St Lukes were very good, but when she was passed back to her own team, the feedback just stopped. She got a very sore throat and nobody seemed to know why. She'd no idea if it was a side effect because nobody had explained what part of her body had been irradiated!

She keeps all her own files as the hospital doesn't seem to coordinate anything. So she arrives with a big wad of paperwork and appointment slips.

This is an old lady who isn't particularly good any of this stuff, tends to be quite worried about dealing with 'authority' and just goes along with all this stuff.

She's having to book her own blood tests, has no idea what they're for etc. Spends her time freaking out in case she doesn't get a blood test in time before some particular treatment that requires the measurement of some blood chemistry beforehand.

I don't know why a sick, old lady is dealing with that stuff herself...

The information is there, but you have to dig for it.

Again, I'm not faulting the medical team here as she's actually getting really top notch technical treatment, but the problem is the lack of an interface layer between them and the patient. They really badly need this.
The hospital's administration people are effectively just queue managers. That's all the seem to do.

The system is extremely broken in certain hospitals and I honestly don't think it's a lack of financial resources. Throwing money at the problem won't solve basic structural and management issues like this.

I'm not saying there aren't resource issues, but this to me seems like an entirely organisational issue. It's not being tackled. They need to actually get patients to act as secret shoppers and discover how the system REALLY works and how to fix it.

treecreeper · 07-10-2015 08:42PM

being ill as i am and a public patient i recently returned from the uk NHS system for rare diseases treatment and assessment - comparisons -
group thinking in nhs has the neurologist and physiotherapist grovelling on the floor assessing movements, measuring, marking and mapping.
ireland - interview in a bare room producing nothing.
NHS - consultant can hold your hand when speaking of vital important information on living with a rare disease
HSE - consultant plays 'what do you want me to do?' as if he doesnt know himself.
NHS - consultant pushes you back to ward chatting all the way
HSE - consultant fecks you out after a brief interview porter called waiting forever.
NHS - consultant will advocate
HSE - NOne do this
there is absolutely no team work for patients in the HSE, they dont understand it, in the NHS you can have teams all over the place and interlinking. it seems so natural there to do this, they do not treat their patients like sh....

dissed doc · 07-10-2015 08:49PM

treecreeper wrote: »

being ill as i am and a public patient i recently returned from the uk NHS system for rare diseases treatment and assessment - comparisons -
group thinking in nhs has the neurologist and physiotherapist grovelling on the floor assessing movements, measuring, marking and mapping.
ireland - interview in a bare room producing nothing.
NHS - consultant can hold your hand when speaking of vital important information on living with a rare disease
HSE - consultant plays 'what do you want me to do?' as if he doesnt know himself.
NHS - consultant pushes you back to ward chatting all the way
HSE - consultant fecks you out after a brief interview porter called waiting forever.
NHS - consultant will advocate
HSE - NOne do this
there is absolutely no team work for patients in the HSE, they dont understand it, in the NHS you can have teams all over the place and interlinking. it seems so natural there to do this, they do not treat their patients like sh....

The NHS was to be and still is for the moment a component of the British identity since it's founding, so rightly or wrongly it inspires and consumes the goodwill of the employees, who are beginning to desert it.

The HSE is an administrative system for executive managers, it can by it's nature never inspire loyality, and even more so, because it openly attacks it's own employees.

The public decide along with the media, how public bodies treat public employees. If you don't like what you are seeing, it is because it reflects how those people have been treated over the past decade. Consultants have been bullied for a decade in all media and by the HSE. What do you expect? Hand holding and compassion? Human nature doesn't work like that.

It is what it is, and the way the people are is the way people are. If you or anybody want that caring compassionate interaction, you should know, it comes from the top down. Demoralised and bullied staff do not have to make excuses for reacting in a human way to their treatment at the hands of the media, politicians and public over the past decade.

treecreeper · 07-10-2015 09:58PM

i am unsure what you are trying to say here.
what if, you as a sick person became sick and then treated in the above way. which came first the chicken or the egg.
i do agree that the organisation is demoralised and bullying is rife both within and from outside.
therefore to cure such an ill is to kill it off!
many want to see change.
many in the hse are really good and caring.
but if the whole thing is in chaos from top to bottom and inside out, where can it go from here?
it is getting worse not better.
i am not using any excuse for poor services, bullying from top to bottom and inside means that everyone has a right to bully another no matter?
when you become sick for the first time in your life the shock of bad treatment is awful.
period.
when you become sick for hte first time in your life and meet some expertise in all aspects of care the shock too is evident inside i feel different.
the rest is awful.

_Tombstone_ · 07-10-2015 10:11PM

How have consultants being bullied in the media?

treecreeper · 07-10-2015 11:20PM

media is selective.
anyone trying to get a point across is chosen, selectively by media.
therefore between politicians and media you have a basic autocracy.
no one will allow you have your say unless they say so.

whether media bullies consultants by allowing the public say what it wants to say might be a way of saying this.
but to speak of bullying, i have never seen or heard of bullying of consultants in the media.
they argue over their pay scale, which isnt the same as bullying.

we have a culture here in ireland, as one person said the NHS is part of their identity.
but the culture here in ireland is not good towards patients.
consultants do strutt.
they rule.
they are to be believed whether right or wrong and pretty selective who and how they treat people.
me saying that is not bullying them.
the day they hold a patients hand in care or wheel them back to the wards by showing that extra step of empathy is the day i see our culture of arrogance weakening towards what should be equal share and care in sickness.

drzhivago · 02-01-2016 03:28AM

Phill Ewinn wrote: »

Can I ask why it is that doctors and nurses and their unions and associations don't push or lobby for changes to the administrative process??

Everyone understands the inefficiency of the administrative processes.

They do, and have done for the last 3 decades (the limit of my political awareness, afraid that as a child I was not that interested) but reading reports now doctors and nurses have been lobbying for far longer than that.. the issue is you are lobbying against a machine

A number of years ago there was a issue arising which both medical and nursing unions wanted PR help with, approached 10 large firms who all said couldn't help, it would be a conflict as they were already either engaged by Department or HSE

Says it all really

Shtanto · 13-01-2016 03:07AM

I still don't really understand how the HSE operates really. Is it broken because there are too many managers? Is it a case of a bureaucracy expanding to meet the needs of an expanding bureaucracy?

I mean I'd know a little bit about healthcare from having MS for a few years now, but I can't understand where all the money is going. Are there more managers than doctors? There really ought to be more doctors and nurses than managers.

locum-motion · 13-01-2016 10:05PM

Here's a little illustration of HSE bureaucracy:

Before the HSE, there was an office in Dublin that was responsible for making payments to doctors and pharmacies that worked in the General Medical Services system. It was called the "General Medical Services (Payments) Board". So far, so good, I hear you say.

Then the HSE was created. They changed the name of the GMS(P)B.

The name they chose was:

"Health Service Executive - Shared Services - Primary Care Reimbursement Service"

They took a 5-word-long name (which was probably about 2-3 words too long to begin with) and replaced it with a 9-word-long one (in which 3 of the words were the same word).

Any organisation that thinks that that's a good thing to do in the name of efficiency is not likely to be able to run a 100m race, not to mention the healthcare system of an entire country.

Shtanto · 14-01-2016 12:44AM

locum-motion wrote: »

Here's a little illustration of HSE bureaucracy:

Before the HSE, there was an office in Dublin that was responsible for making payments to doctors and pharmacies that worked in the General Medical Services system. It was called the "General Medical Services (Payments) Board". So far, so good, I hear you say.

Then the HSE was created. They changed the name of the GMS(P)B.

The name they chose was:

"Health Service Executive - Shared Services - Primary Care Reimbursement Service"

They took a 5-word-long name (which was probably about 2-3 words too long to begin with) and replaced it with a 9-word-long one (in which 3 of the words were the same word).

Any organisation that thinks that that's a good thing to do in the name of efficiency is not likely to be able to run a 100m race, not to mention the healthcare system of an entire country.

So medical staff payroll was too sensible?

locum-motion · 14-01-2016 01:16AM

Shtanto wrote: »

So medical staff payroll was too sensible?

Well in fairness, it's not payroll for employees, it's organising payments to thousands of separate companies who are contractors.
But yeah, why not Health Reimbursements Ireland or something?

What exactly is the problem in the HSE?

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