We need more complex solutions than just throwing more cash at the HSE

THE first public political flashpoint of the new year is again the unrelenting overcrowding in hospital emergency departments. It’s a recurring nightmare.

Flashback – July 21, 2005: 181 people were on trolleys; 2006 – trolley count averaged 221. Health minister Mary Harney announced a “national emergency”.

Flashback – November 2015: 439 patients were on trolleys. A 91-year-old patient was left waiting on a trolley for 29 hours before accessing a bed in Tallaght Hospital. There was uproar in the Dáil, and the emergency department task force promised activation of “full capacity” protocol.

Flashback – December 2015: Health minister Leo Varadkar, HSE directorgeneral Tony O’Brien and Liam Doran of the Irish Nurses and Midwives Organisation jointly announced €44m for 1,600 extra nursing home places under the ‘Fair Deal’ scheme, and €30m was allocated for 250 extra convalescent/ rehabilitation/transition beds in community and district hospitals, reducing delayed discharges from 800 to 570. A joint ‘escalation directive’ of framework and procedures was to manage elective admissions and utilise private hospital beds. There were 243 patients on trolleys.

By any yardstick, the peak of 677 patients on trolleys this month is the worst ever escalation.

Since 2011, Fine Gael health ministers James Reilly, Leo Varadkar and Simon Harris have grappled in vain to get ahead of seasonal systemic trainwreck chaos in emergency departments (EDs).

This calamity is despite record exchequer health funding of €15.3bn (an increase of €685m on 2017 and a HSE “winter initiative” that was supposed to absorb the past lessons).

The atrocious political handling of this latest healthcare crisis has been superficial.

Just throwing more and more money at the mess, while blaming monolithic HSE bureaucracy, fails to absorb both the complexity and changing challenge of a chronically sick and significantly ageing population.

Benjamin Franklin’s words, “If you fail to plan, you are planning to fail!”, are absolutely apt. Economic and Social Research Institute projections (based on census data) for the next 12 years reveal a population spike of an extra one million people.

But the numbers over the age of 85 will double. This will result in increases in demand: up 37pc for hospitals, up 27pc for GPs, and up 54pc for nursing homes. Admissions to our EDs of over-90s are already rising by 22pc annually. By 2030, total hospital admissions are set to double.

Despite policy imperatives of this demographic dynamic, politicians prefer populist, vote-winning initiatives. They promise free universal healthcare to under-six-yearolds, under-12-year-olds and under-18-year-olds, along with reduced prescription charges, proposing free GP care even to the wealthiest kids. It’s utterly irresponsible, flying in the face of dire extra emergency care capacity for the elderly.

The forthcoming Bed Capacity Review Report recommends up to an additional 2,500 extra beds (by 2030) at a current capital cost of €1m per bed, plus current costs of €6,000 per week. This alone will not prevent the cycle of overcrowding. We must fundamentally reform investment, planning, procedures and policies of hospital and primary care to achieve lasting change.

It’s time to ask stark questions of our primary care and GP structure: Have EDs become a convenient dumping ground for inadequate ‘out-of-hours’ GP cover? Anecdotes of patients

unnecessarily being sent to hospital abound – to be sent home, having been given a yoghurt and water after five hours in casualty. There is also a lack of data that gives us a clear picture of the number of unnecessary presentations and referrals.

Developing alternative hospital injury clinics and facilitating X-rays and blood tests outside hospitals in 70 strategic primary centres is overdue. The Sláintecare report, when not pursuing ideological (public versus private) red herrings, contained valuable recommendations to develop national primary care.

We also need to review how we retain the expertise of our young doctors, who are trained in their field at a cost to the taxpayer of €250,000 per student. Allowing them to freely emigrate immediately for personal gain and benefit of foreign health regimes appears naive, given the acute recruitment shortages in Ireland.

It’s also absurd during this critical flu season that two million medical card holders who need basic ‘over the counter’ medicines of paracetamol, decongestants and cough mixtures, have to get a GP’s prescription instead of going directly to their pharmacist, putting additional unnecessary pressure on doctors’ surgeries.

The pharmacy-based Minor Ailment Scheme still remains to be implemented. Meanwhile, uptake of the flu vaccine is still pitifully low amongst those in the most vulnerable categories.

Diverse initiatives to take the pressure off EDs go well beyond predictable Pavlovian responses of simply supplying more beds and staff.

Electronic patient records with a unique genome sequencing identifier through a national e-health system would provide seamless transition from GP practices to all hospitals – ending multiple repeated diagnoses and endless paper records.

The National Epilepsy Care Programme is a model of how to prevent epilepsy patients languishing on trolleys. By establishing pathways for patients with access to specialist nurses within 10 days, and follow-up plans, they’ve achieved reduced dependency on emergency admissions by 20pc.

Within hospitals, the biggest problem remains patient flow and delayed discharges. Every night, across our total 12,000 acute care beds, there are more than 500 patients who are clinically fit to discharge, but can’t be released due to lack of home care provision or a community non-acute hospital bed.

Any plan must make provision for district and community hospital secondtier beds to be available for chronically, rather than critically ill, elderly patients.

Nursing homes must adapt care towards provision of medically supervised intravenous drips. Palliative care is required. Many long-term elderly patients shouldn’t be in hectic trolley corridor horror, they should be re-routed elsewhere.

Politicians won’t let clinical experts of emergency medicine determine our optimal nationwide network of EDs.

Recommendations to reorganise complex care at the Midlands Regional Hospital, Portlaoise, have languished in procrastination on Simon Harris’s desk for a year. The Health Information and Quality Authority plays second fiddle to local constituency pressures.

Individual horror stories of patients can be ameliorated or prevented. The HSE winter initiative and emergency task force forum doesn’t have an adequate seasonal safety valve. A more rapid trigger to temporarily cancel elective hospital admissions and divert to temporary use of vacant private hospital beds is self-evident. Reaction times in transferring trolley patients from Cork University Hospital, for example, were belated.

Total private and public health expenditure will exceed €21bn in 2018 – placing us in the premier league of health spending per capita. Irish healthcare requires smarter, tougher political choices, based on a decade of calibrated planned growth of investment in primary care and tiered hospital bed capacity.

Private and public health spending will exceed €21bn in 2018 – placing Ireland in the premier league