An Expensive and Dysfunctional Health Service
Dr Fergal Hickey, Consultant in Emergency Medicine, Sligo University Hospital
We are here to celebrate memory of Patrick McGill who died in November 1963. At the time of his death he was just short of his 74th birthday. This was a remarkable age given that the life expectancy of an Irish man born in the year of his birth, 1889, was a mere 50 years. In view of the nature of the physical work he endured, his wartime service and the fact that he had multiple sclerosis, it is remarkable to think that he lived as long as he did.
Let us image that someone like Patrick is forced to interact with the Health Service in 2016 and let us consider what his experience would be. For the purposes of this paper let us assume that Patrick is 79 and has become increasingly unwell over recent weeks, especially over the last week. He is ultimately seen by his General Practitioner who feels that he requires hospital admission. She feels that he is sufficiently ill to warrant ambulance transport to hospital and arranges this. Given the pressures on the health service generally, he may well not receive an appointment with his GP on the day of request and is likely to have had to wait for an ambulance as it is likely that the National Ambulance Service will be responding to higher priority calls and struggling to meet time targets for its emergency response. On arrival at the Emergency Department (ED) it is likely that there are a number of ambulances seeking to off load their patients. As the ED is full of admitted inpatients, a free space is not forthcoming and therefore Patrick will join a queue of patients on ambulance trolleys awaiting a space.
Eventually Patrick gets a space in which he can have the belated medical assessment and receive the treatment he should have had earlier. A decision is made that he requires hospital admission. However, he languishes for 20 hours on a trolley before a hospital bed becomes available. As an inpatient he has a multitude of tests and is found to have an end-stage medical condition from which recovery is not possible. Patrick has a prolonged hospital stay before it is clear his recovery is not sufficient that he can return home and it is felt he needs transfer to a nursing home. The Fair Deal process is undertaken and Patrick remains as a delayed discharge in the hospital for a prolonged period of time before being finally transferred to the Nursing Home. Unfortunately, he sustains two unwitnessed falls while in the Nursing Home and is transferred by emergency ambulance to the local ED where he is seen, has x-rays and a decision is made that there is no fracture or injury that requires intervention. On a third occasion, he is acutely confused as a result of sepsis and is transferred by emergency ambulance to the ED and is readmitted to hospital after another extended stay in the ED. Patrick’s underlying medical condition further deteriorates and he is transferred back to the Nursing Home after a decision is made that he is not for resuscitation should he experience a cardiac arrest. In spite of the expectation that he is returning to the Nursing Home in anticipation of his imminent death, he inevitably becomes more unwell and for fear of him dying in the Nursing Home resulting in a HIQA investigation, he is transferred to the ED in a 999 ambulance. An experienced senior nurse in the ED recognises that Patrick is dying and as there is no hospital bed available manages to create space in the quietest corner of the ED by moving other patients on trolleys on to corridors and into other non-clinical areas to allow him die with a modicum of dignity. Some of Patrick’s family manage to make it to the ED before Patrick finally passes away. RIP.
Sadly this is the experience of many of our elderly and infirm relatives and can only be described as both inhuman and dysfunctional. Not alone does the dysfunctionality have a human cost it also has a significant economic cost with each of the delays, the missed treatment opportunities, the additional burden on the ambulance service, the inferior outcomes, the poorer quality of life and the missed opportunities for other patients to be treated adding significant costs to a health service that can ill afford not to spend its money more effectively and more wisely.
According to the CSO, using a newer methodology for costing, Ireland spent 10.2% of its GDP on health in 2013 – this suggests that Ireland had the second highest health spend in the OECD. We can dispute the figures but what is certainly true is that we have a costly health system and we do not get the outcomes that other countries spending similar amounts expect and achieve. Not alone is our health service dysfunctional therefore, it is also expensive in OECD terms.
So why is this?
Lack of a Shared Vision
Fundamentally there is lack of a shared vision as to how healthcare should be delivered for the Irish population. As Irish political footballs go, healthcare is undoubtedly the worst example with a long history of either bad decision making (very often overtly political) or, more typically, no decision-making at all. One could expect a degree of strategic direction from a country’s Department of Health, although in Ireland this direction is difficult to find. If the ministerial briefing notes offered to the new Minister are a marker of strategic direction, it is obvious that there is a deficit.
Failure to Plan
In spite of the great increase in the number of elderly and very elderly patients in the population, particularly those living with multiple complex medical conditions which would have killed them in the past, there is little evidence of systematic service planning to meet the needs of this important group of patients who tend to be disproportionate users of the health service.
Even the most casual observer will also have been aware that Ireland had a shortage of both acute hospital and community beds prior to the recession. To have almost 2,000 beds removed from the system during the period of austerity with only a few hundred returned in the past year at a time that demand for healthcare was increasing so much has only served to worsen this very serious capacity shortage. The unwillingness to face up to the extent of the capacity problem by both the HSE and the Department of Health has merely allowed this situation get worse and none of the necessary investment required to bring the infrastructure of the Irish Health system even up to late 20th century levels has taken place.
A chronic lack of consistent accurate information to inform service development also means that any plans that are developed are not infrequently based on a false or misleading premise.
Culture of Denial
The general culture of denial is obvious throughout. Whether one takes the example of the recent comments of the Secretary General of the Department of Public Expenditure and Reform that there is no recruitment crisis in Health Service when this is so glaringly obvious or the years of playing down the extent of the ED trolley crisis by either changing the way figures are calculated or using spurious comparisons to suggest that the problem is improving, denial is ever present. It is axiomatic that the first step in resolving any problem is to accept that there is a problem and understand the true extent of it. This capacity for denial has certainly disillusioned many in the health service that are enthusiastic about service improvement.
Local Politics and Politicians
Undoubtedly the most corrosive contributor to a lack of a shared vision is local politics. For many local politicians the local hospital is seen primarily a source of employment (and therefore votes) but also is seen as providing local kudos. Very little thought is given as to how healthcare should be delivered at a system level and no local politician irrespective of whether in government or in opposition can be seen to be “soft” on the local hospital issue. Furthermore the multi-seat nature of Irish constituencies means that there is intense competition to be seen to be the greatest ‘supporter’ of the local hospital even when medical evidence suggests that an alternative configuration of healthcare delivery would be better. The short political cycle and a focus on an always imminent election mean that strategic planning is eschewed in favour of naked short-termism. Threats or perceived threats to services provided in the local hospital have the potential to spawn single issue hospital candidates as well as huge flurries of activity on local radio and in the print media. Many of these debates are characterised by very little discussion about the issue at hand (e.g. the recent furore about 9 hospitals no longer receiving major trauma victims even though these represent less than 1% of an ED’s workload), instead the focus is on the potential risks to services and various “slippery slope” arguments.
Failure of Implementation
Although the Irish healthcare system has not been good at strategic thinking, it has a number of strategies which are as good as any that exist in other developed countries. Even where good national strategies exist (Primary Care Strategy; Vision for Change etc) or, in my own area, the national Emergency Medicine Programme Report (2012), these reports rapidly become shelf ware with very little coherent attempt at implementation. Rather than implement excellent strategies that have often been the product of genuine multidisciplinary collaborative working, the Irish healthcare system seems to be hardwired to repeat errors made in other countries even where there is incontrovertible evidence these interventions simply don’t work. For example, the NHS has spent huge sums of money investing in multiple alternatives (including Polyclinics, walk-in centres, NHS Direct Helplines etc.) to care provided at EDs only to discover that these are more costly; don’t have any impact on the ever-rising numbers attending EDs and of themselves generate new work which in turn brings even greater costs.
Following ‘False Gods’
In recent years, the health system has followed a variety of “False Gods”. Examples include the assumption that much of what happens in hospital can simply be moved into primary care; the majority of problems within the hospital system can simply be addressed by improving flow and the notion that creating additional “doors” into the hospital can in some way improve capacity. The overlap between the volume of acute care that can be provided in primary care and that that can be provided in hospitals is much smaller than many believe. Undoubtedly, a significant amount of chronic disease care currently provided on an outpatient basis in hospitals could be more appropriately delivered in primary care. However, this is much less the case for acute or emergency care. Although investment in primary care is, of itself, a good thing and will benefit patients, it will not address the current capacity constraints in the hospital or system or in community services, and certainly will have no significant impact on those languishing on hospital trolleys. The preventative element of primary care, although important, is very poorly developed however and were it to be developed its impact would unfortunately not be felt for many years.
Flow improvement into, through and out of the hospital is clearly important but optimising this will only marginally improve the situation rather than address what is essentially an absolute rather than relative capacity problem i.e the problem is primarily due to a shortage of beds rather than an issue of how these beds are utilised. The current vogue for creating additional pathways of admission into the hospital e.g. by use of Medical Assessment Units, Surgical Assessment Units, Paediatric Assessment Units etc. misses the fundamental point that changing the number of doors into a building has no impact on the internal capacity within the building i.e. if there are 300 hospital beds and 330 acute admissions then putting additional routes into the hospital is not going to address this capacity deficit.
While all of us strongly support the good intentions of HIQA in ensuring that those in long-term residential care have facilities that meet the appropriate standard for 2016 and ensuring that care provided in Nursing Homes properly meets society’s obligations to its citizens, the unintended consequences of this focus has been to reduce significantly the number of long-term care beds which in turn has impacts upstream throughout the acute hospital system resulting in longer ED trolley waits and longer waits for long-term care in hospitals. Longer trolley waits of themselves increase the chance that an older patient will not be able to return to an independent existence, causing perpetuation of the vicious cycle. A strategic plan to create additional capacity in this sector should have been implemented once the impact of HIQA’s actions became apparent but, as we all know to our cost, this did not happen.
Fears of the wrath of HIQA have certainly encouraged proprietors and staff working in Nursing Homes to send patients to our EDs far too frequently and often entirely inappropriately, even when a patient is expected to die of their underlying medical condition and hospital care has nothing to offer such patients. This has frequently resulted in moribund patients being transferred inappropriately by ambulance to an ED for them to die in hospital rather than in the place that they currently call their home.
Toxic Relationships and a Lack of Trust
When the HSE came in to existence in January 2005, it used as its tag line Easy Access, Public Confidence, Staff Pride but, by common consent, has not been successful in achieving any of these aspirations. While its access issues have been well described, there is a very serious staff morale problem within the service which has resulted in increasingly adversarial interactions between staff groups and their employer which has often seen issues which would be resolved in other healthcare systems in the normal management-employee paradigm ending up as intractable industrial relations issues in what from a medical perspective are entirely inappropriate fora. The ED nurses’ industrial dispute is but one of many examples of this and reflected the belief amongst ED nurses and their representatives that there was no other way to have concerns about ED crowding and staff shortages addressed. Not alone is there very little trust within the Healthcare System of the management line on any issue, very little of the HSE’s public pronouncements are trusted even where these are medically appropriate, altruistic and accurate.
One can only hope that the Minister’s attempt to get broad consensus on what kind of health service we want and need over the next 10 years will bear fruit. However, the concern has to be that many of the problems that are there for all to see and that have negatively impacted on how we have managed and delivered healthcare hitherto will not be addressed and may fatally undermine even this good intention.