Why trolley crisis is a big success story

By Niall Hunter

Congratulations Leo Varadkar (wherever you are). The latest figures show you are overseeing an efficient public health system.

Most rational people would feel it is stating the obvious to say that record ED trolley figures and spiralling waiting list numbers are not a good thing.

This is undoubtedly true, if you are rational person.

But having 600 people on trolleys, 60,000 people on treatment waiting lists and 377,000 waiting for an outpatient appointment is, according to the skewed principles underpinning the running of our health service, a big success story.

Preventing patients from easily accessing public hospital services is the central article of faith that has underlined our health system for decades.

Our health service is run on a complex system that controls, filters and delays access to care, however much it is needed, based on financial, bureaucratic, political or vested interest considerations.

Preventing people from getting treated in a timely manner is what our public health service is all about. This helps meet HSE targets, to some extent balances the books, can help boost the coffers of private medicine, and allows administrators and health planners to bury their heads in the sand when they hear about an explosion in chronic disease and an increase in elderly patient numbers.

Certainly, controlling access to care also prevents breakdown of a service under unbearable strain.

Optimising quality patient care? Safety? Lip service about that sort of thing ceased in private in the upper echelons of the Department of Health and HSE around the time the Troika hit town in late 2010 and has continued to be absent even since the Troika left in late 2013. In fact, the health executive has now more or less come clean and admitted that our broken down health service isn't very safe.

But don't worry, there will undoubtedly be a solution produced to ease the current crisis. Problem is, it's unlikely to be a very good one.

When the system is overloaded and people get angry about it, we generally get some cobbled together temporary medicine borne not only of political expediency, but also of an apparent lack of willingness of the various interest groups to work effectively together to formulate long-term improvements. How many more working groups, taskforces and delivery units do we need?

We are dealing with something much less personal or humane than a health service, we are dealing with a health system, a term which nearly always has negative connotations.

And such systems are almost always built to fail, if you are a patient or harassed front-line worker.

But in a sense, many of these failures, eg very sick people getting sicker or even dying on trolleys and waiting lists, are in fact successes, if you subscribe to the religious cult-like tenets that underpin bureaucracy, policy-making and funding control in the service.

We have a system, rather than the individuals working hard within it, that ultimately puts the patient second. It cares more about balancing books, meeting targets, industrial relations point-scoring, and when some pesky atrocity occurs, applying an expedient ‘solution' that reads well for a while in the media and then turns to dust.

By the way, can we ask James Reilly for our money back? He spent well over €2 million on experts alone as part of the tens of millions forked out between 2011 and last year to resolve for once and for all the perennial waiting list and ED crises.

But in their heart of hearts, James Reilly, Leo Varadkar and the rest of the Government probably know that in the absence of root and branch reform of the service (which should have been completed a decade ago but nobody has had the guts to undertake) and proper investment in the right places, nothing will change.

So in a few weeks or months time, as the depressing headlines and dire safety warnings recede temporarily in public memory, we will continue to wait for news of proper targeted investment and real reform in the health service.

Unfortunately, neither investment nor reform is likely to take place in the short, medium or long term. This is because the Government isn't willing to invest adequate resources in the service and the political or industrial relations will doesn't exist for real reform.

You don't have to consult the usual health economists or expensive experts to outline what needs to be done. Any average person in the street would practically know it all off by heart. It's like reciting the Apostles Creed of dysfunctional Irish healthcare.

So what do we need and will we ever get it?

We need more investment in community residential care and home care so that elderly and infirm people, once their acute care in hospital has ended, can be effectively managed elsewhere and they don't have to stay in a hospital bed needed by other acutely ill patients. Unfortunately, the type of investment necessary, and which has been greatly curtailed in recent years, isn't going to materialise in the short or medium term.

We need a properly structured primary care system, where GPs and their teams can effectively treat patients with long-term heart, lung and other conditions so that these patients don't regularly end up in EDs suffering on trolleys. Unfortunately, there is no immediate prospect of this happening due to an unwillingness to invest extra funds, or to transfer jealously-guarded funding from the hospital sector to primary care.

We were supposed to have been given a proper primary care system designed to take pressure off hospitals in the early noughties, but pretty much nothing has happened since, and the consequences of this foot-dragging will be dire.

Dr Joe Clarke, head of the primary care division of the HSE, told a recent diabetes conference that unless primary care is adequately resourced to take on more of the burden currently being carried by hospitals, the health service will become overwhelmed.

We need many more hospital beds to be opened and staffing in ‘bottleneck' hospital centres increased to cope with current demands. Again, funding restrictions and recruitment embargoes may put paid to this notion.

Better teamwork needs to be employed and more efficient patient management systems agreed, between the key staff groups in hospitals.

Of course, there is only so much you can achieve with better systems if demand exceeds bed and staff supply. However, the efficiency of these systems and the level of teamwork tends to vary between hospitals. Some hospitals with large elderly catchment populations have relatively low trolley numbers, while others elsewhere traditionally have high numbers. There must be some explanation for this.

Recent research at TCD among health administrators showed that a key block to change within the health system was what is euphemistically termed ‘cultural issues'. In other words, demarcation disputes and difficulties in getting groups of staff to agree to act effectively together to do what needs to be done. In this survey, one senior official said : "I'm the CEO but I still have no authority to tell any doctor what to do".

Minister Varadkar needs to move beyond simply agreeing with everyone that the health service is terrible (mind you he seems to have become quite popular as a result - go figure), and start acting like a proper health minister.

Eventually, he will have to come up with solutions in terms of both reform and funding.

Unfortunately, many of those reforms may take years to implement, even if the political will to implement them should magically appear.

Also, it still appears to be Government policy to sacrifice the need for adequate health service funding on the altar of more tax cuts, and safety on the altar of box-ticking and bean-counting.

But this should hardly be surprising, as most attempts to make make our health service better and safer are usually sacrificed to political expediency.

Concern over ED overcrowding continues


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