The health service

We just had an encounter with the Irish A&E process for an elderly relative.

I’ve seen many operations management problems in many environments. The comment I would make is that the Irish health service is a broken failing process. There are undoubtedly many great people trying their best within the system, but the system doesn’t work and is broken. Building a healthcare system that works is not an inordinately difficult problem, either as a public or a private process.

Clearly there are also a bunch of people in the system, lifting money out of it as the failing system comes into contact with ‘for profit’ agents who know how to pick pockets of a failing system. Further the Irish ‘insurance system’ which was designed to give privileged access to public assets for ‘middle class’ ireland has morphed into a ‘system’ for a group of health care professional’s to lift half a million a year out of the state sponsored ‘insurance’ system.

The result is quite shocking. Irish healthcare is veering dangerously toward complete breakdown. Many older geriatric patients are clearly endangered by the system.

Given the intellectual calibre of the typical Irish educated hospital consultant, and the relative incompetence of the health management, I can only lay the blame fairly and squarely on the hospital consultants, for being too financially greedy to bother to sit down and engage their formidable intelligences to build and produce a safe efficient system.

Net, net the result is - don’t ever get sick in Ireland. The system is broken, it won’t be fixed, and it is going to get worse, a lot worse.

A quick review would lead to a guess that there is €5bn of wasted spend per annum in the system. But the shocking thing is that - you still can’t pick up the litter from in front of the main door of one the the ‘goldstandard’ regional hospitals. Shame on the senior medical professionals who won’t take responsibility and leadership.

I agree the health system here is farcically dreadful - it brings it home to you when you encounter health systems in countries that are either significantly poorer than Ireland or in equally dire financial circumstances which work perfectly adequately - and their citizens expect nothing less.

However, I am puzzled why you think it is the medical consultants that should design a new system (and also pick up the rubbish? - couldn’t quite work that part out?). The system can only be changed by government, as it was designed (or at least developed incrementally - I wouldn’t dignify it with the word ‘design’) under their watch and it is they who pay for it. Consultants are the major financial beneficiaries of the messiness and inequality inherent in the system and human nature is such that people respond to incentives and, in particular, tend not to proactively work against their own interests.

Plus, the fact that hospital consultants are good doctors (or should be at least) doesn;t make them good systems analysts or managers. I have been struck by the one dimensional quality of the intelligence of the doctors that I know - they are clearly superb at what they do but curiously naive in terms of their understanding and analysis of wider social, economic, business etc issues. (Apologies in advance to TI … anecdotal evidence from a small sample and all that …)

How on earth do you think your A&E experience is all the fault of Consultants?

There are undoubtedly problems with A&E but few of them, if any, have a damn thing to do with consultants. My sister is currently working nights (9PM to 10AM) in a large Dublin A&E, an SHO - not an (evil) Consultant - so I have some good knowledge of the area, and the first problem is ease of access: it’s too easy for people who don’t need to be in A&E to get in, meaning its excessively difficult for people who do need] to be there to get in. And one of the serious issues causing that are the GP’s. The GP’s are a far bigger problem than the (evil) Consultants (many of them higher paid too) but the headline driven, Joe-Duffy-led Irish public rarely give a dirty look to the shambles that is is the modern GP service. Anybody with a brain can see that GP’s have effectively disappeared from the out of hours and home-visit care giving world… which has had a massive impact on A&E’s across the country, over loading them with cases which should not be near a hospital. An anecdotal example from my sister would be a lady in her fifties who waited in A&E for thee hours with shoulder pain from a rotator-cuff injury, she rang her GP who told her to head in to A&E (probably because he was sick of listening to her) - now a rotator cuff injury is painful and irritating (I have one myself) but it shouldn’t get close to A&E and it shouldn’t have taken a second of a Doctor’s time, not to mind the half hour (at least, when the excessive admin issues are dealt with) that it did take. There are tens of these cases hitting every A&E, every single day, and all of them slow down the care that people like your elderly relative should be getting.

The Consultant issue is a red herring, it’s complete nonsense and only distracts from some very real, but solvable, problems.

Would privatising the entire A&E system help? I have used the VHI clinics and they work very efficiently - doctors running around! Is the logjam causes by bed availability and how do you manage that?

Education on misuse of A&E system and penalise by way of fee of €300 any visit to A&E arising from drink/drugs/

GP’s in medical card system must be made sign up to service level agreements aimed at achieving minimum daily hours and out of hours coverage

Resources - need to direct appropriately but may mean making choices around expensive drugs where no real clinical benefit - life extension by matter of months _ this is emotive. Should people get IVF at no cost?

The primary problem with the Irish (and UK and US) health systems (not just A&E) are the lifestyle diet and excercise habits of the citizenry.


We suffer quadruple the amount of heart attacks per capita as France.
Their much admired health system isn’t necessarily more efficient than ours, it’s just not swamped with Irish levels of sickness !

Is it a simple matter of advertising what A&E is actually for to cut the number of people attending without needing to? Obviously booze contributes a big number of patients but I guess in those cases there are real injuries and emergencies but surely the trivial stuff could be reduced by clear advertising and triage.

Charge them instead of seeing them for free. People don’t value services they don’t pay for.

The other side of that coin is that a few very sick people may not use services they need if they have to pay for them. It’s a trade-off. On balance, I would favour a fee.

Agree with so much of what’s been said.

I think everybody who goes into A&E should be, at the discretion of a nurse/doctor, subject to a breathalyser and if over a certain limit the standard A&E charge should rise to €300.

If you spend a few Fridays/Saturdays in an A&E you will not believe how many attendees are drink related. It’s borderline obscene.

Perhaps we need an ideology tax at the point of purchase.

As Ardillaun says, one outcome of charging (again as people have already ‘paid’ though taxation) is that people will avoid seeking treatment they don’t think they can afford. That’s common in the US and so A&Es are confronted with people with very advanced disease who only who only show up when things are catastrophic, piling on costs for treating what may have been minor complaints earlier. Price is not necessarily the most efficient method of allocating resources, if it were there would be no propertypin.

LOOOONNNNG time lurker (having patiently been waiting to buy a house for the last 5 year blahblahblah ) with a few posts. The amount of problems with the health system might fill up a whole new website and my personal experience and first hand knowledge compelled me to reply.

problem list - in no order of blame as there is a system wide malmanagement

**Consultants **

That is very true as a lot of the public resources eg facilities, theatre time, beds are occupied by private patients - this is mainly because hospitals are reimbursed by insurance companies for these services and it thus serves as an extra income. But the single INDIVIDUAL whose pocket benefits most is the consultant’s -as they don’t need to buy expensive equipment for their offices - they just use the public hospitals’ etc and receive a fee. No expenses just income. Public consultants should be compelled to give up their private practices or their private practices should be completely separate from the public hospitals eg separate offices, operate and investigate in private hospitals. But the state benefit from the fact that private individuals are managed in public hospitals - thus this would not change. It is all about money in the end isn’t it??

**General Practitioners **

The amount of practical hands on education that GP’s in Ireland receive during training is astounding. After medical school all medical students do an intern year - mostly spend doing long hours on the ward doing paper work, bloods etc. GP’s then go onto the GP training scheme where they receive 2 years of hands on training in ± 4 disciplines of medicine and then they spent 2 years in a GP practice being further educated by there MOSTLY incompetent superiors. No wonder GP’s cannot handle the most basic of emergencies themselves. I will however concur that their hands are mostly tied by an overcrowded system since they don’t have access to immediate investigations such as x-rays, immediate blood results etc and usually need to wait months/ years for a patient to be seen after a referral. Thus the easiest way is just to sent a patient into A&E for an x-ray, blood test or specialist opinion. AND patients with a GP letter usually don’t need to pay the A&E fee - what convenient way to wash your hands.

**Patients ** The sense of entitlement is astounding!!! Does the fact that you pay taxes really allow you to demand care for things like varicose veins, bunions, etc and should this and so many other treatments be free?? What about just free care for trauma and cancer?? and rather lower taxes?? Most people attending A&E does not need to pay the fee since they are MEDICAL CARD HOLDERS. And if your GP is in anyway going to sent you into A&E why not just come directly and save yourself the extra trip for your sore throat or alcohol detox tablets. METHADONE - don’t even get me started !! The abuse of AMBULANCE services by drunk and drug intoxicated people but the patient with the heart attack arrives by taxi!!! FAMILIES refusing to care of their elderly parents or just dumping them for a bit of a break - clogging up beds for MONTHS.

Okay I think I should stop - can continue the whole night but this is now turning into a rant.

Having worked in a few medical systems around the world - I have nowhere seen a system being so much abused on so many levels but there are very decent and hard working front-line personnel for which it is not about the money but rather patient care - them I salute!!! THANK YOU for staying sane

I have a theory that even if they could see you quicker that people are kept waiting in a and e as a disincentive to coming back

I don’t think a charge would have to be particularly high to discourage timewasters - it does, though, need to apply to everyone.

Isn’t there already an A&E charge? Pretty sure I paid one the last time I was in A&E, or at least my Dad did. But I could be wrong as I was there for a head injury and my memory of the situation is mostly second hand.

On the health service, they REALLY need to invest more in pre-screening, or at least dropping the waiting lists. Two years ago I got referred by the GP for screen for something. In and paid the consultant and got offered the test in 4 days privately, or I could go on the waiting list for at least 4-6 months. What annoyed me was that if I had the disease and waited the 6 months, the survival rate would have nearly halved and the cost for the medical treatment would have gone up by many multiples. Given that treatment is covered by the state in either case, it makes no sense even just financially for the waiting lists to be so long.

The charge to attend a and e is 100 big ones my friend. I know because I was recently refused entry to Warerford Regional Hospital unless I paid it. I scratched my retina and was literally rolling on the floor in agony so I wrote a cheque. The eye injury was the most painful thing I have ever experienced including giving birth without the aid of drugs. By the way once I got in the door my treatment in WRH was top notch. I was seen within two minutes of writing the cheque,

I know that in the kids hospital in Crumlin there are signs up saying that nobody is refused treatment if they don’t have money on them & that Finance will bill you later.

Finance are efficient at billing too- after a recent Saturday night visit the postman dropped the bill thru the door on the following Tuesday.

I don’t think advertising will work - the people that are needlessly clogging up A and E don’t care that they are doing so and don’t have anywhere else to go - and many of them won’t pay the fines if they are charged retrospectively (and you can hardly charge them there and then).

What would help as others have said is a primary care system that is available outside Mon - Fri office hours. The region I lived in in Spain had primary care centres which had GPs, nurses, paediatricians, physios, various mental health professionals etc all in one centre. Every resident was assigned to one centre and at night and weekends, one out of four centres was open for emergencies (i.e. cases that could not wait until Monday morning but were not serious enough to require hospital A & E treatment. Seemed to work very well - anytime I used the primary care centre outside hours it was busy but running efficiently and the two times I had cause to use a public A & E, it was deserted. I guess the fact that there was much less of a binge drinking culture also contributed.

Front line staff can be very hard working, very noble, and very good intentioned: but it still doesn’t mean that the system and those people cannot be criticised. As GermanFred alluded to, the operational aspects of A&E (or at least the Mater, which I have been through) are terrible, and serve to create work and overhead for the staff there and to worsen outcomes for the patients. (I’m going to rant… get the juices going for the day)

It’s really like the story of the man in the woods cutting trees with a blunt axe. He says he can’t take time to sharpen the axe as he’s too busy cutting wood.

A&E story: close relative (young man) ended up in A&E with a bang on the head during the most recent icy winter. Also hurt arm (put in sling) scuffed knees etc., Had taken a few drinks (was St. Stephen’s night), but main self-inflicted aspect of injury was he had leather soled shoes. Was clearly concussed (after phoning me to tell me what happened, he then phoned me again 30 mins later to tell me what happened, and when I arrived into hospital he was “how did you get here?”). When I went down to A&E, whole place is in chaos, as usual. After several hours he’s discharged. Had a symptom of feeling his ear blocked (which he had that night) but had not asked whether he could fly with that (was due to go to NY). Went up to VHI Swift Care next day to pay the money to get an answer. Doctor there looks in his hear, says “did you just walk out of the hospital?”, “no, I was discharged”, “did they XRay/CT your skull, you’ve bleeding in your ear, you might have a Basal Skull Fracture, that could kill you”. “No, they mostly looked at my arm” (because the arm in sling was the most obvious injury, though not at all serious, and they seemed not to have looked further).

She phones hospital, makes lots of dark sounds “I’m sure you understand how serious this is, this patient should never have been discharged, it’s vital he get reexamined quickly” etc., Gets us name of a doctor there, and we head back to A&E. Back in A&E, we then get sort of “readmitted” but without paperwork (because we have the name of the doctor and he’s been briefed somewhat). Once we were on the “inside” of the glass doors, I didn’t want to get out for fear of ending up right at back of entire queue trying to explain to admin at front desk about basal skull fractures. Met the doctor the VHI doc had spoken to, he went away. Then, nothing happened for ages and nothing was communicated. That’s maybe OK, but my persistent fear was that this doc would finish shift, and we’d be sort of stranded in no man’s land. I watched my watch, once per hour I nabbed the doc on his way through the corridor to ask him status or what next step was going to be (mostly not to be forgotten). On the last of these interactions, he snapped at me “look around you, see all the sick people, he is not my top priority”. I genuinely wondered at that instant whether I was being provoked to get a reaction that would get me thrown out. I very calmly responded that he was my priority so I had to ask the question, and we wouldn’t be here if he’d been fully examined 2 nights ago. I don’t remember what was said immediately after that. However, about 15 mins later the doc came back with a post-it with the name of the doctor from the previous night “you might want to have that” and a calmer attitude.

Finally he did get a CT, bone was cracked but it wasn’t serious, he could travel. I never saw a doctor look in his ear, and by the time we were getting discharged the shift had changed so yet another doctor was dealing with him, and the first interaction we had was the discharge. I asked him for the details on the investigation and diagnosis/situation. Also asked him had anyone looked into the ear. He said he couldn’t see it on the charts but someone must have done so. I asked him if he was sure he was happy to sign the discharge without having evidence it was done. He at least went through the motions and did it.

There are tonnes of things wrong with that system, both efficiency and effectiveness driven. It showed up clearly again in the aftermath because the CT picked up another small thing to get checked. The appointment to see the neurologist took so long to get (3 or 6 months, mad) that the CT was no longer valid (standard time-frame expiry, whatever it was, months in any case) so the first thing he did was schedule another CT (cue further wait, wasted time for patient, radiographer, radiologist, etc.,).

There’s a whole collection of problems in the system

  • Poor handling of information (between staff, across time)
  • Lack of standard procedures and checklists
  • Poor communication to patients
  • No streamlining of process (a quickly investigated and discharged patient frees physical space in the hospital, and mental space for the medics who can then file and forget, and not have the likes of me nagging them once per hour for half their shift)
  • etc.,
    For many of these, it comes down to doctors to make the changes. No administrator can provide the medic with a checklist for examining a head injury. At the same time, the medics need to be able to take on board innovations and ideas from operations specialists, as the training a hospital consultant gets is clearly not the kind of training that lends itself to large scale systems thinking. The culture seems to me to be one of work harder and harder, but not necessarily question the systems.

Some places have a great primary care out of hours system - Caredoc does out of hours GP care for south Leinster and Tipperary, there’s something similar in Co Clare (at least there was 8 years ago as I remember a friend using it on a surfing trip down there), DubDoc is an out of hours GP service that works out of James’s Hospital, and DDoc in North Dublin is fantastic. This is a very large swathe of the population covered, and there are probably other services covering different areas that I don’t know abut.

I had a very sick relative being cared for at home earlier this year (was bedbound, terminally ill and didn’t want to be anywhere near an A+E - quite understandably). I found was a hell of a lot easier to get medical help out of hours - given the patient’s condition DDoc were happy to send someone if necessary and usually arrived within an hour or so, and they were very good. They also gave useful advice over the phone a couple of times as well. If you wanted a GP house call it had to be arranged a day in advance, which is not that useful for emergencies. The local GP wouldn’t even come out to confirm the death in the end so that the body could be removed to the funeral home - ended up waiting 3 hours till 6pm and calling DDoc to do it. Including that visit we used DDoc 3 times in about 3 weeks, I think.

For most cases they don’t do house calls that way, you travel to their centre if you can. They do a phone triage first with a nurse and they will send you to A+E if they think it could be something imminently life threatening.

Not everyone is aware of these services, unfortunately, so I suspect a lot of people probably do go into A+E when a call to one of these would suffice.

This is always the challenge. The person needing “x, y, z done NOW” is real, but so are the patients who will present tomorrow and next week and year. Total outcome will depend both on the immediate response, and the long-term learning.

A&E is the most extreme case, but I know of a friend who’s a consultant (I’ve posted the story elsewhere on Pin) and there are similiar contradictions and insanity in that specialism/hospital-dept. (handling of waiting lists, no standardisation between consultants on technique, etc.,).

It’s not only the responsibility of consultants. However, they have a major leadership role, are connected to the operations side of the house, and are generally reasonably intellectually able. They definitely have an opportunity to help fix the system; and they certainly have the capability to stymie any attempted fix that they don’t like.

And I do agree, that ultimately what would fix the system best would be a tough cadre of hard nosed and intelligent managers to break down a lot of the sclerotic accumulations and reinvent things. It’s just a question of where they will come from.