The health service


#21

The Irish Health Service gosh where to begin?

VI Declaration: I am a consultant in 2 of Dublins largest hospitals. I trained and worked in the NHS for 10 years before joining the Irish Healthcare system in 2003. I’ve been a consultant for 4 years.

@Germanfred sorry to hear about your experience. @Txirimiri thanks for the hat tip, I’m sure present company was excepted, but broadly I agree.

By way of defense of me and my coligues when choosing a carear in medicine the barriers to entry are high. You have to be motivated and very committed. it starts at school. you are interested in science and caring for patients I began like may others volunteering in hospitals and working for the St John ambulance. Once you get to med School the focus is all on pure learning Anatomy, Physiology, Chemistry Biology etc before moving on to the practical arts of the Practice of medicine. The next 10-15 years are very long hours and per hour very little pay. my first year the pay structure was full pay for the first 40 hours, half pay for the next 32 hours and then nothing after that. Ie you wer paid for the first 72 hours. Our average hours were 90 pw the longest week I worked was 128 hours which included a 56 hour shift. The gross pay worked out at about £1.20 per hour. Once you get on to the higher specialist training it is all about your speciality and you and your family make sacrifices to pursue that training often moving over seas. By the end of it you are a very well trained doctor in your specialist area focussed on clinical excellence, most of us tag on a management course to tick the box prior to the consultant interview but by that stage almost none of us have any experience of or interest in management.

@Txirimiri by the end of this its not surprising many of us my self included (Pin you saved my life and a fortune) are a bit one dimensional.

The best roll for a consultant is; adequately resource them and point them at the patient. Most of us would be happy to full fill that roll to the full. But we work within one of the most obstructive, unionised institutions where no one can be sacked for anything.

For avoidance of doubt I have zero sympathy for anyone who doesn’t discharge their contract in full. For the record I dont admit any private patients to public hospitals.

The consultant contract requires 37 hours of programmed monitor-able audit-able work + on call. After I’ve discharged my contract I still have some free time (remember I’ve never been required to work so few hours in a week) so I do some private work after my public commitments.

I have a very good example of the public vs private system.

I work with Surgeon A doing cases B in the public hospital one after noon each week. We rarely are able to do more than 3 cases per week together in the time available in the public hospital and cases are often canceled at short notice. There are days when I go in and my whole list has been canceled no one has informed me and there is nothing for me to do but drink coffe and as a certain song goes “chat up the nurses and be generally subversive”.

I work with the same Surgeon A doing the same cases B in a private hospital. We regularly do 12-16 cases in the same time that we manage to do 3 in the public.

Why?

Its the whole f@*king system top to bottom. No accountability at any point and no incentive to do any better. Tiny examples as to why: in the public, only the porters are allowed to move the patient from the bed to the table and table to bed at the start and end on an operation. If we muck in because they are late, delayed elsewhere etc it becomes a union issue. One day I changed the 13 amp fuse on a plug because we needed the machine to start a case, it nearly resulted in a hospital wide strike by the electrical engineers. If the list finishes early the nurses get re-deployed to the wards which they hate therefore the list always expands to fill the time available regardless of the workload. Consultants are forced into management to sort out and improve shit like this because we want to work but its a mess and we hate it, its not what we are trained to do and its sole destroying.

In the private hospital, people get sacked, time is money, if the porter isn’t there even the radiologist mucks in and moves the patient of the bed. If we are quick and efficient we get to go home early. If the list is canceled we all either dont come in or get to go home and dont get paid.

It would be nice to scrap the whole public service and start again.

The health service is like an old plane fixing it and changing things is like trying to repair it while it flies along.

A&E is a mess. The biggest problem is work load. It’s used as a GP service. This is intolerable and no amount of tinkering will fix it. There should be better out of hours service and personally I think all GP care should be free. This would overnight fix the A&E problem.

When you become a consultant you see lots of small changes that would improve the service. I identified a minor change that would save our hospital 60K pa in its drug budget. When implemented it would have actually reduced infection risks for the patient and slightly improved care and make zero difference to everyone else’s practice. No brainer right?

It took me 2 years to implement this minor change, I had to talk to he head of every feckin imaginable department and it felt like wading uphill through treacle. The change made no difference to me personally so the resistance to change was truly unbelievable. Another very minor change in our departments practice bringing us unto date with what many other hospitals were doing 20 years ago caused unbelievable resistance from the nurses that resulted in us doing weekly and in my opinion completely unnecessary training courses for 8 weeks a waste of everyones time.

When you think what it would take to actually implement a major practice change the mind boggles! I’m worn down by it already, why bother. I’d just prefer to get on with what I’m good at .

Please dont think I’m blaming Nurses or Porters for the problems thats not the case its at every level in the organisation including my own and some of my erstwhile collages give the rest a bad name.

But…

Its not so bad, every day people are treated people get sick and get well 70% or more of it works very well. From my management coures I recall our spend vs health benefits or activity or something is not bad when compared internationally (perhaps some of the chartists can help support or refute that)

Its customary to end these rants with something positive or a suggestion on how to over night improve the system so Ill not do a Morgan Kelly and leave you with the suicide icon so here goes TI’s quick fix heath service:

  1. Make GP care Free to all would instantly ease pressure on A&E
  2. Make 24hr GP access mandatory every where in the state by way of GP CO-operatives again would help A&E
  3. Allow staff to benefit from improved efficiencies otherwise who cares what it costs or how quick you get your work done. (let them go home early or spend the saving in their own department)
  4. Dont deploy consultants in managerial postions they are clinicians through and through and crap at management in most cases
  5. Allow people to get sacked from the public service
  6. Come down like a ton of brick on consultants not discharging their full public contract (IMHO this would be a handful)
  7. Sick with one health care system ie full National health system or fully private. The bastard version gets the worst of both

edit changed a do to dont


#22

Top post TI.


#23

Two things I’ve noticed in France that could ease some of the strain in Ireland:

  1. Availability of testing centres - they’re all over the place. If I need blood work done, I can have it within a day in a large city; perhaps take two days in a smaller town.
  2. Availability of machinery - “clinics” of GPs (normally 3+ sharing a premises) generally have their own small xray/echograpy machines. If I present with a damaged wrist, they’ll check me out first and only send me to A&E if necessary. For non-urgent cases, you can book an xray or echo at a clinic that specializes in these.

#24

thanks TI

un-fuppin-believable


#25

as good a post I have seen on the Public Service in a long time. Good to get an insiders view to tell the real story
Your experience mirrors so much of my own in the Public Service even though we are both in different professions/organisations.

The Public Service is run by the unions…and the Unions do’nt give 2 fiddlers about the customers…they believe the organisation exists to keep their members in insulated, and well paid jobs, from which they can never be fired (short of committing murder!).

I firmly believe if the ‘job for life’ rule was got rid of in the morning, the whole system would be transformed overnight


#26

That doesn’t seem right. Couldn’t they bill you after treatment. I doubt everyone who ends up in the ER has a wallet/cash on their person.

Mind you, 100E is cheap. I went to an ER overseas with a broken ankle. I had an xray and a nurse wrapped the ankle and gave me crutches. I did not see a doctor at all. Bill was 4k. Yep. I had insurance, but even if I didn’t they would have treated me.


#27

psqh.com/janfeb05/100k.html

Any of these in place in Ireland


#28

I hate to reinforce an us and them view of the PS but there is a comedy moment that I am loathe to pass up. I actually know of a woman who killed her husband and her job, in the DoJ no less, was retained until her release from prison…


#29

I hope they counted the years in prison towards her pension.


#30

well, you have knocked me for 6 with that 1 :open_mouth:
I genuinely though murder was the 1 thing to get you fired in the PS and now I discover it is’nt!!! She probably just got moved to a different section which is apparently the solution for everything


#31

(at the risk of opening a can of worms) - when a woman kills her husband how often is the charge actually Murder?


#32

2 great posts from the coalface!

Thank you both!

Wife is a consultant who has worked as an Intern/SHO/Reg in the health boards, as they were. We then went abroad so she could do her MD. She then worked in the NHS as a consultant and we then came back to Ireland when she took up a Professorship.

As a family we’ve sacrificed a lot to allow her to pursue her career - and along the way I’ve learned a bit about the system.

When she worked as a junior doctor she did work on private patients in public hospitals for consultants. She was expected to do this as part of her training and both the hospital and the consultants made money off this. She also worked incredible hours. Junior doctors keep the whole system afloat (and awash with cash).

Doing her MD was insightful into how research is published - and not! - in the medical field. Drug companies are hugely beneficial to the area of medical research.

The NHS works well and adapts to changing circumstances - until some minister comes in with a political agenda and screws the whole thing up. The NHS/primary care trust are also just as hog-tied by rules and regulations as the HSE. As an example my wife identified a major multi-million pound saving for the hospital that the CEO was extremely excited by - it allowed patients to self-manage in the home environment, entailing a win-win for the hospital and the patient - but it all came to nought because it required the GPs to get on board and the politics of the primary care trust made this impossible. There was no incentive to make a cost saving of to improve the patient management experience. Inertia is the natural state of the system.

And on returning to Ireland the most obvious thing to me was the current health service in Ireland is enormously damaged by politics and does it’s best to work in spite of this. The current debacle over the Childrens hospital is a classic example. Senior medical people have informed the process but the political piggies all want to skew it for votes and developers - so expect some half-arsed outcome to result.

Because politics are so entwined with the Irish system, and because the political system here has failed due to chronic economic mismanagement, there will be major decisions made in the future by uninterested parties that will result in loss of services that will impact on the citizen.

The Mary Harneys, the Brian Cowens, the Seánnie Ftitzpatricks and the Michael Fingletons of this world will be the ones responsible.

But will they pay?


#33

What’s it like to be the trailing spouse WGU?

en.wikipedia.org/wiki/Trailing_spouse


#34
  1. The GPs should be handling more of the daytime and evening trivia and chronic disease cases that wrongly end up in A/E but I wouldn’t want to see them facing too many drunks on the weekend. That can be a frightening experience for a GP on his own. My folks had their clinic attached to the house (don’t know how common that is these days) and one Saturday night a gang of lads came down with their injured comrade and laid siege to the place.

In one of our local hospitals, we have GPs working in the casualty dept. and treating their type of stuff, leaving casualty physicians to tackle the critically ill.

  1. A huge problem in Ireland and the UK is the mixing of two incompatible systems. Some doctors are inevitably going to drift towards the fee-for-service goodies in their private clinics if they are allowed to do so and neglect their public patients. Either there has to be a complete split between the two systems or hospital bosses have to start getting strict on making the big earners (e.g. ophthalmologists) turn up for their public work each day.

#35

I have a categorization?

Cool!

Each time I have to rejig everything to accommodate the medical community so they get the expertise they need feels like this:


#36

My mother has been in hospital in Ireland for the last few weeks. She is suffering from vascular dementia as far as we can make out though having had her attend a geriatric consultant in one hospital over the last 18 months for evaluation and now having her in another hospital with a geriatric consultant attending along with a geriatric psychiatrist, there is still no diagnosis. A formal diagnosis makes little difference for her medically except that without it we cant proceed to put in place the correct care for her when she comes home. The various medical authorities are basically passing the book, even though they are all based in the same building! They are eager to send her home but still bullshit us on getting a diagnosis that would enable us to get POA which is a real stumbling block as she gets distressed and paranoid over her finances. She has means and until now we have been covering the cost of carers who come to her home but we need to step it up at this point and get people with better training to deal with her as she gets really paranoid and pretty hurtful to the women who have been looking after her. She also fires people etc. All very common for folks with her condition. This has been going on for 3 weeks while she has been an inpatient and I have no doubt these doctors have charged the state plenty of coin and will continue to but they will not coordinate to facilitate us to organize things for her next stage of care.

If things don’t change in the next day or two we will have to go parish pump on their asses and start calling politicians! It is inexplicable to me that this bureaucracy cannot get their shit together to help us out when they also want her out of the hospital. My sister has written stating that we will not accept her discharge until they DO THEIR FUCKING JOBS.

Her care has been excellent and she is happy there but the bureaucratic incompetence of the consultants is eyewatering. Just an anecdote obviously, but we are left with no recourse but the most useless inbred approach of pretending to trade votes to get someone to step on these fools from above.


#37

Because of the shortage of doctors in A&E, the HSE has followed the UK’s lead in drafting in GPs to cover shifts.
Telegraph - GPs ‘paid £1,500 a night for A&E shifts’
In today’s Irish Mail, they refer to a GP working 46 hours over two shifts in Cork University Hospital and earning €3500.


#38

Free GP care for over 70s to be introduced

rte.ie/news/2014/0709/629629-free-gp-care/

So Means testing gone for wealthy over 70s

I can see how they could argue that free gp care can help unclog the hospitals with sick older people. Opionions?


#39

The vote buying begins. I truly dread to think what will be unleashed over the next 2 years to try buy the 2016 GE


#40

Wasn’t free GP care for all part of the government manifesto in 2011? Reduced to free GP care for <6 and >70