NO COUNTRY FOR SICK MEN
A PERFECT storm is an expression that describes an event where a rare combination of circumstances will aggravate a situation drastically. It is also used to describe a hypothetical tornado that happens to hit at a region’s most vulnerable area, resulting in the worst possible damage by a hurricane of its magnitude.
Rather than becoming immediately embroiled in the emotional aspects of the difficulties we face, I would ask the reader to look at our medical needs objectively and dispassionately, in the first instance, and then to look at how we need to meet those needs.
Fundamental to any discussion is gaining an understanding of the change in delivery of medical care over the years from a situation where one had the family doctor and then “the hospital” to a situation where we now have primary care, secondary care and tertiary care.
A reported 95% of medical illness is managed in primary care. This is done by the patient and their family, their general practitioner, public health nurse and by the proposed expansion of the primary care team to include physiotherapy, occupational therapy, pharmacy and others within the community who team together to keep the person well, promote health, manage the majority of illness and look after the community from the cradle to the grave.
The 5% of medical illness which requires hospital-based care needs to be analysed in detail: a proportion of patients have needs which can be best met in an extremely specialised environment where the availability of experts in various specialties within medicine, under one roof, with high- level technological support can yield the best outcome. As medicine has become more complex, the areas of sub-specialisation have expanded. I refer to neurologists, nephrologists, cardiologists, respiratory physicians, rheumatologists and emergency medical specialists to name but a few.
For a more comprehensive list, I would refer the reader to the Cork University Hospital website. These specialties are located in tertiary care facilities such as CUH.
These centres were designated as tertiary care facilities many years ago on the basis that patients would be referred directly from primary care, or secondary care, if appropriate, or following investigation of what were called undifferentiated illnesses. These were illnesses where it was not immediately obvious which speciality was most appropriate and the patient was, in these circumstances, best managed initially or completely under a generalist.
A generalist was to be a highly trained physician or surgeon whose training and expertise was in whole person care, as opposed to sub-specialising. They were to work in secondary care facilities. These were facilities such as the general hospitals which were resourced and supported in doing what they did best — caring for the vast majority of the spectrum of illness in the community, near to that community. They were to investigate and manage these illnesses efficiently and cost effectively and to use the resources of the tertiary care facilities when and where appropriate.
Tertiary care specialists were to hold outreach clinics in these facilities and appropriate specialties such as geriatrics, gastroenterologists, dermatologists and others were to work full- time in secondary care facilities or shared with the tertiary care facility.
With the expansion of medical and surgical specialties and the spiralling costs of medical care it has been necessary to look at how and where we deliver medical care and to reconfigure the services to ensure that the most appropriate care is delivered at the most appropriate location and for the most appropriate patient.
Evidence-based medicine has shown that for cancer care the best outcomes will come from specialised centres where all the sub-specialties are housed under the one roof.
In other words, rapid diagnosis in primary care, secondary care or in tertiary care will lead to your operation /intervention in a tertiary care facility.
Emergency medicine requires special mention. A significant majority of urgent cases fall into the category of minor injuries and should be seen in general practice or in minor injuries units. These units have traditionally delivered well to appropriate cases in secondary care facilities. For serious medical emergencies such as high-impact road traffic accidents, serious fractures, heart attacks and strokes, the direct admission through the tertiary care facility of emergency medicine is most appropriate in the shortest possible time and by the most direct route. This ensures that these cases have immediate access to personnel and facilities for advanced medical investigation and intervention which are located at a tertiary care referral hospital.
These cases should be assessed rapidly in the community by the general practitioner who is equipped and resourced appropriately, working side- by-side with emergency care technicians, paramedics and now the advanced paramedics. The patient should be stabilised and a decision made on a case-by-case basis as to the most appropriate action; in the majority of cases of such severity, this involves immediate transfer to the tertiary care facility. In certain emergencies, however, lives have been saved where transfer distance or gravity of patient’s medical condition dictated that the patient was first stabilised in the nearest secondary care facility prior to onward transfer. The human cost of removing this option in rare but life-threatening emergencies needs to be debated.
So where has it all gone wrong? Forgive me if I concentrate on one region but it should be possible to extrapolate to all regions within the country with some individual variation.
In this region, Cork University Hospital (CUH) has to be taken as the hub and all other hospitals as spokes in the wheel of care which reaches out into the communities of Munster.
Cork University Hospital has a bed capacity of 850, though 62 of those have been removed in the past 18 months and it is impossible to get accurate figures from the HSE at present on the precise number of beds available for care. Suffice it to say that OECD figures in the Health at a Glance 2009 report suggest that Ireland has 2.7 beds per 1,000 of population versus OECD average of 3.8 per 1,000.
CUH has over 40 medical and surgical specialties — including neurosurgery, intensive care and emergency medicine — to make it a tertiary care facility for all the hospitals in the Munster area. Indeed, its emergency department is the country’s only level 1 trauma centre.
CUH is one of eight designated cancer centres nationally. The new cardiac and renal unit are designed to serve the needs of Munster.
I can give you many reasons why our hospital system does not work but the main ones are: management, management and management.
Although there are some excellent people involved in the management of our health services, there remains a significant lack of joined-up thinking and leadership.
Ask each and every specialist in the tertiary care facility how many beds they individually need to run their department and deliver a quality service which reduces waiting lists. How much operating time does an individual specialist need and how much are they getting? For the designated cancer specialist centre what is a reasonable time from presentation to investigation, to intervention, and what are the obstacles to achieving internationally agreed targets?
Of the 50,000 patients processed through the emergency department at CUH in any one year, how many needed the services of a level 1 trauma centre, and how many could have been managed in a dedicated minor injuries unit, either elsewhere or in a separate area of the CUH campus, creating efficiencies in time and patient management?
How much more efficient could the emergency department be if it was not the entry point for every single acute service in the hospital?
What are the implications of running the CUH at, probably, 120% of capacity? What are the effects on the wonderful staff and the vulnerable patients? We have yet to find out. What has HIQA said about this? Nothing! Yet there appears to be a tacit agreement between HSE, the Department of Health and HIQA that we can continue to front-load the services of CUH. !
To quote de Valera: “It is, indeed, hard for the strong to be just to the weak”.
This inefficiency in managing our resources has serious spin off effects: In 2009, 17,761 procedures were cancelled nationally and CUH cancelled 1,261. The Fine Gael spokesman on health at the time, Dr James Reilly described the figures as “scandalous” and said hospitals were trying to operate in a health system that was “broken”. He went on to say that “cancelling operations has become policy for managing hospital gridlock.
In response to the feeble HSE explanation, Dr O’Reilly said: “Cancelled operations have a real impact on patients — postponing important procedures, prolonging pain and delaying investigations which may lead to early detection of illness.”
Minister of Health please note!
So how does an “ordinary” storm become the “perfect” storm? To imagine this I have to take you on a voyage of disbelief:
Pour more and more work into an under-resourced primary care. Bully and harass that system if emergencies are seen after hours.
Effectively remove many of the medical, surgical and other services from the spokes of the wheel of care — Mallow Hospital, Roscommon Hospital and others. Use HIQA as the justification if you find it expedient. Ignore the directive of HIQA that no service was to be removed until alternative or better services were in place. Strangle the funding to smaller hospitals to ensure that they fail.
Centralise ambulance services so that access to these at any time is made more difficult.
So where can we go from here? At this perilous time in the state of our nation we look for clarity and leadership from our government.
We look to them to protect the vulnerable while at the same time making our systems efficient and effective. We look to them to communicate with those at the coal face in a meaningful way to work out the best way forward. We need cohesion between the Regional Directors of Operations of the HSE, those making reconfiguration happen in an appropriate way and the Minister for Health. Let us rid this country forever of this paternalistic, autocratic “bureaucracy knows best approach”.
Should we persist on our present course we are steering towards the eye of that “perfect storm” this winter.
Let us hope that the Minister for Health dons the captain’s hat, heeds the weather reports, acquires a compass, and sails out on that sea of shared ambition to land on the shores of success.
Dr Bertie Daly is a general practitioner in Newmarket, Co Cork
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