Dr Chris Luke: How can we address the overcrowding of our hospitals?

I believe we are facing a crisis as great as the Covid pandemic. In dealing with the latter, this little nation revealed a remarkable capacity for solidarity, innovation and flexibility. We are going to need all of these qualities again.

'Sadly we’ve actually been in a Major Incident Response mode for years and years.'

The hallmark of an emergency physician is a focus on solutions for the problems right in front of them, while also bearing in mind that the heart attack, infectious disease or severe injury may have a complex ‘origin story’, a hidden severity, and all sorts of ramifications in terms of treatment. What this means in practice is that there is usually little time to discuss the patient’s diet, smoking habits, or inexplicable desire to walk into traffic. What matters is dealing with their most life-threatening injury or illness in a semi-reflexive manner, deploying skills that have been honed through repeated drills, and delivering interventions that are evidence-based.

So, if someone in charge asked me how I’d ‘manage’ the current calamitous inundation of hospital emergency departments (EDs), I’d think first of the practical remedies that I’ve seen work in the past, and occasionally some measure I hadn’t used before but had seen in the medical literature, or at a lecture or workshop.

‘Major Incident Response mode’

In relation to our desperately overcrowded emergency departments, then, I’d advise getting into ‘Major Incident Response mode’. This means recognising that a situation is beyond the normal capacity of the system to cope; creating a cordon around the ‘scene’ (ED), and only allowing certain designated people through the cordon (e.g., patients or professionals); doing what is necessary to reduce the number of further casualties of the initial hazard (e.g. a toxin, infection or source of injury); and urgently triaging or sorting the existing victims according to their clinical urgency, before sending them off for further specialist care, while stabilising other cases, with basic treatment at the scene.

Aside from rehearsal for this kind of major incident management, I’d ask for an appropriate number of specialist and general clinical staff, and I’d deploy them in teams to designated areas, to operate autonomously. I’d seek to ensure clear lines of communication between the frontline teams and behind-the-lines support, as I’d rely on these to give me a constant supply of staff and material and whatever else it takes to keep the ‘operation’ going, like fuel, food, fluid, pharmaceuticals, kit, and facilities for the staff.

The bigger the incident, the bigger the response and, while I’ve seen many incidents over my 40 years of practice, I think the best example of a really effective response is the approach to the Manx2 airplane crash at Cork airport in 2011, to which almost the entire cohort of hospital and pre-hospital emergency professionals in the county of Cork responded so well.

But then I’d come to my senses. And, shaking my head, I’d say: “Sadly we’ve actually been in a Major Incident Response mode, for years and years. And the supply lines have become unreliable. We regularly run out of kit and medication — and space to treat the ever-increasing number of casualties. It’s almost impossible to get the doctors or nurses we need, and we’re losing so many of our best to exhaustion and despair. And who’d blame them: they don’t have even have time for a pee…”.

To be honest, that’s the nightmare that affected me every day in the final years of my clinical practice. But there is (always) hope, and here’s a notion that’s been gestating in my head since I quit the frontline. 

In my vision for the future, our population, professionals, and politicians would realise that the situation in our EDs has evolved — like the climate crisis — over decades of inertia — and that, along with the shocking consequences, the causes are not dissimilar.

Aside from the ‘demography’ of patients and professionals, the important ones include industrialisation (healthcare management has aped car factories since the 1990s, spewing out efficiency targets and treating staff like automatons); globalisation (the Irish and UK health systems have for far too long relied on staff from developing countries, just as they let their own graduates emigrate), and the commodification of healthcare (the flourishing of private practice is in contrast with the public sector, whereas they could be mutually supportive).

But that’s enough of the underlying pathology. What about the actual measures I might introduce now that I’m awake again?

Well, here are the five ‘quick fixes’ for the chaos at the frontline I would introduce if I were (miraculously and genuinely) in charge:

• 1. Treat the ED staff as the vital assets that they are: pay them what they are owed, and mind them as if healthcarers were actually a remarkable and admirable group of people who need respect, courtesy and kindness; and give them the time off they need - or lose them.
• 2. Orient the entire health system towards the crisis, for as long as it takes: suspend elective work until the waiting time for an ED patient to be admitted or discharged is no longer potentially lethal; oblige every hospital CEO to attend the ED daily to monitor the crisis and the evolving responses; assign to every ED a team whose function is to look after the staff and to undertake work that otherwise deflects from actual patient care (e.g., finding chairs or trolleys, tidying and cleaning patient and staff areas, ensuring that staff and patients have access to hot food, drinks, and rest). ED patients must be admitted to one or two extra beds per ward in every hospital until the crisis is eased; infectious disease control must be ramped up: mandate or incentivise mask-wearing and vaccination; and urgently deploy the finest marketing minds in the most comprehensive self-care and preventive education programme for the population ever seen.
• 3. Treat nursing home staff as the vital assets that they are: pay them what they are worth and treat them with respect and kindness so that can dispense the same to our loved ones. The quickest way to provide/empty hospital beds is to properly resource nursing homes.
• 4. Treat general practitioners as the vital assets that they are: give our GPs the support they need (e.g., access to imaging and outpatient clinics).
• 5. Enable pharmacists to provide much more primary medical care (e.g., let them prescribe or offer acceptable alternatives to a doctor’s prescription where there are shortages of a medication).

I believe we are facing a crisis as great as the Covid pandemic. In dealing with the latter, this little nation revealed a remarkable capacity for solidarity, innovation and flexibility. As we face a future where the number of health and community care professionals is dwindling, and the capacity of the healthcare system faces sustained and potentially overwhelming pressures, we are going to need all of these qualities again.

Even more vitally, we must accept that we all have a role in supporting our health service.

Dr Chris Luke is a former Consultant in Emergency Medicine at Cork University Hospital and the Mercy University Hospital in Cork and the Royal Liverpool University Hospital.