A 20-year-old solution to help Ireland’s ailing hospital system — with its acute bed and consultant shortages
Australian Prof Michael Watts looks to North America for a 20-year-old solution that if we copy, might just help Ireland’s ailing hospital system — with its acute bed and consultant shortages — start healing
I have been inspired by colleagues to put pen to paper, having read the excellent article citing neurologist Dr Colin Doherty (‘Four simple steps to saving the health service — top doctor’, Irish Independent, 18/03/2018 by Niamh Horan). The tiresome argument that the failing acute health system, and hospital crowding, is simply because we do not have enough beds is being relentlessly rolled out.
This, and the refrain that if we fix primary care all will be solved. But it’s not true!
In this short piece, I will focus on secondary or hospital care. I have no doubt that an excellent responsive primary healthcare system would improve the situation in acute hospitals, but I am convinced it will not solve the problem completely.
The manifestation of the failing acute hospital sector has been labelled ‘the trolley crisis’. People who have either attended an emergency department (ED), or been referred there by their general practitioner (GP), and a decision has been made to admit them to a hospital bed. Patients racked and stacked in an environment that is unsuitable, unsafe and inhumane.
A figure is generated every day, one by the Irish Nurses and Midwives Organisation (INMO), and one by the Health Service Executive (HSE). This is called the ‘Trolley Gar’, and is used to measure the dysfunction in the hospital sector, and used by politicians to wrap the HSE over the knuckles. This, and the lengthy waiting lists for scheduled care.
As pointed out eloquently by Consultant Gastroenterologist Dr Anthony O’Connor, in a frequently cited tweet at the end of 2017, this trolley count has nothing at all to do with EDs, but is a manifestation of a failing hospital system. Patients are on trolleys because they have nowhere else to go. Given the EDs are not broken, they do not need fixing. As much as we need more staff in Ireland, doubling, tripling or even quadrupling staff (doctors and nurses) in the ED will not fix this.
This is not just a local problem either. As an Aussie, I keep in touch with the media at home.
This issue is also biting hard in Australia, as it is in every Western health service. I refer to Western health services because these tend to be better funded, are more accountable, and equally, serve a population that is more prosperous, manifest by an extended life expectancy.
The problems of longevity
It is successful ageing that is both the solution, and, unfortunately, also one of the main reasons we are in trouble. Life expectancy has skyrocketed in the past 100 years. We have got so much better at treating and preventing cancer and cardiovascular disease, that we have created a new breed of patients that require healthcare.
As bipedal primates, the great apes who lived longest, we have more than double the life expectancy of our nearest living ancestral cousin, the chimpanzee. Theories about what causes ageing are still being developed, but what is clear is that functional reserve in all biological systems decline as they get older.
In essence, when we hit a pothole in the road of life, i.e. an infection, or an error in deoxyribonucleic acid (DNA) replication, our ability to recover and repair declines with age.
Sooner or later, our mitochondria fail, protons stop pumping, adenosine triphosphate (ATP) is no longer generated, and the cells that make us up, die. This can be gradual and predictable in conditions like Alzheimer’s disease, but is often rapid and unpredictable in onset in many other common conditions. This can thus lead to a need to rapidly access unscheduled care services. Enter the ED. Enter the request for a bed, and additions to the trolley count.
Getting back on your feet is key in the recovery from acute illness in older people with reduced functional reserve.
The illness that caused the decline is often what would be regarded as trivial in a biologically younger person, but disastrous and life-threatening in an older person.
It can often present atypically, and require a skilled diagnostician and the help of interdisciplinary care, such as physiotherapy/mobility assessment and occupational therapy, to aid functional recovery, which may take time, much of which is spent in an acute hospital bed. Languishing on a trolley is completely retrograde, and simply adds to the strain on functional reserve; it can be the tipping point to which there is no potential recovery achievable.
This is not saying that older people are the cause of the crisis, but that they are the victims most likely to be affected by it.
It is interesting to look at how hospitals are adapting to the demographic changes affecting healthcare. Ireland, up until recent times had one of the lowest populations of people older than 65 in Europe. This, however, is set to change over the next 10 years.
Inadequate model of care
The question to be asked is: ‘Is our current model of acute hospital care ready to deal with this demographic change?’ The answer is obviously, no.
The current model of acute hospital healthcare in Ireland was never designed — it evolved. We are now an effectively rural country, spread out over a relatively large land mass, with too many hospitals. Even in the capital, one large hospital, properly equipped could potentially service the healthcare needs of Dublin. There are massive economies of scale when it comes to hospitals.
The model of acute healthcare is equally not designed. It is frontline, represented by the ED and led primarily by consultants, but run by trainee doctors. We call these doctors by what they are not — non-consultant hospital doctors (NCHDs). That says it all.
NCHDs are at the coalface, and when an ED NCHD calls for help, much of the time it is to another sub-specialty NCHD, primarily medical or surgical. It is most often at this point the decision to admit is made; enter the dreaded trolley.
It is often the next day that the consultant on call the previous day, comes down to the ED, to wriggle his or her way between the trolleys in corridors, and tries to assess patients. We call this the ‘post-take’ ward round. It is like a bad afterthought, and a term we just accept as healthcare professionals (HCPs) (more on this later).
As bad as this is for patients, it is also professionally very difficult for consultants. No privacy, no way to take a confidential comprehensive history (the most important intervention in my book), and very difficult to do a full comprehensive physical examination.
What of the training environment for these NCHDs? What specifically of their training, and how this is being delivered? Add to this the difficulties imposed by the European Working Time Directive, and you can understand why survey after survey confirms Irish medical graduates are leaving.
We train more than 700 new doctors a year. More than enough to replace and expand our current consultant and GP workforce. However, less than 20 per cent choose to stay in Ireland.
Add to this the consultant retention and recruitment crisis. Some 15 years ago, you had to fight for a consultant job, when 20 plus candidates would be shortlisted for one job, all of them eminently qualified, many of whom would be Irish citizens looking to come home.
There is now a struggle to even put forward a panel of appropriate candidates, particularly outside Dublin, with jobs re-advertised again and again. Consultant jobs currently remain unfilled —unheard off in Ireland previously.
The public/private divide
We need to consider the public/private divide and how our large public hospitals work. This includes the contracts public consultants hold, how they are paid, and how insurance companies reimburse both hospitals and doctors.
Insurance companies on the whole do not reimburse most non cancer-related outpatient treatments for the common medical patients that often end up being admitted by an NCHD that has no other choice.
Access to diagnostics is similarly affected by this. In general, a computed tomography (CT) scan done on a private patient as an outpatient in the public hospital will not be reimbursed (both hospital and consultant). You have to stay overnight in a bed, thus you have the perverse incentive to admit. Thus, the system has a certain level of passivity to allow an NCHD, with little option otherwise, to admit a patient, who the following day is seen by a consultant.
If the patient elects to be private, the consultant gets paid, the lab gets paid, the radiologist gets paid, and the hospital gets paid. Everyone is a winner; except the most important person — the patient.
The patient may well need all of the above involved, but the key question that needs answering is — does that patient need a bed? I am not saying that insurance companies by dint of the way they reimburse are causing unnecessary admissions, but I am saying it is an inappropriate incentive.
I have always assumed the reason insurance companies have this ‘overnight rule’ is to stop an avalanche of unnecessary requests for tests/consultant opinion.
I also believe it remains one of the impediments for giving GPs more open access to diagnostics, and for hospitals to develop non-admission pathways (which I will also return to soon). The causes of the problems are easy to identify, and obvious. There is no point looking to blame the politicians, the banks, Lehman Brothers Holdings Inc. (the former global financial services firm), the Department of Health or the HSE. There is the need to acknowledge the system is broken and not fit for purpose in the 21st Century and must be fixed.
I presume Sláintecare is the current solution on the table. I will not dwell on this, as it could distract from the point I wish to make. I have doubts, as do many others if there is the political will, or the cash to implement it. The money comes from the public. That means paying a lot more tax.
How do we fix this?
As stated by Dr Doherty, more beds will not fix the system. If the health system were described as an addict, then beds would be its opium. You just want more and more. If there is no threshold for determining who needs a bed, the more beds there are, the lower the threshold to use them.
Notwithstanding that, given the ageing demographic and age-associated decline, beds are needed, and the number required will increase. Comparing ourselves to other Organisation for Economic Co-operation and Development (OECD) member countries is interesting, and confirms there is no relationship between bed numbers per 1,000 people versus the level of crowding in the acute hospital system of that country. Equally, that Ireland is not relatively starved of beds, and that it does seemingly spend significant amounts on healthcare per head of population compared to other countries.
Let us summarise the Irish health system, before I propose a potential solution.
1. The frontline — the ED — is provided by NCHDs, led by a small group of ED consultants
2. If the patient is deemed to require specialist care, they are referred to the on-call medical and surgical NCHDs
3. Admission is the frequent outcome. If there are no beds in ‘the house’, patients wait on a trolley in the ED
4. Patients see a consultant physician/surgeon the following day on the ‘post-take’ round.
1. The frontline and the use of trainee NCHDs to provide this service needs to be re-examined. Doctors, like pilots, need to be trained. They need supervision as part of a structured curriculum-based training programme. In addition they also provide an invaluable service, and without this, the 24/7 healthcare system we have now, would fall apart. The question for me is ‘Are we training the doctors for the health service of the future?’ I think not, well not comprehensively anyway.
I work for the Royal College of Physicians of Ireland, and I am involved in the postgraduate training of hospital doctors. What follows are my views and not those of the College I am a member of, and provide services for.
In medicine we train many different subspecialties — Cardiology, Respirology, Geriatric Medicine, Diabetes/Endocrinology, Neurology, Rheumatology, Dermatology, Palliative Care Medicine, and Gastroenterology. We also train people in General Internal Medicine, and currently a trainee can only do this if training in another sub-specialty. We call this dual training.
Hospital consultants in Ireland 50 years ago were generalists. The so-called ‘county physician’ did the lot. In addition to providing all of the above services, they would deliver your baby, and potentially take out your appendix.
Times change, and medicine has become specialised, and with that, patient outcomes have improved. It is my view that the unintended consequence of this tidal wave of specialisation, is that generalists have been swept aside.
Many of the sub-specialties above have abandoned General Medicine altogether, but a core retains it, specifically, Geriatric Medicine, Respirology, Diabetes/Endocrinology, Gastroenterology and Rheumatology. However, these specialties in themselves are becoming more specialised, and are likely to continue to do so (medicine never goes backwards). The training and the curriculum that underpins that training will get more complex, and ultimately what will suffer is General Medicine. This process is well under way.
North America woke up to this 20-plus years ago. Probably driven more by the financial costs of hospital services driven by expensive specialists, the ‘hospitalists’ were born. Now, North America’s fastest growing specialty, hitting the dizzy heights of 60,000 plus. These doctors are generalists, and their focus is on dealing with primarily unscheduled attendances. They take responsibility for patients, and call sub-specialists when their services are needed.
There are many critics, however. The hospitalists have encroached on the domain of other specialties; there are questions about career, longevity, and job satisfaction. Many of these criticisms are well founded, but there are solutions, and they are being implemented. The bottom line, however, is in North America, a country driven by spiralling costs; the hospitalists remain a growing ‘specialty’ and in my view will continue to do so. Not because of cost-saving alone, but ultimately because they are purpose trained to deal with the population of patients they serve.
Thus I am suggesting we begin to train the ‘Irish hospitalist’. This is not to denigrate sub-specialty training, but rather to facilitate its progression. The ageing demographic, with age-associated complex multimorbid presentations, will demand it.
Many have proposed that Geriatric Medicine would fill this void. As a trained geriatrician, I believe if there was enough of us, such that the other core components of specialist Geriatric Medicine could also be dealt with (falls services, dementia services, bone health, continence services, stroke, and rehabilitation), it might be possible. Geriatrics, however, is not immune from the forces driving other sub-specialties in medicine. The recent advances in acute stroke care and the development of 24/7 reperfusion therapy is a good recent example. You simply can’t do everything.
Another factor that must be considered in my solution is the duration of training. A sub-specialist consultant post-medical degree, with dual training in General Medicine, takes eight years to complete. One year as intern, two as a senior house officer, and five as a specialist registrar. Probably long enough, particularly when we compare ourselves to North America, where a hospitalist has three years training.
Finally on this issue, does Ireland have a cohort of wannabe potential Irish hospitalists? Anecdotally, I would answer absolutely yes. Of the 700-plus doctors we generate per year with medical degrees, those that want to be a clinical doctor have broadly two choices if they want to train in Ireland. Firstly, become a GP and join a GP training scheme. Secondly, train to become a hospital consultant. These are quite stark choices, and there is nothing in between. It is my view that a relatively rapid hospitalist training scheme would be extremely attractive to Irish graduates, as long as there was a reasonable expectation of a well paid job with good working conditions at the end of it. This is emotive stuff within postgraduate training circles. Most, if not all, know my views, and no doubt if this tome ever reaches the public domain, I will be in hot water. So be it.
2. So now we have our hospitalists on the frontline, working with our ED colleagues. The decision to admit or otherwise will be made by them. But they need more than just the option to admit. Experience and appropriate training does not necessarily mean patients will simply be treated and sent home. Quite the opposite may occur. Experience and training may well pick up stuff that the inexperienced and less trained miss.
What is lacking at this stage are clinical pathways for the common general medical presentations and specialist trained nurses. My area of interest is in venous thromboembolism (VTE) — blood clots in the legs and/or lungs — serious and the third biggest cardiovascular killer after stroke and heart attacks in Europe, with 50,000 deaths per year. It sounds dramatic, but you do not need to be a doctor to look after the vast majority of these patients. What you need is an evidence-based pathway, with trained specialist nurses, who do this and only this.
This nurse will do a far better job than any overworked NCHD, is far more likely to discharge the patient, and will have much faster consultant specialist input. My service is doing this, and being supported by local management to expand and make it more comprehensive. The same formula could be applied for many other common conditions that end up in our ED.
3. What of the so-called frail multimorbid older patient that simply needs admission. Again, you apply the same model. Specialist nurses with care pathways, linked to specialist geriatricians, wards fully equipped with interdisciplinary services, links with community services etc. Currently, Beaumont Hospital has a similar service called the Frail Elderly Intervention Team (FIT). The FIT idea, I believe, is an excellent one, and has the acronym to boot.
4. The previously referred to ‘post-take’ round will then become a thing of the past. Sub-specialists will do what they are trained to do, the Irish hospitalists will become the quarterbacks of the acute hospital system and specialist nurses, under the governance of consultant specialists, will provide pathway-driven care.
The cost of the recession in the public sector remains a gaping wound. Teachers seem to get plenty of media airtime, and are quite vocal about young teachers being recruited being paid less than their colleagues for doing the same job.
The same is true for consultant doctors in Ireland, and it is one of the reasons we cannot fill vacant posts. Doctors that speak English have the world at their feet, and Irish-trained doctors more so. It is a competitive market, and the damage that was done must now be repaired. The argument that there should be a graded pay scale I would also argue against. If the patient is under you, and you are the sole practitioner responsible, why should you get paid less? I don’t think the prosecuting attorney is going to give you a discount, just because you are a newbie on less pay.
Once we have parity of pay for parity of work and responsibility, it will still be years before the reputational damage of the cuts are repaired.
Paul Weller said “and the public get what the public want”— an ironic lyric in the song Going Underground. What do the Irish public want? They know they want good quality healthcare, but do they want a public-funded National Health Service (NHS)-type system, or do they want a system that provides basic free healthcare with the option to top it up privately. As a ‘blow in’, my sense is that the Irish are more philosophically aligned with the North Americans than the British on this issue. That being said, the current health reform plan on the table, also known as Sláintecare seems more NHS-aligned.
I do not want to get political, but we must decide. The current hybrid system does need a rethink, however. It does not necessarily need to be dismantled, but the relationship between the insurance companies and the public system needs to be re-examined. In particular, the way private patients are treated in public hospitals, including the way insurers reimburse public hospitals and consultants.
I thought private/public hospitals co-location made sense. It suited the 2008 common consultant contract to a degree. I would, however, have gone further with regard to how the contract was structured. Specifically offering new consultants a flexible percentage of a public contract, and only paying them that percentage of a public salary, according to their individual needs and that of the employer. Look to Australia, for an example of how it works. Either way, the consultant contract will need a rethink — a torturous prospec, when I think back to how long and difficult it was to negotiate the 2008 contract.
Ireland’s strength has always been its people. Its doctors, universities and training bodies are exceptional. Irish graduates are sought the world over. We need a health service that works better, and stops the ‘brain drain’. We also have the luxury of looking abroad, to get the best of what other countries have done to deal with the changes in the population accessing healthcare. Make no mistake; the Irish acute hospital system is in big trouble. The trolley crisis is going to get worse. Just building more beds in a system that needs a complete overhaul, will be expensive, slow and also ultimately fail. Let the healing begin.
Prof Michael Watts is a Consultant Physician at University Hospital Limerick. He is a fellow of the Royal College of Physicians, the National Specialty Director of General Internal Medicine, and the Adjunct Professor of Clinical Medicine at the University of Limerick Graduate Entry Medical School (GEMS).