How would you solve the trolley crisis

echo beach

Qualitymark wrote: »

What about paying hospitals per cure?

Who would define 'cure'?
A terminally ill patient would soon find no hospital willing to treat them because there would be no payment.

Vorsprung

echo beach wrote: »

Who would define 'cure'?
A terminally ill patient would soon find no hospital willing to treat them because there would be no payment.

Not to mention those with chronic diseases/malignancies. Some of our most expensive drugs are spent on cancer patients as you say, antiretrovirals aren't cheap. That new fancy drug for paroxysmal nocturnal haematuria is a lifelong medication, something like 400k a year.

Not a practical idea unfortunately.

Money is going to be given from next year based on work done as opposed to block grant (to acute hospitals anyway). It's a good start in that it rewards work done.

Abby19

Quote:
You'd wonder further if the tests/scans were available as routine for hours outside 9-5. I've worked in a large Dublin hospital where I've had to refer patients for admission at 6pm because I cannot get the CT scan they need because radiology is closed. They then languish on a trolley for upto a few days


This is lunacy - hugely expensive machinery and highly qualified staff being under-used because of 9-to-5-no-weekends working hours.


Whatever about the machines lying idle - it's not as simple as simply getting a scan done
- Yes more radiographers would be required to run the CT/MRI scanners.
- You'd need more porters to transport pts - and possibly more nurses or healthcare assistants if the pt needed a special, or to be accompanied. (I have personally wheeled pts down to radiology/labs during the normal working day because no one else was available and my pt would lose their slot)
- You would also need more Radiologists to review the scans and report on them. Sometimes they are read and reported by trainees (junior doctors on the Radiology training scheme, from First year Regs to Fellows waiting to apply for consultant posts) but need to be signed off by the consultants. There aren't enough consultants when they are run 9-5.
- Extend the opening hours to 24 hours is trebling the operating time, increasing by 16 hours (there is always emergency cover currently). Qualified applicants are not applying for Radiology vacancies (a large factor is the new entrants contract whereby new hires would be working for a large amount less than their colleagues). Trainees are leaving to go overseas for better opportunities and more humane working conditions. ~Half the current graduates from Irish Medical schools currently have done Grad Med and paid for their own degree, so comments about forcing return of service aren't very helpful. Some of them have simply no option as they simply cannot service their education loans on their salary, and pay for all their mandatory exams, medical council fees, professional indemnity, books, courses, that they need to do to advance professionally.

If you want to understand some of what is required by extending a service to 24/7 from 9-5 Monday-Friday with emergency service evenings and weekends take a look at the information posted in rebuttal to Jeremy Hunt and his ill thought comments on extending NHS to a 24/7 service. 98% of junior doctors in the UK voted for Strike with 76% turnout.

Junior Doctors here still work illegal hours >48 hour workweek and 24 hour shifts (should have been capped at 13 hours since 2006 according to the European Working Time Directive. Who will man the service if working hours are extended. Many many doctors currently work illegal hours - should they just work even more illegal hours?

Ireland is overly reliant on overseas doctors, but with recent changes they need to get a new visa and renew their GNIB each time they move hospital (which can involve queueing at ~4am in the morning to try and get seen the next day as there is no appt system). Oh and they get charged handsomely for each one too.

For ways to reduce unhelpful admin - Each hospital (or group of hospitals) issues their own contracts for junior doctors, rather than the HSE themselves. Even though there is a nationwide NCHD contract. So each individual HR dept types in the name and the start and finish date.
You change hospital - you get a new contract.
You also change payroll dept, and spend a few weeks/months on emergency tax. Always a lot of fun. Some posts rotate at 3/4/6 monthly intervals. At 3 monthly intervals you are pretty much permanently on emergency tax. Makes for interesting conversations with your Bank Manager.

As you can imagine you need Garda Clearance to work as a doctor. And each time you change hospital group you have to reapply for clearance. From Birth!!! The Gardai don't issue one till a certain date, and then you just apply for clearance from that date on, you have to start at the very beginning each and every time. It is linked to your PPS number so it is unlikely you could slip through the crack. It's so inefficient!

There aren't enough nurses, yet there are over 2,000 applications for registration in with the NMBI. With many qualified nurses working as healthcare assistants as they are waiting for their paperwork to be processed (vvv slowly)

And if you do manage to free up hospital beds by discharging pts to the community with appropriate homecare packages there will be additional costs.
The cost of the increased homecare package. And the costs of the bed that has been freed up and whatever tests/procedures the new pt occupying it will require.

Yes an extended service would be good, more money would be required to pay for it, but you need qualified people to staff it and they really are not widely available.

FortySeven

@Abbey19

Excellent input. I think it is clear to most here that the issue is not with the fronline workers who are doing extraordinary work but the administration behemoth behind them, your observations on the processing times of documentation are largely echoed throughout all branches of the civil service. It is widely recognised that the productivity of these departments is more than lacking, bordering on the criminal imho. Yet this appears to be an area of discussion that is shouted down, bullied into submission with union representation and when pushed for improvement, threats of strike action.

I personally believe it is time for the frontline staff to make a stand and contest this situation but I get the feeling that there is a 'we're all in this together' type scenario due to overlapping interests within the union frameworks.

What would be your opinion on this situation?

Abby19

FortySeven wrote: »

@Abbey19

Excellent input. I think it is clear to most here that the issue is not with the fronline workers who are doing extraordinary work but the administration behemoth behind them, your observations on the processing times of documentation are largely echoed throughout all branches of the civil service. It is widely recognised that the productivity of these departments is more than lacking, bordering on the criminal imho. Yet this appears to be an area of discussion that is shouted down, bullied into submission with union representation and when pushed for improvement, threats of strike action.

I personally believe it is time for the frontline staff to make a stand and contest this situation but I get the feeling that there is a 'we're all in this together' type scenario due to overlapping interests within the union frameworks.

What would be your opinion on this situation?

There are unions (IMO and INMO) and then there are statutory bodies (the Irish Medical Council and the INMB). There are other statutory bodies for other healthcare professions, but I am more familiar with these.
We have no say in the running of the statutory bodies whatsoever. Note the IMC arbitrarily raised the registration fees this year at a few weeks notice (unlike the INMB and nurses who had a number of months notice and so could protest it). Doctors cannot work without registration. We are simply sitting ducks. And working long hours makes it really difficult to attempt to do anything about it.

The annual reports make interesting reads ...
Here is the most recent INMB one, from 2012-13 http://www.nursingboard.ie/en/publications_annual.aspx . Check out from Appendix 1 on (around page 48). Interesting to read the makeup of the board, the attendance of Board members at the various Board and committee meetings and then how much they claim in expenses. IIRC they get some funding from the government but most is from members fees.
There's also an organisation chart from 2012 which may be out of date, but there were only 5 employees in the registration dept - and a current backlog of >2000 applicants.

The IMC one is for 2014 - https://www.medicalcouncil.ie/News-and-Publications/Reports/Annual-Report-2014-.pdf
Council and meeting expenses of €644k
Page 55 lists expenses
Page 66 lists attendance at meetings
I am not alleging any financial impropriety - but Doctors subscriptions/fees are pretty much the only income so it makes for a difficult read. My subscription this year was nearly 2 weeks take home pay - there was no option to pay in installments - had to be paid upfront - I needed it to work.
https://www.medicalcouncil.ie/Registration/Fees/

INMO has a fairly good set of teeth.
IMO not so much.
But then a union is only as strong as its members - and when you can be working 70-80 weeks you don't have much energy to fight and you are supposed to be studying for exams/doing research/write papers/apply for your next training scheme/read up on whatever your pts have.
There can also be the 'don't rock the boat' attitude - let's face it - you'll need a reference for your next position/training scheme.

FortySeven

Thanks for your reply, wages certainly look on the face of it to not be excessive, have to be honest, nice pensions. Definitely not hamming it on the scale of the IFA for example. 7 meetings a year for over a hundred thousand sounds excessive but I have to assume there is a lot of work between meetings to justify this workload to pay ratio.

I didn't realise the failure rate, that registration is almost 50% fail across the average. Scary.

Definitely seems to be room for improvement as with all bodies but my main query is towards those civil servants working on everyday hospital and medical administration tasks within the HSE framework more-so than the actual representation of the doctors themselves.

What would be your opinion on this background army of people who organise the day to day functions. My own dealings with various offices, making appointments, reporting for appointments etc have been largely negative experiences, some shambolic and some just downright difficult. Do you see this in your work and what do frontline staff make of it ?

For example, I know how important it can be to cancel appointments rather than not show therefore allowing for someone else to use that time but when I tried to do this by calling the number provided on my letter, it just rang out. I'm a persistent person and I rang that number all day with no response. It meant I missed an appointment and was returned to the end of the waiting list with Neurology. There seems to be a culture of apathy in these offices, I have stood there at the window with an office full of people, some having the craic while the phone rings constantly and the queue is epic yet there is no urgency with these people, they seem to operate in a different time metric. Does this sound about right to you and do the frontline staff not find this infuriating?

MPFGLB

I have worked in the NHS for many years both at central government policy making , hospital and local commissioning level
I have worked on many rationalizing, demand & capacity planning & public health development projects

While there is room still for efficiency saving, better ways of doing things including reducing bottle necks in any system and reducing administration overheads . getting rid of waste especially in procurement, having multi disciplinary teams, adequately trained staff of appropriate seniority and a closer working between social care & health care...all these still do not solve the problem facing healthcare in the developed world at present...even the most efficient functioning system will only bring you so far. ( I believe recently in England the chancellor said that efficiency saving will account for 20% of a required increase in budget and that is pushing it)

The fact is the demand for healthcare is increasing exponentially with a increasingly aging population who are living longer with more complex health needs
Once upon a time not so long ago you died of heart disease,strokes, etc alot sooner...now you last longer and develop more long term conditions including dementia
Modern Science can keep you alive longer...
As friend of mine who is a nurse said about a hospital she used to work at where they had a lot of elderly patients.."Come to Hospital X and live forever"

More investment is key unless there is an over haul on the system and review of what constitutes a health service

In Ireland I don't know why there is not universal healthcare ? I don't understand what the point is paying insurance when it does not seem to afford one better care and you still have to pay your GP for every visit . Would it not be better to invest that money in a national healthcare system

and before everyone slags off the NHS it is actually a very good system but not perfect (which is ?) And from my experience of both systems I would definitely prefer to be sick in the UK than in Ireland . There are certainly more accountability and watchdogs in the NHS (England) system. (Health decision making/budgets have been devolved).Plus there is more investment ..just this year alone another 2.5 billion increase in the budget above that already planned

One issue that can help is more community clinics that are open 7 days a week that help with more minor injuries , provide more comprehensive primary care and provide step down facilities for elderly patient who may not need to stay in a hospital but cannot be discharged because there is no where to put them. I did a report in North London about 4 years ago on elderly admissions and about one fifth were minor injuries, UTI, dehydration, confusiion, falls,etc for elderly with long term conditions like dementia . They did not clinically need to be in hospital or if they did they didn't need to stay long...but many stayed a long time as they had no where to go

Baron Darzii ( A Labout peer in the last government and a surgeon trained at Trinity college Dublin) had developed plans in redevelopment of the NHS including developing community care clinics that could provide 7 day primary care and minor surgery along with centers of excellence for severe conditions that seemed to me to be quite good but Tories got in and scraped them as not theirs.Only now are they looking at them again.

I am not sure how much consecutive Irish governments have invested in healthcare but it does not seem enough. they seem very behind the curve. There seems to be alot of stop gap thinking. When me and my Irish friends retire we would would like to return to Ireland but I am not sure if I could afford to live in Ireland given the state of the heath care service and given I would have a free and better service in England

FortySeven

@MPFGLB

I would say the NHS is the standard all nations should aspire to, coming to Ireland from the UK was a real eye opener when it comes to healthcare.

I am from Scotland and have seen the personal care provision with my Grandparents and while there are questions about its funding sustainability it certainly seems to be a much improved system of dealing with elderly patients. Is this something you would advocate as a way forward for England? It seems to go some way towards easing the strain on the hospital floor. Prevention is better than cure.

My own ideas are based around this very tenet.

Personal care of the elderly in home as much as possible with primary care centers for more pressing requirements and hospital as a last resort.
A change in drug policy to effectively decriminalise drug use and target the funds freed up through crime reduction etc to specialist drug and alcohol addiction units where heroin for example can be administered in a controlled environment. This would also allow contact for rehabilitation over time and reduce od, amputations, hepatitis and other associated conditions currently causing issues.

I think these two policies alone would reduce patient numbers massively and provide healthcare on a social level and move it away from a last resort reactionary system.

topmanamillion

For anyone that thinks the solution to trolleys in A&Es is opening more beds, which is the main part of Varadkers masterplan, I say it's nonsense.

You can open all the beds you want. If there's no front line staff to look after the people in those beds all you're doing is swapping a trolley for a bed with no improvement in care.

It also reminds me of a trick Harney used to pull when she would visit A&Es. Any trolleys would be immediately moved upstairs to bed wards before she arrived.

If I had the choice of decent care on a trolley for myself or my loved ones or inadequate care from over worked staff in a bed, well sign me up for a trolley.

It's also worth noting many of the "trolleys" are the same as the beds in bed wards.

The problem stems from the cronyism and top heavy nature of the HSE. While I wouldn't like to see redundancies I believe simple things like certain qualified medical and health care staff in managerial positions being contractually obliged to work a set amount of hours in the front line would be immensely helpful. Taking very well qualified people out of offices and meeting rooms and back on to wards.

More longterm - Forget embargos on recruitment. Freeze all promotions within the HSE for a set period in order to facilitate dissolving made up roles which were invented when the health boards were emalgamated. It may take decades but surely a plan to shave the top heaviness of the HSE in whatever time frame would be welcome.

Increase responsibility within these management roles and make salary partly dependent on meeting targets. Currently there is no responsibility within the HSE from management. A ward/department manager either medical or health care can claim they have no influence on wastage and it's impossible to find a Manager who's responsibility it is. Well, give them the power to have an influence and reward/penalise them when they succeed/fail. Link their success and failure to the budget they are given. If it costs xmillion euro to run a department (HIQA well helpfully provide this figure) and the budget given is less than this,then their success and failure will be measured accordingly. No more bonuses for bonuses sake.

It's the government's job to tackle employment wastage and hospital managements job to tackle day to day wastage.

Responsibility, it's a wonderful thing.

Nichard Dixon

Abby19 wrote: »

Quote:
You'd wonder further if the tests/scans were available as routine for hours outside 9-5. I've worked in a large Dublin hospital where I've had to refer patients for admission at 6pm because I cannot get the CT scan they need because radiology is closed. They then languish on a trolley for upto a few days


This is lunacy - hugely expensive machinery and highly qualified staff being under-used because of 9-to-5-no-weekends working hours.

This is exactly the issue. In Ireland the thinking doesn't rise beyond we are saving money by having as few radiologists as possible (and other similar jobs). But this lack of radiologists means far more money is wasted in delay. If you had radiologists 24/7, even if they weren't flat out all the time, then the time of the rest of the hospital would be better used treating people in a timely way rather than having them waiting.

Vorsprung

My original point about scanners lying idle wasnt intended to imply an extension to 24/7 working, but I don't think 8am-8pm working is unreasonable,particularly during the week. This would free up slots for outpatients too. For routine non contrast scans (eg CT, MRI), you don't need a radiologist present. Extend this to weekends say 9-5 and you start to see improvements in waiting times for scans, though admittedly you might potentially find a delay further down the line in a patient's journey through the treatment process. Hiring radiologists is a matter of will as described above.

This is only a small part of the inefficiency in the system!

MPFGLB

FortySeven

Yes I am all for personalized care . It makes sense but has to start with primary care being more pro active & stronger, including better community care. Personalized care is so important when dealing with multiple long term conditions that I see my aging relatives starting to develop. (and they live about 60 miles to the nearest hospital)

Of course strong investment in public health is key to prevention .But governments tend to ignore or under invest in public health. That mostly because they are only looking for short term fixes that bring them up to the next election.

And then there is accountability and patient management . I do think that has not being developed in Ireland to the extent that is required.

For instance my mother ended up on A/E trolley for 2 days last year ....until she was finally admitted and correctly diagnosed. She had been going to her doctor for over a year. This doctor together with a colleague saw her at least 30 times but did not diagnose her nor refer her for diagnosis . They just kept giving her antibiotics until the point she was so sick there was no where left to go but A/E and even then she didn't want to go. If she has been diagnosed and manged better on an outpatient basis she would never have ended up in A/E. She has switched doctor now and has better care. But the previous doctor and colleague continue to mismanage patients without any accountability (its a small community and everyone knows what they are like. I really think both these doctors add to the burden on the nearest A/E)

Qualitymark

Vorsprung wrote: »

My original point about scanners lying idle wasnt intended to imply an extension to 24/7 working

Not full-time, but it surely makes sense to have - as you say - the scanners fully staffed from 8am to 8pm, and to have a skeleton staff, rotated from among the general scanner staff, working outside those hours. How many people die because there's no scan and no X-ray to show what's going wrong at 3am on a Saturday morning?

Is it still the case that X-rays are carried from department to department and hospital to hospital rather than being emailed (with the patient and GP getting a copy to lessen the possibility of errors of identification - the wrong patient's X--ray being sent)?

bob50

Firstly I would open a urgent care centres these are similar to whats available in England

They can deal with cuts, bruises, colds sprains flus etc

Theres no need to go A&e with these problems imo this would take most of the pressure of the A&E depts.

Secondly for people who are arrive drunk into a/e put portacabins alongside a/e depts. with matressess so that they can sleep it off after been triaged I know some people who could be very ill who arrive in drunk and they would have to be seen in the a/e

Vorsprung

Qualitymark wrote: »

Not full-time, but it surely makes sense to have - as you say - the scanners fully staffed from 8am to 8pm, and to have a skeleton staff, rotated from among the general scanner staff, working outside those hours. How many people die because there's no scan and no X-ray to show what's going wrong at 3am on a Saturday morning?

Is it still the case that X-rays are carried from department to department and hospital to hospital rather than being emailed (with the patient and GP getting a copy to lessen the possibility of errors of identification - the wrong patient's X--ray being sent)?

Plain Xray radiographers are available 24/7 in most hospitals. Scans are available after hours in emergency cases, that isn't a problem in most cases and involves a discussion with the on call radiologist before he/she and the CT radiographer come in. These guys have a specialist CT qualification so there is only a specific pool of them available. Ultrasounds are rarely needed on an emergency basis. MRIs are a problem, I've never seen an out of hours one done in Ireland. My points are in relation to patients who need urgent (ie admitted patients) but not emergent scans and those outpatients who would be in a position to come somewhere from 5-8pm or at weekends.

A new national imaging system (NIMIS) has been largely rolled out amongst public hospitals which negates the need for films to be taxied from one hospital to another. Still an issue with the private facilities, I'm not aware that there's a plan for them to come on board. I **think** GPs are due to come onto NIMIS; I'm fairly sure most departments communicate radiology reports via Healthlink. Both systems are due to be incorporated into the national electronic health record system which is coming up to the tender stages.

Qualitymark

bob50 wrote: »

Firstly I would open a urgent care centres these are similar to whats available in England

These are already available for the rich, though last time I heard, the hospitals would refuse to accept their X-rays if they sent a patient in with a break, etc, so the unfortunate patient would have to go and get nuked again in the hospital…

Secondly for people who are arrive drunk into a/e put portacabins alongside a/e depts. with matressess so that they can sleep it off after been triaged I know some people who could be very ill who arrive in drunk and they would have to be seen in the a/e

Only trouble with this is that having a few drinks can mask serious stuff. (Some years back I rushed to support a man who was going down on one side with every step outside one of those private clubs in Stephen's Green; to my amateur eye he looked as if he was having a stroke. He gestured at the club and I helped him in, and tried to tell the staff of my worry. They grabbed him and disappeared with him, and basically booted me out; my impression was that he was a regular drunk, and probably someone famous in politics or something like that. Always wondered what happened to the poor little soul.

But yes, drunk tank hospitals should certainly exist; there's a hospital regularly used for drunks from the Holyhead boat - they have it set up with drips and all to rehydrate the creatures as they're fed in off the boat. Apart from anything else, it would be a good way of getting drunken and druggy people into the system for help with their addictions, and probably a salutary shock to those who don't think of them as drunks or druggies.

j.mcdrmd

FortySeven wrote: »

Definitely not hamming it on the scale of the IFA for example.

Have you heard of a guy called George McNeice?

He tried to take 25 million, from the Doctors in the IMO, off the back of a smaller membership than the IFA had.

FortySeven

j.mcdrmd wrote: »

Have you heard of a guy called George McNeice?

He tried to take 25 million, from the Doctors in the IMO, off the back of a smaller membership than the IFA had.

No, but I have now, what a scumbag! Still, the reports I read seem to indicate more reasonable remuneration packages are in place now. That's a positive.

Abby19

Qualitymark wrote: »

Not full-time, but it surely makes sense to have - as you say - the scanners fully staffed from 8am to 8pm, and to have a skeleton staff, rotated from among the general scanner staff, working outside those hours. How many people die because there's no scan and no X-ray to show what's going wrong at 3am on a Saturday morning?

Is it still the case that X-rays are carried from department to department and hospital to hospital rather than being emailed (with the patient and GP getting a copy to lessen the possibility of errors of identification - the wrong patient's X--ray being sent)?

Vorsprung wrote: »

My original point about scanners lying idle wasnt intended to imply an extension to 24/7 working, but I don't think 8am-8pm working is unreasonable,particularly during the week. This would free up slots for outpatients too. For routine non contrast scans (eg CT, MRI), you don't need a radiologist present. Extend this to weekends say 9-5 and you start to see improvements in waiting times for scans, though admittedly you might potentially find a delay further down the line in a patient's journey through the treatment process. Hiring radiologists is a matter of will as described above.

This is only a small part of the inefficiency in the system!

I do like the idea of running machines for longer, but that would bring its own problems. Out of hours there is an on call rota for running the scanners, and reading the scans as there is an on call rota for pretty much all frontline staff, so yes there is 24/7 cover for emergencies.

Running the machines themselves will increase throughput. But the scans themselves need to be reviewed and reported a radiologist. Lots of plain films can be read at the time, but CTs and MRIs - yeah you should spot barn door stuff, but the more nuanced changes? There are is a delay as it is getting scan reports when the machines are run 9-5 routinely (average 8 hours), and emergency scans out of hours. If increased to 8-8, that is a 50% increase, so 50% more scans that need reporting in a system that is struggling at the moment. So will merely push the bottleneck to the reports from getting the scans.

You can get verbal reports on emergent scans, but for most scans the official reports take longer.

A radiography degree is 4 years (I am not sure of professional training after this). A radiologist has a medical degree (5-6 year undergraduate, 4 years postgraduate with a 3-4 year primary degree minimum), intern year, usually 2 years basic specialist training and then has professional training in radiology and professional exams - 5 years, so it takes a minimum of 8 years post graduation from medical school to be eligible to apply to for a consultant post.

Abby19

FortySeven wrote: »

What would be your opinion on this background army of people who organise the day to day functions. My own dealings with various offices, making appointments, reporting for appointments etc have been largely negative experiences, some shambolic and some just downright difficult. Do you see this in your work and what do frontline staff make of it ?

For example, I know how important it can be to cancel appointments rather than not show therefore allowing for someone else to use that time but when I tried to do this by calling the number provided on my letter, it just rang out. I'm a persistent person and I rang that number all day with no response. It meant I missed an appointment and was returned to the end of the waiting list with Neurology. There seems to be a culture of apathy in these offices, I have stood there at the window with an office full of people, some having the craic while the phone rings constantly and the queue is epic yet there is no urgency with these people, they seem to operate in a different time metric. Does this sound about right to you and do the frontline staff not find this infuriating?

I can't speak about the entire system, but here is a bit of detail about appts and the clerical staff who make/manage them.

A consultant's OPD clinic usually has a consultant and a number of NCHDs seeing patients. Busy clinics can see well over 50 patients in a morning or an afternoon.
The pt may be seen, sent for scans/tests and then seen again the same day once these are done.
There may be a number of clinics in the week, e.g. a couple of mornings or afternoons or a combination. Each consultant tends to have a secretary. That secretary has to pull all the charts for those clinics. And remember these are paper charts. And if they aren't in the regular storage area they have to go chasing them. Some patients have multiple co-morbidities, so are seeing multiple services so their charts could be in use elsewhere. Or someone has pulled their chart for a review to understand their case better, or for research. Patients can have multiple volumes, and all volumes should be available in the clinic as you don't know if you need to reference historical data.
On clinic day they check in the patients, make any follow up appts. Afterwards depending on the facility they may have to type up all the clinic letters that have been dictated. They will be contacted to make follow up appts on pts on discharge. They make appts as directed from the referral letters sent in by GPs or other consultants. They field calls from pts wondering where they are on the waiting lists, needing to reschedule appts because the date doesn't suit, or last minute cancellations.
Some have voicemail set up. This can fill up within a day.
Some have a policy of not having voicemail so that people have to try again so they can try and sort them out on the spot when people do get through, as it may be too difficult to make out what pts are saying in their message, but the pt may assume everything is sorted simply by leaving the message.

You mentioned you tried to ring in and cancel your appt. How close to your appt was this? Was it the day of the appt? Did you just try on the one day or did you ring back another day? They could have been sick/on holiday/pulling charts/running a clinic/or simply job sharing and working part time.

Not having a go but trying to better understand your situation and also giving you a better idea of what goes on behind the scenes.

As for clerical staff joking with one another - why shouldn't they be allowed do that in their workplace? Do you chat and joke with your colleagues? Humour can be a helpful coping mechanism in a stressful situation. I remember State Pathologist Marie Cassidy making a similar comment when someone commented on how she appeared to be inappropriately cheerful at murder scenes. You mentioned waiting in a queue to check in. Well once you check in you'll probably be waiting to see the doctor/healthcare professional, so it simply moves the queue along but does not actually delay being seen in the clinic itself.

Lastly clinics are deliberately overbooked to allow for a % of no shows. Or all the last minute urgent cases that have to be seen within a set period, so squeezed in regardless of how many are there to start with. As an NCHD in the morning seeing the clinic list you sometimes pray for a few no shows or you know you'll be running late working through most or all of your lunch and be lucky to grab a few minutes to grab a bite and some caffeine to survive the afternoon clinic.

Whatever about no shows at clinic, what _really_ annoys me are no shows for procedures. And knowing theatre and staff are under-utilised because someone didn't show and didn't cancel. There is a waiting list, and people can be called in on a days notice depending on procedure, their health status and availability.

FortySeven

@abby19

I had to cancel on the day due to my colleague having a death in the family, there was no way I could take the time I had allotted.

I appreciate the informative post, I was not impressed with the attitude of the staff if I am honest. I work a very stressful, fast paced job and we work at speed and it is very difficult. There seems to be only one gear for workers in government departments but I suppose I would prefer to work like that too and the private sector is probably not the best comparison. While the consequences of getting something wrong in my workplace have serious knock on ramifications throughout businesses in the region I suppose there is not the same threat of lawsuits and of course the real risk of affecting someones health or worse.

I will try to be less judgmental going forward.

Qualitymark

How much consultation is there between the Department of Health/Minister for Health and the people working at all levels in hospitals and GP surgeries, and indeed with patients, in working to end this crisis?

Dr.No

As others have stated alcoholics and drug users make up a small number of patients coming
to ED. They may be seen as time wasters but they require care and treatment just like everybody else. The majority of patients in ED are elderly. The average age of ED patients in the hospital I work in for example is 74. Many of these have multiple medical problems.
There is no easy answer to solving the crisis in healthcare. In the UK, with which I am more familiar, winter pressures are now extending into the summer. It is easy to suggest increasing hospital bed capacity but that doesn't solve the problem as we want to keep people out of hospital.

tayto lover

No need to build or open new care centres. Just use the existing run-down hospitals. Loads of them all over the country - Louth County, Monaghan, Navan, Roscommon etc etc

Qualitymark

Another report today complaining about filthy hospitals

http://www.irishtimes.com/news/health/tallaght-hospital-told-it-must-do-more-to-prevent-c-diff-1.2451420

Despite the implementation of control measures, inspectors who visited the ward in September found brown staining on the under surfaces of commodes, which they said was of particular importance in controlling transmission of the superbug…

Hiqa recommended recommends the hospital carries out an immediate deep clean of the unit and reviews the systems for maintaining the physical environment and all equipment

Vorsprung

Abby19 wrote: »

Running the machines themselves will increase throughput. But the scans themselves need to be reviewed and reported a radiologist. Lots of plain films can be read at the time, but CTs and MRIs - yeah you should spot barn door stuff, but the more nuanced changes? There are is a delay as it is getting scan reports when the machines are run 9-5 routinely (average 8 hours), and emergency scans out of hours. If increased to 8-8, that is a 50% increase, so 50% more scans that need reporting in a system that is struggling at the moment. So will merely push the bottleneck to the reports from getting the scans.

Last comment I'll make on imaging. Agree, but as I suggested before,hire more radiologists. We have enough of a throughput of SpR on schemes around the place. It costs money but does not require a 50% increase in radiologists. It is not a bad investment. I suppose there's a list of priorities the length of an arm going around.

echo beach

There isn't an easy answer to this complex problem. The aim has to be to keep people out of hospital and away from A+E which is obviously easier said than done.
One part of the problem is those who are frequently admitted to hospital, often only shortly after being discharged. Their families will tell you that the person was 'sent home too soon'. The transition from 24 hour care in an acute hospital with full nursing care and medical care up to consultant level to a situation where the only support is from over-stretched GPs and PHNs is too drastic for some.
I would suggest a system to identify these people, say anybody re-admitted within 3-4 months. Have an intensive process trying to find out exactly why the patient had to come back into hospital and if, with the benefit of hindsight, it could have been prevented. Then avoid sending the person back home to the same conditions that will almost certainly result in the same outcome, readmission.
Concentrating resources on these patients (sometimes called rather unkindly 'frequent flyers') and following up to see if it helps might be better than a scatter-gun approach of spending money without knowing if it delivers results.

Gael23

The focus needs to be on keeping people out of hospital. Primary Care needs resources to do that.
As has been said, something needs to be done to fast track the fair deal scheme, there's elderly people in hospital beds for weeks that can go to a nursing home.
Stop increasing private health insurance, that way some patients taking up beds for elective procedures in public hospitals can go to a private one.

ants09

1- stop the agency workers,
2- make redundant any staff that's incompetent or abuses there position.
3- hire competent staff
4- renegotiate costs, as in medicine's, materials, etc
5- transfer patients to hospices that can be transferred.
6- **** the unions, they either work with me or else if there members go out on strike give them there p45.
7- no worker can double job.
8 - show the workers it can work, but they have to work with me.
9- any staff that has suggestions on improvements listen too and implement if good.
10 - bring in my own people to implement my ideas in each region
11- do away with committes and departments that don't contribute to the health service.

Qualitymark

People who are experts, a question - how do the 'Primary Care Centres' work? (What a terrible, blurry name - couldn't they have thought of a more defining name? Primary care might be anything from a creche to a canteen.)

Heard about one in Wicklow, where apparently locals can go for all sorts of tests rather than going to the hospital; it seems to act as a kind of triage service for the hospitals - but maybe I have this wrong.

How do they work in terms of public and private treatment? What's available in them? Who sends patients to them?

And how many are there, and to what standard, and where?

Abby19

To all who have commented above to hire more consultants. Please check out this page. And note the number of ads with 'extended closing date', 'further extended closing date' and 'immediate filling. http://www.hse.ie/eng/staff/Jobs/Job_Search/Medical_Dental/Consultants/?pageNumber=1

In February this year there were 325 consultant vacancies http://www.imt.ie/news/latest-news/2015/02/consultant-vacancies-abnormally-high.html

People are not applying for these posts. They could be in a smaller peripheral hospital so could be signing up for a 1 in 3 or 4 call. (For non-medical people that means they are on call every 3rd or 4th 24 hour period. They have to be available at the end of a phone for questions and come in to the hospital if the patient is unwell, every patient that was admitted to the hospital under their speciality in that 24 hour period is their responsibility and they would be on call every 3rd or 4th weekend, so from Friday 4pm to Monday 9am, they provide that same cover.) And then they'd be on a significantly lower salary than their existing colleagues on the older contracts. Equality legislation states equal pay for equal work. And working conditions (and pay) are better overseas. Ireland is competing with other english speaking countries for a small pool of well trained specialists, eg, America, Canada, Australia, NZ, the UK.

The majority will have worked overseas on a fellowship on completion of their specialist training to gain further experience. The conditions here don't seem to be very successful at enticing them back.

Kurtosis

Gael23 wrote: »

The focus needs to be on keeping people out of hospital. Primary Care needs resources to do that.
As has been said, something needs to be done to fast track the fair deal scheme, there's elderly people in hospital beds for weeks that can go to a nursing home.
Stop increasing private health insurance, that way some patients taking up beds for elective procedures in public hospitals can go to a private one.

Agree fully with your first two points, illustrates that the trolley crisis is a symptom of problems in the health service as a whole.

I have to disagree on the third though, more on a philosophical level. While it would undoubtedly help reduce overcrowding, it would be counterproductive to the policy of trying to eliminate the two-tier system by introducing universal health care. Obviously the government only has finite funds to spend on health and in order to ration these we get a situation where there is a queue or waiting list for services. One example is in A&E where there is a fairly literal queue though with prioritisation based on seriousness. Another is hospital waiting lists for procedures, again with some prioritisation through the Special Delivery Unit (and formerly the NTPF). Obviously, with private health insurance one can also avoid the waiting list, which in my opinion is a very unfair situation. That's why I'd disagree with facilitating the current inequality in access to procedures in order to relieve a fairer form of queuing.

Abby19

Qualitymark wrote: »

People who are experts, a question - how do the 'Primary Care Centres' work? (What a terrible, blurry name - couldn't they have thought of a more defining name? Primary care might be anything from a creche to a canteen.)

Heard about one in Wicklow, where apparently locals can go for all sorts of tests rather than going to the hospital; it seems to act as a kind of triage service for the hospitals - but maybe I have this wrong.

How do they work in terms of public and private treatment? What's available in them? Who sends patients to them?

And how many are there, and to what standard, and where?

I can answer some of your questions.
Primary Care as in first level of care, in Ieland basically means care in the community. Secondary care is typically in a hospital, many of them the smaller hospitals around the country. Tertiary care are basically larger hospitsals, those with specialist care, or centres of excellence, many of these would be the cancer/research centres and mainly located in the large cities, eg Portlaoise and Mullingar have paediatricians, but Crumlin or Temple St are the main specialist centres, eg cardiac go to Crumlin, metabolic disorders go to Temple St. Based on better outcomes when care standardised with greater numbers if the same conditions.

Primary Care centres were proposed by the HSE where you get a number of community based specialities together in a single location. Eg GP, physio, chiropodist, dietician, Public health nurse all in one location. Maybe the physio/chiropodist/dietician only there a set number of days per week/month.
Any GP should be able to refer there (I stand to be corrected in that one though).
They can have multidisciplinary meetings to discuss complex cases to ensure best treatment for their patients. Possibly CWO may be involved.
Was talking to one GP linked to one and it had been working grand when initially set up, but then when members of team left they weren't replaced. So services available may vary.
My understanding was the GP was still self employed and claiming from the HSE for any GMS services supplied, but that the remainder were HSE employees.

How many there are I don't know

Qualitymark

Ah, thanks. Kind of like the French version, except in France the primary care centres also have laboratories that do blood testing, X-rays, etc, and as far as I know you can walk in off the street to them, as you can to specialists in France, without being referred by a GP.

Abby19

Qualitymark wrote: »

Ah, thanks. Kind of like the French version, except in France the primary care centres also have laboratories that do blood testing, X-rays, etc, and as far as I know you can walk in off the street to them, as you can to specialists in France, without being referred by a GP.

Let's not mention the war that is blood testing!?!?

According to GPs the GMS was set up as an acute medical service, but they have been asked to take on a lot of chronic care in community. After getting their gross income cut by 40% (think about how much their net income has been cut as they still have to pay heat, light, mortgage/rent, rates, receptionist, nurse, cleaner, etc.) The rural Practice allowance has been cut so smaller rural practices are not viable (I think a number are running on permanent locums as they are quite simple not financially viable) And mileage to visit patients for house calls removed. These also have an effect on the ability of older more infirm patients being able to remain in their homes.
The under 6 contract so that there is less time to see older sicker patients.

HSE is required to have free blood testing facilities, they do have free phlebotomy services, at the local hospital. However this may not be convenient for patients, as your local hospital may be over an hour away. HSE expects GP to just do these bloods for free. GPs feel they are providing service that they are not contracted to supply so charge patients. Some patients complained and HSE deducted cost from GPs. And the HSE have helpfully added that they are looking to negotiate a new contract with GPs.

Gael23

penguin88 wrote: »

Agree fully with your first two points, illustrates that the trolley crisis is a symptom of problems in the health service as a whole.

I have to disagree on the third though, more on a philosophical level. While it would undoubtedly help reduce overcrowding, it would be counterproductive to the policy of trying to eliminate the two-tier system by introducing universal health care. Obviously the government only has finite funds to spend on health and in order to ration these we get a situation where there is a queue or waiting list for services. One example is in A&E where there is a fairly literal queue though with prioritisation based on seriousness. Another is hospital waiting lists for procedures, again with some prioritisation through the Special Delivery Unit (and formerly the NTPF). Obviously, with private health insurance one can also avoid the waiting list, which in my opinion is a very unfair situation. That's why I'd disagree with facilitating the current inequality in access to procedures in order to relieve a fairer form of queuing.

You are right. But what you suggest is the ideal solution, which the government won't have to funds to implement anytime soon. With that considered, I think taking private patients out of the public system is the next best thing.

Qualitymark

Gael23 wrote: »

You are right. But what you suggest is the ideal solution, which the government won't have to funds to implement anytime soon. With that considered, I think taking private patients out of the public system is the next best thing.

Perhaps if private patients were taken out of the public system, and public funding were removed from private treatment, the expense would be such that private patients would demand a fully private system?

sdanseo

Stop giving medical cards to people who don't need them.

My Granny is 89, and often makes the point. She gets free travel, free GP care, free healthcare of all kinds in fact. She could afford and would be delighted to make a contribution the the cost - a senior's rate, rather than totally free - when she goes up to the doctor or takes the bus.

I agree with state benefit as a bar below which no one can fall, but the opposite also applies. No-one should be propped up above the bar when they can support themselves. All of this stuff needs to be means tested.

I like the point about the €100 charge for A&E being extended to medical card holders but perhaps have a check and balance here so that people who genuinely needed hospital treatment don't pay when they can't, maybe have the A&E consultant sign off that hospital treatment was required as opposed to a GP, etc.

Gael23

Qualitymark wrote: »

Perhaps if private patients were taken out of the public system, and public funding were removed from private treatment, the expense would be such that private patients would demand a fully private system?

Theoretically yes. But that would result in a huge hike in insurance premiums which would be counter productive.

Wibbs has it best. Sprains and fevers and cuts go to GP. Also, double the prices at vending machine for everything except water. People with private insurance should not have to be in public beds.

Qualitymark

sdanseo wrote: »

My Granny is 89, and often makes the point. She gets free travel, free GP care, free healthcare of all kinds in fact. She could afford and would be delighted to make a contribution the the cost - a senior's rate, rather than totally free - when she goes up to the doctor or takes the bus.

There is absolutely nothing stopping your granny from buying a Leap card and using it if she feels this way.

topmanamillion

[Deleted User] wrote: »

Wibbs has it best. Sprains and fevers and cuts go to GP. Also, double the prices at vending machine for everything except water. People with private insurance should not have to be in public beds.

You do realise sprains need to be xrayed to rule out a break?
Fevers can be a symptom of anything from the flu to meningitis.
Cuts or wounds can occasionally require specialist treatment.
Essentially each case is dealt with on an individual basis.
I don't believe any GP is referring people with scuffed knees to A&E departments!

I don't know what you hope to achieve by doubling the price of Mars bars and tayto which are already about twice as expensive as retailers.

sdanseo

Qualitymark wrote: »

There is absolutely nothing stopping your granny from buying a Leap card and using it if she feels this way.

Have you ever tried teaching an elderly relative how to use technology? :rolleyes:

topmanamillion

topmanamillion wrote: »

You do realise sprains need to be xrayed to rule out a break?
Fevers can be a symptom of anything from the flu to meningitis.
Cuts or wounds can occasionally require specialist treatment.
Essentially each case is dealt with on an individual basis.
I don't believe any GP is referring people with scuffed knees to A&E departments!

I don't know what you hope to achieve by doubling the price of Mars bars and tayto which are already about twice as expensive as retailers.

Let the GP decide if patient needs to go to hospital. Simple!

The snacks are unhealthy but can raise a little extra revenues by charging more.

Qualitymark

sdanseo wrote: »

Have you ever tried teaching an elderly relative how to use technology? :rolleyes:

Speaking as that elderly relative, I'm often the one teaching my juniors how to do it. But anyone who regards a Leap card as 'technology' but wails at using a free travel card is certainly beyond help If the granny doesn't feel she should use her free travel card, buy her a Leap card for Christmas, put €20 credit on it, and walk her down to the local shop to show her how to buy another €20 worth when she needs it.

As for raising the prices in vending machines, I'm puzzled as to how that would help to reduce the number of people on trolleys. Is this purely a punitive attitude - "The trouble with the poor is that they have too much money"

As for the horror of pwivate patients having to soil themselves by being accommodated in pubwic beds - Oooh! I'll catch something! - the mind boggles.

j.mcdrmd

Abby19 wrote: »

To all who have commented above to hire more consultants. Please check out this page. http://www.hse.ie/eng/staff/Jobs/Job_Search/Medical_Dental/Consultants/?pageNumber=1

I looked up a contract for a Consultant Doctor, randomly, it seems to be for 39 hours per week.
http://www.hse.ie/eng/staff/Jobs/Job_Search/Medical_Dental/Consultants/PBGMCA01.html

My question is, does anyone have any idea how that is supposed to work given this?

Abby19 wrote: »

every patient that was admitted to the hospital under their speciality in that 24 hour period is their responsibility

And this?

Abby19 wrote: »

And then they'd be on a significantly lower salary than their existing colleagues on the older contracts.

Abby19

j.mcdrmd wrote: »

I looked up a contract for a Consultant Doctor, randomly, it seems to be for 39 hours per week.
http://www.hse.ie/eng/staff/Jobs/Job_Search/Medical_Dental/Consultants/PBGMCA01.html

My question is, does anyone have any idea how that is supposed to work given this?

Originally Posted by Abby19 View Post
every patient that was admitted to the hospital under their speciality in that 24 hour period is their responsibility

And this?

Originally Posted by Abby19 View Post
And then they'd be on a significantly lower salary than their existing colleagues on the older contracts.

I'm an NCHD - so that is how I have seen teams and call work.
Did a bit of googling and here is the contract itself - goes into a fair bit of detail so I won't try and summarise. Happy reading!

http://www.hse.ie/eng/staff/Resources/Terms_Conditions_of_Employment/ccontract/ccontract2008081214.pdf

The post you listed was split across 2 hospitals, so probably complicating call further.

How it works in individual consultant cases I don't know, e.g. overtime, time in lieu,etc, I don't know. But there are usually a number of consultants per speciality and they divide calls between them. Smaller hospitals have less consultants, so more frequent call, so less attractive.
But I do know some of the surgeons whose teams I've been on have been called in during the wee small hours to operate on complex cases, and still round in the morning. And as a student I was with a surgical team who had a complex case that started at ~2pm, I left around 6pm, it finished at 2am, but they rounded as usual at 7:30am the next day.
Consultants on call also round on weekends and give directions to the nursing staff and the NCHDs on duty over the weekend. They tend to do this outside of visiting hours so families don't tend to see them.

Regarding the different payscales for new entrants - there's a lot in the media about that over the past few years and is reported to be a significant factor on the low numbers (or no) applicants for open posts.

Kurtosis

Gael23 wrote: »

You are right. But what you suggest is the ideal solution, which the government won't have to funds to implement anytime soon. With that considered, I think taking private patients out of the public system is the next best thing.

That is true, I would just hate to see money being spent on changes which would further solidify the two-tier system which would then have to be undone later to implement UHC, particularly when there are other changes that could be made that would at least keep health system reform moving in the one direction.

The issue of lack of funds for implementing reforms was touched on by the Director General of the HSE in the last few days (HSE running just to stand still, with plan based on false economy). Good to see it being recognised that improving the health service does require some investment.

Qualitymark

Abby19 wrote: »

To all who have commented above to hire more consultants. Please check out this page. And note the number of ads with 'extended closing date', 'further extended closing date' and 'immediate filling. http://www.hse.ie/eng/staff/Jobs/Job_Search/Medical_Dental/Consultants/?pageNumber=1

In February this year there were 325 consultant vacancies http://www.imt.ie/news/latest-news/2015/02/consultant-vacancies-abnormally-high.html

People are not applying for these posts.

Couldn't see any wage rates quoted on these…?

Graces7

Have been a little puzzled by some news items re patients on trolleys as I thought and think that that is so when patients are waiting for a ward bed? People seem to think that they are waiting to be assessed and treated? I was some hours on a trolley in A and E but was already on a drip and pain relief and in fact the trolley was far more comfortable that the bed later. Just one aspect that has puzzled me. I was referred by the GP by phone; he did not see me but assessed the need as needing an ambulance.