The current hospital / A&E crisis

maninasia · 10-01-2023 2:49am

https://www.boards.ie/discussion/comment/120087117#Comment_120087117

you missed his core point 'caps should have been removed on GPs'

It should be an open market, private operators should be able to open franchises across the country ,current system is dogshit and failing badly.

They cant keep up, won't keep up, time to completely revamp the system so people can actually see a doctor.

And its not like GPs are cheap either.

Doc07 · 10-01-2023 3:37am

https://www.boards.ie/discussion/comment/120088380#Comment_120088380

On ‘They cant keep up, won't keep up, time to completely revamp the system so people can actually see a doctor.’

Hard to argue with that, access needs to improve. I would think ‘caps’ only refer to practices having medical card lists but private work is not restricted as in I’m not aware there is any cap on qualified GPs or even a private primary care franchise as you say, opening private facilities.

ILoveYourVibes · 10-01-2023 3:41am

I don't know whether I should say this.

But I will.

But i had a kidney infection that I only managed to get rid of coming up to christmas ....it took three months to get rid of it.

I asked my GP to maybe ring into the pharmacist ahead of christmas incase it came back to have a standby course of anti biotics (it was something the other gp in the practise suggested). He said oh no ..dont worry if it comes back we will just send you to A& E over the Christmas they have everything there etc.

My GP was going to send me to A& E for a complex UTI. 😐️

That is nuts.

I didn't go ..cuz im sane.

Also i got the TINIEST bit of bleach in my eye during covid lockdown ..GP and a pharmacist BOTH insisting i go to A&E ...I did. I wasted people's time in there they just gave me eye drops I felt so embarrassed.

Now I go to a laya dr during weekends ..its ok. Faster than A& E obv you have to be with laya and pay though.

I have always wondered if there is a bias. Oh you seem super fragile get yourself to A&E ....

10-01-2023 3:58am

A&E is like the magic dumping ground for all things. My elderly relative was referred to A&E by her GP because she needed a routine X-ray! It should have been handled by an X-ray unit, instead she waited about 16 hours.

The scenario she was put though in a major hospital was so bizarre you couldn’t make it up. She was brought in for a minor procedure, which could have been done as an outpatient and ended up with a 3 week delay as an inpatient - for someone who simply didn’t need or want to be there. She was being delayed by a nightmarish internal bureaucracy and days turned into weeks! Everyone was doing their best but the shambles of an organisation couldn’t manage to communicate between people or departments, so nobody knew what was going on.

Meanwhile an elderly patient was being made feel she should be somehow grateful and being gaslit about the procedure being tomorrow, then the next day and so on…

The poor woman was nearly gone around the twist and is extremely active, outgoing and very competent and capable.

When she suggested going home, she was getting told then she might be waiting months to get the procedure… it was a Kafkaesque nightmare and I don’t think anyone knew what anyone else was doing, yet they were all doing their best.

In the meanwhile she was being given routine jabs of anticoagulants because she was in bed and she was terrified she might get COVID because she was in hospital and was using her own FFP2 masks.

In the end she went home anyway & came back in as an outpatient !!!!!????

If that kind of thing is going on throughout the system it’s no wonder we have massive issues.

ILoveYourVibes · 10-01-2023 4:22am

https://www.boards.ie/discussion/comment/120088411#Comment_120088411

I'm sorry about your relative. I hope she was ok. It must have been so stressful.

That reminds me I had a seizure a few years ago ...they made me stay in until I had the MRI scan ..which was NOT necessary because I was able to go back with my parents and the Doctors were told they would watch me like a hawk and i could go in later for the scan when it was available.

They kept me in hospital for EIGHT DAYS ..talking up a bed until the MRA machine was available. I have private insurance so my dad thought maybe it was just to get the insurance. But no it's hospital policy. But if you can go back home and someone is going to be watching you 24/7 why not? I can understand if you lived alone.

My was like look we are just taking her home this is ridiculous. But the doctors started to get really aggressive. The MRI by the way came back totally clear.

When they released me even though they then knew I was ok they told me it was hospital policy for me to go out in a wheel chair and made me do it. It was nuts. I bet someone else could have used that wheel chair. I was perfectly able to walk! My dad was laughing!

10-01-2023 4:26am

It was hugely stressful for her - luckily the ward situation meant there was no issue with visitors so we got into her every day for as long as we could reasonably hang out and brought her in home cooked meals.

The food was appalling.

It wasn’t as if it matters as she wasn’t being actively treated for anything anyway!

This was on the public system, so it wasn’t anything to do with insurance. They just seemed to not know what was going on and everything just drifts and drifts and drifts…

The worst bit is because it’s all well intentioned you feel you can’t complain …

On the private side (in a public hospital)

I remember going myself as a private patient to do a 24 hour BP monitor as arranged by a cardiologist. I turned up, expecting to be hooked up to a cuff and sent on my merry way - as I have done several times with GPs (you could nearly do it yourself it’s so straight forward) but I was ushered to admissions wondering why … that was followed by taking my insurance details and having me put sitting on a trolley in a day ward. A nurse then came out and put a BP cuff on me and I as given a cup of tea for some reason and then sent on my merry way and VHI got a fat bill for a day case!! I was going out thinking wtf was that all about … clearly €€€€€

From my point of view it was a totally wasted morning and pointless bureaucratic nonsense. From the system’s point of view it was the waste of tight resources and a bill being generated that could have been handled entirely in primary care or just done by a nurse in the cardiology private clinic.

What strikes me about Irish healthcare is there’s a lot of administration but very little management.

There’s also nobody looking after individual cases in hospital. You’ve a consultant who might as well be a freelancer and in a co-working office. Breezes in and out. The nurses do their best but seem to have no oversight role at all. So you end up being bounced around without any notion what’s going on and having to keep track of your own care yourself a lot of the time.

Seems GPs barely get kept up to date either - just the odd letter. They aren’t really in any position to monitor what’s going on or advocate for you.

Every patient should be assigned a case manager and every ward should have an active management team who can actually do things. They don’t seem to understand the what management is. It’s not just form filling and admin.

Gael23 · 10-01-2023 4:49am

What is happening in UHL is inhumane. It is depriving patients of the fundamentals of privacy and dignity in healthcare

10-01-2023 4:55am

What’s going on is an utter disgrace. It’s also not being solved and it’s been an issue for as long as I’ve been alive.

Even pinning it on individual ministers is pointless. I don’t agree with some of the way things were handled but it just seems like everyone who tries to fix it gets destroyed by it. I don’t think it’s going to change. The system chews up anyone who attempts to reform it and it’s looking like it’s literally so stuck in its ways that it likely beyond reform.

We need some far more radical reorganising and total restructuring of how sooo many things in health work and it’s going to take a political consensus and various issues with inertia, unwillingness to change and vested interests who are quite happy with it being how it is need to be just overridden. It cannot continue like this. It’s beyond the beyonds.

A lot of things need to be just disbanded and completely redesigned from the ground up.

Ireland has plenty of financial resources and the talent to do it. The fact that we don’t have a world class public health system at this stage is an utter indictment of this county. We should be utterly embarrassed by it. It’s absolutely shameful.

Dav010 · 10-01-2023 8:11am

https://www.boards.ie/discussion/comment/120088380#Comment_120088380

What caps are you referring to? What restrictions on opening practices.

The biggest issue facing patients is the lack of GPs outside of urban areas, rural GPs are closing their clinics/retiring and have no replacement, or, moving their clinics to larger towns and amalgamating with other GPs, I’m not aware of any cap that prevents a qualified GP from replacing a colleague or starting a new practice in any area where one is needed.

maninasia · 10-01-2023 8:18am

Expanding the free service in 2023 but no extra doctors!

What could go wrong. Bunch of clowns in government.

Also , believe me , urban areas dont have GPs either.

maninasia · 10-01-2023 8:23am

https://www.boards.ie/discussion/comment/120088492#Comment_120088492

You need to work on your manners mate.

Actually there are 3 major issues called out in the competition report.

One of the major ones seems to be accessing the medical card scheme for GPs who want to start a new practice.

Anyway, there certainly are significant barriers there.

https://www.google.com/url?sa=t&source=web&rct=j&url=https://www.ccpc.ie/business/wp-content/uploads/sites/3/2017/03/General-Medical-Practitioners-Report.pdf&ved=2ahUKEwiBtpmhu7z8AhWbBIgKHfFtA0gQFnoECAwQAQ&usg=AOvVaw3mSgzc0FatCx1V6WY6SvYE

Key findings

The Competition Authority has identified three factors that are having an impact on competition in GP services in Ireland:

1. Restrictions on the number of qualifying GPs;

2. Restrictions on advertising by GPs; and,

3. Restrictions on GPs wishing to treat public patients.

These restrictions are contributing to difficulties being experienced by patients - in terms of accessing regular GP services in

certain “blackspot” areas of the country and rising prices for private patients.

The cost of visiting a GP has risen rapidly in recent years, significantly outpacing the general rate of inflation in the economy.

There are indications that a substantial number of private patients are delaying GP visits due to cost factors and are “shopping

around” for cheaper consultation fees. The State paid an average of €65 for every GP visit made by a public patient in 2008.

In examining these issues, and engaging with those with the power to make reforms, the Competition Authority has identified

solutions to improve the supply of qualified GPs and facilitate informative advertising by GPs, and their implementation

has already been progressed. Training more GPs and allowing them to advertise will have a limited impact on competition

however, unless those GPs are able to get a General Medical Services (“GMS”) contract.

A GMS contract is very valuable to a GP practice; very few GP practices operate without one. The current GMS system

favours existing GP practices and protects them from competition from newly qualified GPs.

The restrictions on competition arising out of the GMS system affect both private patients and public patients.

• Both public and private patients have fewer GP practices to choose from, and

• There is less pressure on GP practices to compete on price for private patients and to be innovative in the service

they provide.

The impact of the GMS on private patients is often overlooked. It is assumed that “the market” will take care of them. This

ignores the fact that the market for private patients is itself significantly affected by the operation of the GMS. The GMS

system impacts directly on the commercial behaviour of almost every GP practice in the State, affecting decisions on where

GPs locate, the number of GP practices established, the nature of such practices and the profitability of individual practices.

This in turn affects the provision of services for private patients and indirectly in

maninasia · 10-01-2023 8:28am

Also.....apart from specifically mentioning more part time female docs...

''The path to becoming a GP in Ireland is much more structured than in the past. Doctors must now undertake four years of

specialist training in general practice before qualifying as a GP. As a result, the number of new GPs qualifying in Ireland is

dependent on the number of specialist GP training posts available, in a way that was not the case in the past. The number of

doctors being trained as GPs will need to rise substantially in the years ahead as a result of all these changes in the GP profession

and to cater for predicted population growth.

In examining the training of GPs in Ireland, the Competition Authority identified an issue that has historically impeded the

number of GPs qualifying in Ireland each year. Currently all training programmes for GPs require that all trainees complete four

years of training: 2 years of hospital–based training with some off-site training (“Phase 1”) and 2 years of GP practice-based

training (“Phase 2”). GP trainees receive a salary from the Health Service Executive (“HSE”) during each year of their training. No

recognition or flexibility is granted where a trainee has previously obtained equivalent relevant hospital-based training. Doctors with

previous training who obtain a place on a GP training course must often repeat training they have already completed.

The Competition Authority met the Irish College of General Practitioners (“ICGP”) in 2008 and argued that the requirement to

repeat training was costly, inefficient and ultimately was limiting the number of new GPs available to treat patients in Ireland. We

proposed that an alternative intensive course – a “Phase 2 Orientation Programme” - could be introduced as a fast-track option for

doctors who have completed relevant hospital-based training. It would allow doctors with prior relevant hospital-based training to

proceed directly to the in-practice phase of GP training. This Programme would be equivalent to the off-site component of Phase 1

of GP training and provide doctors with appropriate knowledge and orientation for general practice. This proposal was deemed to

be a workable solution by the ICGP.

There is general agreement that the recognition of prior relevant training would remove a bottleneck in the number of qualified

GPs Ireland can produce each year. Implementing the Competition Authority’s fast-track system for training GPs would help

alleviate predicted shortages in the number of GPs in Ireland, in an efficient and cost-effective manner. The issue of the funding of

additional Phase 2 GP trainee places is a matter under discussion between the HSE and the''

Dav010 · 10-01-2023 8:49am

That report was published in 2010.

Up to recent years places on the GP training schemes were actually under subscribed and went unfilled.

Since in was published, UL have commenced their post graduate medical course. The HSE is also no longer responsible for GP training, it is now overseen by ICGP, who have increased the places available by over 100 in 5 years, there are currently just under 1000 Doctors in the training scheme at the moment.

It is also worth noting that since that report was published, the HSE in March 2012 introduced an an open entry option for GMS contracts, any GP can apply by filling out the required application.

Newly qualified Doctors emigrating is a bigger problem that lack of undergraduate places in my opinion.

In relation to advertising, if clinics are at capacity, shopping around is not an option. Advertising prices has the effect of pushing prices up. If the demand is there, GPs can just check what prices others are charging and if theirs is lower, just put it up.

And again, as another poster said, there is no cap or restriction on GPs eligible to practice in Ireland coming here and opening a practice. There is no cap on a newly qualified GP taking up a position in a rural Practice where there may be greater need, they just don’t want to.

getoutadodge · 10-01-2023 11:34am

32 billion and counting... It wasn't that long ago that 32 B was the entire annual tax take of the state. Consultants are one of the richest cohorts in the country. I stumbled across them by chance in a Middle East Gulf resort many years back where they were on the annual foreign bash. The hotel in question was the plushest in town ...500 bucks per night...tax deductable no doubt.

NIMAN · 10-01-2023 12:11pm

https://www.boards.ie/discussion/comment/120088425#Comment_120088425

Nail on head. The problems aren't through lack of money. There is a lot of money being thrown at the problem, but its getting worse.

The health budget is €20bn+. I would say if it was increased to €40bn it still wouldn't be fixed.

Floppybits · 10-01-2023 12:37pm

https://www.boards.ie/discussion/comment/120089187#Comment_120089187

The problems are there are so many obstructions in the way like Public Service management, we have seen what Robert Watt has done to Slaintecare and how that has stalled, then there are the unions and then there is the actual HSE. A huge opportunity was missed to slim down the HSE back office when it was formed when Bertie Ahern said there would be no redundancies. In the private sector when companies merge there are always redundancies and opportunities for staff to either go or look to move to somewhere else.

Money is not really the problem either but its how it is dispersed, how much of the money actually gets to the services that need it by the time each group along the way have taken their cut. As I said in a previous post it seems Frontline services, I am not just talking Healthcare but all frontline services, have to fight tooth and nail for every penny but further up the chain there seems to be not shortage of money to be used up.

redlough · 10-01-2023 12:44pm

https://www.boards.ie/discussion/comment/120086073#Comment_120086073

Read the post, I said I don't know if it is or isn't stressful.

If you think it isn't then why not become a doctor

maninasia · 10-01-2023 1:14pm

https://www.boards.ie/discussion/comment/120089336#Comment_120089336

That's not my point either.

Blah blah you do it blah blah isn't worth arguing with.

Apart from being lots of stressful jobs out there to choose from , for healthcare being a GP would be on the lower scale of stress and lifestyle adjustments. That's my point.

Dav010 · 10-01-2023 2:03pm

https://www.boards.ie/discussion/comment/120089473#Comment_120089473

Are you speaking from experience?

maninasia · 10-01-2023 2:09pm

Doesn't matter, anybody can tell the difference between a hospital shift job and non shift non weekend work job.

Not complicated.

Why do I need experience to have common sense.

Dav010 · 10-01-2023 2:16pm

https://www.boards.ie/discussion/comment/120089754#Comment_120089754

Because you have no insight into either position, is the obvious answer.

maninasia · 10-01-2023 2:57pm

I do have a very obvious insight.

GPs generally don't do shift work,weekends evenings.

Does it sound as difficult as working in Hospitals ?

What are you trying to say lol. Make sense man.

Dav010 · 10-01-2023 3:38pm

https://www.boards.ie/discussion/comment/120090003#Comment_120090003

Are you speaking from experience, have you worked in either/both an Hospital/GP Clinic?

I might think I know what it is like working in IT, but as my experience is limited to working in Hospitals and health Clinics, I know that even though I occasionally sit at a computer, I really don’t have any insight into what being an IT worker is like.

Anita Blow · 10-01-2023 4:40pm

https://www.boards.ie/discussion/comment/120090003#Comment_120090003

I'm a hospital doctor.

Although GP may not have the physicality of a hospital job, it certainly has volume of patients and a much greater degree of clinical risk.

Many of us in hospital medicine would have great difficulty dealing with the level of risk that a GP handles on a daily basis (Wide-variety of clinical presentations across almost all specialities with limited access to diagnostics upon which they can make their initial diagnosis & management plan).

GPs also do engage in weekends/evenings/nights as most are required to partake in their local out-of-hours service

NIMAN · 10-01-2023 4:43pm

https://www.boards.ie/discussion/comment/120090533#Comment_120090533

Your reply got me thinking.

Do you think more GPs are referring patients to A&E in greater numbers as the years pass, as a means of 'covering their asses' in case anything is missed or misdiagnosed?

Swaine · 10-01-2023 4:46pm

Too many hypochondriacs with medical cards clogging up A&Es. Should be a flat €100 for EVERYONE to be paid immediatly at reception.

This would slash numbers significantly.

Anita Blow · 10-01-2023 5:50pm

https://www.boards.ie/discussion/comment/120090547#Comment_120090547

I think it's probably multi-factorial and not out of any malice/laziness despite what the public seems to think about General Practice.

1) GP caseloads have ballooned to unsustainable levels due to inadequate supply of new doctors and addition of free GP care for paediatrics. This is the cause of people not getting an appointment with GP for ages. Appointment times reduce to try get as many people seen in a reasonable timeframe, but that means less time to spend with the patient and as a result a GP may be afraid of missing something & send to ED to be sure.

2) Patient expectations have increased that a diagnosis is correct and immediate. Consequently GP practice has become more litigious and this leads doctors to practice defensively. Eg- I'm 99% sure this is a benign chest infection but I'd feel more reassured if i had a chest x-ray to outrule a focal pneumonia

3) Medicine has become more complex than what it was in the 00s & 90s. There's a greater reliance on bloods & imaging to make a more accurate diagnosis, which GPs don't currently have access to. They must triage what could potentially be severe from benign without any diagnostics. The problem that the public don't often understand is that what's sometimes severe presents benignly and what's benign presents severely. Eg- The kid with 5 days fever >40c & headache is an ear infection, the kid who walks in with a week's cough but no fever is a severe pneumonia needing IVs. In a hospital I can do bloods and imaging to reassure myself that the ear infection likely isn't meningitis, or that the cough is likely viral. A GP however has to make that initial decision blind, and has to do it about 20 times over in the day with all their patients. It's a level of risk that the public don't fully appreciate.

Ultimately I think GPs are scapegoated. In a normally functioning system a GP should be able to refer to ED if they want a second opinion about something acute or want more investigation to reassure both doctor and patient. It's no different to me calling cardiology to read an ECG if I'm unsure about it.

Obviously community access to diagnostics would help a lot but would need centralisation of practices and a lot of investment

Geuze · 10-01-2023 5:56pm

@Anita Blow

thanks for that post.

Is there any way some blood analysis and imaging could be decentralised to the GP practice level?

Are there machine that exist for such a volume of patients?

Anita Blow · 10-01-2023 6:09pm

There isn't.

When someone presents with infection we may do a couple of tests to assess not just the infection itself but the patient's overall health in the context of that infection. For example if a GP sends in a kid with a vomiting & fever, and they've dipsticked their urine and confirmed a UTI I might do a full blood count and CRP to help me differentiate is it likely to be kidney (more severe) or bladder (less severe), and I might do a U&E to tell me if they're dehydrated. It might be that the infection bloods show it's not severe, but that the U&E tells me they're quite dehydrated in which case I'd admit for IV fluids even despite a seemingly small infection. If it does look like a severe infection, I would take a blood culture to exclude sepsis which needs to be incubated in a lab for 36h.

Our infection blood tests also help us determine whether an infection is more likely to be bacterial (more severe) or viral. These however are lab blood tests that don't have a point-of-care machine that could be used in a general practice.

NIMAN · 10-01-2023 6:43pm

@Anita Blow

Just reading a couple of your last posts, really does show what a hard job GPs have, and perhaps why many might have doubts about patients?

I know many GPs get crucified on social media by folk who basically think they are their own private doctor. Some of the abuse I have read about doctors or their staff is way OTT.

I do feel they are in a lose-lose situation these days.

The current hospital / A&E crisis

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