The current hospital / A&E crisis

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

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

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.

I've worked in emergency departments and feel very lucky to be able to do bloods or imaging to reassure myself about a clinical decision or guide my management, or to be able to pick up a phone and speak to a specialist team for advice. Even if ED is backed out the door I don't begrudge a decision made by a GP to refer- they're making the best decision based on the information available to them at the time.

I know most would be glad to access community investigations to save referring, but to do this we need infrastructure and we also need far more GPs. Taking bloods from a kid for example would require an additional nurse to help and can take up to 20-25 min which means less people that can be seen in that day.

I'm a Medical Scientist myself working in a hospital laboratory and the vast majority of our work comes from GP practices.

All of our GP workload is done and processed on the day the sample is taken. On our busiest days (Tuesdays and Wednesdays) some work may be left over, but all GP samples are processed and reported within 24 hours of the sample arriving to the laboratory. A lot of people who have samples (blood, urine, swabs, faeces etc) taken at GP practices are probably told to call or come back in a week or more for the results, but in reality they are done long before that.

We often have to phone GPs to notify them of very abnormal results that need immediate attention. If it is after 5pm, we call the out of hours GP service with all patient details and they contact the patient and tell them to come to ED.

I am just giving my experience from our hospital. Some of the bigger hospitals in Dublin, Cork, Galway may have longer turnaround times, but many of the smaller hospitals would be the same.

47 patients perfectly well on wards over 6 months to be released from a hospital bed (€878 per night x 182.5 = €160k per patient), it's a good job money pissed up against the wall is standard practice in the HSE, €7.5 million up the Swan E.

Those patients are not " well enough " to go home though ..that is the point. They need step down care . In hospitals that have been systematically closed or cutback over the years .

They certainly don't need all the funding that it costs to keep a patient in a busy general hospital , but funding is still necessary for appropriate care elsewhere in the community.

That report also states 6000, not in hospital , are waiting for homecare . A system that has been decimated over years and years of cutbacks and ignored by politicians who refuse to move Slaintecare forward.

Where are these people? Are they home with their families struggling to manage and ending up readmitted due to lack of appropriate care in the community ?

Are they unnecessarily taking up a nursing home bed ? So many would be happier and managed just as well at home if adequate home care packages were available.

Slaintecare addresses better community care and chronic disease management ..in the community . Thus relieving pressure on hospitals and allowing them to do what they should be doing .

That’s not the training infrastructure im talking about. Each training post needs to be attached to a medical team, consultant supervisor and in the case of GP needs a GP trainer for the final two years of the scheme. Lack of investment in physical infrastructure (hospitals) and staff (trainers and medical teams) mean that this is still lacking. We need more medical teams and more consultants to be able to facilitate an increase in training numbers for any speciality.

I am in regular contact with homecare agency workers and they've said that there seem to be more people getting homecare packages recently. Sounds like a good thing to alleviate hospital overcrowding? Not if the homecare agencies are going to "squeeze in" even more "care" without taking on more staff. Which is what appears to be happening,

Result is an already poor service (as per my other thread in this forum) is in danger of becoming worse with even more problems with missed and truncated care visits. The latter is probably resulting in widespread time card fraud by the agencies and their workers as they are paid PUBLIC MONEY for work not carried out. Little or no oversight by the inept HSE. Possibly adopting a see no evil approach.

Meanwhile, the current media attention comes off the same HSE and government as trolley numbers in hospitals come down. Problem transferred elsewhere where there is less attention, job done.

Looks like one of the seven is ex HSE

Should they be recruiting people that have no health service experience?

Where I work in community healthcare we say 2-3 days but that's to give time for the physical results to return and the consultants to get some time to review.

UHL lab seem to actually have them done within 24hrs because the very rare occasion something serious came up we got a phone call in that time.

Its all just smoke and mirrors...

Reminds me of these posters in the hospital:

We can probably cover the cost. What we can't cover is the shortage of doctors.

Free GP care will make things much worse because we don't have enough GPs as it is. Free GP care will increase the number of people going to their GP thereby crushing the system and making it very difficult indeed to see a GP.

Only a clown would think this is a good idea.