Saturday, 26 July 2008

HSE cost cutting

Posted by: Dr. Jane Doe

I'm hearing an an awful lot these days about how the HSE is woefully hard up for cash and needs to cut costs as a matter of urgency. People get very angry about this, as it will, no matter what, affect patient care.

Staff are not being hired, existing staff are being "redeployed" or their positions done away with, and new units and departments are not being opened as there is not the money to do so nor to staff them appropriately. Having worked as a doctor in Ireland for three years before emigrating Down Under for a better life, I can see a lot of ways the Irish health service could improve things for their patients and their staff that would also be very cost effective.

While I was working in the morass of chaos and hostility that is every day as an NCHD in Ireland, I was generally too busy trying to stay awake through 36 hour shifts and just trying to drag myself through the days to really see where the problems lay. Yes, we all had a sense of utter dissatisfaction and knew vaguely that things weren't working well, but qualifying how this was so was often difficult to do. After working Down Under for almost a year now, time and time again it has struck me how efficient the system is. How organized and streamlined. And by extension, how cost effective.

At first, in sheer relief at being away from the Irish health service, all I noticed was how easy it was for ME, to get my work done and done well and how stress free my days were. How I wasn't exhausted and depressed. However, looking closer at the whole picture, the system is designed to be easy for everyone. Other staff, but ultimately and most importantly, for patients. Patients here get fantastic care, from doctors and nurses who are looked after themselves and feel happy in their jobs as well as able to provide a good service in their jobs.

Recently there has been a mass exodus of junior doctors from Ireland, mimicking the 80's almost. In the past month a fair few have come from Ireland to where I'm working now, and I have usually been asked to show them around and orient them. Talking to them, and hearing their shocking stories about the way Irish hospitals continue to run, it makes me furious that no-one is doing anything about it still, after all this time. It used to be that Irish docs, on completing their intern year, did the obligatory rite-of-passage thing and went to Australia for a year, had a blast, went bungee jumping, snogged a surfer or two, and then returned to Ireland to get onto a GP training scheme or medical scheme etc and settle down to get their MRCPs and become a specialist registrar. This has changed even since I graduated. Now they are leaving, and not going back. All the NCHDs I have talked to in the past few days that escaped Ireland have no immediate plans to ever return. Many are expending their studious efforts on getting exams that will allow them to train as consultants in other countries-their USMLEs, Canadian boards, Australasian exams or even MRCP UK. Even many of the GP trainees are leaving Ireland and training over here-and staying. For the first time ever this year, the medical scheme in a certain part of Ireland had to advertise twice-still could not get staff and had to advertise in the UK. The chickens are finally coming home to roost.

I will illustrate example by example over the next few posts how inefficient, disorganized and downright unpleasant it is to work in the Irish health system compared with working in a well run system such as the one down here. What I'll do is give an example of a certain simple task, for example, obtaining and reviewing an Xray, that forms a daily part of any doctor's job. I will illustrate what it takes to do this in Ireland, and what it takes to do this here.

Example number 1) Obtaining and reviewing a chest xray. Scenario: You've decided a patient needs an x-ray, say, of their chest. You think they might have a pneumonia but they're elderly and not spiking a temperature, and have a history of congestive cardiac failure, and you need to differentiate so you can treat them appropriately.

Obtaining and reviewing an Xray in Ireland:

Find an Xray form. You could put it in the outbox to go down to the radiology department after letting the patient's nurse know they are for an xray. The problem with this is you don't really know if it will be collected and dropped down, this varies from hospital to hospital, from ward to ward. Some places have times that porters/orderlies come and collect these things. Some don't. Some require the nurse to bleep the porter to collect it and drop it down. Some porters won't come and some nurses won't bleep.

So it's really better in a lot of cases to run down to the department yourself with the form. This takes about 10-15 mins if you factor in walking down (quickly), after first making sure it's ok with your consultant or registrar if you leave the ward round to do so. This in itself will result in further problems and disruptions during the day-the consultant will order tests you won't know about and in general you won't know what happened with anyone they saw on the round while you were gone, which means you'll get bleeped a lot about things you don't know about until you manage to make time to go up and review the charts of anyone they saw while you were gone. No-one will be understanding about the fact you missed what happened, they in fact will be angry with you.

Anyway: You get down to Radiology and go up to the desk. The girl there tells you that after you register the xray at the desk you have to take it around yourself to the xray department. You do this. Another 10 mins or more, depending on whether anyone is available to talk to you and take the form. (Note: If it is something like an ultrasound, you may need approx another 15 minutes to try and justify to a unimpressed sonographer why your patient should have an ultrasound. They may refuse and you will have to do some more tests on your patient to strengthen your case, and return to them at a later time/date.)

Anyway. You return to the ward round and later during the day you have to check the xray. You go down to the Xray department. You look first in the Xray dept in a box that they keep some of the most recent Xrays in. It's not there. At this point it has been moved to somewhere in the department in some pile and only people who work in the radiology dept could really know where it is. You spend the next twenty minutes looking through piles of Xrays and checking the names on them and asking around and generally getting underfoot. Assuming you eventually find it, you cannot take it out of the department to let anyone else look at it, so if you are unsure about something you see on it-is that a pneumothorax in the left upper zone?? you have to take it to a radiologist to get a verbal report.

This is where you start sweating and feeling nauseous. Radiologists want you dead. They do not want to give you a verbal. They want you out of the dept and out of their lives. This is because they are much too busy and their workload is too great. Any mistakes they make are immortalized in film. The consequences of making a mistake are too great for them, the media typically does not let serious issues like a dangerous workload get in the way of a good old witch hunt when a doctor is involved. So they are weary, and not happy to see you, most of the time. This is where you have to justify why you need a verbal. You had better know ALL of that patient's history off by heart, blood results, everything, because if they ask, and you don't know, it will not bode well for you.

Assuming you get through that part ok, 15-20 mins later, and arrive back up to the ward having a diagnosis of Congestive Cardiac Failure (CCF), you can now treat your patient. You wrote the Xray form at 11 am. It's now 15:30. You think they should have some IV Frusemide to treat their CCF. You chart it. Nurses in Ireland do not give IV medications in the first instance, they only can give them "as per protocol" ie. after the doctor has given the first dose. There is no evidence based reason for this practice, and it is not safer or better for the patient, it just is. Frustrating for doctors AND nurses. So you go to the drug room. The IV press is locked. You ask around for about ten minutes till you get the key. You draw up your frusemide, go and give it and then go to sign for it. Someone has taken the medication chart. You should have remembered to keep it locked tightly under your arm or sign for it before you actually gave it but you forgot because you were drawing up the frusemide. You look all over the ward. Someone has it but you can't find it and your bleep is going mad. You leave and a while later you get a bleep to come up give the Frusemide because the nurse can't give a first dose IV. You explain you've given it but someone took the medication chart and you were called away and couldn't sign for it. You are told to come up and sign for it. You do so. It's now 16:15.

Obtaining an Xray and reviewing it Down Under:

Find an Xray form. Fill in the details. Go to one of the fax machines on the ward (there are several so people don't have to wait). Fax it down to the Xray department. Approximately 30 mins later you see, as you continue on the ward round, your patient being wheeled off by a porter that xray sent up to get them.

Approximately 20 minutes later you check the PACS system on one of the ward computers to look at the xray. You haven't left the ward. You think there might be a pneumothorax in the left upper zone, so you turn to ask your reg who is still on the ward with you finishing the round. They tell you there isn't one, and spend a few minutes discussing chest xrays with you and you learn what bronchial cuffing looks like and commit to memory.

You go to chart the IV Frusemide and let the patient's nurse know you have charted a stat dose of something. They thank you for letting them know and you say thank you back. You continue on the ward round. After about half an hour you bump into the same nurse who says how much easier your patient is breathing after all that fluid was diuresed off of their lungs. You are glad the problem was easily solved and that your patient is now comfortable. You thank her/him for letting you know. You bump into the family as they are visiting and update them on the patient's progress for a few minutes before continuing to see the rest of your patients. You faxed the form at 11am. It's now noon. However, you never left the ward.

You know what's happening with all your patients as you were on the round. You were taught several things on the round by your consultant and now you are a little less ignorant. See what I mean? Patient was treated more quickly, less overtime was paid to a doctor, less people were left waiting while the above shenanigans took place which results in quicker and better care for those patients also. Less money wasted. Better outcome. If the HSE wanted to cut costs, all they have to do is attempt to provide an efficient sensible service. It's not hard.

Next week I'll give another example of a simple task and compare its execution in both systems, then compare how caring for patients well is actually cost efficient, something I feel the HSE does not understand.

Dr. Jane Doe


  1. Interesting post. What do you think is the best way to fix proceedures in Ireland? Who is responsible? Are all these protocols set by each hospital or at national level?

  2. From what I can see, protocols can be set individually by hospitals or even by wards as to how things work there and who does what. Insanity. Pure, shining insanity.

    A couple of things that could fix the above scenario:

    Invest in fax machines, plenty of good quality ones for every ward and department. Cut down on doctor time running from dept to dept begging and pleading. Fax requests straight from where you are to where they do what you need. This also cuts down on relying on nurses to bleep porters and porters to come and get things. Less manpower and more efficient.

    Every hospital in Ireland needs PACS as a matter of urgency! This is a computerised Xray system that has all xrays of patients in the hospital stored on it-CT scans, MRIs, everything. The minute the Xray is taken it is loaded onto PACs-and the doctor or nurse checks it from anywhere in the hospital. No running around, wasting time fruitlessly digging through the radiology dept. Less time wasted=money saved.

    It has to be said-at some point we will have to value and respect our nurses education and experience and allow them to perform the tasks that would be part of their normal role in any other country. We educate these people to degree level, and then teach them once they start work not to do any of the things they were taught about. Yes, from our end it's time consuming and annoying to run around giving first doses of things the nurses are going to be giving from then on, but how frustrating is it for the nurses? They have to wait for sometimes HOURS while an overworked and up the walls intern or SHO tries to find a minute to come up and administer something to make their patient more comfortable or stable, and they have to watch the patient wait, console them, and take the aggro from them and the family about the delay. I feel for the nurses. They don't get the respect that they get in other countries because of protocols like this-the public's attitude is often unfortunately that they are only good for bedpans and the like because they are banned by protocols and managers with their heads up their asses from carrying out any other tasks or furthering their knowledge or skills. It's a disgrace. We are wasting them.

  3. As a GP in Oz I remember 25 yrs ago the system which was over here, before the fax or computer. Seems pretty much like the curren Irish system., only better. I wouldnt mind working in Ireland but this is a turnoff.

  4. Have to say I was shocked when I read your blog. Didn't realise this is how it's done in the publics.

    I'm working in a private hospital at the moment. It's my job to order X-rays(as a ward clerk). It's done through i-soft...order the test (there's a list to choose from or just type in the code/first few letters), type in what the patient had or is having done and whether they can walk or need a wheelchair/oxygen. Test request prints off down in the DI dept. All this takes less than thirty seconds. X-ray ring, ask if the patient is ready then send their porter up. Patient comes back. Report is typed and put on the system which can be viewed and printed off on the ward. X-ray send films up when they are finished.

    Chasing films is still a major headache but still, sounds a lot better than what you had to endure.

    You're dead right about nurses being undervalued. My mum trained in England and taking ECG's was a routine part of her job. When she was working in ICU here she had to fight to do the same thing (in bloody ICU!!!).

  5. Hi there, thanks for replying to my first post Jane.

    I haven't worked in the system yet, although I will in the next few years, so I still have a complete outsider's viewpoint.

    I can't quite understand why the system that supports lots of highly trained and intelligent people is allowed to be run so badly?

    If so many doctors have worked in other countries and experienced better conditions, why do they accept such rubbish back home? Why is no one advocating for changing work practices?

    I have to say in general the medical organisations, IMO and IHCA, are rubbish at PR. I am sure there are plenty more stories like yours out there but the public doesn't hear enough of them. All they hear is waiting lists and mistakes, and most people lay the blame only with doctors for those.

    Posts like yours should be a regular feature in the Irish Times health supplement.

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  7. Jane

    Hello and well done on your first post with the 2 weeks team. It's great!

    You paint a brilliant picture of the lot of an Irish NCHD. I don't know whether or not you got to see the 'Junior Doctors' series (2006/07) where 'Sinead' was filmed chasing up x-rays exactly as you describe and the miles she walked in the process.

    Harney loves spouting about how privatising healthcare in Ireland is going to improve things for public patients but you never EVER hear her talk about improving the conditions in the public hospitals, some of which are so outdated that it's a bad joke. She needs advisers (like you) who have worked at the coal face, to tell her what needs to be changed. As you say, simple investments such as fax machines could save huge amounts of time and money in the long run.

    Here's a couple of links to a recent spat in the media between Harney and David Begg (general secretary of IcTu) over co-location following the Supreme court ruling on risk equalisation. I'd be interested to hear your comments.

    Anyway, keep up the great writing. I look forward to your next post.


  8. Hey Steph!
    thanks for your kind words. Tried to copy and paste the above links but they're not working-sound interesting though. I hate colocation and the privatisation of the Irish health system. We have a noble idea in the public health system, it just needs a few improvements, which could probably all be effected by about half the money being poured into these private hospitals. grrr.

  9. Sorry, Jane

    They were too long-winded! You should be able to copy and paste these.