Sunday, 24 August 2008

A Different Way of Doing Things

Posted by Dr. Jane Doe.

I’ve been pondering the way in which healthcare is delivered here and looking at why it seems to work so well here in comparison to Ireland. I am gradually getting used to the way things are done here, and hence the differences are not always apparent to me anymore the way they were when I first arrived to the Antipodes. However, the recent influx of Irish junior doctors fleeing the system back home have reminded me of ways of doing things and procedures in place back home that I had forgotten about. And one of the things that I had almost forgotten was the difference in the general attitudes and perceptions surrounding hospital delivered healthcare at home. This sounds like it might be a woolly, subjective thing, but actually it is not. The attitudes and perceptions that people have influence them to shape systems and procedures accordingly.

One of those things that struck me here was the attitude of both doctors and patients towards the delivery of healthcare. The perception in Oz/NZ is very much “We will fix the problem you came to us with. The other things must be dealt with in due course, through the proper channels, unless they have direct influence on the outcome of the problem you came to us with.” The doctors make no secret of this, if you are admitted to hospital with pneumonia, we will treat and cure your pneumonia. The gastro oesophageal reflux symptoms you have been having you will need to see your GP for. If he/she thinks it is appropriate, they will prescribe you something and/or refer you for a gastroscopy, at their discretion. The high blood pressure that is somewhat inadequately controlled you should mention to your GP while you are there, and they should adjust your antihypertensives accordingly. We will cure your pneumonia, and then you will go home. We will not see you in clinic in 4 weeks time to check on your chest, make sure you have had a gastroscopy, and check your blood pressure. Your GP can comfortably manage all of those things. If they have a query about anything they are welcome to contact us.

Hospital consultants in both countries, for the most part are specialists who usually participate in acute medical “take” in the interest of service provision ie. they have general medical patients with non-specialist requiring problems admitted under them every few days or so on a rota that they share with other specialists medical consultants. This is essentially how acute hospital based medical care is delivered.

If you employ the attitude above, the “We will fix only what you came to us with” attitude, what you DON’T get is Outpatient Clinics with 50+ people in them every day, waiting and stewing because they have to wait, and getting all upset because they were seen by a junior due to sheer workload and also because they are a return patient with no serious problems. Because the above patient and others like them can be followed up perfectly well by their GP. Indeed, they SHOULD be followed up by their GP for these things-ultimately the GP is going to need to be the most familiar with all of these problems and manage them accordingly.
In addition, the specialist consultant, say, an Immunologist who does medical take, is not seeing return patients with heartburn and high blood pressure in their clinics-they are seeing the people that need to be seen with rare T-cell deficiencies, severe combined immunodeficiency, people with atopic conditions, treatment refractory asthma, etc etc. Hence not too much of a wait for the specialist appointment if you really need one.

In Ireland, usually, most patients that come in under any consultant are booked for follow up appointments in Outpatients to check, basically, that they’re ok post discharge. The attitude among patients and staff is that the patient is going to have an NCT while they’re in hospital. There are a few reasons for this. (For those of you not from Ireland an NCT is a type of car servicing that sorts out the whole car so it can stay on the road-a roadworthiness check)

Every doctor is acutely aware of the waiting times in Ireland for procedures due to understaffing and stretched resources.

Your patient has been having heartburn for the past few months. They’ve lost a little weight but they think that’s maybe because they’re not eating so much because they have heartburn but they’re not too sure really. You ask have they tried anything for it-ah sure they got tablets from the doctor but they’re not really sure, maybe they were for the chest infection.

Hmm. The pneumonia’s gone. Patient is well, and should go home. But there’s the heartburn and the possible weight loss. Their haemoglobin is fine and it sure ain’t urgent. But they’ll be waiting for months and months on the outpatient scope list, so might as well sort it while they’re here as you never know, it could be something. It’ll mean a couple of days more in hospital as the inpatient scope list is pretty busy and your patient is pretty non-urgent but better to keep them in. More nights in a hospital bed that costs 600 euro a night. Their blood pressure’s high too. You’d better tinker around with their meds. Might add in an ACE inhibitor, they’re on all the other stuff already. Now you need to be monitoring their U&Es while they’re in hospital for the next few days.
Well they got their scope after three or four days, and now they’re on their way home. Seeing as how you ordered the scope, know the story, and also tinkered with their antihypertensives, they will need to be seen by your team in Outpatients really. The GP could follow up this stuff, but if there’s anything on the scope they will need a referral to a gastroenterologist or a surgeon, and again, this will happen faster if they are in the hospital system. And this happens to almost all your patients, and hence outpatient clinic lists grow ever longer.

In Oz/NZ if their pneumonia is gone you send them home and send a detailed letter to their GP. The GP makes an appointment for the patient to have an endoscopy which is done in a couple of weeks. There is no real indication for doing it sooner. They adjust the antihypertensives and check the renal function. The patient does not have to return to hospital for an outpatient clinic visit and wait a couple hours. All the stuff that should get done, gets done, in a timely manner. The scope lists aren’t clogged with not so urgent inpatients who need to be sorted before discharge otherwise they will be waiting weeks/months, and paradoxically, this means there is a little less total waiting time for scopes.

I can see why we did things the way we did in Ireland. The waiting lists for things are so long, we try to find ways around them, each one of us, for our own patients. But is this behaviour influencing the length of the lists and having a boomerang effect for us? I don’t honestly know, but thinking about it like that, I fear it might be.

But patients as well as doctors think differently in Ireland too. A large proportion will not be satisfied with you simply curing their pneumonia. I have been called out of clinic or away from ED because they want their antidepressants adjusted or maybe changed before going home. I explain that it’s not really appropriate for me to do that as I am not the doctor that is managing their depression (usually their GP or occasionally a psychiatrist). They become VERY unhappy with me as do their families and I end up having to get a psychiatric consult before they go home. Again-not so urgent-so maybe waiting another night in hospital before they see the psychiatrist. You can’t force someone out of the hospital if they really don’t want to go.

This simply does not happen here. I don’t know why. Patients seem to understand how the health service works here much better, and they tend to understand that certain things are more appropriately followed up by their GPs. But it is also pretty easy to see your GP here. They’re not very expensive, and there are a lot of them and it is really easy to get an appointment as they are not all snowed under. I walked in to a random surgery here one day for a check-up. I was waiting about ten minutes and they apologized for the wait! I’m quite used to waiting myself up to two hours at times back home, and usually bring a book and a drink, or my IPod. It’s expensive to see your GP at home if you don’t have a medical card, and access can be an issue as they are very, very busy.

Here in the Antipodes there is a fair amount of revenue spent on educating the public. There was my personal favourite, the “1-2-3 Where should I be?” campaign a few months ago that explained in an easy to understand, logical and unpatronising manner the difference between your GP surgery, the 24 hours acute care walk in services, and the Emergency department, and gave examples of conditions appropriate to each one as well as numbers to call if unsure. It was on billboards, TV, bus stops- everywhere. I thought again and again how we could do with that back home. How could you always know if you are not a medical person and you are in pain, where you are better off being?

It looks like more staff and resources again are at least one of the answers. The city I live in currently, I swear there are at least three medical centres on every street. GP access-SO not a problem. When I phone to make an appointment for an inpatient I’m given whatever day or time they want, instantly. There are one or two MASSIVE 24 hour GP acute care facilities and they too are easily accessible and uncrowded. If they refer you for a scope, chances are good you will get it in a couple weeks, because there are more resources and staff per capita than at home. Hence uncomplicated hospital discharges stay just that. Specialists don’t have to be hospital based GPs for at least half their clinics. People who need specialist appointments get them faster because specialists aren’t being hospital based GPs for at least half their clinics.

The next answer is more controversial. We need free access to primary care for all our citizens. Cost is a limiting factor in a LOT of people’s unwillingness to attend the GP in Ireland. I am not an economist. I don’t have a lot of ideas how this can be achieved. Practically, I think we may have to accept that we will have to ultimately pay more taxes, but I don’t really know. But it needs to happen.

Public education is another thing we need. Most Ozzies/Kiwis will tell you the names of their tablets, inhalers etc, and can often tell you doses as well. A LOT of Irish patients can’t. Because the time has not been spent telling them. The time, and the staff, often simply aren’t there, or are too busy. I have never seen posters telling people the most appropriate ways to use the public health services available to them back home.

All of the above, unfortunately, cost money. A LOT of money. More staff, more resources, more public health involvement in educating the public, more media campaigns to do so. This isn’t a post on how to save money for once, but a post on how things would perhaps be if there was more money to spend. And I don’t have the answers to that one.
Dr. Jane Doe


  1. Have you ever worked in the UK? Where do we fit in? It seems to me that over the years we have moved from a system like that in Ireland to one more like that in NZ.

    I do a highly specialised clinic. I deal with the specialist problem only. In the old days I would also fix the BP, obesity, heartburn etc. The result was swamped clinics. Now anything over and above the presenting problem gets left to the GP.

    It used to be so difficult to get anything done as an outpatient that inpatients tended to be given a 100,000 mile service while they were in. Now it is treat the pneumonia and the GP can organise the follow-up radiograph, sort out the anaemia etc.

    With the help of your analysis I can see that very gradually there has been a substantial change in the way we deliver healthcare in my bit of the UK. And, as you imply, the patients need to grasp the change so that they do not have unmet expectations.

  2. Jane

    You raise a lot of very good points, as always. I agree that attitude and education have a lot to do with the problems here in Ireland.

    The latest ploy by the HSE to reduce healthcare costs and waiting lists, is to try to push more and more services onto primary care. The problem is they haven't put the necessary funding in place to allow GP practices to develop in keeping with this change of emphasis. Funding for GP training is also a major issue. Another excellent scheme was 'Hospital in the Home' - where teams of healthcare staff visited long term patients in their homes to administer treatment thereby keeping people out of the hospitals - but this too went by the board with the cutbacks.

    I saw my GP last week and have been put on the waiting list to have a gastroscopy performed at a large teaching hospital. It's a 'direct access' service for GP's which means that they no longer have to avail of the opinion of a specialist until/unless it's required. Sounds good to me but I'll reserve judgement until I've been through the process. I'll let you know how it works out.

  3. It's crazy that a visit to a GP costs an individual patient €50, yet dropping into a day ward, specialist OPD, phoning "the team" etc is free. Why on earth would patients accept their "NCT work" being done by the GP when for years it's traditionally been done "for free" by NCHDs? I don't think there is an easy answer to this.

  4. Oh and Jane, one other point. I agree with everything you've said in your entry, but I think another factor at play in the Irish hospital setting is fear of litigation in a country where claims against hospital doctors now exceed the US, both in number and in the amount claims are settled for.

  5. Tazocin-I was actually going to say something about that-but my post was getting kinda longwinded! :) Definitely defensive medicine and watching your ass are HUGE HUGE factors in the amount of tests we order and investigations we do. There is a fantastic system in place here called ACC that does not allow patients to sue doctors at ALL-there is instead a system of no-fault compensation in place. IT works fantastically for both patients and doctors. Might post on that next! thank you for bringing that up!

  6. Maybe I should rank NZ higher in my list of destinations for next year! At the moment Brisbane is my Number 1 choice...

  7. Tazocin, Brisbane should remain your number one choice, the climate is much better (ie warmer)than NZ.

  8. Yea, Oz trumps NZ in my opinion, having worked in both. The hospital system is pretty much the same in either, but you get better pay in Oz, and the climate is kinder.

    Dr. Thunder