Saturday, 6 March 2010

The 6 hour wait. This total con is coming soon to an Irish emergency department near you.

Irish emergency departments are stretched to the limit.

The above statement is no surprise to anyone who lives there. Sick people languish on trolleys for days at a time in crowded hospitals all over the country. The health ministry is the poisoned chalice of Irish politics. We've had the same health minister in place for many years, who has succeeded only in pissing off the staff, and improving some select health indices, while ignoring anything that doesn't fit into a succinct soundbite.

Recently, our esteemed minister has realised how spectacularly unsuccessful her tenure has she tried her hand at deliberately misleading the public. Mary Harney told us that things are grannnnnd, as overcrowding in A+E departments has vastly improved, and that it's confined to a few repeat offender hospitals.


I'm currently working in Australia, where we're fed less nonsense. BUT......we have less need to spin the issues over here. We have well staffed emergency departments, where the staff aren't exhausted, and there's senior support easily available. Australian politicians are as disingenuous as their Irish counterparts, if not more. However, they have no need to explain to the population why their elderly relatives are left to fester on uncomfortable corridor trolleys in overcrowded departments. That's because it doesn't happen.

Back in Ireland, however, there are 3 options available to our political elite:

1) Try a quick fix, in the hope of picking up votes in time for the next election.

2) Do something about it. It might take time, it might take money, and it might not win immediate votes. But by looking at health as a problem that will need a consistent approach over time, it will reap benefits for the population.

3) Lie about it. "Problem? What problem?" Ooohhh look.......a penguin!".

Option 1 has been tried. As anyone with a rudimetary grasp of health would have guessed, it didn't work.

Option 2 is, well, we all know that's never been a viable political strategy for politicians who have to get re-elected every few years.

So, option 3 has been tried. Minister Harney seems to have been chilling in her office one random wintry day, just after we'd reached a national record of having 500 patients in A+E departments around the country who needed a bed, but were instead accommodated on trolleys.

"How can I put a spin on this disaster?". "Is there any way I can get a few votes out of this?".

So, she calls in her PR people: "OK guys. I want you to get in touch with all the broadsheets, and tell them that overcrowding is improving. Tell them it's only a problem in a few hospitals. And tell them it doesn't really matter if the elderly lie on hard trolleys for days, as long as they're being treated. And tell the tabloids that a monkey has been seen on the grounds of Beaumont Hospital. That'll distract them from the issue".

"Em, excuse me, minister...." a young upstart in her media division may have said, as his more experienced peers shook their heads in despair...."...But last week we saw more people than ever waiting on trolleys in emergency departments, and hospitals that didn't have overcrowding problems in the past are now struggling to find beds. Oh, and there are studies showing that people are more likely to die or deteriorate if they are left on trolleys i overcrowded departments".

"Well, duhhhhhhhhhhhhh. But do you think that would win me any votes?????".

Obviously, that conversation is a figment of my imagination. But it beggars belief how one politician can spout so much nonsense, unchecked by her department.

It's a given that politicians in Ireland are not the people we look to for guidance during tough times. We simply hope that we can survive, despite their interference. I had hoped that we could turn to our professional bodies at times like this. I had hoped they would lobby the health department, and to try and push the minister in the right direction.

But sadly, this hasn't been the case.

In a letter to the Irish Times recently, the president of the Irish Association for Emergency medicine wrote that the NHS in the UK had abolished overcrowding in their emergency departments. The letter can be viewed at

The same consultant went on radio recently, espousing the virtues of the UK system, and claiming the problem was "eradicated" by 2005.

Now, I was working in acute medicine in the NHS in 2005, and the "eradication" of overcrowding is a crock of balls.Yet this is what our senior emergency doctors are pushing for. The British model involved telling the population that they will no longer wait more than 4 hours for a bed when they attend an emergency department. Anyone who works in the UK knows this is rubbish. This was classic Labour party spin, and nothing more.

Sure, the stats say that 98% of people get seen within 4 hours. But that means very little. You might see a nurse practitioner, rather than a doctor. You might have the wheels removed from your trolley, so you now technically have a bed. You might get moved to a different corner of the emergency department, which is called "a ward". You would not believe the strokes that get pulled in effort to convince the British public that the 4 hour waiting period has been a success.

This strategy won't work without extra resources. You can't just announce tomorrow that all patients must now be seen and admitted within 6 hours, without providing new resources. We need more staff to see these patients. We need more nursing home beds for the 1000 inpatients who no longer require treatment in acute hospitals, but just can't be sent home safely.
We need expensive scanners being used out-of-hours, rather than sitting idle for 16 hours a day. People should not be in hospital for days, awaiting only the results of a scan. They should not be in an acute bed, waiting for a nursing home bed to open. And the exhausted staff shouldn't be lumped with more useless targets, without the resources to help them. We already have Irish doctors working up to 48 hours straight, so how are we going to work them harder??

This is all about resources. It's not about targets, and bullying and demoralising staff any more than they already are. But it won't be a quick fix. It may not win votes in the next election. Or the election after that.

Is someone going to step up to the plate and take this bull by the horns? Sadly, this doesn't look likely in Ireland. So, for the forseeable future, those who can afford it will buy health insurance. Those who can't will suffer poorer health. And those who are trained to work in the system will emigrate to Australia.

Dr. Thunder


  1. Believe it or not in parts of the UK we are going to solve this problem by closing hospital beds and looking after the patients in the community in poylsystems. It is what we call here an Irish solution - partly because of the origin of its robotic progenitor.

    The really frustrating thing is that the problems you describe have been going on in the British Isles for as long as I can remember. While they are not easily solved it is easy to see that some things could be done overnight such as, as you imply, keeping scanners open at least 16 hours per day.

    None of these problems can be solved by doctors. Doctors always want test results as soon as possible. The good thing about targets is that they worry managers more than doctors and for the first time managers begin to understand the problems and look for the solutions that are so obvious to those at the coal face.

  2. Not sure where you are in Australia, but in NSW, bed block leading to trolley pile up in the ED is an almost daily occurrence (as is the unscrupulous way that the administrators fix the numbers to suggest it doesn't happen). I wouldn't be booking the tickets to Australia yet...

  3. @ dr grumble: I do agree that targets have their place. The 4 hour target has certainly focussed the minds of NHS managers....even to the extent that I would get almost manhandled away from sick patients to see people who weren't particularly unwell, but were about to break the 4 hour mark. I think targets must be accompanied by resources. At the moment, the UK public are basically being misled in a very big way about the 4 hour target situation.

    @ Jane: I'm not in NSW, but have done quite a bit of emergency in Oz, and have been admitted as a patient twice (once in NSW actually). All in big busy tertiary centres. People do hang about on trolleys. But in Ireland people can literally be on a trolley for days. Their medical inpatient team will see them in ED and carry out tests etc, while they spend their entire admission on a trolley in a corridor. This isn't just a case of waiting for a trolley overnight while patients get discharged the next morning.

  4. Yeah, again - we've got an analogous problem here. It's not uncommon for our patients to be admitted from a trolley, then spend days down in the ED, waiting for a ward bed. They move 'em from the trolley to a bed (ie trolley without wheels), largely, I think, because the ambos can't leave them until they're off a trolley. Plus, the hospital can shuffle numbers, move them into a special, dark, neglected corner of the department, and call them "inpatients" - therefore, they come off the "ED waiting list" stats and the minister stays happy. Nonetheless, it's still not a ward bed, it's still not real inpatient care, and it's a despicable situation. Your original post really isn't that different to what I'm seeing every day down here. I truly wish it was.

  5. Interesting observation, Jane. Having said that, it's not been my experience in Australia. I'm not saying it doesn't happen in Oz, just that it's not systemic, like it is in Ireland.
    As I said, I've been a patient in 2 different hospitals in 2 different states in Oz, with no problems like that. I've also worked in 3 other hospitals in Australia, and not come across the problem. I'm not saying there aren't problems. Just that I haven't experienced them at the kind of levels we see in Ireland, where it would be hard to find a hospital where it's not happening.
    Having said that, even if it was systemic, setting an artificial target without adequate resources to support it, is not the solution. No matter what country you're in.

    Dr. T

  6. I find it heartening to know that not all of Australia is as bad as the states I've worked in. I've worked in multiple hospitals (tertiary, base and remote) in the two biggest, busiest and most populous states (NSW and Victoria), which I guess, unfortunately, affects a greater proportion of Australians than those states who appear to be doing things better. These two giants of the country leave much to be desired - I certainly wouldn't recommend working here in our current state of affairs. Indeed, I wonder whether it's a good thing to compare Ireland to Australia as a whole, given that the former is much smaller in geography and population alike. I fear if you compared Ireland and NSW pound for pound, for example, you'd see more likeness than difference. I love hearing positives about my home country; don't get me wrong - but I really don't think it deserves the praise you've heaped upon it in this case.

  7. Without getting too far away from the subject, I think the Oz system is much better to work in than the Irish one.
    I would argue (anecdotally) that most Irish docs would tell you the same thing after workig in Oz. If you want to work i Ireland without doing 24-72 hour shifts in an acute specialty, it's very difficult (maybe with the exception of ED/ICU). Whereas that's not the case in Oz. Longest shift I've done in Oz was 26 hours. But the overwhelming majority of my shifts are 8 hours long.
    If you're a patient in Ireland, it's highly highly unlikely that you'll get an admission without waiting 24 hours+ on a trolley. I have never ever had a patient in A+E in Oz anything close to that. I've also never known anyone to go through that in Oz. That's not to say it doesn't happen. But it's not something you hear about publicly often. Whereas in Ireland almost everyone has relatives who has waited days in A+E. It's a common conversation piece. When I was admitted in Sydney, I could't believe how quick and painless the process was.
    I know you don't recommend working in Oz, and Oz isn't perfect. But the amount of junior docs working 48hour+ shifts in Ox would be low enough. You certainly can get jobs easily where that's not something you have to do. In Ireland, it would be almost impossible to get a job like that.
    Irish docs love Oz and NZ. And there's a good reason for that. I've had crappy days in Oz while at work. But life is a hell of a lot better than it ever was working in Ireland or the UK.

    Dr. T

  8. I don't recommend working in Australia along the same lines as you do. As much as I'd love you to be right in your effusive praise, Australia isn't universally the land of milk and honey. The administrators and politicians have screwed things up to a shameful extent - I'm not really surprised you've not heard about what's going on in different states, given that local media tends to cover its own backyard (and in over simplified terms when they do) and not much beyond that. Similarly, I couldn't tell you much about the state of Tasmania's healthcare system, for instance.

    I guess what I'm ranting on about is that there's a big caveat to your original post. Come to Australia, by all means, but do your homework beforehand. Talk to incumbent staff if you can, and steer well clear of those area health services that are under siege.

  9. Addit:

    Another perspective from impactednurse - check out his "piss and vinegar" archives for comments regarding the current crisis in the ED:

  10. I still think the original point stands.....If you want to avoid working shifts 24-72 hours long, it is possible to do it in Oz. If you want to work in an environment where people don't wait on trolleys for days at a time, it's possible to do that in Oz. If you want to have a life while you're a junior doc, it's possible in Oz.
    If the comments made by jane above are true, it may not be possible everywhere, but it's pretty much impossible anywhere in Ireland.
    I guess the proof of the pudding is in just how many Irish and UK docs are out here. Oz is full of us. Compare that to the amount of Ozzie/NZ docs you see working in Ireland.
    I used to dread going into work in Ireland and the UK, but I love my job here :D

    Dr. T

  11. Nice article. very interesting, thanks for sharing.

  12. Αn imρreѕsive shaгe! Ӏ've just forwarded this onto a friend who has been doing a little homework on this.