On the frontlines of the health crisis

An interview with Dr. Ciara McMeel, a GP working in West Tallaght

There is a common perception that our health service is in crisis. However, there is little understanding of where the problems lie and what can be done about them. We interviewed a GP working in one of Dublin's poorest areas to get a view from the inside.

Is there a problem with the Irish health service?

Yes, there are serious problems in both primary care (GP service) and in secondary care (hospitals). The GP service has less obvious problems than the hospital system, as those who are seen are generally well looked after.

However, there is a large number of people who aren't eligible for medical cards and who can't afford to pay to see a GP or to buy prescription medicine. The first time that these people come into contact with the health service is often when they appear in an A&E department with critical symptoms. Often times these crises could have been avoided if they had seen a GP in time.

Although the hospital system is generally free to use and you are generally well looked after once you have been admitted, the major problem is getting in. The only ways to get admitted to a hospital is through an A&E department or by being referred by a GP.

If you arrive at an A&E department with serious symptoms, you might have to wait at least 8 hours before you are even seen, then lie in a trolley for 3 days or more waiting for a bed to become free. If you are referred by your GP, you will generally have to wait for between 2 months and 2 years before getting an appointment to see a specialist - and these people aren't even included in the government's waiting list figures.

Is it just a problem of not enough money?

Money is obviously important, but it's not the only problem. The fact that many people can't afford to see a GP means that they come to hospitals only when a crisis hits. Also, people who are waiting a long time for an appointment have to show up at A&E departments when their symptoms flare up.

For example, if you are waiting for an operation on your gall bladder for a couple of years, you might have to visit A&E six times or more before your operation is scheduled. This is a serious problem as crises obviously have to be prioritised and they are very expensive to deal with.

If you arrive at A&E, having had a heart attack, you will need to use expensive equipment and be cared for by highly skilled staff in an intensive way. If you had been able to afford to see a GP in time, or had an appointment to see a specialist sooner, this could have been avoided and the care would end up being far cheaper. In fact, a system where primary care is free, like the NHS in Britain, probably ends up being cheaper in the long run as many problems can be spotted through screening and prevention before they reach crisis point and require expensive treatment.

Another problem is that it is increasingly difficult for the health service to recruit and retain key staff, such as doctors, nurses and physiotherapists. Many of them have to put up with extremely difficult positions and low pay. In particular, I don't know how it is possible to survive on a nurse's salary in Dublin and as a result many are emigrating or getting jobs in the private sector. This is the main reason that wards are being closed in hospitals.

Nurses in most units are highly skilled and when one quits it is often impossible to replace them. For example, if there aren't enough specialised nurses to man an intensive care unit around the clock, the hospital has no choice but to close the beds.

Finally, there is the fact that many private patients are heavily subsidised by the public system. When a private patient takes a bed in a public hospital, their insurer pays for the bed and the consultant. The public is left to pick up the tab for all of the other areas that are crucial to their care, such as nursing, junior doctors and administration.

If you compare the difference in costs between a private bed in a public hospital and a bed in a fully private hospital, you get some idea of the level of subsidies. I don't mean to blame private patients, it's a problem with the system and people who can afford it are obviously going to opt for the best care available.

The government are reforming the health service administration and are creating an executive to replace the health boards, is this likely to address the problems?

In general, relations between doctors and the government have been very poor. The health boards are bureaucratic, inefficient and mainly run by people who have no experience of actually working in the system. They are manned by senior civil servants and business people rather than doc-tors or nurses. Doctors also have a lack of faith in the health boards due to a history of guidelines on working times and various EU regulations being ignored.

The health service executive will be another top-heavy bureaucracy run by people with no experience in health care. It is part of the government's drive to introduce private sector management into a system which has to be run on ethics and where cost can't be the bottom line. This leads to a situation where hospitals are tied to a fixed budget and are penalised if they exceed it. Thus, medical staff are unable to respond to crises when they arise. Again this can actually be more expensive in the long run.

When hospitals aren't allowed to purchase new machinery for screening or have to eject the 'least sick' patients to admit new serious cases, the consequence is more people coming to A&E in crisis conditions which are expensive to manage.

How can the problems be addressed?

Well, as a GP, I'm biased. Prevention is better than cure and we should spend more money on picking up problems early. Free, or at least affordable, access to GPs for check ups and screening would pay off in the long run.

In hospitals there is currently a crisis that has to be managed. They are using all the money that is available to them and they simply need more money, especially to pay for more nurses with better pay and conditions. There are currently many beds that are empty for lack of nurses. Re-opening these would provide badly needed beds for patients. Hospitals should also have the right to break their budgets in times of crisis.

The administration of the whole system should be radically reformed. Health boards should have much more direct accountability and should be made up of people who actually work in the system. Representatives of doctors, nurses and other hospital workers have a much better insight into the problems. It's a waste of time to have to ex-plain problems to outsiders and the benefits of certain spending decisions are obvious to health workers even though they might go over budget.

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This edition is No80 published in March 2004

Workers Solidarity No80