The trolley emergency: when will they ever learn?

The other day, I googled “patients on trolleys” and 0.34 seconds later I was presented with 384,000 hits. No matter what year I chose to explore further, from 2000 to the present, the media coverage and public commentary was depressingly similar to that of recent months. Here is my random selection of excerpts from the national newspaper and electronic media outlets over the past 15 years.

“The most pressing deficiency is capacity. We have a bigger population and an older population and we do not have the hospital beds to deal with this. It is a historic problem which has been exacerbated by the advances in medicine and greater complexity of the health service today. We also need to develop the physical facilities too”.” Micheál Martin, former minister for health, July 2001

In January 2005, three and a half years later, when the number waiting on trolleys for treatment in emergency departments (EDs; formerly called Accident&Emergency) around the country was 224, Mary Harney, the then tánaiste and health minister, said: “I think from the spring of this year you will begin to see measurable improvements. I’ve asked the Hospitals Office to publish on a daily basis, data, not just in relation to accidents and emergency but data in relation to people treated and I think we need to get all of the data out into the public arena so the public can see what’s happening and we’ll be able to measure the results and the outcomes.”

A year later, a record 422 patients were said to be on trolleys. “What is needed is a capital investment programme for our hospitals to provide more beds and additional staff,” according to Sinn Féin TD Seán Crowe.

A new record high of 455 patients on trolleys was reported in March 2006. Tony Fitzpatrick, then industrial relations officer of the Irish Nurses Organisation (now the INMO), slammed the situation, which he said was getting worse for frontline staff, saying: “Our members are trying to deliver quality care, but the situation is intolerable.” Fine Gael deputy Dr Liam Twomey TD accused the then tánaiste of abjectly failing to deal with the overcrowding crisis. “If we needed proof that the A&E crisis is out of control, the INO figures are just that . . . It is hellish for the patients, often elderly, waiting on trolleys in uncomfortable and hazardous conditions,” he said.

In January 2008 a headline in one of the national daily newspapers read “400 languish on trolleys as A&E crisis hits new peak”. A Dublin-based A&E consultant described waiting for a bed in a hospital’s accident and emergency unit as “like purgatory” for frail, elderly patients.

“We are firmly back in the territory of March 2006 when the minister described A&E as a ‘national emergency’. The minister’s failure to provide long-promised community beds is at the root of the problem; misguided cutbacks, imposed with the minister’s sanction in the last four months of 2007, have played a part in adding to the problems now. In particular, budget cuts which saw patients refused discharge from acute beds to community facilities or supported at home with home-care packages were a false economy” said Dr James Reilly, former Fine Gael spokesman on health, in January 2008.

Later that year the Health Service Executive (HSE) announced that more than 250,000 bed days were lost over the 17 months from January 2006 because of delays in discharging patients who were ready to leave hospital. In 2007, this number was 165,000 and in the first five months of 2008 it was 85,000 bed days.

“What these bed figures are showing is the impact of the Fianna Fáil government’s failure to invest taxpayers’ money in essential health services while the coffers were full . . . As the government’s mismanagement of health continues, things look set to be even worse next year,” said Damien English, Fine Gael TD, in August 2008

On January 19th, 2012, the Examiner reported that 2011 was "the worst year in a decade for patients on trolleys". The paper referenced the Irish Nurses and Midwives Organisation (INMO), which claimed that 86,481 patients were left on a trolley waiting for a hospital bed; a 14 per cent increase on the 2010 figure.

Following the death of a patient on a trolley in a Dublin ED, the Health Information & Quality Authority (Hiqa) undertook an investigation and published its report in May 2012. The then chief executive of Hiqa, Dr Tracey Cooper, spoke of the “persistent, and generally accepted, tolerance of patients lying on trolleys in corridors for long periods of time with a lack of clarity as to who was accountable for these patients. This puts patients at risk, is not acceptable and should not be tolerated in any hospital in Ireland.” Dr James Reilly, who was by then minister for health, said that “patients in all of our acute hospitals need the assurance that this matter is being dealt with in an effective way, that lessons have been learned and that quality assurance systems are being put in place across the country”.

In August 2014, when 346 people were treated on trolleys, the INMO claimed that these numbers were more than double those in August 2013. “These figures, and the increased level of overcrowding and loss of dignity to patients, represent a dire warning, for the entire health system and the government,” said an INMO spokesperson. “This level of overcrowding, as a result of ever-increasing demand, also confirms that there is an immediate need for additional bed capacity (both acute and continuing care) to deal properly, safely and respectfully with admitted patients requiring in-patient care.” Liam Doran, general secretary of the INMO, said: “The trolley/ward watch figures for August are truly shocking and represent a clear warning that our health service has already cut back too deeply. We cannot talk about an economic recovery, benefiting everyone, while we are facing such unacceptable pressures in our health service.”

On January 6th, 2015, it was reported that there were 601 patients on trolleys: this was before the annual flu epidemic had been officially declared. One spokesperson said, “Terminally-ill patients are being left to languish on hospital trolleys for four days as worsening January overcrowding chaos gripped emergency departments.” On January 20th, the number of patients waiting on trolleys was described as having “fallen dramatically” to 431, only to rise again to 530 on February 10th and reduce to 460 on February 20th. For the next four weeks the figure ranged from 450 to 500.

On Monday, February 23rd, during an interview with Pat Kenny on Newstalk radio, Minister for Health Leo Varadkar noted that the number of patients on trolleys was 338, a reduction but, as he so eloquently added, “still bloody awful”. (Amen to that, everybody agrees.) The Minister went on, just like his predecessors, to say that things would be much better by the end of the year. Incidentally, the number increased again to between 404 and 463 during that week.

So, it is evident that successive health ministers have expressed genuine concern as well as some confidence that they would solve the problem; each in turn has been lambasted by the opposition of the day; indeed, in many cases the same individuals have played the role of minister in one period and then, having swapped jerseys, as opposition critic after a general election.

The numbers of patients on trolleys quoted above are totally unacceptable, all of them. To me, 10 patients on trolleys for anything more than an hour or two are 10 too many, never mind the appalling figures that have been a daily reality for far too long. An emergency department taskforce was established by Varadkar last December; its recommendations were published this month. The Government’s decision to provide an additional €74 million – €44 million to the Nursing Home Support Scheme (NHSS) and €30 million to cover the cost of additional temporary contract beds until June and more permanent community, convalescence and district hospital beds – is, of course, most welcome. Also welcome are the promise of speedier processing of applications and approval for the NHSS and the other proposals in relation to urgent care access, more efficient hospital care service delivery and chronic disease management, if they are realised.

The INMO data for patients on trolleys each day state that, in January this year, the number ranged from a low of 259 on January 2nd to a high of 601 just four days later; the number fell below 350 only three times that month; in February, the number ranged from 393 to 557 and fell below 350 on only two occasions and in March the number ranged from 307 to 520 and fell below 400 only once. Leo Varadkar has expressed the hope that, “by the coming winter, there should be no more than 70 people at any one time waiting on trolleys for more than nine hours in hospitals”. I am reminded of the expressed hopes of previous ministers for health from this Government and previous governments, and wonder. Seventy people are still too many, and nine hours on a trolley is too long for anyone for whom the need for hospital admission has already been decided.

The ED Taskforce Report is the latest attempt to address the “patients on trolleys” problem. Ironically, the core issue is not and, in my opinion, never has been primarily an ED problem; rather it is a direct consequence of the reduction of hospital inpatient bed capacity.

So, when will they (we) ever learn?

A "third world" health service First a few observations: I have never subscribed to the mantra that we have a poor health service in this country; too often we are told that Ireland provides a "third world" health service. This is simply untrue; anyone with any familiarity with so-called third world countries know this; our situation, challenging as it is, bears no comparison to healthcare provision in those countries with endemic poverty and deprivation.

Many working in healthcare in Ireland, including those in the oft-maligned HSE, provide high-quality and supportive care that many patients and their families appreciate. This is not in any way to deny that some patient experiences can go seriously wrong. Such occurrences, quite rightly, are always the subject of internal review, and sometimes to more formal inquiry and investigation. Medicine has never been a 100 per cent precise science: the aim is to provide high-quality and safe patient care and to minimise adverse events, near-misses and error to the greatest possible extent.

All that said, there is no justification for the continuing 'patients on trolleys' disgrace; there must be zero tolerance for the practice. The INMO has been one of the most consistent and fiercest critics and has, in my opinion, identified the core problem, namely the inadequate number of acute hospital beds. Some 2,500 (probably more) acute hospital inpatient beds have been taken out of the system in recent decades.

Reduction in acute hospital bed numbers This bed reduction began in the mid to late 1980s. I remember only too well the impact of the loss of 70 acute beds in the teaching hospital where I worked; two 35-bed wards were closed. Traditionally, GPs, when seeking a patient admission to hospital, used to ring their local hospital when seeking a bed for one of their patients with an acute medical or surgical illness. In my opinion, the referring GP's clinical judgment was invariably correct; prior to the reduction in acute hospital bed capacity patient referrals, as described, were invariably admitted directly to a bed in the appropriate medical, surgical or paediatric ward, usually on the day of referral. (Interestingly, one rarely hears of children on trolleys. Perhaps there is appropriate paediatric bed capacity?)

Once the bed capacity for adults was reduced so drastically, this GP referral pattern changed utterly. Many GP colleagues have said to me that they gave up in frustration phoning for a bed given that they were all too frequently left “hanging on” for inordinate periods only to be eventually told that there was no bed available. Not surprisingly, their patience having worn thin, many took to advising their patient to go directly to the local hospital’s ED. The widespread belief , and increasing reality, was that going straight to ED represented patients’ best chance of getting a hospital bed. Thus began the so-called ED crisis with which we have become all too familiar. As already stated, the so-called “ED crisis” has, in my opinion, never been primarily an ED problem; rather it is a direct consequence of the reduction in acute hospital bed capacity that started in the 1980s and has escalated ever since.

The Acute Hospital Bed Capacity report, published in January 2002, described the unacceptably high bed occupancy levels in most of our acute hospitals, ranging from 85 per cent (the preferred level in a minority) to as high as 123 per cent (both unacceptable and unworkable) in many hospitals. The report's authors concluded that an additional 3,000 acute inpatient beds were required to address the problem and ensure the provision of a safe and high-quality service.

An average bed occupancy of 85 per cent in our acute hospitals would provide the required flexibility in bed capacity to manage the variable demands on acute hospital services throughout the year, and not just in winter. This recommended average bed occupancy has, possibly with a few exceptions, not been achieved. Indeed it seems to have been largely ignored by successive governments and healthcare planners.

The 'good news' that is our ageing population Meanwhile, appropriate planning for the implications of our ageing population in terms of healthcare provision and other needs have not been adequately addressed. The 2014 estimate is that 12.4 per cent of the population in Ireland is 65 years and over. The numbers (male 275,114 / female 323,036) will approach 1 million by 2030 and 1.5 million by 2050. The projections for the older elderly (those 85 years +) are even more striking in the coming 30 years. This age group increased by 28 per cent between 2006 and 2011. The reality of an ageing population is good news; the majority will enjoy good health well into older age. Inevitably, however, there will be an increase in the absolute numbers of individuals with the illnesses of ageing such as arthritis / falls / fractures, heart failure, chest disease, stroke, cancer, mental illness and dementia and service planning must take this reality on board.

There is frequent reference in the media to a category of patients in acute hospital care, older patients in the main, euphemistically described as being "medically discharged"; that is, they no longer require to be in the acute hospital setting. It must be remembered that such patients have significant illnesses such as heart failure, chronic chest disease, stroke and dementia. Many have combinations of these diagnoses; their needs are complex and what many need is intensive multidisciplinary rehabilitation rather than placement in long-term residential care. The Boston-based surgeon and author Atul Gawande, in his 2014 Reith Lectures, touched on this subject pointing out that many of these patients, when asked, express a strong preference to going home while accepting a range of community-based assisted living possibilities rather than being placed in long-term residential care. Each person has the right to be centrally involved in any such discussions and decisions and is as entitled as anyone else to exercise personal choice in these matters. The subject is discussed in greater detail in Gawande's recent book Being Mortal published last year; it should be mandatory reading for all doctors, other healthcare professionals and those politicians with healthcare related responsibilities.

Much more 'unfair' than 'fair' The Nursing Home Support Scheme (NHSS) – cleverly, if rather disingenuously, referred to as "Fair Deal" – has been in operation since 2009. What is fair about levying additional charges on people who, through no fault of their own, suffer debilitating illness that lead to their need for long-term care? The charges applied in the NHSS would be unthinkable if they were applied to younger patients with cancer and heart disease, regardless of the considerable cost these illnesses incur. It is appropriate to seek 80 per cent of a person's pension, whatever that pension may be, as a contribution to the cost of their residential care, but not to levy further charges on their primary domestic residence – not to mention all other assets they may possess and to do this on an annual basis, currently for a maximum of three years. The original percentage deduction was set at 5 per cent and, despite assurance to the contrary, it was not too long before this was increased to 7.5 per cent. Recently, statements and counter-statements have been reported of a possible further percentage increase.

The NHSS is currently being reviewed. It is widely acknowledged that the scheme is inadequately funded to meet current needs, never mind the inevitable additional future demands. Recent media coverage has speculated that among the recommendations being considered by the NHSS Review Group are: decreasing the amount of money excluded from the financial assessment of those applying for the scheme (currently €36,000 for a single person and €72,000 for a couple); a possible further increase in the assets levy, currently at 7.5 per cent; and an extension to the three-year limit for levying these charges. These possibilities all have the same effect on the vulnerable minority, more money being extracted from them. “Fair Deal”, how are you. Minister of State for Older People Kathleen Lynch says these additional charges will not be imposed, but that was also said when the original 5 per cent levy was introduced. I share the concern and outrage that respected advocacy groups for older people such as Age Action and Alone expressed recently.

Not just about long-term care The truth is that there will be more, not fewer, patients with complex healthcare needs in our acute hospitals in the coming decades. The "bed problem" will not be sorted by merely placing more and more people in long-term care.

Alternative models must be explored. Why, for example, cannot individuals who avail of the NHSS use the monies, granted as they are to a named individual, to support care in their own home and not, as at present, towards funding long-term residential care only? Furthermore and separately, funding for the Home Care Packages scheme must be considerably increased, year on year, for the coming decades to keep pace with the certain increased need.

A short-term measure popularly advanced to address the “trolley crisis” has been the cancellation of a range of planned elective surgery, often at very short notice. This, too, in my opinion, is not acceptable. It results at the very least in much patient inconvenience, not to say individual distress and discomfort, and a further delay of uncertain duration to their required procedure/treatment. Two wrongs do not make a right.

Reconfiguration of health services There is much in the reorganisation of acute hospital care introduced in the past decade that I fully support. Examples include: the increased day care activity (medical, surgical and many diagnostic procedures); the centralisation, in a smaller number of appropriately resourced and staffed hospitals, of more specialised healthcare services such as cancer care, cardiac care, neurology/neurosurgery care, renal (kidney) diseases; and the proposed reconfiguration of the existing acute hospital structure into collaborative Hospital Groups. The establishment of Acute Medical Units (AMUs) and Acute Surgical Units (ASUs) in some acute hospitals, with direct GP access, has also been welcomed as a beneficial development and should be introduced to all acute hospitals. Furthermore, many patients currently going to ED might be more appropriately triaged to such AMU/ASU facilities, as appropriate.

However, the essential corresponding investment, development and reorganisation of general practice and primary care has fallen well short of the recommendations outlined in the Primary Care: a New Direction report published in December 2001, and the many subsequent policy documents for enhanced primary care. The agreement announced recently on the role of GPs in the manatement of chronic disease (asthma and diabetes, for starters) is a welcome straw in the wind.

Intolerable reality The implicit acceptance of the 'patients on trolleys' reality, which has continued unabated for 15 years is intolerable and must end. The single most telling initiative, in my opinion, would be for the Government to increase acute inpatient bed numbers such that the desired average 85 per cent bed-occupancy is achieved as recommended in 2001. This will provide each acute hospital with the required flexibility in bed capacity to cope more compassionately and efficiently with acutely ill patients, not just for the predictable annual increased demand every winter but throughout the year.

In addition to this, however, significant resources are required to further develop multidisciplinary rehabilitation services – “step up”, not “step down”; to properly resource general practice and primary healthcare services; to provide many more homecare packages; and to extend the use of the Nursing Home Support Scheme to help fund the applicants’ preference for care at home – all to be part of any overall plan.

Do nothing, or more fairly, do too little now, and the consequences for those unlucky enough to become ill over the coming decades do not bear thinking about.

Prof Cillian Twomey is a retired geriatrician