Hospital care should have been the issue of Election 2024

Imagine a never-ending economy class flight with no entertainment and you have a close picture of many of our hospitals. These are not the places of care or sanctuary they should be, writes Professor Rónán Collins
Hospital care should have been the issue of Election 2024

The Injury The Of Of Staff Cause Hospital Of In The Up Burn Build Overcrowding Real Out Mounting Is Daily Of Psychological Phenomenon Photo File Healthcare The

Ask your politician would they have their own healthcare in your local teaching hospital?

Despite all the press coverage of hospitals in the last 12 months, it doesn’t seem to be the hospitals that are exercising the nation’s concerns. Vox pops seem to suggest it is housing, price of groceries, energy inflation that are the burning issues of the election. 

Some news analysis of the ‘grey’ vote suggests it will be pension issues that predominate. Here, as in American elections, it seems it will be "the economy stupid". Those of us in the frontline of healthcare had hoped for "it’s the hospital’s stupid" that would be the defining issue of our election. 

In many respects it is a more immediate concern for older people and all of us that hope to live any length of time. It might come as a shock to the invincibility of youth but one in four of us will have a stroke, one in 10 will break a hip (one in five over 50) and over half of us will die in a hospital setting. 

It would seem important then to consider what care you might get and what that care will look like. Currently our public university teaching hospitals are beyond struggling. For many people a hospital admission will be the most traumatic experience of their lives, not just because of their illness, but because of the environment.

Sláintecare

The political solution mooted for the ills of our healthcare system is Sláintecare, the political vision for a single-tier health system. Cross-party consensus seems solid, until you ask a politician will they be using their local teaching hospital for their own healthcare needs. 

Then, the consensus conviction of a single health service for all begins to look a deal less solid as politicians, somewhat surprised at having to consider such a notion, mumble hurriedly about all-party working groups, etc.

Sláintecare was not meant for the political classes it would seem, at least not from what is being passed off as acceptable hospital care. Perhaps they have the vision of personal healthcare as being met in a comfortable private tower, far from the madding crowd, or in the comfy sanctuary of private mental health which appears to be the limit of the national discussion on that aspect of our health system. 

I haven’t heard someone with a less relatable mental health issue like schizophrenia being asked of their experience of ‘public’ mental health units. It’s as if they don’t exist.

Sláintecare, it would seem, is designing hospitals for ‘other people’ or replacing the hospital as the system leans on a gamble on what is termed a ‘leftward’ shift (not a political term I hasten to add) into more community-based treatments. This is good and I’m an ardent fan as a geriatrician of people receiving care nearer home or at home, receiving care in “the right place at the right time” in Sláintecare speak.

Except the notion that the hospitals are storing up inpatients unnecessarily or that we can treat much more of our emergency admissions at home is a fallacy. Stroke, sepsis, cancer, trauma, heart attacks and pandemic cannot be managed by ‘integrated’ and ‘enhanced’ community structures with little proper structure, leadership or any meaningful outcome measures, other than often duplicated and even unnecessary activity. This is hardly an alternative compensation for a functioning hospital system.

We have latterly acknowledged our error in not increasing the adult bed capacity which has been reducing for the last two decades despite the repeated warnings from the Irish Medical Organisation, amongst others. At the time of the pandemic we had over 2,000 fewer beds than we had in the early 90s.

 

Currently our public university teaching hospitals are beyond struggling.
Currently our public university teaching hospitals are beyond struggling.

The catch-up will take time and likely be a pocketed approach, but let us at least start to acknowledge the precise nature of our healthcare estate problems.

Hospitals, in case anyone had any doubts, are expensive to design, build and maintain. Heath inflation exists in an ‘upward only’ economic environment as technology and public expectation are uni-directional influences on health spend. Rebuilding a functioning university teaching hospital system will be expensive and will need continuous fiscal nurturing.

The Sláintecare ideology of discouraging a ‘public’ hospital being able to attract a patient's insurance income will not only serve to impoverish that system further from the much-needed investment in infrastructure and technology, but also embeds the concept that health insurance is not about social solidarity but rather about privilege.

God forbid a person might decide "I have health insurance and want to go to a teaching hospital where I heard the care is excellent and I like the concept of my insurance money going to a ‘not for profit hospital’ to contribute to the care of everyone". We have an excellent and needed private health service, but it should not be better than our teaching hospital system, where we train our healthcare staff, which it currently is fast becoming if not already there.

Our hospitals do not hasten recovery but rather decondition older people with trollies, endless noisy days under glaring lights, immobilised and made incontinent. File photo
Our hospitals do not hasten recovery but rather decondition older people with trollies, endless noisy days under glaring lights, immobilised and made incontinent. File photo

A family recently described to me their father’s distress at vomiting and being incontinent in front of a ward of people on a six-bedded ward, an all-too-common experience that nurses have to try manage. 

To preserve the dignity of death and avoid distress to others, staff often spend hours trying to orchestrate a move of a dying patient to one of the few side rooms they may have available. A move that should be routine and a minimum to give patients and families that solace and care.

I go home worrying about the psychological trauma of my hospital’s environment on my patients, playing bed moves over in my head so we might be able to make an attempt at some individualisation of care and help people feel safe and secure. It is a sapping emotion for healthcare workers to be ashamed of the environment in which we are trying to ‘heal’ people.

A patient’s frustration, sleeplessness, fear and anger are often manifest in our hospitals and impede their recovery or worse. HIQA, it seems to me at times, are a classic example of "regulation makes the compliant more compliant", often concerned with the banal, ignoring the more relevant. 

Asking a HIQA inspector once had he noticed the lack of space to nurse or toilet people on our six-bedded bays with dignity, or prevent infection, they commented: "That’s not on our list".

Burn-out

But poor hospital environment has broader effects. The recent events at University Hospital Limerick have again brought hospital overcrowding into sharp focus. Such conditions may cause patients harm, condition staff to poor process, lack of medical rigour or frank disinterest due to empathy burn-out among staff. 

Imagine day after day leaving work with the moral injury of "I couldn’t do my best or help my patient get comfortable, feel better, feel safe" or "that was a really dehumanising experience for that poor patient being incontinent, acutely confused or dying in full view of everyone". 

The mounting build-up of this daily psychological injury is the real cause of the phenomenon of burn-out in healthcare staff. 

It is a major reason why so many of our doctors, nurses, therapists are abroad in Australia and other countries. We are fortunate to have a talented diverse health workforce but it is also an expensive truth that it is an exception now to see an Irish-trained nurse practising on many of our wards.

Patient dignity

"Design for older people and you will include everyone," to paraphrase the great geriatrician, Bernard Isaacs, was a call for a non-ageist inclusivity in healthcare design. Our teaching hospitals are old, undersized, poorly designed and not fit for modern healthcare. 

Recent experiences with covid cruelly exposed this. Our hospitals do not hasten recovery but rather decondition older people with trollies, endless noisy days under glaring lights, immobilised and made incontinent. We lose their hearing aids, dentures, phones, disabling people and removing their means of communication. 

We provide wards without privacy or spaces to discuss the most of intimate of things, or to be assessed with dignity or toilet. Places without any aesthetic and no room to mobilise. Imagine a never-ending economy class flight with no entertainment and you have a close picture of many of our hospitals. 

The recent events at University Hospital Limerick have again brought hospital overcrowding into sharp focus.
The recent events at University Hospital Limerick have again brought hospital overcrowding into sharp focus.

These are not the places of care or sanctuary they should be. Our hospitals have become a Keatsian place "where palsy shakes a few sad last grey hairs, amongst the groan and fret".  

We must change this and have the political bravery to talk about hospital experiences without rancour or sanction. Let’s have a new social contract for our nation’s healthcare. 

Let’s state that our public teaching hospital system will:

  • Have all the necessary modern technology and capacity to treat illness to the best medical standards and have a strategic plan with appropriate professional advisory mechanisms to keep abreast of health technology.
  • Seek to foster social solidarity, and use and expand the health insurance system we have to invest in a not-for-profit health system for all that choose to use it, rather than having complete reliance on outsourcing to the private system.
  • Be designed to ensure people have privacy, dignity and access to amenity to create a sense of safety, comfort and security, providing single rooms where desired, as a right.
  • Be designed and gerontologically attuned to meet the needs of an aging population, protective and restorative of their function and property from the moment of admission.
  • Be a modern place of work where people can realise the full potential of their training in healthcare for the treatment of others. A place they are not ashamed of.

This is an intergenerational concern so when it is our turn to need hospital care, irrespective of our income or background, we can have faith that our hospital system that trains our healthcare professionals will have the best of technology, personnel, design and will meet our needs. 

If our leaders are not happy to be treated in our public hospital system, if our teaching hospitals are not as good or comfortable as our private institutions, then they are not good enough.

That must be our standard. That must be our Sláintecare.

  • Professor Rónán Collins is a consultant physician in geriatric and stroke medicine

 

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