The charge to attend a and e is 100 big ones my friend. I know because I was recently refused entry to Warerford Regional Hospital unless I paid it. I scratched my retina and was literally rolling on the floor in agony so I wrote a cheque. The eye injury was the most painful thing I have ever experienced including giving birth without the aid of drugs. By the way once I got in the door my treatment in WRH was top notch. I was seen within two minutes of writing the cheque,

You do not have to pay this charge if you have a medical card, even if you attend multiple times in one day (walk in get triaged and left waiting while more serious patients are treated, get annoyed that you run out of fags so head off somewhere, lose place in queue, return, have to be triaged again and so on).

Also, as mentioned above, you do not have to pay this charge if you have a GP letter, many GP's will refer for anything and everything (sometimes to just to get an annoying patient out of their office). The out of hours locum GP's are the worst for this in my experience, I presume out of fear of litigation or plain incompetence in many cases.

I find it is very hard to be overly sympathetic for the non-critical patient complaining about a nine hour wait when there are nurses and docs busting their asses to treat really, really genuinely ill people behind other curtains. One teenager who had been admitted after a few too many bacardi breezers (and had been quite, shall we say, obnoxious on arrival) I think learned what a & e is for when she was put on a trolley just beside the resucitation bays and saw at least three cardiac arrests come in. I actually did feel bad for her, she was very subdued and quiet after that, I don't think she went out that evening expecting to see those sights.

An advertising campaign is badly needed, along with fines for messers.

I know that in the kids hospital in Crumlin there are signs up saying that nobody is refused treatment if they don't have money on them & that Finance will bill you later.

Finance are efficient at billing too- after a recent Saturday night visit the postman dropped the bill thru the door on the following Tuesday.

I don't think advertising will work - the people that are needlessly clogging up A and E don't care that they are doing so and don't have anywhere else to go - and many of them won't pay the fines if they are charged retrospectively (and you can hardly charge them there and then).

What would help as others have said is a primary care system that is available outside Mon - Fri office hours. The region I lived in in Spain had primary care centres which had GPs, nurses, paediatricians, physios, various mental health professionals etc all in one centre. Every resident was assigned to one centre and at night and weekends, one out of four centres was open for emergencies (i.e. cases that could not wait until Monday morning but were not serious enough to require hospital A & E treatment. Seemed to work very well - anytime I used the primary care centre outside hours it was busy but running efficiently and the two times I had cause to use a public A & E, it was deserted. I guess the fact that there was much less of a binge drinking culture also contributed.

Front line staff can be very hard working, very noble, and very good intentioned: but it still doesn't mean that the system and those people cannot be criticised. As GermanFred alluded to, the operational aspects of A&E (or at least the Mater, which I have been through) are terrible, and serve to create work and overhead for the staff there and to worsen outcomes for the patients. (I'm going to rant... get the juices going for the day)

It's really like the story of the man in the woods cutting trees with a blunt axe. He says he can't take time to sharpen the axe as he's too busy cutting wood.

A&E story: close relative (young man) ended up in A&E with a bang on the head during the most recent icy winter. Also hurt arm (put in sling) scuffed knees etc., Had taken a few drinks (was St. Stephen's night), but main self-inflicted aspect of injury was he had leather soled shoes. Was clearly concussed (after phoning me to tell me what happened, he then phoned me again 30 mins later to tell me what happened, and when I arrived into hospital he was "how did you get here?"). When I went down to A&E, whole place is in chaos, as usual. After several hours he's discharged. Had a symptom of feeling his ear blocked (which he had that night) but had not asked whether he could fly with that (was due to go to NY). Went up to VHI Swift Care next day to pay the money to get an answer. Doctor there looks in his hear, says "did you just walk out of the hospital?", "no, I was discharged", "did they XRay/CT your skull, you've bleeding in your ear, you might have a Basal Skull Fracture, that could kill you". "No, they mostly looked at my arm" (because the arm in sling was the most obvious injury, though not at all serious, and they seemed not to have looked further).

She phones hospital, makes lots of dark sounds "I'm sure you understand how serious this is, this patient should never have been discharged, it's vital he get reexamined quickly" etc., Gets us name of a doctor there, and we head back to A&E. Back in A&E, we then get sort of "readmitted" but without paperwork (because we have the name of the doctor and he's been briefed somewhat). Once we were on the "inside" of the glass doors, I didn't want to get out for fear of ending up right at back of entire queue trying to explain to admin at front desk about basal skull fractures. Met the doctor the VHI doc had spoken to, he went away. Then, nothing happened for ages and nothing was communicated. That's maybe OK, but my persistent fear was that this doc would finish shift, and we'd be sort of stranded in no man's land. I watched my watch, once per hour I nabbed the doc on his way through the corridor to ask him status or what next step was going to be (mostly not to be forgotten). On the last of these interactions, he snapped at me "look around you, see all the sick people, he is not my top priority". I genuinely wondered at that instant whether I was being provoked to get a reaction that would get me thrown out. I very calmly responded that he was my priority so I had to ask the question, and we wouldn't be here if he'd been fully examined 2 nights ago. I don't remember what was said immediately after that. However, about 15 mins later the doc came back with a post-it with the name of the doctor from the previous night "you might want to have that" and a calmer attitude.

Finally he did get a CT, bone was cracked but it wasn't serious, he could travel. I never saw a doctor look in his ear, and by the time we were getting discharged the shift had changed so yet another doctor was dealing with him, and the first interaction we had was the discharge. I asked him for the details on the investigation and diagnosis/situation. Also asked him had anyone looked into the ear. He said he couldn't see it on the charts but someone must have done so. I asked him if he was sure he was happy to sign the discharge without having evidence it was done. He at least went through the motions and did it.

There are tonnes of things wrong with that system, both efficiency and effectiveness driven. It showed up clearly again in the aftermath because the CT picked up another small thing to get checked. The appointment to see the neurologist took so long to get (3 or 6 months, mad) that the CT was no longer valid (standard time-frame expiry, whatever it was, months in any case) so the first thing he did was schedule another CT (cue further wait, wasted time for patient, radiographer, radiologist, etc.,).

There's a whole collection of problems in the system

• Poor handling of information (between staff, across time)
• Lack of standard procedures and checklists
• Poor communication to patients
• No streamlining of process (a quickly investigated and discharged patient frees physical space in the hospital, and mental space for the medics who can then file and forget, and not have the likes of me nagging them once per hour for half their shift)
• etc.,

For many of these, it comes down to doctors to make the changes. No administrator can provide the medic with a checklist for examining a head injury. At the same time, the medics need to be able to take on board innovations and ideas from operations specialists, as the training a hospital consultant gets is clearly not the kind of training that lends itself to large scale systems thinking. The culture seems to me to be one of work harder and harder, but not necessarily question the systems.

Some places have a great primary care out of hours system - Caredoc does out of hours GP care for south Leinster and Tipperary, there's something similar in Co Clare (at least there was 8 years ago as I remember a friend using it on a surfing trip down there), DubDoc is an out of hours GP service that works out of James's Hospital, and DDoc in North Dublin is fantastic. This is a very large swathe of the population covered, and there are probably other services covering different areas that I don't know abut.

I had a very sick relative being cared for at home earlier this year (was bedbound, terminally ill and didn't want to be anywhere near an A+E - quite understandably). I found was a hell of a lot easier to get medical help out of hours - given the patient's condition DDoc were happy to send someone if necessary and usually arrived within an hour or so, and they were very good. They also gave useful advice over the phone a couple of times as well. If you wanted a GP house call it had to be arranged a day in advance, which is not that useful for emergencies. The local GP wouldn't even come out to confirm the death in the end so that the body could be removed to the funeral home - ended up waiting 3 hours till 6pm and calling DDoc to do it. Including that visit we used DDoc 3 times in about 3 weeks, I think.

For most cases they don't do house calls that way, you travel to their centre if you can. They do a phone triage first with a nurse and they will send you to A+E if they think it could be something imminently life threatening.

Not everyone is aware of these services, unfortunately, so I suspect a lot of people probably do go into A+E when a call to one of these would suffice.

Your relative was a serious patient. He had head trauma. He should have had full neuro exam and at least been kept for observation. Due to the fact that he had alcohol on board, he should be presumed to have some sort of brain injury as nobody can determine if those symptoms are as a result of the trauma or the alcohol so you have to presume worst case.

There are checklists available for examining head injuries that are perfectly adequate, obviously in this case the resources available in the a & e department were not enough to meet demand, so a major emergency should have been called. The snow was particularly manic time, but sadly if a major emergency was called everytime it should be - we would be in a chronic state of emergency. So the staff trundle on. A&E can stop accepting patients and divert ambulances to next nearest hospital - but those hospitals are packed too, so this happens rarely.

Unfortunately, frontline staff do not have the time to make the systemic changes - people literally are dying in front of them and they need x,y or z done NOW. Sorting out allocation of resources, patient care pathways etc is not the job of these staff, nor should it be. It is managers, government, nurse managers etc. Just to add, I dont work in an a & e department so I have no vested interests.

This is always the challenge. The person needing "x, y, z done NOW" is real, but so are the patients who will present tomorrow and next week and year. Total outcome will depend both on the immediate response, and the long-term learning.

A&E is the most extreme case, but I know of a friend who's a consultant (I've posted the story elsewhere on Pin) and there are similiar contradictions and insanity in that specialism/hospital-dept. (handling of waiting lists, no standardisation between consultants on technique, etc.,).

It's not only the responsibility of consultants. However, they have a major leadership role, are connected to the operations side of the house, and are generally reasonably intellectually able. They definitely have an opportunity to help fix the system; and they certainly have the capability to stymie any attempted fix that they don't like.

And I do agree, that ultimately what would fix the system best would be a tough cadre of hard nosed and intelligent managers to break down a lot of the sclerotic accumulations and reinvent things. It's just a question of where they will come from.

The Irish Health Service gosh where to begin?

VI Declaration: I am a consultant in 2 of Dublins largest hospitals. I trained and worked in the NHS for 10 years before joining the Irish Healthcare system in 2003. I've been a consultant for 4 years.

@Germanfred sorry to hear about your experience. @Txirimiri thanks for the hat tip, I'm sure present company was excepted, but broadly I agree.

By way of defense of me and my coligues when choosing a carear in medicine the barriers to entry are high. You have to be motivated and very committed. it starts at school. you are interested in science and caring for patients I began like may others volunteering in hospitals and working for the St John ambulance. Once you get to med School the focus is all on pure learning Anatomy, Physiology, Chemistry Biology etc before moving on to the practical arts of the Practice of medicine. The next 10-15 years are very long hours and per hour very little pay. my first year the pay structure was full pay for the first 40 hours, half pay for the next 32 hours and then nothing after that. Ie you wer paid for the first 72 hours. Our average hours were 90 pw the longest week I worked was 128 hours which included a 56 hour shift. The gross pay worked out at about £1.20 per hour. Once you get on to the higher specialist training it is all about your speciality and you and your family make sacrifices to pursue that training often moving over seas. By the end of it you are a very well trained doctor in your specialist area focussed on clinical excellence, most of us tag on a management course to tick the box prior to the consultant interview but by that stage almost none of us have any experience of or interest in management.

@Txirimiri by the end of this its not surprising many of us my self included (Pin you saved my life and a fortune) are a bit one dimensional.

The best roll for a consultant is; adequately resource them and point them at the patient. Most of us would be happy to full fill that roll to the full. But we work within one of the most obstructive, unionised institutions where no one can be sacked for anything.

For avoidance of doubt I have zero sympathy for anyone who doesn't discharge their contract in full. For the record I dont admit any private patients to public hospitals.

The consultant contract requires 37 hours of programmed monitor-able audit-able work + on call. After I've discharged my contract I still have some free time (remember I've never been required to work so few hours in a week) so I do some private work after my public commitments.

I have a very good example of the public vs private system.

I work with Surgeon A doing cases B in the public hospital one after noon each week. We rarely are able to do more than 3 cases per week together in the time available in the public hospital and cases are often canceled at short notice. There are days when I go in and my whole list has been canceled no one has informed me and there is nothing for me to do but drink coffe and as a certain song goes "chat up the nurses and be generally subversive".

I work with the same Surgeon A doing the same cases B in a private hospital. We regularly do 12-16 cases in the same time that we manage to do 3 in the public.

Why?

Its the whole f@*king system top to bottom. No accountability at any point and no incentive to do any better. Tiny examples as to why: in the public, only the porters are allowed to move the patient from the bed to the table and table to bed at the start and end on an operation. If we muck in because they are late, delayed elsewhere etc it becomes a union issue. One day I changed the 13 amp fuse on a plug because we needed the machine to start a case, it nearly resulted in a hospital wide strike by the electrical engineers. If the list finishes early the nurses get re-deployed to the wards which they hate therefore the list always expands to fill the time available regardless of the workload. Consultants are forced into management to sort out and improve shit like this because we want to work but its a mess and we hate it, its not what we are trained to do and its sole destroying.

In the private hospital, people get sacked, time is money, if the porter isn't there even the radiologist mucks in and moves the patient of the bed. If we are quick and efficient we get to go home early. If the list is canceled we all either dont come in or get to go home and dont get paid.

It would be nice to scrap the whole public service and start again.

The health service is like an old plane fixing it and changing things is like trying to repair it while it flies along.

A&E is a mess. The biggest problem is work load. It's used as a GP service. This is intolerable and no amount of tinkering will fix it. There should be better out of hours service and personally I think all GP care should be free. This would overnight fix the A&E problem.

When you become a consultant you see lots of small changes that would improve the service. I identified a minor change that would save our hospital 60K pa in its drug budget. When implemented it would have actually reduced infection risks for the patient and slightly improved care and make zero difference to everyone else's practice. No brainer right?

It took me 2 years to implement this minor change, I had to talk to he head of every feckin imaginable department and it felt like wading uphill through treacle. The change made no difference to me personally so the resistance to change was truly unbelievable. Another very minor change in our departments practice bringing us unto date with what many other hospitals were doing 20 years ago caused unbelievable resistance from the nurses that resulted in us doing weekly and in my opinion completely unnecessary training courses for 8 weeks a waste of everyones time.

When you think what it would take to actually implement a major practice change the mind boggles! I'm worn down by it already, why bother. I'd just prefer to get on with what I'm good at .

Please dont think I'm blaming Nurses or Porters for the problems thats not the case its at every level in the organisation including my own and some of my erstwhile collages give the rest a bad name.

But.....

Its not so bad, every day people are treated people get sick and get well 70% or more of it works very well. From my management coures I recall our spend vs health benefits or activity or something is not bad when compared internationally (perhaps some of the chartists can help support or refute that)

Its customary to end these rants with something positive or a suggestion on how to over night improve the system so Ill not do a Morgan Kelly and leave you with the suicide icon so here goes TI's quick fix heath service:

1. Make GP care Free to all would instantly ease pressure on A&E
2. Make 24hr GP access mandatory every where in the state by way of GP CO-operatives again would help A&E
3. Allow staff to benefit from improved efficiencies otherwise who cares what it costs or how quick you get your work done. (let them go home early or spend the saving in their own department)
4. Dont deploy consultants in managerial postions they are clinicians through and through and crap at management in most cases
5. Allow people to get sacked from the public service
6. Come down like a ton of brick on consultants not discharging their full public contract (IMHO this would be a handful)
7. Sick with one health care system ie full National health system or fully private. The bastard version gets the worst of both

edit changed a do to dont

Top post TI.

Two things I've noticed in France that could ease some of the strain in Ireland:
1. Availability of testing centres - they're all over the place. If I need blood work done, I can have it within a day in a large city; perhaps take two days in a smaller town.
2. Availability of machinery - "clinics" of GPs (normally 3+ sharing a premises) generally have their own small xray/echograpy machines. If I present with a damaged wrist, they'll check me out first and only send me to A&E if necessary. For non-urgent cases, you can book an xray or echo at a clinic that specializes in these.

thanks TI

un-fuppin-believable

as good a post I have seen on the Public Service in a long time. Good to get an insiders view to tell the real story
Your experience mirrors so much of my own in the Public Service even though we are both in different professions/organisations.

The Public Service is run by the unions...and the Unions do'nt give 2 fiddlers about the customers...they believe the organisation exists to keep their members in insulated, and well paid jobs, from which they can never be fired (short of committing murder!).

I firmly believe if the 'job for life' rule was got rid of in the morning, the whole system would be transformed overnight

That doesn't seem right. Couldn't they bill you after treatment. I doubt everyone who ends up in the ER has a wallet/cash on their person.

Mind you, 100E is cheap. I went to an ER overseas with a broken ankle. I had an xray and a nurse wrapped the ankle and gave me crutches. I did not see a doctor at all. Bill was 4k. Yep. I had insurance, but even if I didn't they would have treated me.

http://www.psqh.com/janfeb05/100k.html

Any of these in place in Ireland