Doolin Lecture 2016: ‘Capacity: A quart into a pint glass’ Professor Patrick Plunkett. Clinical Professor, Emergency Medicine.
This year’s Doolin lecture was delivered by Professor Patrick Plunkett, a recognized authority in Emergency Medicine (EM) in Ireland. It is clear from the outset that Patrick Plunkett has a deep understanding of population flow and population changes over time. His lecture gave a new understanding and insight into how the current EM problems have been arrived at. A key message is that the population of Ireland is growing. This has been well illustrated with clear undeniable statistics. In 1961 the population reached its nadir of 2.1 million. In 1981 it was 3.4 million increasing to 4.2 million in 2006. This represented a 24% increase. The population has continued to increase, and in the latest Census (2016) it stands at 4.76 million. This adds up to a 40% rise in our population in 28 years. It is predicted that it will further increase to 6.7 million by 2060, in other words pre-famine levels.
The healthcare system has found these demographic changes a challenge. One of compounding factors was that as the population increased, the hospital bed capacity decreased. The number of hospital beds decreased from 17,665 (1980) to 11,832 (2000), representing a 33% reduction in bed stock. Despite this change the number of inpatients remained similar over time. In addition, the period 1996 to 2000 saw a significant rise in day case activity. The bed ratio 3.1/1000 is one of the lowest in the OECD. Between 2005 and 2014 there was a further 13% reduction in hospital beds. Dr. Plunkett explains the ebb and flow in bed availability for ED patients. Elective surgery activity decreases during the holiday periods in the summer, Christmas, and Easter leading to better bed access. For the rest of the year the bed shortages are more pressing.
The Lecture provides simple ‘rule of thumb’ statistics about ED departments. Plunkett points out that 20% of the local community will attend the ED annually. At his hospital, St James, the annual number of attenders is stable at 43,000 per annum. However the category of patient presenting to the hospital has changed. The patient cohort is older and more ill. There is a move away from trauma and minor accidents to complex long-existing medical disorders. The ‘simple’ cases account for 20% of the ED workload and are mostly dealt with by ED nurses. The other groups take time, investigations and frequently require admission (25 -50%). The sickest patients, Triage 1, require intense stabilization and frequently need intensive care. Patients over 85 years pose a number of challenges. While some get better and go home, many don’t. The latter develop psychosocial deterioration and need nursing home placement. Dr. Plunkett has concerns about the nursing home support schemes. He describes it as ‘the long term health care market’. The Fair Deal is difficult to navigate.
In the opening section of the lecture Plunkett provides a historical perspective to our current challenges. Many examples are provided. John Lumsden in 1929 lobbied for economies of scale. He proposed the closure of small hospitals with a greater centralization of medical services. A previous report in 1927 stated ‘we are in sympathy with the attempt to preserve in small towns district or cottage hospitals on the plea that the distances o the central hospital are too great’. In the 1930s the Hospital Sweepstakes was a major source of income for hospitals. At the time of its inception lotteries were illegal in the UK, and the US. As a result the programme raises 75 million pounds, much from overseas. The British Prime Minister expressed concern about the flow of money from the UK into Ireland.
The problems facing Emergency Medicine are easy to understand but difficult to solve. There is inadequate in-patient hospital bed stock. The number of beds has decreased by 40% during the time when the population rose by 40%. The patient demographics have changed with increased numbers of sick elderly attending to ED. The number of patients over 85 years is 70,000 (2016) and is predicted to rise to 85,000 by 2021. The Patrick Plunkett lecture provides great insight into the operation of Emergency Medicine and how it interacts with the provision of the healthcare services. Throughout his delivery he has grappled with the key issues of demand and capacity. EM is the flashpoint of the system. When capacity is exceeded, the numbers in the ED departments swell.
In his concluding remarks Patrick Plunkett quoted the words of Bill Doolin as recorded by JB Lyons ‘history is the story of the past told in the present for the future’. We as a nation must be capable of implementing the aspirations of the proclamation of 1916.
This years Doolin lecture was both highly informative and thought provoking.