An essential component of the professional relationship between doctor and patient is the delivery of competent and timely care. For most patients this can be and is delivered by their GP. 

A small minority have to be referred to a consultant or a hospital service for diagnosis or treatment. At this point, the health system fails to provide for the needs of many such patients as they suffer delays in accessing the needed service. For many, the delay is relatively short but for some it is so long that waiting becomes a nightmare and what should be a seamless service fails to deliver.

The waiting game

Last month, over 300,000 patients awaited hospital evaluation or admission. The number increases every year and waiting times have shown minimal improvement despite a huge increase in expenditure on hospitals since 2005. 

It is difficult to understand why GPs and hospital specialists, who share a common obligation to deliver timely care, have not taken collective action to publicise and rectify this unacceptable situation. There are a number of possible reasons for this inaction. 

Separation 

One arises from the separate development of general practice and hospital care and a growing dichotomy of interest between family practice and specialist hospital consultants over the past 40 years. Historically, family doctors were private practitioners, although a small number of state-salaried dispensary doctors looked after the indigent. In 1972 the dispensary system was replaced by the General Medical Services scheme, which now covers about 40% of the population. 

Consultants also made their living from fee-paying patients referred by GPs to their consulting rooms. They tended the poor in charitably funded voluntary hospitals; virtually the sole providers of inpatient care until the state-built publicly funded county hospitals during the 1930s. Full-time, salaried physicians and surgeons staffed these and they revolutionised hospital care.

The voluntary hospitals continued to exist as independent privately owned institutions, albeit increasingly dependent on state funding. Consultants were not paid for public patients until the introduction of the notorious pool system. Although by 1970 about 60% of the population was eligible for free hospital care many sought private treatment, providing the main source of a consultant’s income. 

In 1979, eligibility for free hospital care, was extended to the entire population. This necessitated a major change in relationship between the State, the voluntary hospital owners and the consultants. Shortly afterwards, the common contract for consultants, which had been three years in negotiation, was introduced and accepted by the majority of consultants. 

The contract guaranteed the right of consultants to private practice within and outside voluntary and state hospitals.  

The provision of universal eligibility without any significant expansion in hospital capacity or consultant numbers put increasing pressure on the system. Coinciding with the growing complexity and effectiveness of modern medicine, the resultant increase in demand for hospital care led to the appearance of waiting lists. 

During the mid-1980s, this was alleviated by the development of the private Blackrock and Mater hospitals but aggravated by the net loss of 2,000 beds to the public system resulting from the closure of nine Dublin hospitals, and despite new hospitals at St James’s, Beaumont and Tallaght. 

The resultant capacity problems made direct referral to a consultant of patients needing immediate admission to unworkable. Consultant inability to source beds or to provide rapid outpatient opinions meant that urgent and problematic patients were referred to casualty departments in ever increasing numbers.

Admission through ‘on-call teams’ delayed access to appropriate beds for those admitted and to specialist outpatient clinics for those who were not. Frustrated GPs felt that consultants had abandoned the traditional relationship between the two groups of doctors primarily responsible for providing an acceptable service. The resultant tensions led to problems that continue to this day.

System failures

Partly because of this growing rift, the Irish Hospital Consultants Association was founded in 1989 to represent consultants, disillusioned by the GP and junior hospital doctor dominated Irish Medical Organisation. 

Today, two separate bodies represent the profession. Their concentration on the industrial aspects of the contracts held by the different groups, and the lack of a joint forum in which to discuss the common interests of patients, is partially responsible for failure of the profession to advocate for removal of the barriers to a unified service. 

Both general practice and hospital care lost as a result of  this rift but patients suffered. Failure to integrate the care systems has serious and persistent consequences. 

GPs are at the heart of our healthcare system. For too long they have been discouraged in their efforts to provide a seamless service to their patients. For many years denied access to diagnostics, and frustrated by long waiting lists for consultant services, they seemed to accept ever-deteriorating patient access to the hospital services without major opposition. 

The consultants too failed to support the development and implementation of a comprehensive primary healthcare strategy. In 2001 the Department of Health accepted the need for the creation of primary healthcare centres throughout the country. Government promised to establish over 500 such centres within a few years. Such a development was to provide many shared diagnostic and specialist services in the community, relieving inadequately funded and overstretched hospitals. 

Frequent contact between GPs and hospital specialists would facilitate admission, when needed, for hospital care. Failure to implement the primary healthcare strategy is one of the most abject of all the failures of the Department of Health and HSE. Given the ongoing reorganisation of the major hospitals, it is more important than ever that primary and hospital care should be integrated, and that appropriate organisational structures are provided.

Failure to reform the administration and funding of the service is another major factor. The Integration of the health boards into the HSE should have united all branches of the health service. Instead, it resulted in further fragmentation in administration and management, reckless duplication of posts caused by the lack of a redundancy scheme and grossly inflated and ultimately uncontainable costs. 

The HSE became a bureaucratic monster, which is now being dismantled at enormous expense. Scandals resulting in popular pressure led to  some achievements in improving services for cancer, but history is likely to judge the HSE experiment to have been a disaster. 

Politics 

The major political problem has been the inconsistency of the policies pursued with varying degrees of interest by successive ministers for health between 1997 and 2011. 

Numerous expert reports were commissioned by the Department of Health itself but very few were even partially implemented because of political and local resistance to change. 

Perhaps the worst problem of all was the blind faith of the last Government in the ability of the HSE to carry through the reform process even when it became obvious that it could not succeed. It is encouraging that the present Minister for Health appears to be tackling the Herculean task of cleaning the Augean Stables, but it is not clear whether he will command the support of the entrenched bureaucracy in his own department and the HSE, without which he cannot succeed.

The doctors must share the blame for failure to implement the Primary Care Strategy and the slow pace of hospital service reconfiguration. Professional reluctance to accept anything less than ideal facilities resulted in overstated estimates of the cost of providing acceptable community and hospital services. Inflated costs frighten those who have to find the money and it stalls development.

Silver lining

Given the current financial crisis, the implosion of the HSE, and a growing public realisation our that resources are finite, there may be an opportunity to reorganise healthcare delivery radically. 

Thirty years ago, doctors were the leading advocates of change in the interests of providing better services to patients. They should resume this role, which they abdicated to management and politicians. Only they can reduce costs while maintaining services. 

For instance, a return to common sense based good clinical practice and abandoning defensive medicine could save enormous sums. Although some practising doctors have been very involved with and helped to steer reorganisation, significant change will not happen unless more participate and all cooperate. Progress would be more likely if the two professional representative bodies were to cooperate in working towards improved patient care.

A reforming minister may facilitate reorganisation but true renewal will depend on significant and continuing professional involvement. Ministers come and go but doctors are there for their professional lifetime. They are obliged to put the patient at the centre of everything they do. To do this they must lead the process of reform.