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Resignations threatened as neurosurgery service on the verge of collapse By Conor Ganley.  

(writing in the Irish Medical Times)In and EXCLUSIVE INTERVIEW Conor  talks to five angry Beaumont Hospital neurosurgeons who warn there will be a tribunal of inquiry if they continue to operate under unacceptable conditions.

“It is reaching a point that neurosurgeons will resign from the public service,” – Mr Chris Pidgeon, consultant neurosurgeon, Beaumont Hospital.

Neurosurgeons at Beaumont Hospital are angry and on the verge of resignation.

The working conditions they experience on a daily basis are often intolerable and their situation is unsustainable.

“The service here is on the verge of collapse. There is shortage of consultants, a shortage of beds and crucial surgical equipment is out of date and regularly breaks down,” says Mr Pidgeon.

Last week, all five publicly appointed neurosurgeons in Dublin met with Irish Medical Times to highlight deficiencies in the national neurosurgery centre.

Mr Pidgeon, Mr Daniel Rawluk, Prof Ciaran Bolger, Mr David Allcut and Mr Steven Young say they have had enough of promises.

Mr Pidgeon believes neurosurgery is in a worse state than it was 30 years ago.

“There are six neurosurgical posts in the public sector in Dublin and three in Cork. The number in Dublin is exactly the same as in 1978. This has been exacerbated by the fact that one has recently retired and has not yet been replaced, so there are now less in post,” he says.

But the consultant problem is only the tip of the iceberg.

Mr Pidgeon says the operating time available is one-eight less than it was in 1978 due to lack of resources.

One session in eight

“Normally, a neurosurgeon would have two operating days in theatre, but we have been cut to one session in eight. We were cut to one session in four three to four years ago. Then, two years ago, that was slackened to one session in eight,” says Mr Pidgeon.

Neurosurgeons deal with head injuries, haemorrhage, brain tumours and acute spinal services. People in bad car crashes and those with Parkinsons also need neurosurgery.

In spite of the high number of road traffic accidents, the Government appears not to recognise the importance of neurosurgery.

“We have been progressively reduced to running a fire brigade service. All of us have waiting lists running to years,” says Mr Pidgeon.

What is frustrating consultants even more is the delay by the Health Service Executive and the Minister for Health, Mary Harney, to approve publication of a report on neurosurgery.

Former Minister for Health, Micheál Martin asked Comhairle na nOspidéal in 2002 to produce recommendations for neurosurgery. It is understood that this report is completed but there are fears that it is being suppressed.

“We have now been informed through Beaumont hospital, that Comhairle signed off on the report in December, but it is being sat on in the Department of Health – by whom we don’t know,” says Mr Pidgeon.

The report’s non-publication means four years have been wasted. Neurosurgeons submitted figures in 2002 to Comhairle, but refused a second request for figures from the organisation last summer.

“We did not re-submit because we thought the right thing to do was to write to them and say we had lost confidence in the committee,” says Mr Pidgeon.

The neurosurgeons want 16 consultants nationally. They expect a substantial expansion at Beaumont while Cork is set to benefit from a doubling to six in consultant numbers.

But nothing will happen until the report is published. The HSE will not meet neurosurgeons until then. Neurosurgeons believe the report, which has been with the printers since 2005, will not be published until after the next general election.

There is some suspicion that the report will present an election problem for the Minister for Health, Tánaiste and Progressive Democrat leader, Mary Harney.

US money has been put on the table for neurosurgery in Galway, but Comhairle are not expected to recommend such a unit. The PDs have a seat in Galway West.

In the meantime, neurosurgery nationally is suffering. Consultants need equipment but neurosurgeons are working with bad and, perhaps, dangerous tools. Mr Pidgeon says there was substantial investment between 10 and 15 years ago, but this has not been sustained.

The surgeons use a computer system, which should be the equivalent of satellite navigation on the brain. However, the system used in Beaumont, they say, is sluggish and keeps crashing.

“It keeps breaking down during cases, particularly our computer-guided system,” says Prof Ciaran Bolger.

“Our computer-guided system is ten years old now and I don’t think there would be a manager in this hospital that would have a ten-year old computer on their desk,” he says.

“It is so old now that the company that made it can’t maintain it,” he says.

Just one of the three computer systems has been upgraded. Prof Bolger says that, if three surgeons are operating on the same day, one will be working without critical instruments.

Up to 70 per cent of neurosurgery requires use of specialised microscopes. One of the three microscopes was due to be upgraded in 2002, but is now “clapped out”, according to Mr Pidgeon. He says it breaks down during surgery.

Prof Bolger says most people with head injuries should be in ICU beds and be receiving head monitoring. Beaumont has just ten ICU beds, which means that patients are in beds in other hospitals without neurosurgery.

End up more disabled

“We manage patients on the phone for other hospitals. It probably means that patients end up more disabled than they would have been,” he says.

When Mr Rawluk left Manchester 14 years ago, he was attracted by a dedicated Intesive Care Unit in Beaumont. This is no longer the case.

“Other surgeons and anaesthetists elsewhere ask us to take these patients. We would love to, but we have to make a choice,” says Dr Rawluk.

“We are making decisions on the basis of access to resources and not clinical need,” says Dr Rawluk.

Never pass a medical.

Mr Pidgeon says patients with non-life threatening complaints are worst impacted by the situation.

“If you have a working man who slips a disc and needs an operation and cannot get into hospital within six months, his employer will fire him. Because he has been fired, because of his back complaint, he will never pass a company medical again,” he says.

If no improvement is made and nothing is done, Prof Bolger expects a tribunal of inquiry.

“In five years time there will be a public inquiry into neurosurgery, like the blood scandal, and the people who will be hung out to dry will be us. I will be trying to justify why Mr Bloggs died on my waiting list and why I was just a cruel bastard for not bringing him into hospital,” says Prof Bolger.

“I was in the Coroner’s Court and got lambasted over a patient who had to wait three or four days to come to us from the neurosurgery unit in Cork. The family blamed me because the women subsequently died,” he says.

“There is nothing more expensive to the State than the cost of a bad neurosurgery outcome. One of those would pay for a lot of equipment in a neurosurgery unit,” says Mr Pidgeon.

Mr Pidgeon says a case is already pending where a consultant has been isolated.

“One of us is being sued for a death on the waiting lists; the hospital’s view is that it is the doctor’s fault,” says Mr Pidgeon.

Poor resources

Mr Young believes that consultants are constantly making compromises with the standards of care because of por resources. “There is going to be a day of reckoning. In five to 10 years time people will say: ‘Why did so many people die?’”.

Mr Allcutt’s special interest is paediatrics where difficulties are perhaps more acute.

“We do not have the facility deal with neonates here. Children are largely being dealt with by surgeons who are not neurosurgeons,” he says.

He believes that the merging of the children’s hospitals will require a dedicated neurosurgery unit at the new hospital.

Mr Steven Young expects the new A&E targets to make things worse. He says Beaumont has already stopped all admissions to keep beds empty for casualty patients.

“The patients that I would bring in over the weekend for my Monday list are patients with brain tumours and aneurisms, who are arguably far sicker than patients who are coming in drunk,” he says.

“It is the norm for me not to have any patients admitted for my Monday list. I am twiddling my thumbs. I might as well get back in my car and drive home. The patients waiting to get in have very serious illnesses,” he says.

The consultants say that three-quarters of the admission for neurosurgery are either emergencies or urgent transfers.

“We are a national service working in a district general hospital,” says Prof Bolger.

“The pressures on the district hospital override the national interest, because the management have no interest in the national picture.

“If we say a patient in Galway is being disenfranchised, they (management) don’t care. They believe it is far better to treat the varicose vein patient from Beaumont,” he says.

He holds the Government accountable, and not management, for the non-prioritisation of neurosurgery.

The solution found by the Irish health service for the neurosurgery elective waiting lists is to treat patients in the UK. Beaumont is by-passed by many consultants.

“We have no capacity to provide basic elective neurosurgery. It all gets funded through the UK. Units in Oxford, London, Bristol and Liverpool are cleaning up at the expense of the Irish taxpayer,” says Prof Bolger.

Beaumont consultants have stopped taking referrals from Cork neurosurgeons to “coil” aneurisms (an alternative to surgery for aneurisms).

“We are the only country in Europe that does not provide brain stimulation for Parkinson’s disease,” says Mr Young.

Several hundred patients have travelled through the National Treatment Purchase Fund, say the consultants.

“It is insanity to be paying someone else to perform work at private rates,” says Mr Young.

Prof Bolger says spinal disc elective surgery costs about Ä5,000 in the Mater or Blackrock clinic. He believes British hospitals are charging the NTPF double that.

Spinal monitoring

The international standard for a removing spinal tumours requires spinal monitoring. This allows surgeons to monitor the integrity of the spinal chord during surgery.

“Do we have spinal chord monitoring during surgery? No,” says Prof Bolger.

“You can take the attitude that I will not do these tumours but, then, patients will have to go abroad,” he says.

Beaumont is planning a private hospital, but consultants believe neurosurgery should come first. Prof Bolger estimates that a state of the art 100-bed neurosurgical service would cost Ä100 million. “A million a bed,” he says.

A rehabilitation unit to overcome three-month waiting lists to get into the National Rehabilitation Hospital, is also needed.

Prof Bolger says head injury patients are being treated by general surgeons all around the country.

He says he spends hours on the phone guiding doctors around the country in managing injured patients.

Not acceptable

“It is not acceptable and they would be the first to say that. They are on the phone every day saying we do not have the expertise. Half our job is spent nights on the phone to the rest of the country. At five o’clock in the evening that is when the telemedicine starts,” he says.

Prof Bolger does not have an office and shares a secretary with 12 consultants.

Mr Pidgeon says the RCSI committees have issued a number of reports, which have found that neurosurgery is not up to standard. A risk management report, commissioned by the hospital, has also been ignored. “People do reach breaking point and we are not very far off signing a letter of resignation,” says Mr Rawluk. “It will say:

‘Dear Department of Health,

You have got three months to restaff neurosurgery.’”

More ado about cancer patients.

Our health service is an inefficient, dirty shambles – where the only person washing their hands is Mary Harney
25 November 2007 By Jennifer O’Connell (Sunday Business Post)

This weekend, two women in the midlands are attempting to come to terms with the news they have spent the last three months dreading: they do, in fact, have breast cancer.
Last week’s admission by the Minister for Health that two more women were misdiagnosed at Portlaoise Hospital brings the shameful total to nine.

Four more will have to continue the agonising wait for the results of their rechecks. These were due to be published last week but - oh dear - won’t now be available for a number of weeks.

And for those who have just found a lump on their breast, the vast majority - anyone under 35 or those whose GPs don’t flag as having a ‘‘high likelihood’’ of breast cancer - have little or no chance of getting to see a consultant in the next three months, a senior health service manager admitted last week.

A report finds that a 17-year-old girl admitted to a Limerick hospital with a serious condition had to be wheeled into theatre by her parents when a porter couldn’t be found to do it.

The mother of a 12-year-old who doesn’t even recognise her after a series of seizures turns to the papers in her desperation to get proper medical help; cervical smears are being sent to the US for analysis because there aren’t sufficient resources in Irish labs; talks between consultants and health service management are once again in disarray; hygiene standards in 35 of the country’s 51 hospitals are failing to meet the mark; one hospital is found not even to have soap available for hand-washing.

Another week, another raft of headlines about delays, incompetence and inefficiencies in the Irish health service. Unfortunately, the corporate superstructure responsible for running that service was too busy chiding us about our national drinking habits to notice.

There are plenty of people offering views on this subject, most of them with expertise and longstanding experience in the provision of health services. I’m not one of them. Nor do I have any special insight into the ideology that is driving health policy.

I just know what anyone else without any special expertise knows - that, whatever this ideology might be, it doesn’t seem to be working. Like anyone else who has ever had occasion to set foot in a hospital, I can’t help wondering why it has been allowed to get into this state, and why no one has been held accountable.

Happily, I’m only a very occasional user of what passes for a health service in this country, and if I wasn’t already grateful for that, last week reminded me just how lucky I am.

Last June, following her nine-month check-up, my baby daughter was referred for tests for a congenital hip abnormality that I also suffered from as a baby.

I got an appointment for an X-ray immediately, and pleaded with the friendly radiographer to tell me if everything looked okay. She said it did, but that, really, I should wait to hear the full results from the Health Board doctor who referred us. Had I done so, I would have been waiting quite awhile.

I finally got the results last week after a confusing series of phone calls to and from my local health clinic - by which time, if there had been a problem, my daughter would now be facing into surgery and many months in a cast, rather than the straightforward brace which would have been able to fix the problem five months earlier. Apparently, the results of the X-ray had gone missing somewhere between the hospital and the GP’s office.

What’s remarkable about this story is that it’s not remarkable at all. Everyone in the country has one like it; many have stories that are much, much worse.

When she launched the Neary report in 1996,MaryHarney quite rightly said that the scandal had been allowed to happen ‘‘because no one shouted stop’’. Yet it turns out she knew about the problems at Portlaoise as long as two years ago.

A consultant raised his concerns directly with her in July 2005,telling her about the ‘‘shambles’’ at the hospital. It took until August of this year, and another intervention by the director of nursing at the hospital, for the review of over 3,000 cases to begin. And now it turns out that the expert appointed to oversee the review is the same expert who appointed the suspended radiologist to begin with.

At a Limerick hospital, Barringtons, breast cancer services are suspended and ten cases are undergoing further investigation after a Tipperary woman was found to have been misdiagnosed and the treatment of her cancer delayed by 18 months. The HSE was first made aware of the problems there in January 2006.

Inexplicably, Harney’s department has claimed that it was only told of them much later, in August 2007,which makes you wonder what else she’s not being told.

But surely Harney can’t also have been waiting for someone in the HSE to pick up the phone and tell her that our hospitals are dirty. As the recent hygiene audit confirmed, a simple visit to the ladies’ toilet in one or two of them would have told her that. And she must have known about the appalling waiting times for women who have been referred to see a specialist because of a lump in their breast. So why didn’t she ever shout stop? Instead, in the case of Portlaoise, she simply referred the concerns back to the Health Service Executive.

Just think about that for a moment. Who does this suggest is really running our health service – the Minister for Health or the mostly nameless, faceless, unelected officials in the Health Service Executive? Because it’s not as if the Taoiseach’s about to stand up to the plate.

As he told the Dail in recent weeks, neither he nor the government should be expected to take responsibility for the 120,000 people employed in the public health sector. Which raises the question: in that case, who should?

Harney’s most salient comment on the whole crisis in the health service was another one that she made, almost in passing, on a radio programme recently. She said she saw ‘‘no reason why we should keep anybody in the health system that isn’t doing the job that they are required to do and they are being paid to do’’.

I’m probably not alone in saying that I would second that.