The new emergency block at St Luke’s Hospital in Kilkenny is a vision of how the Irish health service should be. Bright, airy and spacious, it boasts individual bays to house patients, screened by sliding double-doors. There is a separate emergency department for children and a separate medical assessment unit, all fitted with state-of-the-art equipment.
It is clear no expense has been spared. There isn’t a trolley in sight. In fact, the only thing missing are the patients. Until the block opened today, it was business as usual in the old part of the hospital, where the tiny emergency department is housed in the former laundry.
On the day I visit, a patient lies dead in the unit and the priest is leaving, having administered the last rites. At the other end, behind a flimsy curtain, another hangs on to life on a ventilator. The other four bays are occupied and lines of trolleys take up much of the remaining floor space. There is no privacy or quiet as staff weave past distressed patients, small children and other visitors.
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Dr Garry Courtney, long-time clinical director at St Luke's, pulls a curtain to reveal the fire escape: an open door, leading down steps at an angle. Just how a person with mobility issues would get out quickly in an emergency escapes me.
This is a familiar scenario in the health service, but St Luke’s is different. For years, the hospital has had a reputation for good management, open relations between different departments and staff and between doctors and local GPs. Like other hospitals it has come under pressure from the surge in overcrowding in the past year, but the new block should help.
GP-led intervention
Kilkenny is a bright spot in the health service and the wonder is that other parts have not learned more from what it does successfully. It saw the creation of the first GP co-op in 1989, the first acute medical assessment unit (AMAU) in an Irish hospital and the first GP-led community intervention team.
While others talk about the importance of primary care, St Luke’s has pioneered meaningful links with GPs in the community. Its model for AMAUs, a separate entry for patients from the emergency department, has been copied elsewhere but not always successfully.
Here to witness what makes St Luke’s tick, I am impressed by the communication between doctors, nurses and managers. Staff seem quicker to share thoughts and ideas than I have found in other hospitals.
"It is down to the smallish size of the place to some extent but it's also attitude, and the willingness of different kinds of staff to engage with one another," paediatrician David Waldron tells me. "If I'm at a clinic in Carlow and a child here in Kilkenny is sick, another consultant on the team will sort it out. In some places, you can't make a decision about a patient without a named consultant being involved."
Dr Courtney is big on shared care. This can involve the sharing of care between hospitals – for example, between St Luke’s and the big Dublin children’s hospitals – between different consultants in Kilkenny, and between the hospital and GPs.
"Healthcare is about looking after patients, not creating empires," says Ronan Fawsitt, a local GP. "We have to join up the dots in the health service, to get consultants and GPs working together and to move away from the traditional approach of putting patients on waiting lists."
A hospital is “an idea, not a building”, he maintains, and like many ideas it needs to be rethought. St Luke’s has achieved this by moving away from the idea that the emergency department is the default entry route to hospital. Dr Courtney says: “You need more than one door open to get into Croke Park or the Aviva; hospitals shouldn’t be any different.”
So EDs are for accidents and emergencies only, while the AMAU is the valve that relieves the pressure on it. Most patients are referred there directly by GPs, who correctly diagnose their condition 99 per cent of the time. So a patient with pneumonia is admitted directly to the kind of care needed, rather than getting sicker while waiting on a trolley in an overcrowded ED.
Bed management is crucial if the hospital is full most of the time. “We can’t go off call but we can ask GPs to put off a referral for 12 hours, where possible, in order to ease the pressure on the system,” says Courtney.
Hospital staff hold monthly meeting with local GPs, where problems are raised and solutions mooted. Recently, GPs asked how the delivery of blood samples to the hospital could be speeded up, so patients could get results more quickly. The solution found was for GPs in Carlow to drop off their samples to the district hospital there, for onward delivery to St Luke’s.
As a result of good hospital-GP liaison in Kilkenny, GPs enjoy greater access to diagnostics, such as X-rays and blood tests, than in other parts of the country.
Frustration
There is palpable impatience in St Luke’s with the pace of change in the health service. I meet a pharmacist who relates his frustration with the reliance on paper-based records. He says the HSE collects all the information about the drugs used by a patient, but only for reimbursement purposes.
“We have to call the HSE and transcribe this information, then pass it on to the GP, who has to transcribe it again. It’s crazy. If we had a unique patient identifier we could do all this electronically but that has to happen nationally.”
He says it would make sense for a discharged patient to go home with the medication they need, rather than having to source it in the pharmacy, at least for the first week. But this doesn’t happen because the money would have to come from the hospital budget.
The new block, which was a decade in the planning, includes a library and teaching rooms, as well as video-conferencing facilities. The aim is to make St Luke’s an attractive place for in-demand doctors and nurses to work in. “A hospital that can’t recruit won’t survive,” Courtney remarks.
There is also a day centre named after Susie Long, the cancer patient whose death after a delayed diagnosis a decade ago marks a low-point of the hospital’s recent history.
In the past year, the number of patients arriving at the hospital for treatment has jumped from 20 a day to 30, and those arriving are older and sicker than before. This has put the hospital under pressure, but it is coping. “One queue at ED would be a disaster, so we’ve moved it, effectively,” says Courtney. “It’s been split into seven smaller, manageable queues.”
After 20 years in Kilkenny, Courtney is still eager for change. People need to move away from established ways of thinking, “get out of their silos” and talk more, he says: “I’ll work with Genghis Khan, if it results in things being done.”
