Desmond O’Neill: Clinical glasshouses and stones

Desmond O'NeillOne of the positive aspects of working in smaller hospitals in Ireland is the professional mingling that takes place in local clinical societies. Living and working in a smaller pond means that consultants and GPs tend to know each other better. The mutual sympathy engendered for the challenges of working in other sectors of the fragmented Irish health services is a nice response to the worldwide issue of resolving tensions between primary and secondary care.

It is very different in Dublin, where often hospital consultants, particularly those largely engaged in public practice, and GPs might not recognise each other if they passed on the street. Activities in CPD have largely diverged along specialty lines, with little by way of cross-fertilisation between, say, the small-group activities of the Irish College of General Practitioners and the postgraduate activities of physicians.

The “clinical evenings” that occur in many of the teaching hospitals seem imbued with a strong element of awareness-raising of who is currently engaged in private practice.

Patterns of communication have not fully bedded down for my own hospital, a relatively recent arrival on a green field site whose catchment area stretches from areas of severe deprivation to leafy and wealthy suburbs. The hospital has also suffered from unwieldy and idiosyncratic governance (1), and is under-resourced compared to the other Dublin teaching hospitals.

This has led to huge frustrations among the hospital consultants. For example, when an external inquiry investigated significant numbers of unreported x-rays in the hospital, it was clear that the radiologists, and other consultants, had loudly and clearly reported egregious service deficiencies for many years to the hospital management, to little avail. A claim that 30,000 GP letters had been unopened, was subsequently found to relate to a still unacceptable delay in processing of one-tenth of that number, again symptomatic of both inadequate governance and resources. Thankfully the former is now being attended to, the latter is an ongoing struggle.

In general, however, there has been a diplomatic and collegial recognition between the GPs and individual consultants that clinical practice is challenging for all, that gaps exist in service and communication on both sides, and that our supports are fragile. There are very occasional outliers who, like those isolated Japanese soldiers discovered on remote Pacific atolls believing that the war is still on, seem to think that Sir Lancelot Spratt lives on inside our hospital, and might actually have his omnipotence. However, this would be an atypical experience for most of us in our daily interactions, usually by telephone or writing.

Many of us have made efforts to improve communications—several iterations of a GP liaison committee have taken place, two GPs sit on the committee of our postgraduate centre, and repeated efforts have been made to organise GP meetings, but without success, apart from our annual GP study day, which is usually very well attended.

These issues came to mind last week during a presentation at grand rounds of a survey of what GPs wanted of the hospital, carried out by the Department of Public Health and Primary Care in Trinity College Dublin. Apart from the two presenters, no other GPs were in attendance. The findings were generally unsurprising, presented opportunities for development, and the content was well received by the audience, which included hospital management and students as well as clinicians.

However, it also seemed to have been a missed opportunity for a survey across both groups of clinicians as to how better joint working could be undertaken. For example, one question pointed to the fact that few of the hospital consultants had visited local practices. But the converse is also true, and it would be equally salutary for GPs to see the challenges within the hospital, from the diabetologists—in a system without shared care as yet—trying to cope with huge increases in patient numbers with minimal to no dietitian support, the geriatrician with nearly 100 frail older patients awaiting occupational therapy assessment, to the major gaps in clerical and administrative support with attendant delays in letters from clinic.

They might also find it helpful to learn that communications can be a problem in both directions, and such joint work might also help in teasing out solutions. Even within the care groups, communication can be a challenge: one of the presenters was unaware of the open invitation to our weekly grand rounds, despite the two GPs sitting on our postgraduate committee.

A joint approach to awareness and problem solving might also avoid the elements of rancour which episodically intruded into the presentation, to the professional dismay of the audience. Curbs to excellence in practice can rarely be attributed to other groups of clinicians, but rather to management processes, supports and incentives, and remediable lapses in communication.

The fragile glass houses surrounding our professional working spaces are built up over many years. Awareness of the benefits of their vitreous qualities—nurture, shelter, and transparency—should check impulses arising from broader and deeper frustrations to throw stones.

Desmond O’Neill is a consultant physician in geriatric and stroke medicine and immediate past president of the European Union Geriatric Medicine Society.

1. O’Neill D. The place of faith and religion in healthcare. In Halpenny, O (ed), Steady Air: Exploring Catholicism at Work. Newcastle-Upon-Tyne, Cambridge Scholars, 2013, 1-13.

Correction: This blog was edited on 14 October.