At the beginning of every calendar year the issue of overcrowding in emergency departments (EDs) becomes national news. Representatives of nursing, medical and management arms of the health services are interviewed. Health ministers return from their Christmas break to a barrage of criticism. They describe the problem from their own perspective and propose solutions and strategies for removing patients from the departments, either by preventing them attending in the first place or by moving them onward to other facilities which are in turn over subscribed.

Lack of resources is routinely cited as the cause of the problem. This argument does not bear objective scrutiny. Ireland’s spending on healthcare does not differ significantly from countries that do not experience the same problem. In spite of massive expansion of EDs which barely existed 30 or 40 years ago, the problem of overcrowding has continued to deteriorate. While the problem lies in the EDs, the solution does not and building bigger EDs only makes the problem bigger. However, advising patients to use options other than EDs is at best naïve and at worst offensive. Very few would choose to seek help in EDs if they could access more suitable alternatives.

So who are all these patients on trollies? They are mostly elderly people with multiple co-morbidities who have become unwell or a bit less well or just ‘feeling off’ and have been referred by themselves, their carers or their GPs to EDs in the absence of more appropriate facilities. In the ED they are assessed by doctors with no knowledge of their baseline medical condition and little experience in old age medicine. Because their symptoms are vague, precise clinical diagnosis is difficult. This results in extensive and aimless investigation which reveals some abnormal findings the significance of which is unclear. Progressive diagnostic confusion results in a decision to admit to hospital and invite another set of doctors to start the process again. All of this coincides with the non-evidence-based administration of various medications, usually including antibiotics. As the number of patients increases there is less time to make a full assessment and the threshold for admission falls, further exacerbating the overcrowding.

If we accept that these patients merit medical assessment and intervention but not in EDs then where? It is facile to suggest that their GPs should look after them. In many cases the medical support is least important and other caring and social supports are more relevant. These community based services, including residential care, need to be resourced and restructured so that there are incentives (including financial incentives) to deliver care locally and not refer to EDs. 

For patients who require more complex investigation and management, hospital services other than EDs should be developed. Examples include medical assessment units and direct access to specialist services, including old age medicine. Unfortunately these units are not protected when pressure rises in the ED and they become subsumed into the general failure of the acute hospital service. Similarly, cancelling elective surgery results in stable patients awaiting surgery becoming acute cases in EDs.

Alternatives to EDs must be developed, protected and rewarded when they succeed. Throwing resources at failed models of care is not the solution.