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The diagnostic deficit

Limited general practice and primary care access to essential diagnostic blood testing, procedures such as endoscopy, and diagnostic imaging such as ultrasound, echocardiography, CT and MRI scanning is an important factor leading to inefficiency in the Irish health service.

Limiting GP access to diagnostics inevitability leads to increased demand in the hospital sector. This diagnostic deficit has crippling knock-on effects in many areas of the health service leading to unnecessary referrals, outpatient clinics, and in some cases referral to already over-stretched acute services and emergency departments (EDs).

Many EDs do not have dedicated diagnostic imaging and have to compete with other areas of the hospital system for the limited resources available. GPs should have direct access to diagnostics without need to refer through the hospital referral pathway. Accessing diagnostics in this way is an inefficient use of hospital-based services and clutters outpatient waiting lists and EDs with patients who should be assessed and diagnosed as far as possible outside the hospital system.

If the HSE is serious about reducing ED waiting times, delays in planned admissions for treatment and shortening outpatient waiting lists, then improving access to diagnostics is an essential component to solving these problems.

Delays in accessing diagnostics or inability to access diagnostics at all for public patients is in sharp contrast to the immediate availability of diagnostics for private patients. This stark gap in services access clearly illustrates the inherent unfairness in the two-tier Irish health system.

Limiting timely access to diagnostics is a false economy. Rationing access may save money on investing in diagnostic staff and equipment, but the resultant delays in diagnosis and the need to refer patients to hospital services (both outpatient and emergency services) to access diagnostics has a financial cost, which far exceeds any savings that arise. Diagnostic access is essential to support good clinical care of patients.

Inpatient hospital services also face similar barriers in accessing diagnostics, which results in prolonged hospital stays and resultant stalled patient flow within the hospital system. Many patients are discharged before all their investigations are completed due to pressure to discharge patients once the acute phase of their illness has passed. This adds to the ever-lengthening waiting lists for outpatient diagnostics and proper prioritisation for investigation can be uneven and distorted.

This diagnostic deficit leads to prolonged emergency waiting times, ever present trolley queues in EDs, prolonged hospital stays, delayed diagnosis, lengthening waiting lists for elective admission to hospital, and lengthening outpatient waiting lists. Ultimately this impacts on the quality of health services provision, delayed diagnosis and poorer patient outcomes. Many reports over the last decade have identified this diagnostic deficit as a critical deficiency in the Irish health service. It is one of the bottlenecks which results in the entire system slowing down, being inefficient regarding patient care, but also being inefficient financially.

The provision of properly utilised diagnostics is fundamental to the delivery of quality care. Investment in this area will have positive knock-on saving in every area of the health service, leading to better patient care and effective use of downstream resources.

Hospitals with EDs accept patients continually throughout the day, including weekends. Thus there is a regular flow of patients into hospital requiring acute care and investigation. This, coupled with those who require investigation having been seen in outpatient departments, adds to the number of patients queueing for limited availability. Many diagnostic services only operate eight hours daily, five days per week, while offering limited emergency cover outside of these hours. Thus diagnostic facilities lie idle more often than when in use. This is poor use of a much-needed facility, leading to the backlog and delays in accessing necessary investigations. This mismatch has very significant implications for patient flow, both as inpatients and outpatients.

In the private sector many departments operate seven days per week offering services to patients on Saturdays and Sundays up to 10pm. This should also be the norm in the public service. While this diagnostic deficit exists in our public hospital system it is difficult to see how waiting lists can be tackled and reduced.

Immediate solutions to address this diagnostic deficit are essential and achievable:

Buy services from the private sector while building up capacity in our public system.

Recruitment of extra staff to operate diagnostic equipment in public hospitals.

Purchase extra equipment while maintaining and replacing outdated equipment.

Provide diagnostic services at least 12 hours daily, including weekends.

Provide additional diagnostic services in primary care centres and free up hospital diagnostics.

We must recognise that rationing diagnostic services is a false economy and makes no common sense.

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