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Absenteeism in the HSE. Posted by Dr. Jane Doe

Posted Oct 14 2008 5:00am
Now the HSE are getting all worked up over absenteeism, and its cost to the health service. Agency staff, locums, etc. are expensive, and hiring them is costing lots and lots, not to mention the sick pay you have to give the employees.

Bother. I tell you, you hire these people, give them jobs, sometimes up to a WHOLE YEAR’S contract at a stretch (now that’s job security, eh?) and pay them and everything, and they go and reward you by getting sick or stressed out and tired, and needing time off.

There’s an old army saying (I think it’s an army saying!). “Prior planning prevents poor performance”. It really can be extrapolated to many more mundane scenarios, not just wartime, however.

Agency nurses, locum doctors, last minute staff of any kind are damn expensive to hire, and often hard to find. The HSE is right about that. When I did locum work, if there was less than, I think it was something like, 48 hours notice, then the locum agencies demanded double the normal locum rate on our behalf, and they got it for us too. It paid to keep the mobile phone on and the car full of petrol.

If medical staff go on holidays in Ireland, there is at present no formal arrangement for cover in the majority of public hospitals. Some hospitals used to have a “holiday intern” post to cover planned annual leave of interns only, however, if two interns were off at the same time, then one team was internless, and the SHO had, well, they had a REAL bad week. If your SHO is away, then the registrar and intern have a bad week as the registrar tries to cope with covering a lot of the jobs the SHO does as well as seeing twice as many in outpatient clinics and trying to be there for the intern who has no SHO to supervise them. If the registrar is away, then often the SHO is forced to try and cope with things they’d probably be better off having some more supervision and advice for. The consultant, meanwhile, has to cope with not having a registrar and this means more ward work and busier clinics for them.

When the consultant is away-they do generally get a locum, however I suspect that is for medicolegal reasons more so than anything else.

So when the medical team is down a member, in addition to paying annual leave pay to the person on holidays, the HSE is paying quite a bit of time and a quarter/half to the remaining team members as they try to cope with the increased workload and stay in late.
The waiting times in the outpatients clinics these overloaded doctors are trying to cover get longer and people get angry and dissatisfied and yell at the doctors and nurses.

Worse still, people on the wards wait longer for reviews, decisions, and tests to be ordered. This has a knock-on effect, if you can’t get to review Mrs. X until say, 7pm, because you were just too busy, (30 people in OPD, one in ICU that took quite a while, and A&E reviews) and you decide she needs, say, an OGD, not an emergency one but definitely soon, and maybe a few more blood tests and a gastroenterology review too, then instead of being able to arrange all that in the morning, and maybe getting the answers and being able to send her home the same evening, Mrs. X is taking up a hospital bed for another night.

I don’t know the exact cost of a hospital bed-but I think it’s around 600-700 euro a night just for the basics, bed and nursing staff costs. Factor in the cost of paying the registrar time and a half from 5pm to 7:30pm, and the SHO or intern (whoever isn’t away) too, and it gets pricey. No wonder we can’t afford locums for the sick doctors. Suppose it wasn’t just Mrs.X you didn’t get a chance to sort out till later, but Mr. Y and Ms. Z too? That’s looking more like about 2000 euro today alone just to keep them in hospital till there is enough time and enough staff to look after them properly.

You and whoever was left ran around frantically all day, and made sure everyone was stable, and no-one was going to die, but with OPD running on, and being constantly bleeped to come and do ECGs, IV lines etc, you were not able to sort people out any further and make any better plans regarding their management until all the other staff had gone home. Radiology go to emergency only after about 5pm. Endoscopy suite close at 5pm. Cardiology sure ain’t around to do echocardiograms, stress tests etc after 5pm. Neurophysiology won’t be doing that EEG to diagnose your ?epileptic patient till tomorrow. Get the picture?

Now the obvious, knee jerk, illogical and silly reaction is: Make all those others work 24/7 too. Have Endoscopy open all night! Make cardiac technicians stay in all night! The neurophysiologist should be on call from home! Radiology scan and ultrasound and do CT angiography all night! Pay all those people premium rates to be on out of hours, on call rates, etc, and run the health service into more debt.

Wrong answer. Here’s the right one. All those services remain the way they are. Hire one or two extra junior doctors. Not even very many. Maybe one or two interns, SHOs and registrars for the medical side, and one or two for the surgical side. Pay them a slightly higher rate than normal. Not locum rates by any means. Maybe just time and a half or even time and a quarter all the time. This may not be attractive to all doctors, constantly covering different patients and different teams, even for a bit of extra cash is tiring and a bit stressful after a few months. So incorporate this absentee cover job into everyone’s normal rota. For six weeks out of the year, you cover absent colleagues for a bit of extra money. Everyone will have to do it, it’s not for very long, and in the event of one of you needing holidays, becoming ill, etc, you all have a safety net.

Now no team is ever down a member. If the covering doctor doesn’t know the patients so well, don’t rant and moan about continuity of care! Get them to do jobs for the team! Book scans, do procedures, check bloods, resite some IV lines, and free up the other doctors who know the patients so they can plan management.

Okay, management paid annual leave to Dr. P, and time and a half to Dr. Q for 8 hours to cover Dr. P, but Mrs. X had her scope, blood tests and gastroenterology review, and is on her way out the door with a follow up appointment with the gastro guys. Dr. Q booked all those tests and organized the gastro consult. 600euro saved on Mrs. X’s bed. Dr. Q is an industrious little beaver of a cover doctor, and also went and supervised Mr. Y’s stress test while the registrar was in clinic and unable to do so. It was normal, and after checking his bloods and organizing an Echo as an outpatient and arranging a clinic appointment for three weeks for him, Mr. Y is out the door too! Another 600 euro saved on a hospital bed for the night. Ms. Z had her EEG, and CT brain, Dr. Q got a verbal report and it was normal, and she is out the door after a neurology review. Another 600 euro saved. All before 5pm.

But wait. Three beds have been freed up on the wards now. Three trolley patients have just gotten the green light from A&E to go into those beds. Overcrowding in the emergency department just got a little easier, all because this one team isn’t down a member. The A&E nurses are a little less run off their feet, and things are going faster now that those three people in the corridor don’t need to be monitored and checked on and their families reassured that they really will get a bed soon.

Gosh, it seems like Dr. Q our friendly cover doctor has paid for himself for the week already today, doesn’t it?

Imagine if more than one doctor in the hospital is away at the same time. In a big hospital it is very likely that a couple of NCHDs are away, on study leave, annual leave, maternity leave or just sick, every day.

Instead of slowing everything down, costing the health service thousands every year, and ultimately, hiring locums that may be unfamiliar with the hospital and its procedures for huge prices when and only when patient safety is compromised or the doctors are freaking out, just have a few cover doctors on the roster. Cheaper. More efficient. Safer. Happier staff. Happier patients. Happier management too, as they are saving money.

Hey, surprise surprise, they have the "cover doctor" arrangement in Australia and New Zealand. Just thought I'd throw that in there. I've done it for a couple months myself. My sacred "training" wasn't affected, far from it, I got exposed to a variety of interesting jobs, as well as some I didn't like so well, but all of it ultimately leaving me with a broader knowledge base. And I got paid the extra rates which was good for me!
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