July 10, 2014

Accident and Emergency - a small story of a hospital that worked.

Posted in Irish Independent · 42 comments ·
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Today I am going to tell you about something that happened to me in a not very rich European country, which got me thinking about our health system.

Before I start, there will be no moral to this story. There will be no “We should do this” or “We should do that” and no finger-pointing at possible culprits. I’ll just tell you what happened.

I brought a child – a good friend of my son’s – to an A&E in a small city called Sibenik in Croatia. You may remember the name Sibenik because it was under siege during the opening months of the war in Yugoslavia. It’s a provincial town of maybe 25,000 people with one public hospital.

We had left Ireland earlier that day and the boy initially complained of a sore knee in Dublin Airport. On the flight his knee had swollen and by the time we had landed in Croatia, the knee looked like a balloon.

We thought it was a ligament or similar problem maybe picked up playing football. But during the evening it continued to swell so we thought we’d better see a doctor in the morning.

We headed to the A&E in the local hospital. Given my experience with children in Irish hospitals, I braced myself for a long wait.

But something quite shocking happened. We didn’t wait at all.

We arrived into a new wing of the hospital into a spotless A&E ward. Just to put things in context, Croatian GDP is half of Ireland’s with a similar population.

There were lots of patients milling about but there were also five nurses on standby. One spoke English. She immediately started with the paperwork and told us not to worry.

She produced a wheelchair and whisked us in to the doctor. He diagnosed an infection and said that they’d operate without any delay, to drain and clean out the wound. The doctor reckoned there was about two litres of fluid on the knee and this had to be sorted. On establishing the boy had eaten something just before we headed to the hospital, he postponed the operation for five hours to make sure the general anaesthetic would work. The surgery time was set. We had been in the hospital for 10 minutes at this stage.

Just in case there could be some underlying damage to the knee itself, he suggested an X-ray and ultrasound. An orderly appeared immediately.

If you are getting the impression that we were the only people there, we weren’t. The hospital was extremely busy, with nurses and doctors bustling around. They explained to us that this was, in fact, the busiest time of the year because the local population doubles with all the tourists. They joked that drunk tourists are much more likely to end up in hospital than the locals. We waited 16 minutes for the four X-rays to be carried out.

The radiographer told us to wait for the radiologist. We waited on the trolley in the corridor, which I suppose to an Irish person was a pretty familiar experience. About ten minutes later, the radiographer came out with the photos and reassured us that there was no knee damage but that he’d still need surgery. He also explained in perfect English that he was thinking of moving to Ireland because a colleague had moved to Limerick and was getting what he described as “good money”. He walked with us and chatted for a while about the World Cup, how Croatia had been awful and how we now needed to get the boy some blood tests, which were also done immediately.

We had been in the hospital for about 40 minutes and we’d seen three nurses, three doctors, had had four X-rays and ultrasound, blood tests and had already had a bed allocated in the surgical ward. The nurse asked for our EU blue card to cover the costs of the operation. We (typically) didn’t have it but she said an EU passport would suffice.

At no stage did they ask for money. Within the hour of arriving through the door, we were in a children’s ward in bed with a big TV in the room, showing the tennis. The nurses were extremely kind and said we’d be seen by the consultant surgeon who’d be doing the operation.

Before we had settled in, he’d arrived and straight way asked who was better, Messi or Neymar?

Sitting on the bed, he explained to the 12-year-old exactly what he was going to do, why and how long it would take. As he spoke the nurse hooked up the boy to an intravenous drip and chatted away about how she dreamt of visiting Ireland some day but it was unlikely on her Croatian salary. By the way, the hospital uses generic not branded drugs. The consultant announced he was a big Pogues fan and explained that Shane MacGowan was a genius. They then offered me lunch. A few minutes later, the paperwork was done. They’d have to get a parent’s permission to operate. So they phoned Dublin and then emailed the necessary consent forms. All this was done without any delay. They said the operation would be at 4pm and told us to kick back and watch Wimbledon.

The consultant anaesthetist came around, explained what she’d do and said the kid would be out cold for about an hour. The surgeon came back a few times and smiled, told us not to worry because he’d personally take out, what he called, the “garbage” in the knee.

At 4pm on the dot, they operated.

The boy stayed in hospital for five nights. We could visit at any time of the day or evening. He will head back tomorrow at 8am to get the stitches out. The entire patient experience was simple, straightforward, pleasant and remarkably efficient. There was no waiting at all, no charge at all and the boy will be swimming by Friday.

I have no idea why it worked so well. Maybe we were just lucky. But I’ve taken kids to Irish hospitals and I’ve waited hours for two stitches. This Croatian episode was a totally different patient experience in a hospital that can’t even afford branded drugs. I don’t understand how hospitals work, why they get clogged up and why Irish patients end up waiting for hours on end. But it is clear that it doesn’t have to be that way. I have just seen, in a country with half the income per head of Ireland, a patient experience that is in a different league. You have to wonder why.

 


  1. Tull McAdoo

    Adam tut tut

    • Dear oh dear Jim, have you nothing better to do out there in sunny Perth than wait for an article to drop?!

      Say hello to Frank Stapleton for me if you see him!

      • Tull McAdoo

        When I was doing my PhD back in the day, there was no arriving on blogs at 10.50 with a sleepy head…..smarten yourself up there…haha

  2. ThomasFergus

    A publicly funded health system, free at the point of use, based on the criteria of need alone? I’d say that’s your answer…..

    • odaiwai

      Yeah, as soon as someone is making serious cash out of you being sick, you end up with the sick American Market system.

  3. ThomasFergus

    A left-right divide in the political system? A distinct lack of all things to all people/whatever you’re having yourself politics of FF? Or the alternative of a ridiculous left-right divide in an FG-Labour coalition?

  4. ThomasFergus

    We should either go the American/German insurance based model of private health care (I am virulently opposed) or the British/Croatian publicly funded model. Either way, we should vote for parties that represent one or the other model, not for parties that want to cater for both

  5. ThomasFergus

    PS generic drugs produced in Ireland are often more expensive than branded drugs…..the well paid jobs that domestic generic pharma companies maintain in places like Clonmel and Bantry are largely sustained through hospitals purchasing these drugs and political interference making sure that they do so…….

  6. woodsey

    Nah, ‘It’s your consultants!’ as a Swedish nurse, who’d once worked in Irish hospitals, told me when I’d a similar experience in Stockholm. People who think they’ll ‘waste’ high Leaving Cert points if they don’t take up medicine, find themselves entirely unsuited for such a vocation. So they compensate by seeking high salaries and control of the system to ensure it works best for them, rather than patients. Our fault for not taking them on.

  7. goinghome

    The huge disparity of input and experience is worth spelling out like this as often as possible, and studied to identify and then tackle what’s causing it, which stakeholders, system processes, unexpected influences etc need to be repaired.

  8. patboland

    Positive experience in the Irish Health Service.
    I recently had to call an ambulance for my father who was ill in rural Ireland. I was in Dublin at the time. Within 20 minutes of calling them they were in the house with my father. They called me to tell me all was fairly OK but he would be taken to Sligo A&E.I prepared for the worst given all I have heard in the media. However within 20 minutes of him being admitted he had CT scans and X-rays and blood tests. The results of these were back in an hour.
    Within a couple of hours he was admitted to a bed. He was kept in hospital for I think 5 days. On day 3 I got a call from the occupational therapist to arrange a discharge plan and home help which was put in place immediately. All of this in the aftermath of the biggest austerity drive in history. Maybe we should thank the taxpayer and also The Government and clap ourselves on the back as citizens.
    I think occasionally we need to highlight positive experience which I fully believe greatly outnumbers the negative.
    In the aftermath of all of this I realised that I had unfounded latent fear that when I needed to call on the health service it would be a shambles. In fact nothing could be further from the truth. It is important to get this message out as especially the elderly are scared stiff as they never hear anything good coming over the national airwaves and naturally assume as I did that interaction with our health service would be a life ending experience.
    My experience was excellent so are many others, however we never hear about these good experiences in the media…….there is a need for balance.

  9. I have an intermittent Achillees Heel situation that’s preventing me from living life to the max, ie: Dancing all night. Thankfully, doesn’t stop me shagging. I’ve carried crutches everywhere for the last few months in case I’m stranded by tendonitis. I’ve done the ice pack/painkiller stuff, so now we’re on to the physio/tests/x-ray route to a possible operation.

    When I presented as ‘acute but not urgent’ I was told there was a 6 week waiting list for an English NHS appointment BUT! If I could pay privately, I could be seen in the next day or so… The pitch was crude, inelegant and there were old folk there who looked like a new pair of shoes would be a budget breaker. I told the salesperson (disguised as ‘receptionist’) that, on principle, I don’t queue jump public health provision and if I have to go private, it will be a Spa Clinic in the Vendee, or wherever David is in Croatia, not a gloomy badly decorated Victorian mansion in Mittle Engerland! This did NOT go down well. I wasn’t rude, but I was treated like I’d just flashed my willy. The look of shock at openly challenging the creeping ‘marketisation’ of the NHS on this part of the island of Britain. Stiff upper lip, dont’ explain, don’t complain, get in the health-care trenches again. Erm, no I won’t.

    There are HUMUNGOUS budget / morale issues with the Austerityfied NHS and it’s much the same with the HSE, if not worse. But anyone who’s glanced at coverage of appaling abuse and death at Staffordshire hospitals over the last year knows in their hearts that the dream of the original NHS founders is expiring. In 2011 as the tsunami hit, I was hit by a wave of pulmonary embolisms and had a 33% risk of death that night as I lay wired up to the machines. The ‘professional class’ nurses did their job checking dials, buttons and graphs, then stood around Facebooking and ignoring a senile incontinent man in pain next to me who they’d really, really hurt by clumsily inserting a catheter. Again, I spoke up firmly but calmy about that and the noise they were making organising their weekends. You’d think I’d threatened to blow the ward up! My dentist assures me there’s nothing to be done about an infuriating gap in a back tooth that acts as a food trap and needs flossing after every meal to avoid bacterial putrification which can cause coronary disease. When I raised that issue, I got the “smart-alec on the Interweb” look.

    Robotics & Tele-Medicine are going to hit Western health-care systems like a tornado. As will health tourism to Asia/Arabia/Africa/South America for anything from teeth to tit enlargement/reduction. And someone will figure out how to add a few penile inches sooner or later.. Meanwhile the pure tax funded model of the NHS is looking shaky as a model for a renewed HSE when many Brits are looking to Dutch/French mixed public/private provision with obligatory insurance for earners and safety net insurance for those out of the economically active loop. The Coalition are planning a demolition job under the Trojan Horse rubric of ‘modernisation’.

    There isn’t room for a Corporate Margin in health-care costs that allows access to the lower income quartiles of a population, especially if provision is to be made for the terminally sick, the lame, the lazy and the insane. Of course, with the USA we see the end-game of abandoning any pretence of solidarity in health-care for those groups and also for the working poor and now The Middle Class. Their profit-ravenous Corporations alongside some Europa ones, jealously look to rape the socialised models built up over centuries in older Europe and modelled by the likes of Croatia recently.

    There’s a choice to be made. And for me, to avoid a dog-food diet in old age (unlikey, but another crash is coming, etc) then a little place on the Dalmatian Coast might be just the ticket. They get my modest pension/investment income spending and charitable work/donations, I get their edge of Europe but Catholic culture, cuisine and sunshine with plenty of rooms for the kid’s families to visit as well. And edgy trips to the Muslim fringes. You can see why so many Irish folk bought places abroad in the last boom, but they did it largely for the Hedonic Treadmill sea,sand, sex, sangria stuff like the Costa Del Brits, not on the basis of the savvy health-care consumer retirement index.

    The World Cup interpolation in the article is sound. German tactics banjaxed Brazil but it seemed very heartless. Is that their hospital care model for kids too? Oh, well. The English get their revenge: Germany vs Argentina is a WIN-WIN. Whoever loses, it’s pure schadenfraude to enjoy for the defeated, as was arrogant Brazilian insouciance about countering the talent drain to the Premier and Europa leagues. There’s an international talent contest for ‘soccer’ as there is for nurse bivouacs in Saudi. The NHS nicks most of the nurses from the Phillipines and Poland rather than retrain redudant ex-working class folk. Now Ireland is on a health-care professional export drive. Again! And so on.

    A great thought-provoking article in clear language and one that distracts us all from the mounting horror of #GarthBrooks ! It looks like O’bama is going to save you from yourselves. If there’s no shows, the costs in terms of anti-depressants and ‘counselling for Cowboy Culchies’ will have the Troika back on the plane!
    [flipping flippant ending: was doing well at being a bit sensible, oh well!]

    • DB4545

      This begs the question, is it possible to have an efficient society with a soul? I think we can but it requires some honesty? We as a Country don’t have bottomless wallets so let’s stop pretending we have. We can provide decent services with the resources we have just as Croatia has. We can’t afford and should not model a health system on the British NHS. It’s idealistic but it’s a shambles and it effectively had a euthanasia program for some of its elderly population(and some may argue so have we). How about a few simple gatekeeper checks to minimise chokepoints and keep the system honest.
      1. Everyone pays some fee at point of use for GP services (maybe 5-10 euros for medical card holders) with the ability to reclaim a percentage from income tax above a fixed threshold.This way we can analyse GP use and target primary care more effectively.
      2. People with substance abuse problems and/or anti-social behaviour with hospital staff or who engage in drug dealing are treated in a designated separate area and receive the lowest priority for treatment. This idea is perhaps a bit radical but I think it would transform A & E services for most people. Medical staff didn’t have to deal with zonked out junkies with self inflicted injuries using up valuable resources 35 years ago. I doubt if the Croatian authorities are as tolerant as we are.
      3. Bring back the Matron or her modern equivalent.

  10. Adelaide

    It has always been my observation that we Irish are a right-brained people, hence our thriving culture and renowned ‘craic’. Irrespective of what system is put in place the Irish psyche will render it shambolic, it’s just not in our make-up. I know seasoned travellers who have settled in Ireland because they find the Irish to be truly unique while accepting our lack of left-brain efficiency as a price to pay. A stranger to Ireland will quickly realise after a few days that the Irish lack standards, any standards when compared to most developed countries, but they’ll still return for that uniquely-human Irish experience. As David himself said a few articles ago there’s more to life than bland efficiency, he’d still choose Dublin over Brussels as a place to live.
    I lived a short while myself in Belgium, they are more Germanic than the Germans, it is the epitome of efficient systems/society etc but I would sooner risk my life in third-world basket-case Ireland than settle down permanently among the Belgians. It’s ying and yang, you can have one, but not both. Imagine a people with the Irish sensibility and the German efficiency, what a country that would be! Perhaps on a distant planet.

    • Adelaide

      Following up my observation, the trick to living in Ireland is to minimise to zero your interaction with all Bodies of the Sate and any system/institute that is pre-fixed by the word ‘Public’. That way you’ll keep your sanity. Once you do that then Ireland is as good as anywhere in the World. My only wish is to own a helicopter so I can avoid the laughable network of public potholed roads, off to Donegal anyone?

      • DB4545

        We don’t have some unique “Irish Exceptionalism” that make’s us better. We just have a tolerance for putting up with shit even when we’re paying through the nose for it. We’ve been happy to send our Citizens overseas for abortions because we won’t deal with the issue at home. We send our kids to the ends of the earth for work having educated them at taxpayers expense because we won’t lock up the assholes who bankrupted the Country. Why should you have to avoid public bodies that you fund with your taxes? We are prepared to tolerate wholesale theft of State resources from the very rich and very poor in our Society. When we grow up and say no then we’ll be moving towards a decent society.

    • erm….with the Euro and the Troika remotely monitoring the budget, i *think* that distant planet is hovering into view over the next decade or so….isn’t that the next phase of the plan for Ireland Inc? Not taking the p, seriously, isn’t that the choice that’s been made with Lisbon 1/2 FF/FG Election Musical Chairs: All Change/No change?

  11. douglaskastle

    The spirit of this story I think raises a question to “The Irish Way” of doing things. This comment is written in the middle of the Garth Brooks debacle, it is now tipping back towards happening, we’ll see. But we have seen it all before, with both the Nice and Lisbon treaties.

    Something needs to be done, the system pushes back and the answer is no, then what happens we try it again until the desired result is achieved. Then, after all the ructions and twisting of law and Second Slane concerts for U2, do we try and fix the system so next time is works better? No, the view after the fact is, sure it was grand, we got there in the end didn’t we? and then put any lessons to be learned on the long finger until it blows up in our face again. Case in point, how the fun can we be back in a property bubble again?

    Hospitals though it is a shame, sadly due to it’s very function, people only visit there when they are at their lowest point, to be kept waiting and uninformed only contributes to the misery. We owe it to ourselves to get it all fixed up, maybe even use the phrase “world class” for something Irish other than pubs would be nice.

  12. Foreign Virus is the Cure

    If the Mexican Ambassador can brink Garth Brooks to Dublin we should ask him to change our Health System.

  13. Colin

    Does the Croatian health system have to deal with the same amount of drunks in ‘craic-filled’ Ireland who fight each other every night when rolling out of the pub / drinking den? Does it have the same amount of heroin addicts who demand to be cared for when things go wrong for them? Do Croatian teenagers drive at speed around our city streets and country roads without wearing seatbelts, wrapping their cars around trees, lamposts and whatever else you’re having yourself including ditches? Do Croatian women working in delis slip on vomit on the floor then call an ambulance, and if so, why wasn’t the vomit cleaned up?

  14. michaelcoughlan

    Hi,

    Excellent article.

    My two pence worth is there isn’t a scumbag of a charted accountant with the final say. For example; A nurse in the maternity in Limerick pointed out to me that when she started her career over 30 years ago the wards were all shining but now were shabby and worn. This is because the nurses that time had the responsibility and pride of profession to ensure the wards were spotless. Their salaries were also capable of ensuring they could provide an adequate standard of living for their families.

    Then she went on to point out that we now have a situation where the contract cleaners are brought in on zero hour contracts on min wage and couldn’t give a fuck because the system is shitting all over them. The net result of course is the responsibility is devolved away from where it needs to be because some asshole bean counter thought they could see an opportunity to squeeze another few quid out of the poles.

    What happens then of course which isn’t counted and added to a P&L or balance sheet is the talented honourable nurses who can see the drop in standard vote with their feet (in accountancy terms the losses are externalised) and the whole thing collapses into a shitfest of finger pointing and passing the buck. You can be sure however the accountant got his short term bonus for cutting costs and is onto the next hospital to draw another bonus to fuck everything up there also.

  15. mirko

    David ,
    As much as I am glad about your good expirience with the hospital , I as a Croatian could tell you whole different story about Croatian hospitals . But I am not much of a storry teller , so I sudgest you read about some 600 croatian doctors that are waiting for the papers to leave Croatia . Or you could investigate the recent debacle of our leftist (sic!) government , when they tried to impose a new system of shifts on medical workers , which monumentously failed , so it was simply stopped . Withouth regard to those people who suffered for couple months .
    From my personal expirience with hospitals , I can tell you about a young friend who , after two surgeries in Croatia , came to Berlin , and the doctor who opened her up could not believe that Croatians left her in a condition in which she was . Or the time I brought my little brother to emergency , and we sat there for half an hour as the nurse at reception was watching her late night telenovela .
    It however surprises me that you spend two months a year in Croatia , yet you did not notice how corupted things tend to be arround here , specially in hospitals . Had it been my little brother , we would wait as much as an Irishman waits in Irish hospital , and despite the fact I pay obligatory healthcare for past 20 years , I’d still have to bribe some nurse to just tend to my bro with some humanity .
    Eventually , he would end up doing the surgery in a private clinic by the same doctor that was tendin to him in the public hospital .
    But I am glad all went well for you ;)

    • Dober dan Mirko!

      I understand that the system is in trouble. My Croatian friends have similar stories, so too do friends in almost every European country. The point of this article was to to lavish parise in the system but to highlight that this specific hospital in Sibenik has managed with few resources to make the patient experience as good as they can. Thats all and for doing that I commend them. I didn’t say anywhere that the Croatian system is good, better or even nai bolje! I simply relayed what happened.

      All the very best

      Do vijenje!

      David

  16. desaxony

    I’m a foreigner living in Zagreb, Croatia for 8 years and I’ve also had only positive experiences with the A and E here. The same as you, we’ve always been seen very quickly, got the x-rays and any lab tests done immediately and no payment was needed (only had to show our Croatia health insurance card). Although I speak Croatian, I mostly use English when it comes to medical things here and almost all the Drs/specialists speak English (some German and Italian too!). I can’t speak highly enough of that part of the Croatian health system here.

    Outside of the A and E, the general condition of the hospitals in Croatia are poor though and are in serious need of expansion and modernisation. The staff do well working in such tough circumstances, being underpaid and having to put up with a health system that is rife with issues – corruption, old-school bureaucracy and a seemingly non-existent budget, although more and more they are trying to tackle the corruption in the system.

  17. StephenKenny

    Healthcare systems are classic bureaucracies – they have all the features of the East German industrial planning ministry. To slightly misquote someone or other:
    “A bureaucracy cannot exist as a permanent form of institution. It can only exist until the managers discovers it can effectively vote itself largess out of the public treasury. ”
    This is what has happened in many countries, over the past 30 years.
    It is always the same:

    a. The healthcare managers announce that without a significant increase in budget, they’ll have to cut beds, doctors, and operations.
    b. So they get the money.
    c. More healthcare managers are employed.
    d. All the local car dealerships, private schools, real estate agents, and holiday companies, and kitchen sales companies, promptly get completely unrelated upsurges in business.
    e. Go to (a).

    The reason no one talks about good performance in healthcare is quite simple. What is called ‘good performance’ is simply people turning up and doing their jobs, with at least a semblance of good manners. I also don’t congratulate lorry drivers every time they don’t crash.

  18. DB4545

    On the subject of East German planning I was in Magdeburg yesterday which is in the heartland of what was the old East Germany. I wouldn’t be thrilled about the Stalinist architecture and it didn’t seem like party central but the city centre looked prosperous with a good transport system(mostly trams) and modern industrial estates. I travelled throughout the old Eastern Bloc in the early eighties which was largely a dull grey boring mess. Almost twenty five years after the wall came down these people have got their act together and risen from the ashes again. I prefer Ireland over anywhere just for the partial anarchy and subversive mentality. We don’t like laws and treat them as obstacles to be overcome so that we can do our own thing. But we must be able to do better than we are at the moment given the resources at our disposal. If these people survived being bombed to ashes and bored to death surely it’s not beyond our creative abilities to make our little Country work.

  19. StephenKenny

    What’s fascinating about social and economic structures is how easy it is for them to operate against the interests of those involved, and especially against those who they are designed to benefit. This occurs even on the occasions that the majority of their staff involved believe that they are trying to do the beneficial things they claim.

    This isn’t about conspiracies and smoke filled rooms of enemy agents planing the downfall of civilisation, or about capitalist running dogs. This is about the alignment, or misalignment, of interests.

    Health Services are good example:
    Staff get pay rises for working hard and achieving good results. It sounds so sensible, and so right. So, a wise manager sits down and figures out how to optimize the pay rises and benefits. This makes them successful within the organisation, which in turn encourages their promotion and increase in influence.
    This sort of optimization is also simple: Claim one thing, and do the opposite. So, for example, in a health care institution:
    Claim: We’re all working all the hours we can, with less resources than we could use, so if we increase resources we’ll do even more fantastic healthcare things.
    Truth: We’re maximizing non-healthcare related benefits and spend, and cutting healthcare spend at every opportunity (meaning everyone can see we need more money for healthcare things).
    Result: Media and public believe that the hard working doctors and nurses are having their budgets cut by uncaring politicians.

    Another: Water companies.
    Claim: We’re working hard to get the purest, cleanest, water to everyone, at the best price we can.
    Truth: Since it is self-evident that the less water we have, the more we can charge for it, we’re trying to get rid of resevoirs, not repair the pipes, and get rid of water treatment plants. The final goal of minimizing the processing and water capture costs, while making drinking water only available in bottles and very expensive. Any other water will be untreated, intermittently available, and only good for washing your car with while wearing gloves.

    Another: Politicians
    Oh, this is too easy
    Claim: They’re working very hard on behalf of the population
    Truth: They’re encouraging, supporting, and hiding, a set of activities, laws, and systems, that will enrich the few at the expense of the many – which includes themselves.

    In all these cases it’s important to remember that claim is what people believe to be the case, while the truth is simply what happens, but is never mentioned.

    Everyone tends to get glimpses of the truth in their areas of expertise and endeavour. You see something, a deal, a contract, some statistics, that are quite stunningly terrible, and yet nothing is ever mentioned. By anyone. Ever.

    Finally, the underlying problem is that membership of other social and economic groups have replaced membership of the nation as important. People will happily sacrifice the population of their country (in whatever way they interact with it) for the benefit of themselves and some other structure (class was popular for quite a while, religion, business sectors, etc).

    We are well into the era of apathy. Which is followed by dictatorship. May as well brush the dust off you armbands now.

  20. Reality Check

    David, I had the opposite experience in a Dublin Hospital.
    The main reason for the chaos is organisation – a complete lack of it and the protagonists want it that way.
    I would echo Db4545 comments about the substance abusers choking the system.

  21. Reality Check

    Also I was in Croatia recently too.
    The people, scenery, food and general stress free atmosphere are joyous.
    I never felt in Danger or the ominous presence of scumbags, I once left the car unlocked overnight with the GPS on view. The car was not touched.
    Ireland is a tough place to come back to.

  22. Reality Check

    Also I was in Croatia recently too (Zadar).
    The people, scenery, food and general stress free atmosphere are joyous.
    I never felt in Danger or the ominous presence of scumbags, I once left the car unlocked overnight with the GPS on view. The car was not touched.
    Ireland is a tough place to come back to.

  23. Reality Check

    The Ireland/Croatia comparison is analogous to the quip I once read about the difference between Argentina and Japan – How is it that the Japanese can do so much with so little yet the Argentinians can do so little with so much?

  24. gcy_1980

    This situation reflects strongly some ideas which Sen talks about when looking at development, etc. He says that while income can lead to better outcomes in health, it is not usually the main way to achieve the best outcome. He talks more about the expansion of entitlements and freedoms of individuals. It is a fantastic concept and one that has lead to indicators such as the Human Development Index(HDI).

    In looking at health he talks about support-led and growth-led policies. Support led are the ones that are entailed in entitlements. These would probably be conducive with Croatia. This type of policy was usually seen to be successful during war periods and afterwards. Growth-led are what are driven by income increases. Unfortunately, these don’t usually measure well in comparison.

    So how do countries afford support-led processes with very little income? Sen points to relative prices and costs. The viability of these processes is dependent on the fact that they can be very labour-intensive. So these are relatively inexpensive in poor, low wage economies. The altruistic behavior of neighbours during wars can also show through their expectations of social healthcare. A poor economy may have less to spend on healthcare and education,but it also needs less money to spend on the same level of services. Health outcomes rely on a much broader idea than just income. With a starting point in the support led process, these outcomes will usually be better when income do increase. It can be difficult the other way around. As Ireland is experiencing…
    I suppose what I am saying is health outcomes are determined by more than just the income variable…:)

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