Special Report: How sick is our health service?
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It took a potentially lethal virus and global pandemic to wake up the political class to the glaring gaps and deficiencies in our health service last year.
The fact that pre-Covid we had just 220 intensive care beds captured, in stark terms, how deficient the service was as it faced into the greatest public health emergency in living memory.
Covid-19 exposed the crevices in our creaking health service that has been dogged by persistent problems, such as the winter trolley crisis, burgeoning waiting lists and access issues in general.
- - Professor Anthony Staines highlights the ambiguity over where responsibility lies between the HSE and Department of Health
- - The Irish Patients' Association raises concerns over spiralling waiting lists
- - Questions surround the cost of the build and accountability of 60 additional beds at the hospital
- - IHCA President reveals country's hospitals "are always operating in the red zone"
- - Irish Medical Organisation president, Dr Padraig McGarry, explains how the challenges the health service is facing stem from decades of underfunding
- - Emergency Department nurse Emma Murphy says overcrowding is no longer an option for hospitals
- - A frontline doctor highlights how public health was at its lowest point when most needed during the pandemic
- - Teenager 'could only stay in a seated position for half an hour at a time'
It also exposed significant gaps in how we care for elderly people, many of whom were at increased risk from Covid-19 in antiquated residential care homes and nursing homes without adequate input from public health services.
In short, the pandemic brought into sharp focus, once again, significant gaps in capacity and staffing levels in hospital care, primary and community care, care of the elderly, public health and mental health services.
It has also brought with it additional challenges, including the need to provide separate Covid and non-Covid care pathways and operate services at a reduced capacity, meaning a slower service that will take longer to see patients.
The significantly increased budget will go some way towards staving off the extra challenges posed by Covid-19 and kickstarting some key changes under the Sláintecare strategy.
Those working at the coalface of the service and patient advocates, however, know there is a long road ahead to undo decades of underinvestment in services.
Health service funding has increased by 29% since 2010, rising from close to €14bn to €18bn in 2019, according to official Department of Health figures. Add the Covid-19 pandemic and funding levels will soar to €22bn this year.
Of this record level of funding, €2bn will be spent on the Covid-19 response, while core services received a €2bn boost in budget 2021.
Figures for 2019 show that pay accounted for 43% of the health budget and an increase in staffing levels last year in response to Covid-19 is likely to push that up further.
Staffing levels are projected to increase by 16,000 staff in 2021 compared to pre-Covid levels, which will push up the pay bill by €1.1bn this year.
The average cost per worker is close to €59,000, according to internal departmental figures.
The health workforce grew by a modest 6% between 2010 and 2019, according to official figures.
The transfer of social work staff from the HSE to Tusla in 2014 will have affected the overall growth rate during this time.
Fast forward to 2020 and the increase in staffing levels since 2010 rises to 11% due to the Covid-19 pandemic, which saw the health service shift into emergency mode.
There are now more than 124,000 people employed across the health service — of which close to 12,000 are medical and dental professionals and close to 40,000 are nursing staff.
An extra 1,000 consultants and around 2,000 trainee doctors have been taken on since 2010.
Management and admin staff of all grades have increased by around 2,000 or 12% between 2010 and 2020.
Despite the growth in staff levels, Ireland continues to have one of the lowest numbers of hospital consultants in Europe, according to the Irish Medical Organisation (IMO) and the Irish Hospital Consultants Association (IHCA).
There are around 1.4 hospital consultants per 1,000 population in Ireland compared with the EU average of more than 2.5 consultants per 1,000 population.
The consultant shortfall, both groups said, exceeds 2,000 when current consultant vacancies are included.
President of the IHCA Prof Alan Irvine said the scale of consultant vacancies was largely due to the ‘A’ type consultant contract rolled out in 2012, which included a 30% cut in salary.
Dr Padraig McGarry, IMO president, said Ireland is short 1,600 consultants based on departmental projections and that this shortfall rose to 2,000 when psychiatrists are included.
Meanwhile, the Government intends to significantly ramp up community health services over the next decade by investing in more primary and community-based care.
This will require a 48% increase in the primary-care workforce. In 2016 there were 3,570 GPs in primary care and, with significant reforms, GP numbers could increase to 4,600 by 2031.
Acute hospital activity has increased since 2010, with official Department of Health figures showing greater efficiencies in the use of hospital beds.
The number of acute inpatient beds fell by 4.5% between 2010 (11,369) and 2018 (10,856), but the number of bed days (up 7.6%) and discharges (up 10%) rose, suggesting the length of time patients stayed in hospital fell over the past decade as more patients were accommodated in fewer beds.
The number of day-case beds increased by 26%, from 1,772 in 2010 to 2,240 by 2018, with a 31% increase in activity levels over this time.
On the other hand, psychiatric hospital admissions fell by 16% since 2010, from 20,195 to 17,000 in 2018, reflecting the closure of mental health facilities in recent years. According to the Psychiatric Nurses Association, the number of psychiatric beds per head of population in Ireland is the third lowest in the EU.
A 2018 review of bed capacity in Irish hospitals, however, suggests the need for 2,590 hospital beds by 2031 — 2,100 inpatient beds, 300 day-case beds and 190 intensive-care beds.
Under the €600m HSE winter plan, 483 hospital beds, 89 step-down beds, 17 intensive care beds and 1,161 community beds are expected to be delivered by April.
Budget 2021 has also committed to increasing hospital beds by more than 1,000 to almost 11,900 by the end of the year.
Again, the IHCA and IMO said bed capacity has been an ongoing issue and has failed to keep pace with demand and population growth.
There is a “mismatch” between demand for health services and dwindling resources, the IHCA's Prof Irvine said: “Between 2008 and 2019, we lost around 2.5% of acute inpatient and day-case beds, but the population has continued to grow by around 11% or 492,000 people in that time.”
The IMO's Dr McGarry said, with occupancy rates averaging at 95%, there was clearly a gap between supply and demand.
“The Government proposed capital investment of 2,600 beds falls well short of predicted requirements. The recent budget allows for additional acute beds of 1,146 on pre–Covid numbers. The IMO recommends multiannual investment to increase bed capacity by 5,000 beds,” he said.
He also noted the “significant shortfall” in intensive-care beds at five critical-care beds per 1,000 population in Ireland compared with the OECD average of 12 beds per 1,000 population.
Since Covid arrived, the number of ICU beds has increased from 220 to 285 and will rise further to 321 this year, but this still falls well short of the 579 beds recommended in a recent report.
“This is highly significant as the risk of critical-care beds being overwhelmed has been a major factor in formulating policy,” Dr McGarry said.
The National Treatment Purchase Fund (NTPF) was set up to tackle growing waiting lists across the health service and outsource treatment for those waiting long periods. Care is provided in private and public hospitals.
Since 2017, the NTPF budget has increased from €15m to €100m in 2020 and rises further to €130m this year.
The initiative, however, has yet to make a significant impact on waiting lists, according to official NTPF figures.
Covid-19, which led to the suspension of planned treatment for three months, has compounded the waiting list problem. As of October 2020, there were close to 75,000 people waiting for inpatient or day-case treatment in Irish hospitals.
The number of people waiting more than 12 months has doubled to more than 18,000 since last year because of the impact of Covid-19.
These figures do not take into account the more than 600,000 people waiting for outpatient appointments, more than 250,000 of whom are waiting one year or more for an appointment.
Clearer governance mechanisms are needed as there is a “lot of ambiguity” over where responsibility lies between the HSE and Department of Health, according to Professor Anthony Staines.
The DCU Professor of Health Systems said the health service continued to be challenged by a lack of accountability and too many decision-makers.
The National Children’s Hospital, he said, was a “most grotesque” example, with initial costings of €600 million now expected to exceed €2.4 billion and possibly reach €3 billion.
“There are too many decision-makers and not enough accountability,” he said, adding the €115 million per month private hospital deal made during the Covid-19 emergency phase was also an example of “non-accountability” and represented poor value for money.
Initiatives such as the National Treatment Purchase Fund (NTPF), he added, were not working to bring down “extraordinary” waiting lists for care and treatment but were providing steady income streams for private hospitals.
“The public sector really does enable private hospitals to survive,” Professor Staines said, commenting on the current two-tier public-private model.
While the problems within the service are “entirely fixable” there are no easy fixes, he said, adding that a shift in the mindset of patients is also required.
“Part of the problem is that we don’t want to change it. The system that we have suits a lot of people.”
The Covid-19 pandemic has exacerbated patient waiting lists putting more lives at risk, according to the Irish Patients Association (IPA).
Stephen McMahon, IPA director, said more than 260,000 patients were now waiting over a year for a hospital appointment, which brought with it increased risks.
He said:
Management or system risks and inequity of access, he said, posed considerable challenges for the Irish health service.
The persistent problem of overcrowding in hospital emergency departments, while less evident in the current Covid-19 environment, remained an issue.
In 2019, there were more than 500 patients on trolleys on 75 days over the winter period.
In 2020 hospitals had triggered the ‘full capacity protocol’ on 1,935 occasions due to ED overcrowding, Mr McMahon said.
A leading emergency department doctor has estimated that hospital overcrowding could cost as many as 450 lives, while Mr McMahon said a further 1,200 lives could be lost because of growing waiting lists.
He also remains sceptical about the prospect of a new vision or “promised land” for healthcare.
“We have a legacy of wonderful plans and blue skies but we have never really managed to take off and get there. It is always overrun by the next vision or the next big plan. We really need implementation of plans already in place,” Mr McMahon said.
Covid-19 exposed many cracks in the health service, he said, but there is an opportunity to learn from the pandemic experience this year.
“There is now an opportunity to do it right. Covid-19 has taught us how fast we can make decisions and be adaptable and flexible and that has to continue,” he said, adding that the use of telemedicine was now a “real option” as part of the service.
Overcrowding in the emergency department (ED) at University Hospital Limerick (UHL) has frequently made headlines in recent years.
Even during the pandemic, when ED attendances were down across the country, the lack of space at UHL led to overcrowding and impacted the spread of the virus.
In October, 1,000 patients waited on trolleys at UHL, despite the pandemic, which also led to ward closures and the cancellation of elective procedures.
ED overcrowding has also continued to impact Cork University Hospital, which had the second-highest number of patients on trolleys in October (685).
The addition of 60 beds at UHL is to alleviate capacity pressures, but there are questions around the cost of the build and accountability, said Stephen McMahon, of the Irish Patients' Association.
The first of three inpatient wards, each containing 20 individual en-suite rooms, opened from November 23.
A further 20, single en-suite rooms opened on December 14, followed by the third tranche of 20 beds on January 4.
In addition, management at UHL has sought planning permission for a 96-bed block to be constructed on the grounds of the hospital.
Mr McMahon said the UHL project, which includes three 20-bedded prefab units, was initially costed for €13m but looks closer to €21m.
The project is another example of poor governance and accountability in the health service, he said: "Some of the delay in delivering those beds was linked to an overrun in the budget for the new National Children’s Hospital."
"In the meantime, we have Limerick with the highest ED overcrowding in the country, with all of the risks that it brings," he added.
Pre-Covid, Ireland had one of the lowest levels of hospital beds and one of the highest bed occupancy rates, meaning that hospitals were always operating in the “red zone”.
That’s according to Professor Alan Irvine, president of the Irish Hospital Consultants Association (IHCA), which represents more than 3,000 hospital doctors across the country.
Ireland ranks in the bottom two or three countries in the OECD and Europe for the number of acute beds in the health service.
Prof. Irvine said:
"When you look at occupancy rates pre-Covid, we are constantly in the red zone, running at on average 94%,” Prof. Irvine said before pointing out that, internationally, hospitals triggered a red alert on reaching 85% occupancy levels.
There is a “mismatch”, he said, between demand for health services and available resources.
“The occupancy rate has always been an issue. The system is always operating in the red zone, always above 85% occupancy, which means there is very little wriggle room for any absorptive capacity if there is a shock to the system,” he said.
The gulf between capacity and demand has led to significant waiting lists, which have been further exacerbated by the pandemic.
There are now around 700,000 people on waiting lists across the health service and Prof Irvine warned that some patients may never be seen.
Because of the “baked-in” mismatch between capacity and demand, some review or triage mechanism may be required to manage spiralling waiting lists, he said.
“No matter how many waiting list initiatives you have, you may never catch up with demand," Prof Irvine said.
The IHCA also recently highlighted the high level of consultant vacancies, at more than 720, owing in large part to the 2012 contract, which offered a 30% lower salary to new doctors.
A failure to invest in staff and increase capacity in the health service has led to spiralling waiting lists that have now been exacerbated by the Covid-19 pandemic, president of the Irish Medical Organisation (IMO) Dr Padraig McGarry said.
The persistent problems facing the health service stem from a “mismatch” in manpower, hospital beds and the rising demand for treatment and care.
“The problems of today are the outcome of decades of underfunding and indeed reduced funding. We are constantly playing catch-up and, as such, it appears that extraordinary amounts of funding are currently having to be deployed,” Dr McGarry said.
Funding, he said, “simply has not kept pace” with growing demand from an ageing population.
“In real terms, per capita funding has increased from 2013 to 2019 by circa 2%," he said.
The immediate challenge, Dr McGarry said, is to deal effectively with new waves of Covid-19 infection and the challenge of administrating the vaccination programme.
“The longer-term challenge is to deal with the pent-up demand of the non-Covid workload,” he added.
Dr McGarry said more capacity is required in the public service to end the reliance on private hospitals filling service gaps, such as treating patients waiting for treatment through the National Treatment Purchase Fund.
“The solution must be to expand the public service with adequate supports, which will provide a permanent solution, rather than the current model of directing increased resources into the private sector.
“In the longer term, we need to create capacity in the health service to deal with the demographics that we have, the ageing population, which is not going to go away,” the Longford GP said.
Overcrowding has dogged emergency departments (EDs) for years and 2019 proved to be one of the worst on record for the volume of patients confined to trolleys.
For ED nurse Emma Murphy, who works at the Mercy Hospital in Cork, it has been the biggest challenge for her and her nursing colleagues.
“Last year was the worst. It was horrendous between Christmas and the New Year. You could have had 30 patients on trolleys at times with some people waiting 24 hours to be seen by a doctor.
“Trying to provide adequate and safe care in a department that is overcrowded is impossible. The patients don’t have dignity; some of them are left waiting on chairs when they should be on beds, never mind trolleys,” she said.
When Covid-19 struck in March, the ED at the Mercy underwent something of an overhaul to turn cubicles into single rooms for patients, providing greater protection and more dignity.
However, the ED is getting busier again.
“Some patients are coming in and they are much sicker because there is still this Covid anxiety. People don’t want to come to emergency departments because they are afraid of Covid so they are leaving it that little bit longer and they are sicker when they do come in,” she said.
The promise of additional beds under the winter plan was welcome but an international shortage of staff presented challenges,
In the meantime, Ms Murphy and her frontline colleagues, are bracing themselves for a potentially challenging winter season with Covid-19 in the mix.
“What we’re really worried about is the normal winter increase in numbers and attendances and how that will impact, given that we have reduced capacity because of Covid-19,” she said.
If anything good can come of Covid-19, Ms Murphy hopes that any gains made through recent changes can be retained into the future.
Public health was at its lowest point coming into the Covid-19 pandemic because of decades of under-resourcing, which “relegated” the discipline to the bottom rung of the ladder in the health service.
That’s according to Dr Anne Dee, a public health doctor in Limerick and member of the Irish Medical Organisation's public health committee, who is poised to take strike action over a protracted wrangle with the Department of Health on pay and status.
Despite the vital role played by around 70 public health doctors in response to the Covid-19 crisis, the Government has not delivered on commitments to address the consultant status and pay issues that have been on the table for years.
Any progress to address the issues was now going into reverse, Dr Dee said, adding that plaudits from the department relating to the public health response to Covid-19 rang hollow.
The lack of value for public health doctors, however, appears to go much deeper.
Dr Dee said that little or no action was taken to strengthen public health services, despite “endless reports” and recommendations over the past two decades.
Public health, Dr Dee said, had been run down since the formation of the HSE and “relegated” to the bottom rung of the ladder, impacting on other parts of the health service.
Despite the challenges presented by Covid-19, which exposed critical gaps in public health, there is now an opportunity to build up services, she said.
“We have a great opportunity to reform public health and to start to build up a really strong public health service,” Dr Dee said, adding that a national lead is needed at the “highest level” to develop services.
“This country cannot allow the public health function to be relegated any further than it already has been. It is a big part of the answer to many of the problems right across the health service,” she added.
It has been a tough road for Ronan Foley, aged 15, from Killorglin, Co Kerry, who had critical surgery on his spine last week after waiting for almost three years.
Ronan is one of more than 200 children with scoliosis who have been waiting for life-changing surgery, sometimes for years.
His father Tony said the delays stemmed from the administration or operation of the health service and predated the Covid-19 pandemic.
Ronan, who has quadriplegic cerebral palsy, was seen in March 2018 by specialists who identified a curvature in the spine.
By October that year, the curvature had significantly deteriorated from 42 degrees to 79 degrees and surgery was recommended within three months.
At that time, then-health minister Simon Harris said no child would wait more than three to four months for surgery.
The teenager, however, faced a lengthy wait to get a date for spinal surgery and it was only last month, almost three years later, that the life-changing operation became a reality.
By this time the curvature in Ronan’s spine had deteriorated even further, to 120 degrees.
The lengthy wait for surgery impacted on Ronan’s quality of life and limited his social opportunities, his father Tony said: “He was too uncomfortable. He could only stay in a seated position for maybe half an hour at a time."
Today, Tony and the family are relieved and delighted that the surgery has finally taken place and that Ronan is recovering well.
“The surgery will give Ronan back his quality of life and let him get on with living his life,” Tony said.
“A huge weight has been lifted from us now that the surgery has happened. We have been fighting for a date for surgery for so long and waiting and waiting. It is fantastic that this day has finally come,” he added.