Whatever is said about the current record levels of overcrowding in hospital emergency departments, they cannot have come as a surprise to anyone involved in healthcare.
In September, Minister for Health Stephen Donnelly was expressing concern about a possible “very difficult winter” caused by a “twindemic” of flu and Covid-19. The HSE was given €170 million to plan for this scenario and published a wordy winter plan the following month.
By December, it was clear flu was back with a vengeance, RSV was already putting children’s hospitals under extreme pressure and Covid-19 was making a return. The “twindemic” had become a “tripledemic”.
Just before Christmas, Donnelly said the health service had taken a range of actions to ensure emergency departments were “as prepared as possible” to deal with the expected unprecedented demand from patients. Hospitals were told to spend money on extra agency staff, overtime and private sector capacity.
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New arrangements in hospitals would ensure patients attending an emergency department were seen more quickly, spent less time in hospital and would be discharged promptly, the Minister said. Senior decision-makers (consultants to you and me) would be “immediately rostered” to oversee this more efficient flow of patients.
All of this does not seem to have made a difference. Trolley numbers are teetering close to the 1,000 mark, more than 15 years after the then Fine Gael leader Enda Kenny promised to end the “scandal” of patients languishing on them. Non-urgent work has been cancelled by under-pressure hospitals, thereby adding to the interrelated problem of long waiting lists.
University Hospital Limerick, perennially the worst in class for overcrowding, did not even bother to schedule elective work, knowing its emergency department would be so overrun in January as to dominate all other operations in the hospital. For a time on Monday, ambulances were told to divert from the Limerick hospital to others with all but the very sickest of patients.
There are two answers to the wider problem. The first is more hospital beds; the State appears to be short by about two big hospitals’ worth. According to the Organisation for Economic Co-operation and Development (OECD), Ireland has fewer than three beds per 1,000 people, compared with an international average of five. Mind you, the OECD members with fewer beds than Ireland are Finland, Denmark and Sweden; so it might be worthwhile investigating how those well-run countries manage with fewer resources.
Between 2012 and 2021, Ireland added exactly 1,000 hospital beds, a 10 per cent increase. This was less than the increase in population over that period. Since the Covid-19 pandemic, the money has been there to create more beds, but progress in recruiting staff has been slow.
The second answer to the problem of overcrowding lies in the system itself. On Tuesday, UHL had 97 patients on trolleys; University Hospital Waterford had none. There is a consistent and huge disparity between the best and worst performers: go figure.
The problem is that the system is running out of rope. Exhausted, frustrated staff are voting with their feet
A system weighed down by vested interests is averse to change. It is easier to do nothing than to make changes that might fail. It is easier to leave the same structures and personnel in senior positions than to demand accountability. It is easier to let the acute phase of the crisis blow over until the evenings start to lengthen and the public tires of the trolley crisis.
The problem is that the system is running out of rope. The baseline level of trolleys is now about 500, even in summer when there is no flu or Covid-19 to blame. That means the waiting list problem will never be fixed.
Exhausted, frustrated staff are voting with their feet, in the direction of careers in Australia, the private sector or work in the community.
Overcrowded hospitals cause unnecessary deaths. So do long trolley waits. Other people will die because they are afraid to go into hospitals, or feel discouraged from going there. But these are hidden deaths, and the system seems to be prepared to live with them.