The conventional wisdom has it that the Irish health system needs thousands of extra beds in order to rid itself of chronic problems such as the trolley crisis and long waiting lists.
This thinking is at the core of Sláintecare, the policy document that enjoys near unanimous support among the political parties but gets a more mixed reception from doctors.
The nagging doubts that persist about Sláintecare relate in part to the massive cost of creating new hospital beds in a system that is, by international standards, already reasonably well funded.
So is there another way of reforming the system that does not involve substantial extra expenditure and yet relieves the overcrowding that causes so much suffering for patients?
Well-run hospitals have good throughput. We already know there are major blockages in the system because patients who are well enough to leave hospital are unable to do so because of a lack of options, whether this is care at home or in a nursing home or other form of stepdown care.
On any one day, upwards of 600 patients are stuck in hospital because of this issue. Hundreds of patients wait months to get out of hospital, at great expense to the taxpayer and inconvenience to the hospitals.
So much for the exit problem. Now we learn, from the data provided by the Health Service Executive to The Irish Times, that there may also be an entry problem. Emergency departments are for emergencies, and hospital beds are for seriously ill patients, but from these figures we learn that three out of 10 patients are judged well enough to be discharged within 24 hours of being admitted.
No doubt many make a rapid recovery thanks to the intervention of medical staff, but the suspicion is that many should not have been in hospital in the first place, and would not be there if services were properly organised.
Informed decision-making
Key to the effective running of a hospital is speedy and informed clinical decision-making, yet too many Irish hospitals are staffed by junior, often locum staff who lack the ability, and/or the confidence, to make decisions about the care of patients. "All too often, the person is admitted overnight and then the consultant comes in the next morning and says 'what is this patient doing here?'," says Galway-based vascular surgeon Prof Sherif Sultan.
Another common scenario is that the patient requires tests, or a scan, but these services are not available overnight. So the patient is admitted to a bed, tested the following day, and released if the test is clear.
Overworked junior hospital staff manning the night shift have few options. The patient’s GP may not be contactable and out of hours services are stretched and scant. The hospital pharmacy may be the only place where drugs can be dispensed.
The HSE figures on discharges come with some caveats. The patients involved will have already spent time being treated in the emergency department, and the data is silent on where patients are being discharged to. Yet if the accounts of senior doctors are to be believed, there clearly is a problem with unnecessary admissions that, if tackled, could make a dint in the overcrowding problem in hospitals.