Ministers attending last week's special Cabinet meeting in the Ballymascanlon Hotel to discuss the health service were given a sobering assessment by senior officials in the Department of Health and Children.
The officials described primary healthcare as patchy and overloaded, and saw hospital waiting lists as evidence of "serious deficiencies". Hospital patients were experiencing long delays in accident and emergency departments, and there were "unacceptably high bed occupancy levels" in hospitals. Childcare services, services for older people and mental health services all needed extra resources.
Officials at the Department have been engaged for some months in a fundamental review of the state of the health services, seeking and collating input from many groups in drafting a new health strategy for the State for the next five to seven years. The Cabinet was last week given a snapshot of their work in progress, including very clear statements that while extra investment in health has brought results, even greater investment is still required.
In an apparently calculated effort to bring this message home, the first speaker to follow the introduction by the Department's secretary general was the deputy chief medical officer, Dr Eibhlin Connolly. She presented a damning picture of how the gap between Irish and EU life expectancy has been widening.
The secretary general, Mr Michael Kelly, outlined to the meeting how recent increases in health spending had followed years of under-investment.
Mr Kelly outlined where the increased spending on health in recent years had gone - 65 per cent of it on pay, and 35 per cent on service developments.
Since 1997, the number of day cases treated in hospitals had risen by 70,000, and there had been significant investment in cardiac and cancer strategies. Since last year, 1,300 extra nurses had been employed.
However, the lion's share of extra spending on service developments went to areas of social services which are not publicly identified with health spending, although they come within the remit of the health boards.
Developments in community services included a 70 per cent increase in respite services for the intellectually disabled, with an extra 1,200 residential places and 1,700 day places; 375 extra posts had been created in child and family support services; there were 400 extra day places for the physically disabled and 95 residential respite places and extra therapy services. For the elderly, there were 400 extra beds in community nursing units and over 1,000 new day places in 10 new centres with 880 new staff.
"We have substantially increased the level and type of health and personal social services over the last few years," Mr Kelly said.
He told the Cabinet that progress had been made, but there was "much to do" to address deficiencies in primary care, childcare services, services for the old, mental health services - especially child and adolescent psychiatry - and the capacity of acute hospitals.
His colleague, Ms Frances Spillane, director of the health strategy project team, explained how mental health services, both in psychiatric hospitals and the community, would need investment of £340 million over the next five years.
She said the emerging needs of the intellectually disabled also meant there was increased demand for residential, day and respite services, and for specialist support services for children with behavioural problems and autism. Services for the physically disabled would require £500 million over the next five years, which would supply 3,400 day places, 1,000 residential places and home helps, therapy and other services.
Expansion of child protection services in areas like foster and residential care and homelessness would require £225 million over the next five years. Travellers' health required £6 million.
An assistant secretary in the Department, Mr Donal Devitt, explained how the population was ageing, with every year seeing an increase of 6,000 people aged more than 65 years, and 1,500 aged more than 85 years. Meeting their needs for assessment and rehabilitation units, community nursing units, day and home care teams and palliative care would require 4,700 extra beds and extra staff at a cost of £555 million in capital investment and £470 million extra annually in day-to-day spending over the next 10 years.
Reviewing the hospital service, Mr Kelly cited "evidence of serious deficiencies re waiting lists".
If all the 27,857 patients on the waiting list last December still required in-patient treatment, this would imply that approximately 500 further inpatient beds were required, officials explained. Ireland had the highest bed occupancy level in the OECD and it was "unacceptably high". Occupancy levels in some hospitals were running at or above 100 per cent. [This statistical "impossibility" appears to occur when patients spend nights on trolleys.]
In order to cope with the waiting lists, and with expected population increase and ageing, the Cabinet heard that an additional 4,800 beds would be needed in the acute hospitals over the next 10 years.
About 10 per cent of bed days in the major hospitals were lost due to delayed discharge of patients because of the absence of long-term care and rehabilitation facilities and community support services to facilitate these people returning home.
Mr Tom Mooney, deputy secretary in the Department, made the case for increased resources for primary care supplied by general practitioners, public health nurses and other paramedics. Primary care had the "capacity to make a major contribution to health" and the potential for "promotion, prevention and a wide range of care and curative services".
He said the current "patchy network of health board services" could not do this and was "overloaded". Half the State's 2,200 GPs were working single-handed - often for more than 80 hours a week. Primary care required a major increase in staff, clinics and equipment. With phased implementation, this would cost £40 to £50 million per annum, he said.
The Cabinet heard that the overall health service needs an extra 1,500 nurses per year for current needs, and more if the service is expanded; an extra 175 speech and occupational therapists and physiotherapists; more care attendants to support nursing; and more doctors as recommended by the Medical Manpower Forum.