The Covid-19 pandemic has drawn public and political attention to the Irish health system and the courageous work of health workers on the front line. Before the pandemic struck, reporters from The College View identified and examined some of the major pre-coronavirus challenges faced by the Irish healthcare system, including waiting lists for some chronic conditions, the dependence on locums (doctors in temporary positions) in short-staffed hospitals, and the difficulty some parts of the population – Travellers, the homeless – have in accessing healthcare. These stories present facts and context to understand the Irish health system have been stretched to its limit as it deals with the effects of Covid-19.
People requiring hip and knee replacements are facing the worst waiting lists in Ireland, with over 64,000 people waiting to see a consultant for their treatments. The figures, from the National Treatment Purchase Fund, for January 2020 show that a total of 64,907 people are waiting to access orthopaedic treatment.
Some 14,604 of these cases are waiting up to three months, while 12,684 peoplewill be forced to wait over 18 months.
Orthopaedics is the field of medicine that deals with the correction of deformities in the bones and musculoskeletal system. This includes everything from joints to muscles, ligaments, bones, nerves and skin.
According to the HSE, 4500 hip replacements are carried out every year. Professor John Quinlan, an orthopaedic surgeon working in the Blackrock Clinic, said the waiting list issue is due to a lack of beds across the country exclusively for elective care.
He said appointments are regularly cancelled as the emergency department of a hospital will take priority over any elective care, leading to bed shortages when the emergency room is busy.
Prof. Quinlan said waiting lists lead to worried patients, “The main manifestation is complaints from patients.” He said health service managers do not understand the impacts of waiting lists on patients’ lives.
He said: “You’re dealing with people who live their lives through the medium of an Excel spreadsheet…the grasp on reality can be somewhat distant.”
Dr. Denis Collins, a practising orthopaedic consultant in both the public and private sector, said that orthopaedics has the longest waiting list due to modern advances in patient treatment.
He said: “You have to think back 30 years ago, people with arthritis were not treated, you were just old and that was part of life.”
“Nowadays, it is unacceptable to live in pain, so it’s a relatively new specialty and as a result it’s routine for people so there’s a huge increase in demand, and an aging population.’
Kathleen McNally, 70, went private rather than waiting for a second hip replacement surgery. She said, “I would’ve had to wait three years on a medical card [for a hip replacement]”. According to Kathleen, she went to Louth County Hospital and was told that the waiting list for an x-ray on her hip would take up to nine weeks.
Dr Collins thinks the issue is down to the lack of risk in orthopaedics: ‘we’re not in a life and death situation most of the time…. they’ll just be in pain,’
‘We say it’s dreadful to be in pain, but some other specialists will be jumping up and down saying we need to get my patient in next week, because they will die.’
Orthopaedic specialists treat patients of all ages, including those with scoliosis, a condition where a person’s spine curves sideways.
Alex Partridge, 18, had suffered from infantile scoliosis since he was diagnosed at 18 months-old. He was treated in the public service until the age of 7, when he was then denied a new body brace. As his spine curvature was worsening, his parents were forced to treat Alex in private healthcare, which included day trips to a physiotherapist in Suffolk, UK for treatment.
After spending €6,000 on treatments in the UK, not including travel expenses and extra physiotherapy in Ireland, Alex and his parents decided to confront the public health sector and pleaded that Alex receive surgery to realign his spine. Alex described this period as a waiting game, despite having over a 100-degree spinal curve, he still didn’t know when he was going to receive his spinal surgery.
Alex independently continued his physiotherapy at home so he could increase his flexibility, so his parents had to purchase exercise equipment for him. Alex was a stage performer and as his condition worsened with age his confidence was also affected.
Alex finally received his spinal fusion surgery at age 16. However, if Alex had not received his surgery before the age of 18, he would have been transferred to the adult waiting lists in orthopaedics.
The Irish Hospital Consultants Association said, as of December last year, 563,410 people are waiting to see a hospital consultant.
This is an increase of 48,050 or 9.3 per cent on the same time last year. There are currently 500 consultant posts in public hospitals in Ireland that are not filled. The initial strain on new consultancy jobs was caused by pay cuts in 2012 which were made by the then Minister for Public Expenditure and Reform Brendan Howlin and Minister for Health James Reilly.
According to documents obtained through the Freedom of Information Act 2004, the Ministers brought in the cuts to try and reform the health service.
“I am conscious that securing major work practice change from hospital consultants, the largest single group of highly paid public servants, is of major importance to the major reform process within the health sector, and to the ongoing process of extracting costs from health service delivery,” Brendan Howlin said in a letter addressed to James Reilly in 2012.
President of the IHCA, Dr Donal O’Hanlon said this shortage is “due to the government policy that is driving our highly trained specialists abroad.”
Dr Collins, described how consultants who return to Ireland later in their careers face financial burdens.
He said: ‘When they come back from living abroad, they’re in their mid-thirties, they don’t have a house, they could have a wife and kids and could be in debt and they’re going to start working at 35, they need to be paid appropriately.’
The Department of Public Expenditure and Reform reported that new consultants are being paid up to 51 per cent less than their colleagues despite having the same demanding responsibilities.
In addition, Martin Varley, the secretariat general of the Irish Hospital Consultants Association (IHCA), explained that increasing the amount of beds is critically important for treating more patients.
He said 2,600 beds are needed in the next five years to help combat waiting lists.
“They [the caretaker government] are providing a much-reduced number of beds on a drip feed basis despite the growing crisis year after year”, said Varley, explaining that the 2600 beds should be frontloaded, to ensure availability as soon as possible.
According to Varley, there are several factors leading to the excessively long waiting lists, with a rising and aging population and a lack of beds all playing a part.
Figures from the Organisation for Economic Co-operation and Development (OECD) show that there was a sharp decline in hospital beds after 2008, where Ireland went from 21,789 beds to 12,813 in 2009. This has risen to 14,217 in 2017. This is a decrease of 34.7 per cent of hospital beds from 2008 to 2017. Mr Varley has also said that by removing the two tier pay system for consultants, it would be a significant help in hiring additional staff.
ENT and Dermatology: Under Strain
Patients waiting to see consultants in ENT (Ear, Nose and Throat) and Dermatology face the longest waiting lists after orthopaedics.
Some 64,000 people are awaiting treatment in ENT. ENT has the longest waiting lists over an 18-month period with over 21,000 patients expecting treatment according to the NTPF. The Dermatology sector faces just under 44,000 patients on waiting lists.
In one example, University Hospital Waterford has over 4,000 patients waiting over 18 months for ENT services, which is the longest ENT waiting list in any hospital in the country. Minister for Health Simon Harris has commented that he is aware of the “unacceptably long” waiting lists. Harris has also said he is committed to improving the waiting times for hospital procedures and appointments.
According to IHCA, existing waiting times in the HSE are in a ‘parallel universe’ compared to countries with a similar population such as Scotland.
Dr Donal O’Hanlon said: “There, Scottish hospitals see most outpatients within 12 weeks. Here, the target for an outpatient to see a consultant is four times longer at 52 weeks. The difference is that Scotland has invested in hospital capacity and medical specialists, to ensure that patients can access timely hospital care. In addition, Scotland with a population of 5.5 million has 56 per cent more public hospital consultants than Ireland.”
While the waiting lists are still growing, several political parties have included promises within their manifestos to help alleviate the strain. Both Sinn Féin and Fianna Fáil have promised to end two tier pay for consultants and provide additional beds. Fine Gael have pledged to provide 2600 new beds, alongside 4500 community beds.
All three of the main parties have also included the construction of multiple elective hospitals, which Varley also believes are needed. With elective hospitals, emergency care wouldn’t take up bed space, so cancellations on consultation appointments would be minimized according to Varley.
However the dialogue between hospitals and those being treated as outpatients is lacking. Those already seeking consultation are not being informed and are unaware as to what comes next.
As Alex Patridge, the scoliosis patient described: ‘‘You’re waiting for the phone call, ‘am I getting it [treatment] done today? You’re completely left in the dark.”’
Jennifer Keegan, Aoife McMahon, Tadgh McNally & Isabella Finn
Image Credit: Alex Partridge