A special report of The College View.
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.
Even before the Covid-19 pandemic, the Irish healthcare system was stretched to its limits.
Doctors, nurses, and paramedics have worked tirelessly to treat coronavirus patients, even as they grappled with many longstanding structural problems that have combined to put the entire system under severe strain.
The College View has identified four major factors that have stretched the system to its limits — with ongoing implications for the welfare of workers and the treatment of patients.
Unless addressed, these connected factors will continue to affect a health system in a world irrecoverably changed by coronavirus.
Factor 1: The Trolley Crisis
Patients waiting on Irish hospital trolleys – which official figures put at 12,000 last January — are just one of many indicators of a system at its limit.
As Ireland’s population is expected to increase to over 5.1 million in the next five years, experts say that this system will be incapable of providing the lifesaving treatments patients need.
Dr. Emily O’Connor, President of the Irish Association for Emergency Medicine, an organisation established to advance the care provided to patients in emergency departments, said in the next five years health professionals will only be able to offer people basic medical care under the current system.
Dr. O’Connor said cancer patients and the elderly will receive substandard care and those who require complex surgeries and life-lengthening treatment may be forced to look outside the Irish healthcare system to receive them.
“I think we’re going to get to the stage where patients are continuing to die on trolleys in corridors”, she said. “Doctors in all parts of the system are going to burn out and people are going to stay on waiting lists for electives longer and longer.”
Dr O’Connor noted that patients on waiting lists for elective surgeries, such as a tonsillectomy or hip replacement procedure, will eventually reach the stage where they cannot wait any longer and have to enter into the system as an emergency patient, causing more elective surgeries to be cancelled.
In one example from a major Irish hospital, in the first six months of 2019, 327 elective day case appointments were cancelled in St. Vincent’s hospital. A further 159 elective inpatient appointments were cancelled in the same period, according to figures released from the hospital to The College View.
This amounts to 486 elective care appointments cancelled in one hospital over a six-month period because the beds were being used for emergency care.
According to Dr O’Connor, when elective surgeries are cancelled, the system loses staff labour and resources.
She said: “When elective surgeries are cancelled, anaesthetists go home, surgeons go home, theatre nurses have nothing to do and the health sector doesn’t really have any ability to divert people at such short notice from one activity to another, so the man power that would usually go into running elective care is completely lost.”
This loss of vital resources results in elective surgeons being unable to train their doctors or reduce their waiting lists.
Dr O’Connor compares her current role within Blanchardstown emergency department to being “like the fire brigade, charging around putting out fires everywhere but no one is preventing fires from starting”.
Factor 2: Lack of Beds
One of the main reasons for the cancellation of elective surgeries is that when emergency surgeries come in, the patients occupy beds on elective wards while they recover from their operations, and the Irish healthcare system currently does not have enough beds to cater for both elective and emergency surgeries.
Since the 1980s Ireland has lost more than 25 percent of inpatient bed capacity despite a population increase of more than 1.4million, meaning that there are fewer beds available for those that require a period of recovery in hospital following treatment.
According to the Organisation for Economic Co-Operation and Development’s (OECD) most recent figures, Ireland has three beds for every 1,000 residents. In comparison, Germany has eight beds per 1,000 residents and Japan has 13.1 beds per 1,000 residents.
This shortage was reflected in the Mater Hospital in 2017 where emergency patients accounted for 56 per cent of patients in an elective surgery ward.
With this scenario repeated across the country, thousands of elective patients spend longer waiting for treatment and surgeries, further increasing waiting lists.
Factor 3: Consultant Shortage
The issue of lack of beds leading to patients on waiting lists is further exacerbated by a lack of fully trained consultants in Ireland.
The European average for consultants is 2.45 per 1,000 head of the population, but according to the latest health statistics report by the OECD, Ireland has only 1.44 per 1,000.
This leaves the Irish health system short over 500 consultants.
According to Dr. O’Connor, locum doctors – doctors hired in temporary positions – have to be brought in to fill these consultant positions. But, as many locums are not trained in that hospital or position, they often cannot reduce waiting lists as efficiently as a resident doctor.
She said: “We bring in locums to a hospital they don’t know, a patient cohort they have no experience in treating. They may or may not have worked in the specialty before and that has a huge impact on the efficiency and safety of patient care.
“They may not have worked at the level they’re working at before . . . so the amount of time and supervision that for me goes into keeping those doctors’ practice safe is an awful lot more than I would have to do on a doctor who has, let’s say, worked in my department before”, said Dr. O’Connor.
“That stretches me as a senior clinician even more and that makes things less safe”, she added.
Factor 4: Combined Elective and Emergency Care
As a solution to stresses on Ireland’s health system, some healthcare professionals have recommended that emergency and elective care be separated into different hospitals.
They argue that, if elective beds were not being taken up with emergency patients, then elective treatment would not be regularly cancelled and doctors would be able to reduce waiting lists.
The government itself recommended the separation of emergency and elective care under the 2017 SláinteCare report, which looked at ways to transform Ireland’s health and social care services.
The report suggested the introduction of three elective-only hospitals by 2027.
Researchers examined if such a separation would be effective. In one study, the Saolta University HealthCare Group, which provides acute and specialist hospital services to the West and North West of the country, examined the likely impact of establishing a Regional Elective Hospital in Galway.
The report concluded that a new elective hospital located on the Merlin Park site would significantly improve patient access to elective care by reducing waiting times and cancellations.
Researchers concluded the elective hospital would allow the Saolta Group to significantly increase the level of day surgery it provides and reduce length of stay for patients.
Separating acute and non-acute services through the development of a purpose-built elective facility would also greatly improve efficiency, the report found.
In addition, increasing capacity would enable Galway University Hospitals (GUH), in turn, to significantly reduce their waiting lists.
By segregating GUH’s elective capacity, it would ensure that all elective care would be scheduled, and not impacted by emergency or acute patients from across the Saolta region.
According to Dr. O’Connor, the separation of emergency and elective care will not just benefit the elective side of the hospital, as the emergency department is already acting as a safety net for the health sector.
She said: “If you haven’t got your appointments with your specialist, if you haven’t got your appointment for your scan…and you run into problems, you come to the emergency department, so we’re already filtering out the most urgent cases but we are under enormous pressure and we are really struggling”, she said.
While former President of the IMO Peadar Gillian agrees that the separation of elective and emergency care could be a solution for the HSE, he said that the change would have to be applied across the whole healthcare system to have a substantial impact.
Áine O’Boyle, Aoife O’Brien, Joy Nderitu and Roisin Phelan
Image Credit: Fennell Photography