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State of Emergency

Easy as ABC? Solving Ireland's lethal Acute Bed Capacity crisis

Inpatient bed numbers among lowest in EU and nowhere near demand predicted by capacity reviews.

Noteworthy - The Good Information Project. Overcrowding and our creaking hospital system are constantly in the news. But why do hundreds of people continue to die? Inpatient bed numbers among lowest in EU and nowhere near demand predicted by capacity reviews. Full capacity protocol activated weekly at University Hospital Limerick, often resulting in cancelled ops. Nurse: For the patients, it’s absolutely horrendous. Your dignity is left at the door.

“YOU SEE SOMEBODY who looks just like your mother, your daughter, your favourite uncle. They don’t even have a trolley and they’re in terrible distress. That distress is physical, spiritual, mental. Every molecule is aching with distress.

“And you’re aching… you literally feel everybody’s pain in front of you. The pain is so vast that you kind of implode. You get dreadful moral distress that comes from not being able to give the kindness, the compassion that you are bursting to deliver.”

That’s what upsets Professor Chris Luke the most when it comes to overcrowding in our hospitals. As a consultant in emergency medicine, he has worked for more than 35 years on the frontlines and during Covid came out of retirement to work once again on the hospital floor.

These conditions “have been in place for 50 years”, he explained. Government after government have “turned a blind eye” to the health service and this continues to impact everybody, with overcrowding not only “deeply unpleasant” but also lethal for patients.

The longer you wait in an emergency department (ED), the higher your risk of avoidable harm and death. Luke said that in Ireland, “we estimate that hundreds of people in Ireland are dying every year” because of overcrowding.

Recent UK research showed long ED wait times cause thousands of excess deaths – significantly more than road traffic collisions. Another study found that an extra death occurs for every 82 admitted patients whose transfer to a bed is delayed beyond six to eight hours from ED arrival.

The average ED attendance is now longer than this – at 8.5 hours. That figure was stated by the HSE’s Anne O’Connor at a Joint Oireachtas Health Committee last week. However, emergency medicine consultant Dr Mick Molloy told us this is skewed downwards by minor injuries that can be treated quickly, with sicker patients waiting far longer.

The HSE has a target for 70% of ED patients to be either discharged or admitted within six hours. The Department of Health is “working closely with the HSE to improve ED performance and achieve the targets”, according to a spokesperson. Over 70% of hospitals failed to meet this target in their latest published Management Data Report

Person in scrubs walking down a hospital corridor which has a mental container on wheels to its side. Noteworthy visited University Hospital Limerick last week where people on trolleys recently hit record levels Don Moloney Don Moloney

None of this will be a surprise to readers. Overcrowding and our creaking hospital system are constantly in the news. But why do hundreds of people continue to die? As campaigner Marie McMahon from Clare put it to us: “Why is there no anger?”

Over the past number of weeks, as part of The Good Information Project, investigative platform Noteworthy teamed up with The Journal to attempt to answer this question. We found: 

  • Inpatient bed numbers nowhere near demand predicted by capacity reviews, with increases in recent years only now bringing beds back to their 2009 level
  • Ireland having one of the lowest inpatient and ICU bed capacity across the EU but sharing issues such as staff shortages with many other European countries
  • Frontline workers demoralised and exhausted, with no hospital group meeting its 2021 target for absenteeism
  • Overall INMO trolley numbers rising rapidly, with the West most impacted
  • Emergency consultants calling on modular buildings to be used as a stopgap

The investigation team also travelled to University Hospital Limerick (UHL) which consistently has the highest number of people on trolleys and can reveal: 

  • Hospital management awaiting feedback from HSE’s “expert team” on refined plan submitted last week but not aware if team will conduct an on-site review 
  • Deloitte conducting an “almost complete” report commissioned by hospital CEO
  • Campaigners feeling “utterly failed” by politicians, government and the health service, with some “afraid to attend” due to overcrowding
  • Management saying the full capacity protocol is activated every week often resulting in cancelled elective surgery, with low bed capacity the underlying issue 

THE PROBLEM: ‘Everybody has failed us’

Ann Noonan wearing a white top standing at a podium speaking at an INMO event. Staff are demoralised and feel they are failing the patient, according to nurse Ann Noonan INMO INMO

“For the patients, it’s absolutely horrendous,” Ann Noonan, Irish Nurses and Midwives Organisation (INMO) representative for UHL told Noteworthy. “Your dignity is left at the door and that shouldn’t be.”

The INMO’s Trolley and Ward Watch figures has been increasing back to pre-pandemic levels this year, with UHL numbers breaking all records when it reached 126 on 21 April, equivalent to almost a quarter of the entire hospital inpatient bed capacity.

“These are not people waiting to be seen. They are people who have been seen, assessed and either waiting for diagnosis or deemed that it’s necessary to be admitted to hospital for their care.”

Noonan also explained that their ‘Ward Watch’ figures which they have collected since 2013 take into account trolleys and additional patients placed on wards.

The INMO provided Noteworthy with over 130,000 rows of data from hospitals around Ireland from January 2008 to present. From this, it is clear that overall numbers were trending up before the pandemic, when they dropped dramatically, but since then have climbed steadily.

“At the start of the pandemic, all outpatient and elective work was cancelled.” With people in lockdown, there was also “nothing happening” which Noonan said meant less injuries from activities. This also meant more availability of inpatient beds so less backlog in the ED.

Overcrowding at UHL has hit the headlines repeatedly this year with numerous people speaking out about poor experiences at the hospital.

However, there is also ongoing overcrowding in many other hospitals along the West of Ireland with Cork, Galway, Sligo and Letterkenny University Hospital having the next highest trolley numbers on average this year.

Consultant Molloy explained that for emergencies that occur in Dublin, there is a huge choice of public and private care, but in many other parts of Ireland “there is only one place you can go and yet the bed capacity is very limited”.

The high numbers at UHL this year are upsetting to campaigner Marie McMahon whose husband Tommy Wynne died after spending “about 37 hours on a trolley” in the hospital’s new ED four years ago. Between 50 and 60 others were waiting alongside Tommy on the days he was there.

“It was a shock. You couldn’t move for trolleys. They were all around the corridors and every corridor was full.” Yet, double that number of people were on trolleys last month, despite an extra 98 inpatient beds having been built at the hospital since.

“I’m looking at the anger at other issues” such as the maternity hospital and the cervical cancer scandal “where everybody was galvanised and all the politicians were out and rightly so”. However, she added:  

Why, when people are sick and dying on trolleys, why is there no anger? Everybody has failed us.  

McMahon said her husband “wouldn’t want to die for nothing” and has since campaigned for better hospital facilities as part of the Midwest Hospital Campaign.

UL Hospitals Group released the following statement to Noteworthy: “A complaint into Mr Wynne’s care has been investigated by UL Hospitals Group and a report issued to the family. We have apologised to Mr Wynne’s loved ones for the length of the wait time in ED and for poor communication during his care. For reasons of patient confidentiality, it would be inappropriate to comment further on this matter. We would like to express our sympathies to Mr Wynne’s family on their great loss.”

THE IMPACT: ‘I have apologised more times…’

In addition to talking to campaigners and staff at UHL, last week when 79 people were on trolleys, Noteworthy paid a visit to the hospital and spoke to the executive team as well as bed management to ask why – with extra beds and staff in recent years – it appears overcrowding is worse than ever.

When asked about the situation in UHL, UL Hospitals Group Chief Clinical Director Professor Brian Lenehan, said that “overcrowded and crisis are very emotive words”, and added:

“The facts of the matter are that it is the second busiest emergency department in the country and only has bed capacity of 530, which is the lowest of all the model 4s” – university teaching hospitals. 

Prof Brian Lenehan - wearing a grey suit and purple tie - and Noreen Spillane - wearing a white top and navy suit jacket, standing in front of an ambulance at the emergency department. Prof Brian Lenehan - Chief Clinical Director and Noreen Spillane - Chief Operations Officer of UL Hospitals Group Maria Delaney Maria Delaney

Coming back to the fundamentals, “it’s demand capacity and resource from a [staffing] point of view. Lenehan said that “it sounds simple, but that’s what it is” and “that is known” at every grade and discipline, throughout the HSE, “right the way up to the top, including the minister”.

This needs to include capacity for both unscheduled or emergency care as well as scheduled care. “Over the past number of years, there has been a lot of support, but the Midwest has chronically been underfunded.”

The tender for a contract to build a 96-bed block is gone to the HSE board for approval and once started, it will take about 18 months to build, according to hospital management. But around half of these are replacements of beds coming from older wards. A second 96-bed block is also planned.

“We’re still, by our most recent calculations, 205 beds short of the capacity we need now in 2022,” Lenehan told Noteworthy, who added that the interview was taking place on the proposed site for the maternity hospital with a new outpatients across the road. “The vision is all there but that is billions of Euro.”

Disappointment with Minister’s decision

In addition, he said that they “desperately need” a seperate 150- to 200-bed facility “with a scheduled care focus” in the region. Though he had “no strong views” on where it could be built, he said the sites at Ennis, Nenagh and St John’s – currently model 2 hospitals – would have challenges “to build infrastructure to that level”.

Fianna Fáil TD Willie O’Dea recently in the Dáil asked the Taoiseach to consider establishing an elective-only hospital at St John’s Hospital in Limerick. He said it “has the space, expertise and track record to make this an outstanding success”.

The Taoiseach said that his view for “elective hospitals” was if there is “State land, we should get on with it”.

The group’s Chief Operations Officer and Deputy CEO Noreen Spillane said they were disappointed when Health Minister Stephen Donnelly didn’t announce the development of an elective hospital in Limerick – instead they are to be developed in Cork, Galway and Dublin

We need a facility where we can do our elective work that is not going to be cancelled all the time. Within the resources we have we work very hard to get our throughput of patients. But one group of patients that are continuously disenfranchised and continuously discommoded, [are] patients who are scheduled for care.

In the latest published HSE Management Data Report, UHL had one of the lowest number of acute bed days lost through delayed transfers of care compared to other model 4 hospitals and was better than target when it came to length of bed stay.

However, Spillane said that a full capacity protocol – allowing additional temporary beds on wards – is being used “nearly every week” which “has a huge impact on” scheduled care.

“It’s not the care that we would want to give our patients… When we built our new emergency department, we never said it would solve the crowding problem because we didn’t get the beds at the time, but… we never envisaged the numbers attending would continue to rise in such high numbers.”  

Hospital management criticised

Of the nine model 4 hospitals, UHL had the highest number of ED presentations per inpatient beds and highest percentage of people waiting 24 hours or more in the same Management Data Report. It also had the third highest amount of people leave before completion of treatment.

Recent figures released through a PQ by Sinn Féin’s David Cullinane also showed it had the third highest number of people aged 75 or more waiting more than 24 hours in ED during February and March this year.

“I have apologised more times… than I can count at this stage for cancellations, curtailments and patients finding themselves on trolleys, unfortunately, by necessity due to the bed capacity issues,” said Lenehan.

“We have to balance the risk of the patient in the emergency department awaiting a bed with the patient who is home also awaiting a bed. And you only have the same bed.”

Marie McMahon told Noteworthy that “there’s an issue” with hospital management. She called on management to “come out and acknowledge this” and “don’t fob people off”. McMahon was one of a number of people who criticised management when speaking to Noteworthy.

Local Sinn Féin TD Maurice Quinlivan also told Noteworthy that he “had an issue around management of the hospital, especially around UHL itself”.

When McMahon’s comments were put to him, Lenehan said: “I’m not a manager for the sake of managing. I’m a clinician in management, there to make a difference and a positive impact on patient care. But, when you look into what is good and what could be better in the Midwest, there is an awful lot of good. What could be better? It comes back to capacity and staffing.”

When it comes to staff, UHL nurse and INMO rep Ann Noonan said they are “really demoralised”, “firefighting” and “feel like they are failing patients”.

Though no hospital group met its 2021 target for absenteeism, UL Hospitals Group had the highest percentage absent at almost 8%. 

When asked if overcrowding was impacting this, Spillane said that “it’s difficult to know because Covid would have had a huge impact as well”. Though they had high numbers on Covid leave, she said they “do generally run higher than the national average with absenteeism” and added it is something they are addressing.

“When you have additional patients to look after, of course you are under pressure,” added Lenehan who said they have “very committed, hard working staff”.

The latest workforce report from March shows that UHL had the largest percentage increase in staff out of all model four hospitals with a 16% rise – over 500 work time equivalent staff – since December 2020.

“We had 1,200 new staff last year,” said Spillane, “which is a huge number to recruit into any one hospital group”.

Staff shortages in Nenagh Hospital resulted in the medical assessment unit being closed for a number of days last year. Lenehan said that they “have approved additional WTE” for Nenagh, with another consultant starting in the coming weeks and the fourth consultant post “to be advertised”. 

THE ACTION: ‘Emergency department is only a front door’

In recent weeks, to help tackle this overcrowding, Minister Donnelly asked the HSE to send an expert team to the hospital group.

COO Spillane told Noteworthy that they “only had an initial meeting” with this team on Friday 13 May where they were asked “to come up with a short-, medium- and long-term plan”.

She said that all other hospital groups have been asked to do the same plan. The team they met so far were made up of the “national acutes, national community and the SDU [Special Delivery Unit]“.

When asked if the expert team would be undertaking a review on site, Spillane said they “genuinely don’t know”.

She added that “they also had a call earlier this week” with the COO of the HSE Anne O’Connor as well as the national team “about what actions” the group could take locally and where they “need support”.

To date, the hospital group have submitted their plan, Spillane said, which was asked to be refined down as they had “lots of actions in there”. A revised plan was then submitted and they are “just waiting [for] feedback on that”.

Before this expert team was put in place, Spillane said that CEO of the group, Colette Cowen, had commissioned Deloitte to see if there is “anything else” that they “could be doing”. The hospital part of this report is “almost complete” so they’re moving to the community aspect next week, she added.

However, INMO rep Noonan felt that any investigation team “has to be independent”. Local TD Michael McNamara also felt this was necessary as it meant they were “able to make recommendations that might be politically unwelcome”.

Taking to the streets

One immediate action that the Midwest Hospital Campaign want put in place is the reopening of the three emergency departments at Ennis and Nenagh in Clare and St John’s Hospital in Limerick. These were downgraded around a decade ago and currently undertake acute medical assessments, elective surgery and have injury units.

Sinn Féin’s Quinlivan said that the huge numbers in UHL is not a surprise given these three EDs were closed without UHL being given the extra capacity needed.

However, Michael McNamara said that “the medical advice at the time was that there was an insufficient throughput of patients… to provide a safe A&E”. He said the local injuries units worked well.

Campaigners who spoke to Noteworthy felt “utterly failed” by politicians, government and the health service, with some “afraid to attend” the hospital due to overcrowding. The campaign organised protests over the past two weeks to highlight the issue. 

Photo of a hospital corridor with text overlay - Hospital Type - Model 1 Community / District, Model 2 Outpatients, medical inpatients and assessment, local injuries unit, Model 3 acute medical and surgical, emergency and intensive care, model 4 university teaching hospitals, higher intensive care. Photo - Don Moloney Photo - Don Moloney

The distance from the emergency department for some people in the region was also raised, with some in rural Clare living over 90 minutes from UHL. The hospital group is also the only one with just one emergency department, with all other groups having at least four model 3 and 4 hospitals that handle emergency and acute care.

One of the organisers, Noeleen Moran, said their “campaign is just kicking off”. She said the “only solution is to reverse the closures”. In addition to the protests, local councillors are putting forward a motion for the three EDs to reopen at a Regional Health Forum taking place later today.

Spillane will be attending this Forum and said: “At the moment, we can’t support that.” She added that campaigners were “focused” on this but “having another emergency department with no beds is going to have the very same outputs”.

“The emergency department is only a front door and I’m not sure that people understand that.” She said that “if somebody comes into the emergency department and they end up in a [resuscitation] department”, then cardiology, theatre and critical care back up may be needed. 

Our model 2 [hospitals] provide a vital service for the population of the Midwest. A lot of patients go through them for their day surgery, their local injury units… and that works really well.  

Chief Clinical Director Lenehan added that “everybody is very well intentioned when they’re campaigning and everybody believes what they campaigning for”.  

Disagreement between Department and HSE

Limerick was also included in the Independent Review of Unscheduled Care which was conducted before the pandemic by a team led by Professor Frank Keane, former president of the Royal College of Surgeons Ireland.

The review described UHL as “clearly under pressure” with staff describing it as “a good day” despite 40 patients waiting for admission. It found that none of the hospitals visited “appeared to provide safe and effective care” and identified 30 recommendations “to support improvements”. 

Anne O'Connor wearing a black top speaking at an event. The HSE's Anne O'Connor wrote that the unscheduled care review's publication 'no longer has relevance' Leon Farrell Leon Farrell

However, the HSE opted not to published the review when it was completed in 2020. Anne O’Connor wrote to the Department of Health that November – in a letter obtained by the Irish Patients Associated (IPA) through Freedom of Information (FOI) – and stated:

The HSE has taken a decision not to proceed to finalisation and publication of a report that no longer has relevance. 

The Department of Health (DOH) did not agree with that assessment by the HSE and, in another document obtained by the IPA, the DOH stated that “there are numerous references to patient safety… which raise questions that need to be addressed”. It continued:

It would be of value to the Department for the report to be finalised and for the HSE and individual sites to provide responses addressing the issues raised and the recommendations made.

When asked why the Department’s views differ from the HSE, a spokesperson told Noteworthy that “the Department is of the view that any review should be considered carefully in the context of ongoing planning such as in developing winter plans to ensure that relevant findings are incorporated as appropriate”.

After the IPA failed to obtain the report from the HSE, the DOH released it to them through FOI. The HSE’s stance on its publication was widely criticised when its release was publicised last month.

IPA chair Stephen McMahon, who is also on the Emergency Department Task Force, was concerned “that these are people in charge of developing policy and overseeing it with a fundamental difference of opinion about a very significant report”.

On this, consultant Chris Luke told Noteworthy he could not tell us “how upset and enraged” he was by the HSE stating the report was no longer relevant. He said he “was really wounded by that disclosure”.

“The health system is under enormous strain so the metrics on the dashboard are incredibly important. Please don’t tell me… it’s not really relevant that we’re still grossly overwhelmed… that we have collective mistreatment of our patients.” He added: 

We’re sending desperate dispatches from the frontline and being told from HQ that everything is tickety boo. 

When asked about the report, UHL’s Spillane said that they “had never seen a draft until it was released under FOI”. They have reviewed it and “have been asked to report back on factual accuracy”.

She added that “it’s quite an old report… so quite a lot has been implemented”. They are currently putting together a quality improvement plan “to reflect what has been done and what needs to be done further”.

The report was “the treatment” for the issues linked to overcrowding that are always talked about, according to the IPA’s McMahon. “We’re talking about symptoms ad nauseam and very little about what needs to be done.”

Stephen McMahon wearing a navy suit and pink tie walking down stone steps. Stephen McMahon from the Irish Patients' Association said better governance is needed to tackle overcrowding Sam Boal Sam Boal

THE SOLUTION: ‘As simple as A, B, C – acute bed capacity’

Every expert in emergency medicine or bed management, that talked to Noteworthy, spoke of the importance of patient movement – or flow – through hospitals and how overcrowding results when patients become stuck.

“An emergency department only functions if there is flow two ways – in and out,” explained consultant Molloy who is a member of the IMO Consultant Committee. “The ‘out’ can be into a bed in the hospital or back to their homes if they don’t need to be admitted.”

When emergency departments become full, it not only impacts the people lying on trolleys or sitting on chairs in “inhumane” conditions “where the lights never go off and you can’t sleep”, but Molloy said “the real problem” is that overcrowding “reflects backwards to the person waiting to come in and be assessed”.

The result? Ambulances piling up outside with EDs, longer call-out times for those who need an ambulance, longer waits at home for admission and very often the implementation of full capacity protocol which allows extra temporary beds to be placed on wards.

All of the healthcare workers that spoke to the investigation team said that the overarching issue causing overcrowding was lack of inpatient bed capacity. Molloy put it best when he said that the solution was “as simple as A, B, C – acute bed capacity”.

Noteworthy analysed acute bed capacity in Ireland over the past 40 years and found that despite increases in recent years, bed numbers are only now getting back to 2009 levels. However, during that time our population has grown by over 550,000.

Thousands of beds not delivered

A capacity review conducted in 2002 during Michéal Martin’s tenure as Minister for Health found that inpatient beds had dropped by about 6,000 over 20 years from 1980 to 2000, despite an increase of almost 60% in hospital activity, excluding outpatients.

It also stated that “bed occupancy levels are unacceptably high in the major hospitals”, with this ranging from 85% – the internally recognised measure of full occupancy – to 123%.

At that time – two decades ago – the review recommended that over 4,300 (gross) extra beds would be required by 2011. It also included a more conservative (net) figure of just over 2,800 which was dependent on strategies such as a reduction in delayed discharges being implemented – which would “require significant investment” in long-term care, nursing home, rehab and community support services.

On foot of this, the Government committed “to provide for an additional 3,000 acute hospital beds by 2011″.

Instead, by 2011 a drop of over 1,100 more inpatient beds had occurred. They continued to drop until the following year – 2012 – when they reached their lowest point at under 10,400 beds.

Since then, just over 1,000 have been added back into the system, meaning bed numbers have not as yet been restored to the starting point of this 20-year-old report.

A new capacity review was conducted in 2018 which also stated “occupancy levels across the acute hospital system in Ireland are far in excess of international norms” – running close to “100% across the system”, leading to compromised patient safety and the spread of healthcare associated infections. It stated: 

To reach international standards of bed occupancy would see the need for an immediate injection of the equivalent of an additional 1,260 beds in the system. 

Since then, 500 beds have been added. The review added that “in practice, an increment in capacity is likely” with a mix of hospitals beds and other measures such as residential care and enhanced primary care. 

It also estimated 16,300 (gross) beds would be needed in 2031, though reduced this to 12,600 (net) if reforms including healthy living, enhanced community care and patient flow are also implemented.

Given a recent PQ response showed that there were just over 11,350 inpatient beds in January 2022, that is between 1,200 and 4,950 extra needed by 2031. If the health service continues at last year’s pace which saw a 1.7% increase, Noteworthy calculated that an extra 1,800 beds will be delivered.

Noteworthy asked the Department of Health what it is doing to address overcrowding, particularly in the West. A spokesperson stated that “the Government provided additional investment of €1.1bn in budget 2021 to expand capacity, increase services and support reform”.

“This level of investment is being maintained in budget 2022″ and “a further €77 million has been invested in the 2021/22 Winter Plan”.

However, the spokesperson added that “allocation of funding to specific Hospital Groups and Community Healthcare Organisations is an operational matter under the remit of the HSE”.

When this was put to the HSE, along with a number of other queries, Noteworthy did not receive a response in time for publication.

Beyond capacity – How Europe fares

However, not all agree that beds should be blamed. “Capacity, capacity, capacity… that’s the litany,” the Irish Patients’ Association’s McMahon told Noteworthy. “We’re saying that even with the capacity, you can do better.”

With Ireland consistently near the bottom of the EU when it comes to total as well as acute hospital beds per 1,000 population, Noteworthy spoke to Juliane Winkelmann from the European Observatory on Health Systems and Policies to find out how other countries fare across the continent – given most had higher bed numbers.

Along with her colleagues, she published research recently on the pandemic response and found throughout Europe, hospitals were required to postpone elective treatments to free up hospital beds.

However, another study that Winkelmann co-authored found that “in many European countries, the capacity constraints in ICU wards” for Covid care were “caused by staff shortages and insufficient skill mix rather than bed shortages”.

In Belgium, the Czech Republic and Germany, an increase in ICU beds “proved difficult”, according to this research, “as there was a lack of nurses with ICU expertise and the ICU workforce already faced a high workload”.

Winkelmann is based in Berlin University of Technology and is very familiar with the German health system – one which spends the most on health and has the highest hospital beds per capita in the EU.

“We have more than 2,100 hospitals, with the city of Berlin having more than 70.” This is a result of “huge investment in hospital infrastructure in the 70s” and “there’s a political decision to keep hospitals open in rural areas to ensure access to beds and emergency care”. 

Now it’s really difficult to drive this back, to reinvest and shape the hospital sector more efficiently. 

However, Germany’s high number of hospital beds (7.9 per 1,000 population in 2019 compared to Ireland’s 2.9) results in low staff per bed ratio, according to the latest OECD country health profile. It’s nurse to bed ratio is in fact one of the lowest in the EU. That is despite it having comparatively high numbers of doctors and nurses. 

Julianne Winkelmann wearing a green top and sitting at a desk at an event with European Commission signs in the background. Julianne Winkelmann found that staff shortages caused capacity constraints rather than beds in some countries EU zu Lëtzebuerg EU zu Lëtzebuerg

Unlike our two-tiered health system, Germany has one of the oldest social health insurance systems in the world, providing nearly universal health coverage.

However, Winkelmann told Noteworthy that the “setup of the financing of different procedures creates an overprovision of hospital care”.

She also said that “as with many other European countries, there are too many people arriving at emergency departments, with a share of these hospitalised when it is not always necessary”.

Though not as serious a problem as in Ireland, Winkelmann said there is overcrowding in their EDs with “people waiting for hours to get treated” and people going there when they “do not really need it”.

People also “stay longer in hospitals” with the transition to “long-term care facilities not always working well”. All problems very familiar to those in the Irish system.

The ‘shrivelling’ of primary care

Presentations to ED without being referred by a GP account for over half of UHL’s ED patients, according to hospital management. Emergency consultant Prof Chris Luke said that “primary care shrivelling” due to the retirement of GPs will be “the final straw” when it comes to the trolley crisis.

That means that ED is becoming the main port of access for patients unable to either register with a GP or get access to one out of hours. Luke said that ‘accident and emergency’ was renamed to the ‘emergency department’ for a reason as they can’t be “casual”. 

He said it’s like going to the “butchers looking for a loaf of bread”, no matter how often you are told that the “bakery is next door”.

So even though it says emergency department, with big red signs on the outside, people come in huge numbers with non-emergency issues because they can’t get hold of another access route.

Campaigners and politicians that Noteworthy spoke to said that access to GPs in the Midwest was compounding problems at UHL. 

Shannondoc – the out of hours GP service – “has been scaled back”, explained Noeleen Moran from the Midwest Hospital Campaign, with a number of centres closing in 2020.

“The HSE are constantly advertising in local media telling us to use alternatives, that the hospital is too busy. But what alternatives?”

In a PQ response, the HSE’s head of service for primary care said that “an enhanced model of care has been in operation since March 2020″ with the mobile doctors being introduced which “has ensured that all areas in the Midwest are adequately covered”.

However, Marie McMahon who lives in West Clare said that “if you have to wait” for a GP to travel there from elsewhere in Clare or a neighbouring county, “you’re talking maybe two and a half hours” or “your other choice is to go to UHL”.

Sláintecare should help with many of these issues that are currently feeding into the problem of overcrowding.

It’s “all about getting you care when you need it,” explained Trinity College’s Professor Steve Thomas, who lead the technical team for Sláintecare. “So you don’t need to have private insurance to buy faster access into the care that they need.” 

In addition to an increased focus on primary and community care, it also “expands the number of consultants” alongside public beds. 

It is about reinvigorating the public system so that you have the extra capacity, more accountability, that the care that doesn’t need to be done in hospitals can be done outside, which means that people won’t have to wait as long for the care that does need to be in hospitals.  

Tina Fitzgerald wearing a black pattern shirt and Linda Mullane wearing a white top and black jacket, standing in front of UHL. Tina Fitzgerald, Head of Unscheduled Care, and Linda Mullane, Head of Bed Management at UHL Don Moloney Don Moloney

Diverting patients on other pathways

One initiative implemented in recent years in UHL to address overcrowding is a “bed bureau” – a call centre to link GPs to hospital services, Tina Fitzgerald, Head of Unscheduled Care told Noteworthy.

Health complaints that come in vary but during Covid, breathing and cardiac issues were common. Appointments are booked within 48 hours, according to a staff member.

When GPs call, the team can log patient details on a central IT system and book a slot in either UHL’s acute medical assessment unit or one of the medical assessment units (MAUs) in Ennis, Nenagh or St John’s.

This means that “people who need a medical or surgical assessment don’t need to have it done in ED”.

Another admission pathway that they have examined is scheduled surgery, with preoperative assessments done in advance, meaning that patients “come in hitting the ground running for surgery”, explained Linda Mullane, Head of Bed Management.

They are also looking to other hospitals which have reduced trolley numbers in recent years. One initiative they hope to roll out soon is Pathfinder which a recent study stated is “improving access to alternative care pathways in the Beaumont Hospital catchment area”.

A team of an advanced paramedic and either an occupational therapist or physiotherapist is activated in the event of certain non-life-threatening calls by older people to emergency services. Instead of always bringing patients to EDs, this team has the option of treating them at home.

Two large rectangular buildings with numerous windows - a dark grey one in the foreground and white building in the back. Recently built 60-unit bed block (white building) at UHL Don Moloney Don Moloney

Placing value on life

However, as patients and staff wait for the rollout of plans and promises, emergency consultant Dr Mick Molloy talked about the practical implications of overcrowding, in particular at night in hospitals when access to certain basic services such as scans or transport as well as newer initiatives such as Pathfinder are not available.

With no trolleys to lie on, “you can’t lie somebody down on a floor if you need to examine their tummy”. Without the privacy of curtains, “you can’t undress them in a corridor if you need to examine their chest properly”.

“This is not rocket science,” he added. With over half of the doctors working in his emergency department leaving in the coming months “to work in other areas where there’s not as much pressure”, Molloy proposed that “the only solution in the very short term” is modular buildings.

Fellow emergency consultant Prof Chris Luke also suggested that portacabins be used if necessary. “Yes, it’s inefficient financially,” Molloy said, “but it is necessary”.

“We have had a requirement for that extra capacity for well over 20 years and it hasn’t been addressed.” These modular builds would quickly tackle this “pending a longer term rebuild of all these facilities”.

Molloy asked how much value was being placed on a life and used an analogy of when, in the early 70s, the Ford Pinto hit the streets with a letal safety fault that resulted in a higher risk of exploding when rear-ended.

The company produced a cost-benefit analysis as part of its lobbying efforts which argued against an $11-per-car change that would prevent 180 burn deaths a year.

“We do not want to be in that boat here, in the emergency departments,” the consultant explained. “We know there are deaths arising because people spend too long on trolleys.” 

A hospital trolley with metal bars has a mattress with a white sheet and pillow on top. A heart electrocardiogram (ECG) reading, with lines on the heart beats, is in the background.

This investigation was proposed and part-funded by readers of Noteworthy, the investigative journalism platform from The Journal, and carried out by Maria Delaney.

This work is also co-funded by Journal Media and a grant programme from the European Parliament. Any opinions or conclusions expressed in this work is the author’s own. The European Parliament has no involvement in nor responsibility for the editorial content published by the project. For more information, see here.

The Good Information Project and Noteworthy logos with an image of a person on a stretcher being looked after by two healthcare workers.

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