The Irish population is increasing and people are living longer than ever before.
These two facts – and the data showing the extent of the increases in older age groups – point to the severe challenges facing a health system already struggling to cope with this January surge in viruses. They also point to growing pressures facing the health service in the winters ahead from a greying population.
Without significant investment in healthcare and radical changes in how people are cared for – in hospitals, in the community and at home – the challenge ahead will only become greater.
Even a record €23 billion health budget this year is proving insufficient to withstand the current pressures on the health system. Further investment will be required over the years and decades to come to cope with increased life expectancy and a growing and ageing population.
Census 2022 showed that the population of the State reached 5.1 million, passing five million for the first time since the Great Famine 172 years ago. Projections from the Central Statistics Office show that the population may increase by a further 929,000 by 2041.
The proportion of older people is set to increase significantly. Over the next two decades, the share of the population aged 65 and over is projected to rise from one in seven to one in five. The number of people aged 80 and over is projected to more than double, rising by almost 234,000, by 2041. The greatest proportional increase is forecast to be among people aged 85 and over.
A Department of Health report last month, Health in Ireland: Key Trends, found that the over-65 population had grown by 35 per cent over the past decade, more than three times the rate of growth in the overall population and well-above than the EU average of 17 per cent.
The report also found that the State had the highest life expectancy in the EU, at 82 years, which is continuing to increase. All this will mean more older people requiring more healthcare.
Successive governments are aware of the demographic challenges but official figures around Sláintecare, the 10-year plan aimed at overhauling the health system for a changing population, suggest they may be undershooting on the extent of the problem over the coming decades.
A 2018 review commissioned by the Department of Health on capacity in the health system up to 2031 forecast the population rising to 5.139 million in 2026. According to last year’s census, the population increased to just 17,000 shy of this number, suggesting a significant underestimate.
Where Sláintecare has estimated that 2,600 public hospital beds will be required in the years to 2027, the Economic Social and Research Institute (ESRI), the State’s think tank, has projected that at least 3,200 public hospital beds and perhaps as many 5,600 beds will be required by 2030.
Where Sláintecare suggested there needed to be an additional 20 per cent medical consultants by 2027 to cope with the healthcare needs of a larger and older population, the ESRI is projecting that between 30 and 39 per cent more medical staff will be required and, for nurses and midwives, an increased workforce of between 25 and 39 per cent will be needed.
In absolute terms, that amounts to between 2,575 and 3,236 additional medical staff and between 5,726 and 8,868 additional nurses and midwives by 2035. Those are significant increases at a time when the Health Service Executive fell well short on its own recruitment target last year.
“Even if Sláintecare is fully delivered, which is quite a big ‘if’ in itself, it looks like it would not actually be enough to cater for the demand that is coming down the tracks,” said Dr Brian Turner, a health economist and lecturer at University College Cork.
For years, the State benefited from having a relatively young population, he says, but now the population is ageing faster than the European average and anywhere else in Europe.
“So we are starting to lose that advantage quickly,” said Dr Turner.
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The changes will require significant increases on spending. The ESRI has projected expenditure on public acute hospital care of between €10.8 billion and €14.4 billion by 2035, compared with €5.9 billion in 2018, an annual increase of between 3.6 per cent and 5.4 per cent a year.
Funding the cost of looking after an older population poses further challenges.
Hospital overcrowding
Last month’s Health In Ireland report found there are currently five tax-contributing workers for every one person over 65; this will fall to three to one in 20 years’ time, putting increased financial pressure on the exchequer to fund increasing demands for health services.
Whether the coming winters will see similar hospital overcrowding to the current crisis will depend on whether this winter will be an outlier. Emergency departments have been hit this year with a “perfect storm” of a Covid-19 wave coming on top of a surge in cases of seasonal influenza, respiratory syncytial virus (RSV) and other respiratory illnesses.
The pressure this year may also be unique due to what medics describe as an accumulation of unrecognised disorders and illnesses such as cancer, heart disease and diabetes that went untreated during the Covid pandemic and when clinical presentations may have been overlooked.
This is compounded by some older, ill patients being reluctant to go to an emergency department because of record patient-on-trolley numbers and delays in admission. This means that older people presenting at hospital are sicker and their outcomes are poorer.
“I suspect we will probably be talking about hospital overcrowding next January and the January after. It is more a case of how bad is it going to be. Is it going to be worse than this year or is it going to be about the same or slightly better?” said Dr Turner.
As people get older, they will need more healthcare, putting pressure on hospitals and GPs.
The 2017 Sláintecare plan highlighted the increasingly challenging impact of chronic disease management on the health system from an ageing population. It noted that 65 per cent of those over 65 and four out of every 10 people over 85 have two or more chronic conditions.
“A lot more people will be living a lot longer with chronic illnesses, so the really acute, intensive healthcare might be delayed but the chronic stuff will last a lot longer. That will have an impact not just on the acute hospital system but particularly on primary care,” said Dr Turner.
Rose Anne Kenny, a professor of medical gerontology at Trinity College Dublin and St James’s Hospital in Dublin, said the current pressure on emergency departments in this winter surge of illness shows the need to future-proof health services to care for an older population and adopt the “outside-the-box” thinking that was shown by the health system in response to Covid-19.
“There are many, many elements of our health service that need a complete overhaul. We need a fresh look at how we are going to deliver services, where the pressure points are and new ways of looking at them,” she said.
Prof Kenny, the founding principal investigator of Ireland’s largest adult population study, The Irish Longitudinal Study on Ageing (Tilda), said the data collected through the TCD-based research programme has pointed to potential health solutions for an ageing population.
According to Tilda data, the over-80s tend to visit GPs more often and their hospital stays tend to be longer but they use outpatient services less. The reason, according to Prof Kenny, is that hospitals are not properly organised to treat older people with chronic conditions.
“The hospital systems are often very difficult to navigate in an outpatient setting; they are large and not geared to be one site, one stop,” said Prof Kenny, who is president of the Irish Gerontological Society.
“In other words, you go in with one disorder, say cardiac disease, and you are 80, so you have urinary problems and maybe some cognitive problems. In our current practice, you see a heart specialist and then a memory specialist, but that’s another visit, somewhere else in the hospital.
“The model of one size, one stop for older persons, which we are proposing has not established itself in Irish medicine yet.”
Data collected through Tilda has also helped inform the clinical work at the falls and blackout unit in St James’s Hospital, said Prof Kenny. Falls were leading to injuries resulting in people ending up in emergency departments. The unit aims to treat these patients, freeing up capacity in emergency departments. She estimates that the unit has saved €7 million a year, or the equivalent of an additional full medical ward, at a cost of €350,000 a year for the unit’s team.
She sees other solutions such as dedicated emergency departments for older people, similar to those in operation in parts of the United States, given that healthcare required for older people takes more time and different clinical skillsets compared with a general emergency department.
Increased and improved homecare for older people, which Prof Kenny said is “very undervalued and hugely badly paid”, could help people stay longer – and remain independent – in the community and avoid “a crisis point” in terms of illness, taking away some strain on the hospital system.
By way of example, she points to night services for older people in the UK where homecare providers can help an older person go to the toilet at night.
“That is often a reason for someone going into nursing homecare and yet it could so easily be managed in the community,” said Prof Kenny.
She believes better support services for older people in the community and “joined-up pathways” between community and hospital care should be considered as more of the Irish population grows older. Indeed, one of the objectives of the Sláintecare plan is for increased integration of acute hospital and community care.
Prof Kenny envisages both being “all one seamless service” for older people.
“This is something we have to look at very critically now because this will be an escalating issue year-on-year because of the ageing demographics.”
