They are are called "bed blockers" as if they are to blame for a healthcare system which fails older people who are ill. Elaine Edwards reports
Chronic overcrowding in accident and emergency (A&E) units has almost reached the stage where it is no longer news, sadly for those who find themselves waiting endlessly on a trolley and for those who work amid the chaos.
A&E congestion, particularly in Dublin's acute hospitals, has been unfairly blamed on one major factor: so-called bed blockers. It's a insensitive and bureaucratic way to describe people who are, in theory, ready for discharge from an acute bed, but who need a different model of care.
Around 300 such people are in acute beds in the Eastern Regional Health Authority (ERHA) area's hospitals on any given day - are mostly, but not exclusively, older people, although among them are also other chronically ill patients such as those needing rehab beds.
They include chronically ill people such as stroke patients or people suffering from dementia.
Geriatricians trying to source long-term beds for their patients say the number of beds at their disposal has effectively been reduced year after year. In one acute hospital alone this has effectively resulted in around 100 elderly patients waiting for long-term beds, when previously the figure would have been closer to 20.
One geriatrician who does not wish to be identified says things have worsened in the past year since the cap on public service staffing was introduced and the system where the health boards paid for contract beds in nursing homes also came to an end and was replaced with a subvention. "The elderly extended care area had a lot of temporary staff with a high turnover, and these are the areas that are most vulnerable to cuts," he says, describing the situation that has now emerged as "almost grossly unethical".
"We have patients over a year waiting for beds. It's a disgraceful situation and it's disgraceful the number of people who are being cancelled for surgery.
" I know one anaesthetist who says he hasn't had a full list for two years. There is massive pressure on our colleagues, who are also under great distress at this situation. It's very frustrating for us and very frustrating for them."
And very frustrating for many thousands of others. Behind every person "inappropriately" placed in an acute hospital bed is a family, often frantically trying to find out how the system can work best for their relative, worrying how to fund the cost of long-term care, or wondering if they can cope with caring for their loved one at home.
Some of the State's leading experts in the care of older people say the situation long ago reached crisis point. Nearly one in four - 23.9 per cent - of older people in need of long-term beds will die in hospital while they wait.
Groups representing the interests of older people understandably dislike the crass "bed blockers" term, preferring the phrase "inappropriately placed".
Paul Murray of Age Action Ireland says: "We object to it because it suggests that it's younger people whose entry into hospital is being blocked by older people." He points out that many older people having elective surgery also can't get a hospital bed because of the logjam.
But he asks the question every person who has been at the wrong end of the hospital system wants answered: "What kind of society tolerates a situation where 10 patients over 80 have to wait many hours on trolleys and chairs in the A&E department of a major Dublin hospital?"
He says the demands of older people on the health system should not be used "however unintentionally, as an excuse for the current A&E mess". Older people are entitled to hospital services, just like any other citizen, he says. They are not 'bed blockers', but people who need care and proper 'step-up' rather than 'step-down' facilities when they leave hospital.
There are often delays as families wait for assessment of their relative's needs and then for a means test to establish whether they will qualify for a health board subvention for a private nursing home bed. The most anyone will qualify for is up to €680 a week under the enhanced subvention. But the allowance can be as little as €114.30 or €190.50 per week under the regular subvention system.
There were inequities in the old system where, in theory, a wealthy person occupying an acute bed might not pay anything towards an expensive nursing home bed, while a less well-off person in an adjacent bed might have to sell assets to pay for their care.
This, according to the ERHA, was why it stopped the contract bed system last year - to ensure the system was "equitable, appropriate and effective".
But most people working in the area still see the whole area of who pays what for long-term care as a quagmire of anomaly and inequity.
And most also point out the absurdity of the relative cost of keeping someone in an acute bed compared to funding appropriate care at home or in a nursing home. Estimates start at around €6,000 per week for an acute bed, compared to around €650 to €800 for a nursing home bed.
Doctors feel the subvention system has slowed the system down to an almost unworkable point, especially since families must now search for a nursing home bed and then apply for an assessment and subvention. They are often in a dilemma, because they don't know what funding they will qualify for.
Dr Bernard Walsh, a member of the Irish Society of Physicians in Geriatric Medicine, estimates that around €3 million would cover the cost of appropriate placement for around 100 patients currently in acute beds in the Dublin hospitals.
"We \ no longer have ownership of the long-stay beds. It has paralysed the system and I think it's all unnecessary paralysis that would be a straightforward problem to address."
The problem in Dublin is, generally, not mirrored in other health board regions, but some fear the difficulties now seen in Dublin will eventually be replicated elsewhere because beds are slipping out of the system.
The Eastern Regional Health Authority will spend around €70 million this year on around 3,000 beds in private nursing homes and on care subvention, in addition to 2,260 beds in public and long-stay units.
Even while it has "targeted significant additional resources" at community services in recent years - all welcomed by the geriatricians - the health board acknowledges a shortfall in the stock of public nursing home beds and attributes it, in part, to the closure of many beds during the 1980s.