The history of the Irish health service is a long litany of glittering promises and famous last words. Bold visions and big ideas arrive in a flurry of flashing lights and are then promptly abandoned, forgotten on a trolley in an overcrowded emergency department. Announcing the official opening of the new emergency department at University Hospital Limerick (UHL) in 2017, then-health minister Simon Harris enthused about the “safe, modern, fit-for-purpose facilities” which would preserve the “privacy and dignity” of patients. Less than six years on, the reputation of that “high quality, comfortable” emergency department is characterised by one of its own consultants on national radio as “a national basket case”.
That consultant, Prof Declan Lyons, was a group of 87 from UHL who warned in a letter to this newspaper that the emergency department is “overwhelmed with unacceptable pressure on all staff”. It sees 240 patients a day, 50 more than it was designed for. Patients end up on trolleys crammed together, with barely room for doctors, nurses or porters to sidle past.
Unacceptable. Overwhelmed. Inhumane. This is the language of another January in the Irish health system, words that have become detached from any meaning. “Overwhelmed” implies that this is an occasional phenomenon. “Unacceptable”, as Fintan O’Toole wrote in 2018, “is a big lie... if a situation is unacceptable, it does not become an annual event.” And yet here we are again.
But there is something different about this January, a faint glimmer of something that looks distinctly like the trace of a whisper of a chance that things might eventually get better.
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Not that you’d know it should you be unlucky enough to end up in one of the 14 hospitals which had 10 or more patients on trolleys last Monday. Cork University Hospital (CUH) had 16. Kerry, 21. Letterkenny, 22. Tallaght, 27. Galway, 34. In Limerick – which has particular issues going back to 2009, when emergency care services were withdrawn from smaller hospitals in the midwest – there were 14.
There are two pieces of evidence that suggest trolleys are not an unavoidable annual calamity, but the product of poor planning and a lack of imagination.
[ Hospital overcrowding: Is adding more beds really the solution?Opens in new window ]
[ Waterford hospital shows solution to the trolley crisis in plain sightOpens in new window ]
The first is that, in a handful of hospitals, things seem to be – not a phrase you hear often in relation to the health service – trundling along quite nicely. University Hospital Waterford (UHW) hasn’t, by its own count, had a patient on a trolley since March 2020. Things are not perfect; locally, there are mutterings about occasional long waits in the back of an ambulance or on a plastic chair. The short answer to how this elimination of patients on trolleys has been achieved is not extra resources – Waterford is lobbying just as hard for more of everything as everywhere else – but good management. Tullamore, Portlaoise and hospitals within the RSCI group have consistent low trolley numbers.
Immediate effect
The second piece of evidence is that when Health Minister Stephen Donnelly asked senior hospital staff to make themselves available at weekend to help ease the crisis in early January, groups representing consultants were unimpressed, pointing out that they routinely work extra hours. But the effect was immediate. The day before the appeal, there were 749 people on trolleys nationally. A week later there were 390.
Doctors say nothing will get better without more beds and more staff. This is reasonable. We have fewer hospital beds than most European countries, according to OECD data. Since 2020, 970 have been added, but more are needed, not just in hospitals but in step-down facilities.
Spending taxpayer’s money is something the health service is very good at. Changing work practices and culture is not
The staffing issue is more nuanced. We had four doctors per 1,000 people in 2021, placing us in the middle of the OECD league table, and the fourth-highest number of practising nurses. Since 2020, 18,000 healthcare workers have been recruited, according to figures recently provided in the Dáil. Among those are 2,947 health and social-care professionals and 1,840 doctors and dentists.
It’s still not enough. We need more hospital consultants. Ireland trains more doctors, but also more non-EU doctors, than other countries. Those non-EU trainees pay higher fees and frequently then leave. If universities were encouraged to offer more of their places to Irish or EU doctors, that would provide a better pipeline.
Then there’s the real challenge. Spending taxpayer’s money is something the health service is very good at. Changing work practices and culture is not. Donnelly may have raised hackles by asking senior medics to work weekends, when many already do and other hospitals simply don’t have the resources. But it is clear that hospitals are not generally operating at full tilt throughout the weekend, when 92 per cent of patients are discharged from acute hospitals between Monday and Friday, according to data previously provided by the Department of Health. Just 5 per cent of discharges happen on Saturday and 3 per cent on Sunday.
Yes, hospitals need more beds and more consultants. But they also need to do better with the resources they already have. And the ones that do should be rewarded
Regularly having senior decision-makers and other support staff in hospitals at weekends could mean patients are seen, treated and discharged faster. At peak times, some may even be available to help out in emergency departments. The new consultants contract, which is due to come into effect in February, will normalise the extended working day outside of on-call services, though it’s not yet known how many existing consultants will switch over to it.
Finally, nobody wants to talk about paying HSE staff more, but if we want the best people running our hospitals, managers need to be paid in line with what they could make in the private sector.
Yes, hospitals need more beds and more consultants. But they also need to do better with the resources they already have. And the ones that do should be rewarded. People are not the bed blockers in the system, processes are. Waterford’s trolley record is becoming an albatross around the neck of other hospitals because it shows what can be done.