Healthcare needs more than fiscal aspirins

Significant advances in health spending are traditionally announced in the pre-Budget Estimates, with the Budget itself generally not revealing what the Government intends to do about the sector in the year ahead.

This one might be different, though. Not only is there widespread and growing dissatisfaction with the health service but the Opposition parties are lining up with their own prescriptions for a very sick system.

The need to be seen to be doing something is growing by the day - yesterday's announcement of industrial action by nurses at Beaumont Hospital is another indication of the pressures on a system which looks like a ship that has sprung a great many leaks.

Of these, the one engaging the emotions of more and more people at the moment is chaos in casualty departments. One of the great modern ordeals is the extraordinary amount of time people spend in such departments awaiting admission to wards. Hours of waiting to see a doctor are followed by hours and hours of waiting for a bed.

Some hospitals are planning "major" and "minor" clinics to deal with this. The minor clinic - for those who probably should not have turned up in hospital in the first place - would be physically separated from the major clinic, which would be for those who really need hospital treatment.

It would seem to make sense that funding for such initiatives might be made available in the Budget (funding has already been authorised for St James's Hospital in Dublin) - though without extra beds and staff to back up these initiatives, their effect might well be limited.

Waiting lists are the great bugbears of the public health service. While the various waiting list initiatives of a succession of governments may be presumed to have had an effect, the fact remains that huge numbers of people remain stuck on waiting lists for many months and sometimes for years.

Do not be surprised if yet another waiting list initiative is announced in the Budget - but do not expect miracles either. Some 3,000 of the beds which were taken out of the system in the 1980s and early 1990s have not come back into it. Then there is the fact that we have too few nurses to staff the beds that are there already.

That there are wards closed and operations postponed because of a shortage of nurses is one of the most critical issues facing the health services. Nurse shortages impact on every other aspect of the service. The State can fund all the posts it likes for consultants but the process is fruitless if there are insufficient nurses to back them up.

The nurse shortage is a problem of the cities and most particularly of Dublin. Nurses always did move out of Dublin after they finished their training. But they are also moving out, if the analysis of their managers is correct, because of spiralling accommodation prices, difficulties in commuting to and from work, childcare problems, a perceived worsening in the quality of life in Dublin and an increase in the amount of aggravation they get from people in casualty departments.

Dublin is losing more nurses than it is recruiting. Outside Dublin, it is doctors and not nurses who are hard to get.

One of the proposed solutions to this is a Dublin allowance, whereby hospitals in the capital would pay a bonus to nurses for working there.

If this idea is palatable to the Government, it may well be included in some form in the Budget. But the idea also scares the Government. A Dublin allowance for nurses may well lead to demands from other public sector groups for the same. Other solutions have also been proposed: subsidised housing, childcare, and transport provided by hospitals, for instance. Again, some or all of this may be reflected in next week's Budget, though no hints have been given that this will be the case.

Also facing the health system is the six-monthly rush to get sufficient non-consultant hospital doctors for the various hospitals as half-year contracts end.

This mainly seems to affect hospitals outside the major cities. The problems of the health system are chronic: the cure will be lengthy and difficult. A great deal more is likely to be needed than whatever fiscal aspirins Mr McCreevy dispenses on Budget Day.