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Hospital EDs need more senior decision-makers to relieve blockages

Analysis: Major changes are needed, particularly at the worst-affected hospitals

Minister for Health Stephen Donnelly’s plan for a radical increase in the number of emergency-department (ED) consultants could have a significant impact on hospital overcrowding, if it is executed as planned.

The pressures on EDs, which have been severe for years, are getting worse. The trolley crisis is now a year-round phenomenon. Attendances at EDs this year are at record levels.

At present, the average waiting time for admission to hospital from an ED is nearly 14 hours — and that’s for over-75s. The number of patients waiting in ED for more than 24 hours nearly trebled in the first five months of the year, compared with the same period in 2021.

It is clear major changes are needed, particularly at the worst-affected hospitals — Limerick, Galway, Cork, Letterkenny and a few others.


The overcrowding crisis in our hospitals is a bunch of problems wrapped into one: too many patients descending on EDs; a lack of alternative treatment options; too few staff, especially those capable or making authoritative clinical decisions; too few beds in hospitals once people are admitted; and too few options for well patients to be discharged, thereby freeing up these beds.

A focus on trolley numbers tends to site the problems in the EDs themselves, though often the blockages are occurring in the rest of the hospital and in stepdown care.

Nonetheless, solutions will not be found for these problems without reforming the way EDs are staffed and run.

Compared with similar countries, Ireland has too few doctors and far too few senior doctors. Our health system is heavily reliant on temporary locum staff on short-term contracts. We also have high rate of medical litigation.

The result is cautious, even defensive medicine. Some patients are admitted unnecessarily, others are sent for unnecessary tests, while others again spend longer than is necessary in hospital, because the real decisions have to be made by consultants and, at times, these are as rare as hens’ teeth.

There are 29 hospitals offering ED services in the State on a 24/7 basis, along with 11 injury units. As of two years ago nine of the 29 EDs did not have a consultant available at all times. Some are running a round-the-clock service with a handful of consultants. Unsurprisingly, admission rates can approach 100 per cent at night in some smaller units which have no consultants present at this time.

There are other problems. Emergency rooms have become the default option for accessing urgent hospital treatment, even if the patients might be better off elsewhere.

We have too many EDs anyway, so resources and staff are spread too thinly. But the decade-long controversy over closing the State’s smallest ED in Navan shows how difficult reorganisation can be.

It can take up to two years to recruit a consultant, so recruiting more staff would not normally be a short-term fix. However, Mr Donnelly is pressing for the appointment of more ED consultants to be fast-tracked. The Health Service Executive has been asked to cut out some of the layers in the application process so that final decisions can be made more quickly.

Unlike other specialities, ED consultants tend not to do much private medicine, so they are more likely to be attracted by a public-only work contract. Efforts are already under way within the speciality to interest Irish-trained specialists in ED medicine who are currently working overseas but may be interested in returning home.

However, it is accepted that, initially at least, a proportion of the new posts will have to be filled on a locum basis.