Last month, a 79-year-old woman was experiencing a lot of pain. Living alone and being unable to drive, she called an ambulance. Four hours later, it arrived at her house in north Co Dublin. The woman, who is on a number of medications for various illnesses and uses a wheelchair, was brought to the hospital. Almost five hours later, she still had not been admitted.
Eventually, just before 1am, she and the son who was with her decided to leave. She would be more comfortable in her home, she decided, than sitting in a wheelchair in pain – particularly given the other people around her had been waiting for several hours longer than she had.
Her story is not unusual. Ireland is experiencing a growing and ageing population. With long waiting lists of more than 700,000 and significant overcrowding in emergency departments (EDs), concerns have been raised about how the country will cope with the health implications of these changing demographics, and the increased demand they will bring.
Between 2019 and 2024, the population grew by 422,000, with just under a third of this growth being people aged over 65. The number of people in the population aged 75 years or over increased by 26 per cent between these years.
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And this trajectory is expected to continue. According to modelling from State think-tank the Economic & Social Research Institute (ESRI), the population aged 80 and over is projected to increase by up to 94 per cent – or 135,000 – from 2015 to 2030.
This growing proportion of older people has resulted in increased and more complex health needs. Research from the Irish Longitudinal Study on Ageing (Tilda) found more than three quarters of adults in Ireland aged 58 and older have two or more medical conditions.
Findings from the same study found over-80s tend to visit GPs more often, their hospital stays tend to be longer and they use outpatient services less.
Prof Rose Anne Kenny, a professor in medical gerontology at Trinity College Dublin, and founding principal investigator of Tilda, says less than 10 per cent of people over 70 were not on any drug or diagnosed with some sort of disease.
“Most of it is manageable, but sometimes people present in crisis fashion. As a consequence, they are much more likely to present to the emergency department and will take longer to recover. There is an additional length of stay,” she says.
The challenges are to such a scale in Ireland and other countries that actually what we’ve got to do as well is double down on preventive care; helping people to live healthy lives
— Stephen Donnelly, Minister for Health
There is also a need to ensure doctors are educated in the specific needs of older patients, says Prof Kenny, who is also director of the falls and black-out unit at St James’s Hospital in Dublin.
Falls are a significant issue for older people, with 15 per cent of all emergency presentations in St James’s Hospital being due to falls and blackouts. Repeated falls can often result in fractures, particularly of the hip.
“When somebody starts to fall frequently, it is often indicative of an underlying condition that needs attention,” she says.
“In St James’s, we have placed geriatric consultants in the ED and so when people come in having fallen, they take them to a dedicated clinic space where there’s time to get detailed information.”
This, she says, has resulted in savings of €12 million per year, due to fewer individuals requiring admission to hospital.
Prof Kenny also says there is a need for new models of service that allow for the delivery of care in the community and at home.
[ Just how unsafe are emergency departments in Irish hospitals?Opens in new window ]
“Unless absolutely necessary, hospitals aren’t particularly good for older patients. Weakness of muscles accrues very quickly. In some cases, it can be almost impossible to discharge someone to home to live independently. That’s an extreme circumstance now, but it is not uncommon.”
Minister for Health Stephen Donnelly says growing capacity is one part of dealing with the changing population, but adds: “The challenges of that are to such a scale in Ireland and other countries that actually what we’ve got to do as well is double down on preventive care; helping people to live healthy lives.”
The ESRI conducted research on the impact the changing population will have on demand. By 2030, demand for public hospital services could increase by up to 37 per cent in the case of inpatient bed days and up to 30 per cent in the case of inpatient discharges, from a 2015 baseline, while demand for ED attendance is projected to increase by between 16 and 26 per cent.
The demand for long-term and intermediate care resident places is projected to increase by up to 54 per cent by 2030.
Chief executive of the Health Service Executive (HSE) Bernard Gloster is acutely aware of the pressure the ageing demographic will have on the State’s health services, and on its finances. In fact, he says we’re seeing it already: the “demographic pressure we anticipated has come earlier”.
“So in Ireland, we did a capacity review in 2018, we projected up to 2031. Everything we projected out to 2031 is nearly already here in terms of demand and age profiles and people and consequences and so on,” he says. “And that’s why you’re seeing 9 per cent more people turn up in emergency departments and so on.”
This year, given demand has been outstripping projections, the HSE revised its predictions. “And even that has outstripped us again,” he says.
Mr Gloster identifies the two main challenges to the health service as the ageing demographic and the prevalence of chronic disease.
He says it is well established that the population is getting older and people are living longer. However, he says, “because we’ve cracked the kind of length of life thing, we haven’t necessarily got the quality of it for everyone”.
One of the “enormous challenges” is frailty, which he says “costs money to respond to”.
Mr Gloster has announced his intention to stabilise the HSE’s deficit position by the end of 2025. However, he says that will “only hold for as long as in the years after there’s a realistic existing level of service funding put to that that recognises that demographic pressure”.
But it’s not just within the hospital system that the ageing demographic has an impact. Many general practices are no longer accepting new patients due to their lists being full. In a bid to address shortages, there is a record-high of 1,191 people now training as GPs, supported by Government funding.
There is a need to have a national conversation around sustainable provision. Because if a nursing home closes tomorrow, it’s unlikely a new one will be built
— Tadgh Daly, chief executive of Nursing Homes Ireland
Demand will also increase for homecare and long-term residential care. The number of homecare hours provided is rising, with Budget 2025 set to enable the delivery of 24 million home support hours to almost 60,000 people.
There are on average around 900 applications per month for the Fair Deal scheme – a Government programme that provides financial support for those in long-term nursing home care.
[ Homecare waiting lists worsening in rural areas, sector representatives sayOpens in new window ]
This number has remained relatively static, according to Tadgh Daly, chief executive of Nursing Homes Ireland, the national representative body for private and voluntary homes. Residents are coming in older as they want to live at home for as long as possible, which often increases the “complexity and dependency of their healthcare needs”, he says.
In recent years, a number of nursing homes have closed, which has resulted in geographic blackspots in which some older people find it difficult to access a nursing home bed in the community in which they live, Mr Daly adds.
“The absolute number of beds is not always the best barometer. The location and the types of beds are also important,” he says.
“There is a need to have a national conversation around sustainable provision. Because if a nursing home closes tomorrow, it’s unlikely a new one will be built. So It’s about having all of the services: day services, meals on wheels, home care and residential care.”
Mr Gloster says this is part of the reason why he believes the State’s “dependency” on private provision is too high.
“It’s too easy for a private provider to fall away, and then the State is the provider of last resort. That’s never good for people,” he says.
“So we will not be ready for that demographic unless we get to further catch up on the public provision we have, and we have a good public programme in place, but we need to get there more quickly.”
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