Second Opinion: Acute hospitals should be for acute cases only

More hospital beds will not solve the crisis in our emergency wards, says Jacky Jones

What can be done about the huge demand for acute hospital services? The clue is in the name. General practitioners need to stop referring people who do not have an acute illness to acute hospitals for treatment. Acute hospitals are no place for people with chronic diseases.

The only people who should be attending acute hospitals are those with health problems that can be fixed by acute hospital services. Everyone else should be treated by primary care teams or at home. This is not happening. Levels of activity in Irish acute hospitals are out of all proportion to population growth. The 2014 HSE Annual Report shows that nearly five million attended emergency or outpatient departments (EDs) that year, and more than 1.5 million were admitted. As of October 2015 almost 400,000 are waiting for outpatient appointments. These are colossal figures for a population of 4.6 million.

Commentators from different sectors, including consultants, and patient and union representatives, insist more beds, more nurses and more doctors are the only solutions to the overcrowding problem. They are wrong. A recent OECD report, Health at a Glance 2015, shows Ireland is doing quite well in relation to hospital beds and numbers of doctors and nurses compared to other countries. Our acute hospitals have the same number of beds per 1,000 citizens as the UK (2.8) and slightly more than Canada (2.7). We have more nurses per 1,000 people than the UK and more doctors per 1,000 than the US.

Why are our hospitals not doing as well as Canada, the UK and the US, which do not have such long wait times or so many ED attenders?


Bed occupancy rates provide part of the answer. The OECD report shows that, apart from Israel, Irish acute hospitals have the highest bed occupancy rates among OECD countries at 95 per cent. The US and the UK, which have the same number of beds per 1,000, have occupancy rates of 65 and 82 per cent respectively. An occupancy rate of 95 per cent means that Irish acute hospital beds are full almost all the time.


Irish people are not more acutely ill than people in other developed countries so why are so many people referred to or admitted to hospital? The reasons are the same as they were 70 years ago. Most tests, scans and treatments are available only in acute hospitals. Primary care teams do not have the facilities or the resources to provide treatment in the community and not enough is being done to promote health, prevent disease and deliver primary care services.

In 1945, Dr James Deeny, chief medical officer for the Department of Health, developed a plan for the reorganisation of the Irish health services which included a paradigm shift from the largely curative acute hospital system towards prevention. Parish pump politics ensured the plan was never implemented.

Irish people love their hospitals and ideally would like one in every large town regardless of the fact that outcomes are worse when volumes of patients are low. Politicians will do anything to keep hospitals open.

Preventative services do not attract the same number of votes and patients feel short-changed if they are not referred to an acute hospital for a test.

Ireland is not alone in investing so little in prevention. The World Health Organisation recommends a minimum spend of 5 per cent of overall health expenditure on prevention yet throughout Europe less than 3 per cent is allocated to these public health programmes. Ireland spends even less on prevention than most other EU countries. The HSE's Health and Wellbeing division, which includes services such as immunisations, screening, environmental health, and health promotion, has a budget of just €201 million for 2015 or 1.6 per cent of the overall HSE allocation. Just over 1 per cent of HSE workers are engaged in health and wellbeing activities.

The current system is unsustainable and, 70 years on, it is time for a paradigm shift. The Department of Health is committed to implementing Healthy Ireland: A Framework for Health and Wellbeing 2013-2025. The HSE has produced its own implementation plan, Healthy Ireland in the Health Services 2015-2017.

This plan needs a budget allocation of €600 million a year, three times the current budget. The more money spent on acute hospitals, the less there is to spend on health promotion, prevention and primary care.

Hospital consultants and health unions should not use the plight of 90-year-old citizens on trolleys to argue for bigger budgets. Acute hospitals have enough and should not get another cent until health promotion, prevention and primary care services are adequately resourced. Dr Jacky Jones is a former HSE regional manager of health promotion and a member of the Healthy Ireland Council.