From cancelled appointments to longer waiting lists, screening delays to closed beds, the Covid-19 pandemic has had a devastating effect on normal health provision.
Everything to do with the virus was counted and measured with elaborate precision, but the cost of the pandemic for other patients often went hidden.
Even now, the extent of the devastation is hard to properly assess due to the pandemic and last year’s cyberattack on the HSE’s IT system. People with a wide range of health conditions, in hospital and in the community, have been massively affected by the pandemic. But to what extent, and what needs to be done now?
There is no comprehensive overview of the damage wreaked by the pandemic on the health service, but the limited data available gives a sense of it:
– Almost one million fewer appointments and procedures took place in 2020 and 2021 compared with pre-pandemic 2019.
– Cancer diagnoses fell by up to 14 per cent in 2020.
– BreastCheck cancer screening is running a year late.
– In the past four weeks alone, about 500 procedures have been cancelled.
Massive waiting lists
The situation now is very different from a year ago, and also from the first wave in spring 2020. On those occasions, most of the health service outside emergency care shut down; now, with most of the population vaccinated, hospitals try to continue seeing patients despite recurrent waves of infection.
Some areas saw improvements in the second half of the pandemic, as widespread vaccination allowed health services to get back to some kind of normality, some of the time. But much of this progress was more than offset by the curtailments introduced during the Delta and Omicron waves.
Our already massive waiting lists stayed stubbornly massive, despite considerable investment. By the end of last year, 75,463 patients were waiting for inpatient or day-case treatment, up 4 per cent in a year; a hefty 617,448 people were waiting for an outpatient appointment, up 1 per cent.
Greater inroads were made into the queue for colonoscopies, where the waiting list was cut almost 20 per cent.
More than 250,000 people have been waiting for an appointment with a specialist or a potentially urgent procedure for more than 12 months.
Most waiting lists grew despite €350 million in funding being set aside to cut them. There are plans for a multi-annual approach to cut waiting lists, but for now they remain just that – plans.
Cancer patient Siobhán Gaynor has direct experience of the impact on the health service of Covid-19, having been in treatment before and during the pandemic.
Back in 2019, she says, the initial treatment of her breast cancer went smoothly. But when she started to experience pain the following year, after the pandemic had begun, she returned to a very different health service.
“Everything seemed to take longer, even though I was in severe pain. It was a very different time.”
When it was “taking ages” to get an MRI scan, she eventually made use of her private health insurance. But even then this took six weeks as the country grappled with the virus. A further PET scan she needed was delayed, and it took up to three months for her subsequent radiotherapy treatment to start.
It was a difficult time: “I couldn’t do anything, I felt so unwell. I always seemed to be one scan behind, every time.”
From Dublin, Gaynor is conscious she could use her private health insurance when many other patients don’t have this option. In the public system, scans were a five-day service but when she went privately for one, it could be late at night or at the weekend.
While her tumour was treated, she makes the point that cancer patients need a range of services and many of these were affected during the pandemic. Staff were often redeployed for long periods to other areas of the health service due to the exigencies of fighting Covid-19.
Looking back, she feels she can see both sides of the pandemic coin, having been a patient who was affected and someone who could have been vulnerable if she had caught the virus.
“I think they did the right thing in relation to cocooning, shielding the vulnerable and vaccination. But with any chronic disease such as I have, you need keep a range of services going.”
Internationally, estimates of how much regular healthcare was interrupted are hard to come by, and vary considerably.
One in five Americans said their family delayed receiving medical care or were unable to get care at all due to the crisis, according to a Harvard University study. Among those who said they received delayed care, 57 per cent said they experienced negative health consequences.
From the very start of the pandemic, it was clear the virus spread rapidly in healthcare settings. Limiting the potential spread of infection requires elaborate measures. Infection control measures such as the use of PPE mean everything takes longer, from surgery to patient triage. Separate work streams have to be put in place for Covid and non-Covid patients, thus further reducing the number of patients that can be seen or accommodated each day. Outbreaks require the closure of wards as staff are forced out of work due to infection or being close contacts.
"One of the key issues that the pandemic has highlighted is weaknesses around premises," according to Mental Health Commission chairman John Farrelly. "Many services are still located in multi-occupancy, outdated buildings, and are suffering from years of neglect and lack of funding.
“Many mental health services were operating under capacity as they needed to strengthen infection control arrangements and set aside specific spaces for isolation.This has particularly curtailed arrangements for people visiting loved ones in centres, and similarly for residents who might otherwise routinely return home for weekends.”
Yet the Covid cloud has had a silver lining for some parts of the health service. Admissions and trolley numbers are lower now than they were two years ago before the pandemic. Flu hasn't happened. A BMJ study in January reported dramatic reductions in hospital admissions for common childhood infections in England in 2020, thanks to lockdowns, closures and travel bans.
While cancelled procedures make the headlines, the dynamics that lead to reduced health services are more complex. Hospitals traditionally deal with anticipated surges in demand by simply not scheduling work; this happens each year at Christmas but has also been adopted to deal with Covid-19 surges.
Patients themselves may opt not to seek out care that they need, for a variety of reasons. There may be too many obstacles in their way, or they could be afraid of getting infected in hospital or another healthcare setting.
For Alf Sloan from Co Meath, an inability to access care early in the pandemic resulted in multiple complications. In the end, he benefitted from cutting-edge treatment to resolve the issues that arose while he was waiting for treatment.
In February 2020, the 87-year-old suffered a small fall and scraped his head. With the health service virtually closed during the first wave, he didn’t go to the doctor. By September that year, when skin cancer was diagnosed, the wound had gone “from the size of a small coin to that of a Yorkshire pudding,” according to his daughter Maria.
The cancer was successfully treated using skin grafts, but then he developed bleeds on the brain. These could not be operated on because of the recovering skin cancer so instead doctor used injected glue fed through a catheter into the blood vessels on his brain.
Alf was the first person in Ireland to undergo this new treatment in Beaumont Hospital in Dublin, The Irish Times reported last November.
Despite the end of lockdown, a recent survey carried out for the Irish Cancer Society suggested one in seven people are still putting off seeking medical advice.
This process of long-fingering the treatment of health issues can have disastrous outcomes, as small niggles or eminently treatable phenomena turn into something more serious.
Billions of extra euro have been pumped into the system during the pandemic; this year’s budget is a record €24 billion. Much of the extra cash went to help tackle Covid-19, but there is also funding for reform initiatives and the reduction of waiting lists. Unfortunately, repeated waves of infection are stymieing progress.
As the pandemic drags on, the repeated stopping and starting of elective work, due to successive waves of Covid, is frustrating patients and staff alike. "You want your patients to be happy. It is so demoralising to have to say 'sorry for this' and 'sorry for that' as their procedure is cancelled, when you have so little agency over what happens," says dermatologist Prof Alan Irvine. "That affects every doctor of every age and rank."
Currently president of the Irish Hospital Consultants Association, Irvine says the system lacks resilience: “We were running acute beds at 95 per cent capacity even before Covid, so when any external pressure arises, the only option is to shut down elective work.”
After 20 years of treating patients in the Irish health service, Irvine is only too aware of the “human cost” of delayed treatment: work absence, worse health outcomes and an inferior quality of life.
“Everything gets pushed down the line when hospitals close lists for weeks,” he says. “There is continuous commentary about the health service being under pressure but other than short-term solutions, like cancelling essential scheduled care, there is not enough being done to make our public hospital services more resilient.”
Finding a solution “cannot wait for this or the next wave of Covid to end; it has to be a priority now”.
"You were left lingering with your suffering a bit longer," kidney transplant recipient Peter Heffernan says of his treatment during the pandemic. "If Covid hadn't happened, things might have been addressed more quickly."
Heffernan went back on dialysis last year and says his kidney team were “always there” for him. But when it came to wraparound services such as tests and minor procedures, things took longer.
Many services switched to telemedicine. This was "broadly satisfactory", though Heffernan, from Skerries, says he prefers face-to-face contact with medical staff. "Some services are still delayed but things have improved in the second half of the pandemic."
The HSE measures its performance against reams of key performance indicators (KPIs) but hasn’t published a performance report since last March. The proliferation of goals has resulted in the perennial problem of access to services going away.
Of course, one way of dealing with a failure to meet targets is to change the target. The HSE originally planned to provide almost 100,000 additional outpatient appointments in 2021, papers presented to its board last year show, but subsequently revised this target down to under 33,000.
Provision and procurement of additional activity was "well behind profile" due to the pandemic and cyberattack, chief executive Paul Reid told the board last July, and so the original targets were "revised".
It had been planned to carry out an additional 37,000 inpatient and day-care procedures last year, but this target was halved. Meanwhile, the €210 million due to have been provided for an access to care fund and the transformation of scheduled care shrank to just €98 million. Plans to add additional beds were also trimmed due to pandemic-related staffing pressures.
It isn’t just hospitals that have been affected. In mental health, Reid warned board members that ongoing surges of Covid-19 “may impact ability to deliver new models of care and deliver increased levels of service”.
Whether all these reduced targets were met by the end of 2021 is not yet clear.
As an oncologist working in Cork University Hospital, Prof Séamus O’Reilly saw the impact of lockdowns in delaying the arrival of patients with symptoms into his clinics. “There’s also a lot of mental distress among patients, who are often stressed out, isolated, worried about contact and in fraught situations during the pandemic.”
Because the screening programmes have fallen behind, there will inevitably be delayed diagnoses of cancers, he says, while patients are still afraid to come to clinics. Telemedicine, which took off during the pandemic, is “good but not a sufficient replacement” for person-to-person medicine, he says.
When the pandemic started, many health staff who were nearing retirement put off leaving to help out in the crisis. But now, he points out, they are actually retiring, while other staff are reconsidering their options as part of the worldwide reflection on work-life balance prompted by the pandemic.
For the future, he says, “we need to look how to make disruptive change into transformational change, to make the system better. The pandemic showed we have great people in healthcare but people are exhausted. They don’t have energy for extra shifts.”
Government plans envisage widespread use of private hospitals to treat public patients languishing on waiting lists. The HSE is currently using up to 1,700 bed-nights a week in private hospitals, 80 per cent of it for elective treatment for public patients.
O’Reilly is sceptical about the role private medicine can play. “The private sector is good at procedure-based care but sometimes it’s about the longer journey and longer-term care. Outsourcing can also impact on specialist centres that thrive on high volumes.”
The past two years have been tough, but for the first time conditions may be ripe for transformational change in health. Extra funding has been provided. The pandemic has highlighted the urgency of having a system that is fit for purpose. The crisis showed the health service can change rapidly, as it did through the introduction of telemedicine and e-prescribing or the redeployment of staff and the creation of new clinical teams.
The opportunity for radical change must be grasped now, O’Reilly believes. “If we squander a once in a century pandemic without re-engineering our system, which was broken before it started, that would be a huge opportunity lost.”
“This is going to go on for another two years, so we’ve got to get systems in place for this.”
He highlights three areas where progress needs to be made: making up for ground lost in the pandemic, recruitment and retention of staff and infrastructure.
“We’ll lose ground if we don’t have a catch-up strategy,” he adds, “but to do that you need enough bandwidth in the system.” Catching up means extra clinics, but that means you need more staff to run them.
Traditional institutional inertia got swept away in the first wave of the crisis, allowing radical changes to be made, but has since crept back in, he says. Given the delays in delivering new children’s and maternity hospitals, ways have to be found to provide much-needed additional infrastructure quickly and affordably, he adds.
“We also need flexible work contracts, action to deal with recruitment and retention issues, the maximising of diagnostic capabilities, and a universal health number.”