How Ireland’s hospital waiting list crisis got so bad

Experts give their opinion on cause of crisis and how the health system can be improved

Michael O’Keeffe, consultant ophthalmologist, Mater hospital, Dublin

We have a completely dysfunctional health system where nothing works. It’s inefficient and ineffective at every level. There is no one to take charge at the ground floor and no incentive to do things any differently.

We fail to take care of the little things, like paying highly prized nursing staff a fair salary and providing parking.

Too many nurses spend their days doing routine tasks like form-filling rather than clinical activity involving patients. Following changes in the consultant contract, the only way many medical posts can be filled is by allowing doctors work privately. That gives us doctors who work part time in the public system and who don’t have any great commitment to it.

We have too few beds and too many rolling closures of operating theatres. Operating lists don’t start on time, they are inefficient and they finish at four or five. In the private sector, they continue until the work is done.

We need a tough minister to effect change, and one or two people in charge of the health system at the top. I don’t buy the constant call for more resources; we need to make the present system work better.

Stephen McMahon, director, Irish Patients’ Association

A succession of governments has let the health system down. The system doesn’t seem to have a heart and we are not sufficiently patient-centred. We lack the skill set to deliver results, it seems.

There are principalities of entitlement among the vested interests in health that are not working in the best interests of patients. Take for example the squabbling between the medical and nursing professions over the transfer of duties between them and to other grades.

It will take a lot of small things to improve the system. We need flexibility from the professions and accountability from management, who face no real sanctions for underperformance.

I would like to see some civil outrage about the appalling situation of people languishing on the waiting lists.

We also need to promote the cross-Border health directive so that people on waiting lists can get treatment abroad.

The system needs streamlining. At the end of the day, people are dying or in pain or at risk of an accident while waiting on the lists. No matter what your view is, that’s appalling. It’s one thing to be left on a waiting list, it’s another to be left to do all the running.

Dr Brian Turner, health economist, UCC

We have a particular problem in Ireland with waiting lists; the recent Health Powerhouse survey placed us worst in Europe for accessibility.

The system has been badly hurt from the cutbacks of the 1980s, 1990s and 2009-14 and it hasn’t fully recovered. We have fewer hospital beds than in 1980, while the population has grown by one-third and the older population by twice that.

We have too few hospital beds and we need more. We don’t need a capacity review to tell us that, though it might say where the extra beds should go.

We also need more doctors, particularly specialists – perhaps up to 2,800 extra.

The overlap between private and public in the health system also needs to be addressed. A significant proportion of those occupying beds in the public system are private patients and, even though this raises much-needed funds for the public hospitals, this has to be addressed by separating the different strands in the delivery of healthcare.

Outsourcing work to the private sector to clear waiting lists is pragmatic and works in the short-term but it’s not ideal.

William Behan, GP, Walkinstown, Dublin

In the UK, an orthopaedic specialist might see 12 patients in a clinic and offer surgery on eight of them; here, the specialist might have to see 30 patients and be able to offer surgery to just two people. It’s a very unproductive system, one that is limited by capacity.

In one hospital to which I refer patients, waiting lists doubled in a short space of time after the budget was cut. They cut the budget by 9 per cent but this resulted in a 30 per cent productivity loss because they skimped on the essentials, such as the metal plates inserted into a patient’s leg.

One problem is that people are operating in silos and not talking to each other. There are new layers of management and there is less engagement with GPs than before. The system is not listening to GPs enough.

Studies in Britain tell us that increasing the number of GPs, even by just 1 per 10,000 of population, can result in a reduction in patient death rates of 2-6 per cent. The effect is most pronounced in poorer areas so the effect is to reduce health inequalities.

We simply don’t know how often Irish GPs are referring patients compared to other countries because the studies haven’t been done. However, we do know that Irish doctors refer to emergency departments at two-thirds of the rate the British GPs do. They have an older population but it is clear that far fewer patients are referred by GPs to EDs than in Britain.

There is a danger of over-testing, and some consultants seem to be prone to it, but this is on the private sector.