Reverse trolley: the hospital crisis
Record numbers of patients on hospital trolleys represent a reversal of the reductions achieved in recent years. The only long-term solution is to spend money in the right areas
A patient on a trolly in a corridor in the A&E Accident and Emergency Department of St. James’s Hospital, Dublin. Photograph: Alan Betson
Another key health-policy objective of the Government effectively crumbled on Tuesday with the revelation that more than 600 people were on trolleys awaiting hospital beds.
The Coalition had a number of key goals when it came to power, in 2011. It said it would start work on introducing universal health insurance, put in place free GP care for everyone by 2016, and establish a special delivery unit to tackle lengthy waiting lists and the problem of trolley waits in emergency departments.
Never again, the former minister for health James Reilly repeated on numerous occasions, would 569 people be waiting on trolleys.
In November 2011 Taoiseach Enda Kenny said that, as a priority, the special delivery unit would work with hospitals “to tackle unacceptably long waiting times in emergency departments”. As late as last March, in a speech to the Fine Gael Ardfheis, Kenny defended the Government’s progress in health reform, saying waiting lists and the numbers on trolleys had reduced.
In reality the universal-health-insurance project appears to have stalled. Negotiations are still under way with doctors about the introduction of the first phase of free GP care – let alone the full scheme – and very little is now publicly heard about the special delivery unit.
To be fair, for the first few years in office, efforts in tackling waiting lists and dealing with trolley waits showed some success. Reilly and the highly paid, now long-gone staff he brought in to run the special delivery unit initially concentrated on patients who had been waiting the longest for treatment. At first this was successful, with waits of more than a year effectively eliminated. But the picture was not so rosy for people waiting longer than the internationally recognised target of six months.
Figures published by the National Treatment Purchase Fund showed that 18,255 adults were waiting longer than six months for a planned procedure at the end of October, up from 9,643 when the Government came to office.
On the problem of emergency-department overcrowding, which dates back far beyond the term of the current administration, Ministers were until recently claiming credit for making things better. Almost exactly this time last year Reilly told the Dáil that there had been “a massive improvement”.
“I have always regarded trolley waits to be an unacceptable feature of the Irish health system, which is the reason I set up the SDU in 2011,” he said, referring to the special delivery unit. “Since then we have a 33.8 per cent reduction in the number of patients waiting on trolleys. That is, 29,200 fewer people waiting.”
Reilly acknowledged that although such improvements were significant, “the challenges continue, particularly in the early part of the year”.
Growing, a geing population
So what has caused the surge in the number of people waiting on trolleys and chairs around the country from about 270 last January to more than 600 this week? Much of it comes down to capacity, in both the acute-hospital system and in community services, to deal with a growing and ageing population.
There are about 11,000 beds in acute hospitals around the country. The Irish Nurses and Midwives Organisation maintains that about 2,000 beds are currently closed, mainly for financial reasons.
It is common to hear references to bed closures or shortages, but what these usually mean is that health authorities lack the funding to pay the staff required to keep beds open. A critical factor in the current overcrowding problems, however, is that a significant number of patients in acute beds no longer need to be there on medical grounds.
At any time there are patients who have completed the acute phase of their treatment and are waiting for lower levels of care or supports to allow them to return home. Informed sources say that, in the Irish context, this should be about 400 per day.
On taking office in July, Minister for Health Leo Varadkar was told by officials that in the summer there were about 650 such patients, who are known technically as delayed discharges. Varadkar was told that his department had held preliminary talks with the Health Service Executive about “identifying key blockages and potential measures to address them”.
Over the summer, however, administrators began noticing that, rather than improving, the number of delayed discharges was increasing. The new level is about 800.
For the system to work smoothly, patients who have finished their acute treatment should be found nursing-home or other step-down accommodation, or be approved for homecare packages or community intervention to return home.
But hospitals have reported delays in approvals for the Fair Deal scheme, the State-subsidised programme for patients needing long-term residential care in nursing homes. The scheme has a fixed budget; when this is spent, patients have to wait for new funding. According to informed sources, patients arriving at emergency departments are older than has been the case in the past, and they therefore have potentially greater medical needs.
More money requested
In the process that set its budget for 2015, the HSE told the Government that it would need more money. It asked for an additional €106.5 million to deal with both delayed discharges and pressures on the Fair Deal scheme, both of which feed into the emergency-department difficulties. The HSE received €25 million.
Just before Christmas Varadkar acknowledged publicly that there was a significant increase in emergency-department overcrowding since the summer and that much of the progress made since the Government came into office had been reversed. He convened a task force to find long-term solutions to overcrowding. He said “short-term solutions only work in the short term”.
As one short-term solution, €3 million was brought forward. This resulted in 109 patients in hospital beds being moved to nursing homes.
Under the €25 million made available by the Government, €10 million is to go towards providing an additional 300 places under the Fair Deal scheme this year. A total of €8 million is to be allocated to delivering 115 new short-stay beds, and €5 million will be spent on homecare packages for 600 additional people.
Many hospitals have also begun to cancel elective or nonurgent admissions to free up beds, a move that in itself will lead to longer waiting lists for elective procedures.
The HSE is seeking to deal with the crisis by using existing resources more efficiently. But if the problem worsens next week, pressure will grow on the Government for more long-term solutions: the appointment of more staff and the reopening of more beds.