When hospitals cannot cope with the illnesses of a balmy autumn just how bad is it going to get? asks Maev-Ann Wren
What is in store for the health service this winter? If the pressure on our hospitals is already so great that patients have received treatment in a hospital car-park, how will the system cope with the winter upsurge in illness?
Hospitals were forced to cancel elective surgery last January, when the Minister for Health, Mr Martin, explained to the Cabinet that a "cold spell" always brought an increase in admissions. But when hospitals cannot cope with the illnesses of a balmy autumn just how bad is it going to get?
Could this autumn's crisis not have been foreseen? If anyone is qualified to say "we told you so", it is the Government. This crisis has been visibly coming for some years and no one knows this better than the Government.
Its 2001 health strategy explained "it will not be possible to sustain further overall increases in activity without expanding bed numbers". In a study for the Department of Health epidemiologist Dr Mary Codd pointed out that bed occupancy levels were unacceptably high in our major hospitals, 23 of which were operating above the internationally recognised measure of full occupancy.
Furthermore, the population was increasing and ageing. Dr Codd estimated that by 2011 the number of over 65s would have increased by 20 per cent or some 80,000 people. The elderly need more hospital care and stay in hospital longer. Already in 2000 they constituted 27 per cent of inpatients and accounted for 46 per cent of bed occupancy.
These presumably are the kind of arguments which convinced Fianna Fáil to campaign in the last general election on a promise of implementing the health strategy's commitment to an additional 3,000 acute beds by 2011, a 25 per cent increase.
The Government parties reiterated that promise in their programme for government. What then transpired is no secret. The Minister for Finance, Mr McCreevy, announced last November that funding for the strategy "cannot be addressed at this particular time and won't be addressed next year or the year after". So nothing doing until 2005 at the earliest. Capital investment announced for health in 2003 was marginally lower than in 2002 and little over half the investment required to implement the strategy at the pace envisaged by the Department of Health, as revealed in documents released under the Freedom of Information Act.
Although the Government had announced in 2001 that it would provide 709 new acute beds and subsequently funded their provision, by the middle of this year the number of acute hospital beds actually available had increased by only 303 on its 2001 level, according to a Department of Health count of average bed numbers in the first six months of the year.
Hospitals had been forced to close beds and reduce staff numbers. The global budget for hospitals increased this year by 8.5 per cent, below health cost inflation. For many hospitals which had exceeded budget last year, the increase has been correspondingly lower, an unquestionable cut in funding in real terms.
In the five major Dublin teaching hospitals 104 beds were closed for financial reasons coming into last weekend and 184 in the eastern region. This was only a marginal reduction on the region's peak closures of 195 in June, according to the Eastern Regional Health Authority's count.
Early austerity measures have been sufficiently effective to allow the subsequent reopening of some beds. However, the austerity has come at a cost to patients, almost exclusively public patients, since the overwhelming majority of the beds closed have been public.
Of the 184 beds closed in the Eastern region for financial reasons last week, 174 were designated for the treatment of public patients and just 11 beds were private, according to figures supplied by the ERHA.
All beds closed in Tallaght, Beaumont, the Mater and James Connolly were public, even though each of these hospitals has significant numbers of private beds.
The logic for this concentration on public bed closures is financial. Private beds bring an income to hospitals from insurers, albeit an income which covers only half the actual cost of care. So during this period of cutbacks fast-track access for private patients to public hospitals has remained protected, while public patients have found it even more difficult to access care. This outcome from the stringency measures imposed on the Department of Health by the Department of Finance has made a mockery of the 2001 Health Strategy, which promised that all new beds would be designated for public patients.
Inpatient procedures in these major specialist hospitals were down by 4.2 per cent in the year to the end of August compared to the same period last year, according to the ERHA.
Day case activity, however, rose by 5.4 per cent. So the number of procedures like chemotherapy, which lend themselves to treatment on a day basis, continued to increase but the number of procedures like hip replacement, which require a stay in hospital, has reduced.
Unsurprisingly therefore, notwithstanding the efforts of the National Treatment Purchase Fund to supply treatment for public patients who have waited longest, the waiting lists remain intractable.
In the three months to March, the overall public waiting list had fallen a mere 1 per cent to 28,719 people. The number of adults waiting over 12 months for treatment had fallen but still stood at an unacceptable 4,782. The NTPF's allocation of public funds to purchase private care for public patients, while the State cuts back funding for public hospital care and provides privileged access for private patients to public hospitals remains an extraordinary contradiction. While the provision of acute beds and the equitable allocation of care would alleviate the hospital crisis, its ultimate solution is more complex.
Many patients in acute hospitals should be in convalescent or nursing homes. Many others would not seek treatment at hospital Accident and Emergency departments were there a properly funded and organised primary care system. The ERHA has received an increased budget to assist patients to move to care in nursing homes or at home. This could potentially release 200 beds this year for emergency care, significantly easing pressure on A&E coming into the winter.
Yet here too there is a limit to what can be achieved without significant investment. The Department of Health estimated in 2001 that as many as 4,700 more beds were needed to accommodate the elderly, the convalescent and the terminally-ill. Yet such beds have also been closed in public institutions like St Mary's Hospital in the Phoenix Park, Dublin, where 36 beds were closed last week.
It is no coincidence that the pressures on hospital A&E departments have been most acute on the north side of Dublin (manifest at Beaumont and the Mater) where GP out of hour services are least developed.
In our market model of primary care GPs tend to locate where there are concentrations of private fee-paying patients like on the southside of Dublin. The Government's strategy for primary care announced in 2001 has not yet progressed beyond 10 pilot projects, of which two are in Dublin.
What are the prospects for Government action to alleviate this multi-faceted crisis? The Minister for Health has perhaps been unfairly criticised for focusing on his smoking ban. There is no reason why he cannot tackle prevention and cure simultaneously.
The Government has committed itself to changing how the health service is administered, a programme of reform which encompasses the abolition of the health boards and the establishment of a Health Service Executive. Although Prof Niamh Brennan, the author of a Department of Finance-sponsored report on financial management in the health service, has criticised the pace of this reform, with the support of her sponsor, Mr McCreevy, it stands a better chance of implementation than the health strategy.
A much bigger challenge awaits the Government, which today must reconsider the Hanly Report. In the run-up to local elections publication of the report will open the Pandora's box of which hospitals should offer which services.
Driven by the EU's requirement that junior doctors should work reduced hours from next August, and by the experts' belief that patients often need to be treated in larger centres where professionals' skills are more practised, the report requires a complete change in how hospitals, particularly smaller rural hospitals, go about their business.
Although some doctors have formed a Local Acute Hospital Alliance to fight to protect local services, proponents of the report might well agree with their arguments that services cannot safely be taken from smaller local hospitals without significant investment in primary care, in the ambulance service and in the larger regional hospitals.
Without publication of the report, a reformed health service administration will lack an agenda for action. Without a clear Government plan establishing which hospitals should offer acute services, it is hard to defend investment in more acute beds. And without investment in primary care and the ambulance service, no rural community can be expected to accept the removal of emergency services from its local hospital.
Implementing the report will also require renegotiation of the consultants' contract, since the report proposes doubling the number of consultants so they can provide the bulk of hospital medical care. While the Republic has spent above the EU average on health for the last three years, this followed 20 years of significant under-investment.
Recovering from that history of neglect and achieving an acceptable, modern health service will require the Government to resurrect the promises of its 2001 health strategy, revise it to ensure equitable access, commit to funding it and ask us as a community to provide that funding, whether by taxation or through universal health insurance.
Reforms seldom bring immediate savings. They require duplication at first. The regional centre of excellence must have the capacity to take patients from smaller hospitals before their acute services are run down. Notwithstanding the public's preference for spending cuts over tax increases, low tax regimes and acceptable health care are not really reconcilable.