Ms Susan Clyne:

The Irish Medical Organisation, IMO, thanks the Chairman and committee members for the invitation to discuss the ongoing overcrowding issue in hospitals, as well as delays in admissions and outpatient appointments. For more than a decade the IMO has been highlighting the capacity issues across the health system.

Ireland has a growing and ageing population. For many decades the proportion of the population over the age of 65 years remained static, but it has now begun to change and the pace of that change will accelerate rapidly in the years ahead. In simple terms, an additional 20,000 people each year will reach the age of 65 years and, as life expectancy increases, the number aged over 80 will double. In the last ten years the total population has grown by 300,000, or 7%, while the population aged over 65 years has increased by 166,000, or 34%. That gives an idea of the scale of the problem. At the same time, the healthcare system has undergone significant budget cuts. Between 2007 and 2014, both staffing levels and the number of inpatient beds fell by 13%. Public health expenditure only began to increase from 2015 and even at that, it failed to keep pace with demand. The pressure exerted by demographic changes and financial cuts is manifesting in unprecedented overcrowding in emergency departments and waiting lists for outpatient appointments and elective procedures.

Bed occupancy rates in hospitals have risen to an average of 97%. In model 4 hospitals that figure increases to 104%. These rates are well above internationally recognised safe occupancy rates of 85% for inpatient care and 80% for critical care. The HSE's full capacity protocol which is designed to act as a safety valve when emergency department functioning is compromised has become the norm. The protocol was implemented on hundreds of occasions in 2017. International evidence shows that high bed occupancy rates are associated with a number of adverse factors, including increased risk of healthcare associated infections such as MRSA, increased mortality, an increased probability of an adverse event and risks to staff welfare.

A significant contributor to long waiting lists is inadequate medical staffing levels. Public health services are facing an unprecedented crisis in recruitment and retention in the medical and other health professions, as clearly evidenced by the fact that we have at any given time more than 450 vacant consultant posts. That is in the context of a total consultant workforce of approximately 3,000; therefore, it is significant. Almost 90% of consultants who trained in Ireland but who are currently working abroad have indicated they will not return owing to the discrimination on pay scales. One third of existing consultants are considering taking up a post abroad in the foreseeable future. In 2017 the Public Appointments Service, PAS, produced figures which confirmed that the public health service was unable to attract applicants. For one in ten consultant posts no applications were received and the PAS could not identify a suitable applicant for 22 of the 84 posts. That is a real change in what would have been a highly competitive market ten years ago in which consultants, nurses and other healthcare professionals were vying for jobs in Ireland. Almost 700 GPs are due to retire in the next few years, while, at the same time, 30% of GP trainees are intending to emigrate. Almost 20% of recent GP graduates have emigrated and a further 70% believe they may do so in the near future. That means that a growing number of GMS lists are attracting few or no applicants. Again, they were highly sought after lists, for which there was a lot of competition, but now we see nobody even applying for the posts.

Non-consultant hospital doctors, NCHDs, or doctors in training, are leaving the system in large numbers across all specialties and, alarmingly, it is happening after the intern year, the first year of training. That cannot be explained by the notion that doctors normally go abroad for training. They are doing so very early. There is huge apathy and they believe they will get through the first year and then go abroad to a system that values them and they have no intention of returning. Two thirds of NCHDs perceive pay to be the primary reason for emigration, while 83% believe the pay disparity at consultant level will impact on their decision on whether they should apply for consultant posts in Ireland. Irish trained doctors at NCHD level are three times more likely to emigrate than their UK counterparts. We hear a lot about the struggles of the NHS, yet in Ireland NCHDs are three times more likely to emigrate. We cannot hope to reform or reconfigure health services unless and until they are capable of attracting and retaining sufficient numbers of doctors, nurses and other healthcare professionals to deliver care to patients. That is not the case.

This is a patient care issue. We should not continue to spend money on short-term measures without significant and sustained investment at the same time in the public health service. The annual budgetary allocations do not even keep pace with current service levels and demand. We are not investing in health services. We have had numerous reports, including Sláintecare, the health service capacity review and A Future Together - Building a Better GP and Primary Care Service, all of which show that we need to invest in increasing capacity across the health system, in tandem with a significant budgetary allocation to allow for service development. The main point the IMO makes is that sometimes we tend to focus on one issue in the health service and think that if we provide funding, it will solve everything. The reports all show that it needs to be funded across the board and that everything must happen at the same time because otherwise we are playing a zero sum game and the problems are only going to manifest somewhere else in the service.

There are five key areas the IMO asks the committee to consider for urgent action. The first is increasing capacity in the acute hospital system. The health service capacity review shows that we immediately require approximately 1, 200 additional inpatient beds and 50 adult critical care beds in order to meet safe bed occupancy levels. It is not to meet demand but just to treat patients in hospital safely.

Given that the majority of inpatient admissions now come through the emergency department and there is a considerable backlog for outpatient appointments and elective procedures, the number required is likely to be even higher. We have 1,531 fewer inpatient beds in the hospital system compared to 2007 and this is at a time when the population is growing and, as a result of demographic changes, the elderly population, in particular, is increasing. An immediate assessment of the number of acute beds available is required with the financial and manpower resources made available to upgrade and reinstate beds along with a detailed plan for investment in bed numbers into the future.

As is the case for our colleagues in the INMO, it takes a long time to recruit doctors, as it does nurses. Six months would be a fast turnaround to recruit a doctor into the system. Unless we start identifying, planning and resourcing now, we have no hope in 2019 of making any significant changes. We need to increase the number of consultants across the hospital system. We currently have just 1.43 specialists per 1,000 population compared to a western European average of 2.4 per 1,000.

The Report of the National Task Force on Medical Staffing 2003, often referred to as the Hanly report, set out ratios of consultant to population that would need to be met to provide a consultant-delivered service, which we will all agree is the type of service we should have. That would improve quality of care and patient safety, as important clinical decisions would be made faster and at a higher level. However, non-consultant hospital doctors, NCHDs, continue to outnumber consultants at a ratio of 2:1. We are short approximately 1,400 consultant posts based on current population figures. Given our current difficulties in recruiting and retaining consultants, urgent action is required, or we will continue to struggle to appoint the number and calibre of consultants we need to provide safe patient care. In view of the growing disparity in consultant pay, this has now become a more urgent problem. There were 450 vacant posts at consultant level when the disparity was at a lower level. Now the disparity has increased to, on average, €50,000 per post and it is almost impossible to see how we will get consultants to come into the system. Equal work for equal pay is a basic principle.

Another issue we would ask the committee to consider is to adequately resource the national clinical programmes. Those programmes and models of care such as the emergency medicine programme, the acute medicine programme and the model of care for elective surgery should be fully implemented and resourced. These programmes represent the most effective and efficient use of resources. As a service and as a State, we spent a long time writing reports, which we all agree is the right thing to do, but we then find there is no funding available, they are left on the shelf, nothing happens and the problem worsens. The acute medicine programme was originally set up to provide an alternative pathway to the acute system to allow general practitioners, GPs, to directly refer patients to acute medical units, AMUs. However, due to lack of capacity and under-resourcing of both the emergency medicine programme and the acute medicine programme, AMUs are no longer satisfying the original criteria and with the current overcrowding in emergency departments, they now simply serve as an extension of those departments around the country.

Waiting lists for inpatient procedures primarily affect patients awaiting elective procedures. The model of care for elective surgery, if fully implemented and resourced, will improve access, quality and cost by reducing waiting times, abolishing cancellations, optimising day surgery and average length of stay, standardising care, and optimising the use of theatre resources. It makes no sense for the National Treatment Purchase Fund, NTPF, to purchase care from the private sector while simultaneously having a policy decision that imposes budgetary constraints and rolling theatre closures and cancellations in the public sector.

We need to address delayed discharges with increased resources for long-term and rehabilitative care for patients.No patient should be in hospital longer than is necessary and everyone should be discharged to an appropriate setting. Failure to transition patients to the most appropriate setting increases costs and reduces efficiency as patients are in the wrong place for the type of care they need. While community intervention teams have helped to support early discharges for some patients, we need to invest significantly in long-term and short-term beds for elderly patients as well as inintensive home care packages. That needs to be seen as a priority, given the known demographic changes, not what might happen or whether we will have a bad winter.

We need to invest in general practice and chronic disease management. With an ageing population and growing rates of chronic disease, all the evidence points to the need to shift the model of care towards general practice and a GP-led primary care system. An extensive body of international research shows that continuity of care and a patient-centred approach that is specific to general practice is associated with reduced mortality rates, particularly in the elderly, greater patient satisfaction, improved health promotion, increased adherence to medication, and reduced hospital use.

Chronic diseases, including cancer, cardiovascular disease, chronic obstructive pulmonary disease, COPD, and diabetes account for approximately 40% of hospital admissions and 75% of hospital bed days. Acute services currently undertake an enormous volume of chronic care, at significant expense to the taxpayer, that could, if properly resourced, be managed in general practice. General practice will not immediately resolve hospital overcrowding, but, in the long-term, if we invest now in GP-led chronic disease management programmes, for which GPs are trained, along with capacity measures to build up medical and nursing levels in general practice, we can reduce future growth in demand on the hospital system and patients can be seen and cared for in the most appropriate setting. However, following years of austerity and extensive cuts to the resources available to general practice, the current system is under-funded and working to capacity. Financial emergency measures in the public interest, FEMPI, cuts reduced resources per general medical services, GMS, patient by 38%. The immediate reversal of the FEMPI cuts is required to restore stability to general practice before any new workload can be taken on.

We appeal to all members of the committee to urge the Government, in the context of the forthcoming budget, to seriously address the problems in our health system and recognise the damage caused by delays for patients in accessing much needed healthcare. We also ask the committee to recognise the potential for Ireland and those who work in the health services to deliver a first-class health system if sufficient resources were allocated to allow this to happen.