Ms Vanessa Hetherington:

The IMO thanks the committee for the invitation to discuss the ongoing and persistent overcrowding crisis in hospitals.

Hospital overcrowding, however, is not a new phenomenon and nor are the solutions. Quite simply, the persistent overcrowding crisis in our hospitals, like our record hospital waiting lists, are the direct results of an equally persistent failure, by successive Governments, to invest in bed capacity, infrastructure and medical workforce to meet the needs of a growing and ageing population, a fact which the IMO has reiterated consistently to our politicians. When the Taoiseach was Minister for Health more than 20 years ago the bed capacity need was identified at 5,000 more inpatient beds than we currently have. Since that time there has been little positive growth in capacity yet our population has grown by more than a million and we are now at a point of frightening waiting lists, inability to deliver timely care and too few doctors in the system.

Ireland has a growing and ageing population. During the past ten years the population of those over the age of 65 has grown by 35% and is set to grow by a further 35% in the next decade. While the majority of older people are living longer and healthier lives, an ageing population combined with increased rates of chronic disease and complexity of illness all place additional demands on the system. OECD data show that in 2019 Ireland had 2.9 beds per 1,000 population compared with an OECD average of 4.4, and we were ranked among those countries that had highest occupancy rates at 90%, a figure well above internationally recognised safe occupancy rates of 85% for inpatient care. The HSE is also suffering from a major medical workforce crisis. One fifth of consultant posts are vacant or filled on a temporary locum basis while we require up to 2,000 additional consultants in the next five years to meet the needs of our growing population. We continue to rely on non-consultant hospital doctors, NCHDs, in both training and non-training posts to fill service requirements, and for whom illegal and unsafe working hours are the norm. Last month we saw an unprecedented number of patients boarding on hospital trolleys in our emergency departments, EDs, and wards while our waiting lists for outpatient appointments, diagnostics and elective care are quickly approaching the 1 million mark. The emergency medicine programme set out a target that 95% of patients should be either admitted or discharged within six hours of arriving at an ED. However, the target is currently achieved for only about 60% of all patients and for 30% of those requiring admission to a bed.

The consequences of overcrowding at these levels are dangerous for both patients and those trying to deliver care in an under-resourced environment. Numerous Irish and international studies show that ED overcrowding is associated with increased mortality - within 30 days - and poorer outcomes for patients, whether admitted to or discharged from an overcrowded ED. Studies have also shown that ED overcrowding is associated with delays to receiving pain relief, medication errors as well as greater hospital lengths of stay and the consequent risk of hospital acquired infection. Delays in diagnostics, outpatient appointments and elective care can lead to poorer outcomes with patients presenting at a much more advanced stage of illness. Overcrowding also impacts on staff with doctors across the health service experiencing high levels of stress and burnout.

Covid-19 exposed the fragility of our health services but it did not cause it. The absence of any surge capacity within our health system meant that non-urgent care was cancelled while staff absences, combined with requirements for infection control, reduced capacity even further. It is important to note the policy of cancelling elective care was in place before Covid-19, as the HSE’s full capacity protocol has been in operation in many hospitals on a 24-7 basis. After the initial wave of Covid-19, the IMO met the Oireachtas Covid-19 committee on a number of occasions and proposed to Government a range of measures to address the deficits in our health services but despite two years of the pandemic little action has yet been taken. Urgent and simultaneous investment is needed in a range measures to ensure a robust and resilient heath system into the future. These measures are as follows. We need urgent investment in acute bed capacity and infrastructure, including immediate investment in temporary modular builds. We need to develop, finance and implement a multi-annual capital investment programme in acute bed capacity to include a minimum of 5,000 additional public acute beds. We need investment in stand-alone public hospitals for elective care and to increase critical care capacity to 550 critical care beds. The minimum requirements of 2,600 beds in the Health Service Capacity Review 2018 were never and will never be enough and were based on a significant expansion of capacity in general practice, community care and long-term care for the elderly, all of which has yet to happen. We must appropriately resource diagnostic, radiology and laboratory departments to allow timely access to investigations for both hospital doctors and GPs in the community. We need to invest in secure systems of electronic health records across health systems and community health centres. Systems must be able to communicate and allow embedding of national summary patient records as per the 2019 GP agreement.

Immediate action must be taken to recruit and retain doctors to work in the health service, including targeted measures to address our unprecedented number of consultant vacancies. These include the immediate reversal of the two-tier pay system for consultants and the negotiation of a new fit-for-purpose contract to attract consultants to a career in the HSE. Successive reports and studies have demonstrated that the two-tier consultant pay issue is a major barrier to recruitment. We need to increase the number of specialist training posts to meet future medical workforce requirements. A 38% increase in training posts is required to meet future medical workforce requirements but there is no plan to implement this. We need ongoing investment in the health and social care needs of older people. That means further resourcing of rehabilitative beds, long-term community care beds and home care supports, including intensive home care packages to ensure older people do not remain in hospital longer than necessary. We must continue to invest in the development of general practice including supports for new and established GPs to employ additional GPs, practice nurses and other support staff. We need investment in a programme of GP care for nursing home patients that reflects the complexity of care required. Through ongoing investment in structured chronic disease programmes, general practice can help to reduce future pressure on hospital systems. However, general practice is not without its own capacity constraints with estimates suggesting that between 1,260 and 1,660 GPs will be required by 2028.

Unfortunately, there is no quick fix to hospital overcrowding; without concerted investment across our health system, we will likely be discussing hospital overcrowding crisis for many years to come. This is no longer a crisis; hospital overcrowding, long waiting lists and long ED times have become the norm and they are dangerous not only for patients but for staff.