There are huge difficulties in health, but it would be wrong to give the impression that the Health Service is a complete basket case. Many, many excellent people work within the service and as is often said, once a patient is admitted or is “in the system”, the quality of care is very good, if not excellent. However, following years of cuts and a clear lack of direction, the service is now on its knees and will be hopelessly exposed in the event of any kind of infection outbreak or major emergency. We have to come together in this constituency and every constituency to make Health the issue of the election.

  It is clear that we are just one bad winter away from a complete breakdown in the Health Service. Our Doctors & Nurses are struggling to hold the system together. Chronic overcrowding is now embedded in every single one of our emergency departments, not least in Tallaght Hospital. Counting the number of patients on trolleys is one thing, but the real impact of the trolley crisis is that over 300 patients are dying every single year because hospitals simply do not have the capacity to treat patients in time.

Over 300 patients are dying, every year, as a result of chronic hospital overcrowding(*1)

  Ireland has the second lowest number of Hospital beds in Europe at just 2.8 per 1000 of population, much lower than Northern Ireland (3.5), Wales (3.75) and Scotland (4.4) (*2). Successive Governments continue to strip capacity from our hospitals on a promise of delivering health services in the community that never materialise to the extent needed.

With just 2.8 beds for every 1000 people, the capacity of Ireland’s public hospitals has been cut to the bone (*3)

  Many sections of our Health Services are hopelessly reliant on charity just to function, children’s health services in particular. Crumlin – our largest children’s hospital continues to refurbish and expand its facilities without any support from the State. The hospital completed new Cancer & Cardiac wards over the last few years without a single cent from Government. The total project cost came to just €8.5m.

  1. National Health Policy – Where are we going? 

We will never make any sustained progress in health unless a long term strategy for the service overall is established. One Government establishes the HSE, the next sets out to dismantle it. This Government wasted over 3 years charging towards a Universal Health Insurance model before scrapping their own policy. All of this is hugely counter-productive.

We must take the politics out of health and develop a long term strategy that has the input and backing of all parties – both political and occupational. In effect, a national health strategy that clearly sets out the broad direction and milestones to be pursued regardless of who is in power. The next Government must take this step – will they part with some power for the greater good?

The existing two-tier system is the dreadful legacy of successive Governments and does not belong in any Republic. Those that can afford it, myself included, buy health insurance to skip the queue. The rest must wait, and potentially with life threatening consequences.

The way in which Ireland provides access to healthcare is perhaps the greatest inequality of our time.

I believe most Irish people if given the option would favour a Universal Health Care model akin to the NHS in the UK over Universal Health Insurance involving for-profit private insurance companies.

Any country that has meted out its public healthcare services to private providers has seen the overall cost of providing care sky-rocket. We still have no idea which model the current Government intends to pursue – after almost 5 years in power, the Government’s Health Policy is in tatters. Having promised more than virtually any Government before them, they have abjectly failed to deliver.

As objectionable as our existing two-tier system is, and we must put in place a strategy to remove it, the short term situation in Health is so grave that we cannot even begin to countenance any further moves without first comprehensively addressing the chronic capacity issues. 

  2. Beds & Capacity – Targeted Investment

There is no getting away from the fact that in the short term, at least 1000 additional beds are needed in our acute hospitals. Over the last 10 years, one report after another has consistently stated that a further 3,000 beds are needed, yet still the number of beds in our hospitals has remained static. 

In 1980 there were 17,665 acute beds in the system, in 2014, the number was 11,004 (*4). To some extent the decrease can be justified by obvious advances in medicine and technology ensuring patients can be treated on a same day basis or outside a hospital setting, however, Ireland’s population has increased substantially over that period with the addition of 1.2m people. As a result, bed occupancy levels in Ireland are the highest in the EU averaging @ 92.6% with our largest hospitals often recording figures beyond 100% (*5). Anything beyond 85% is considered internationally to be unsafe, with much greater risk of infection spreading. 

Targeted investment is needed immediately to increase capacity by between 20 – 60 beds in our Acute Hospitals, and provide the staff to go with them.

If the space is not available within existing buildings, then we must build new wards. This doesn’t have to cost huge amounts of money, the HSE & Government would do well to look at what modest investment has delivered at Crumlin Hospital, funded entirely by charitable donations. One off incentives to encourage Doctors & Nurses to return or stay in Ireland will have to be improved, followed by a broader look at pay and conditions.

The promise of ‘care in the community’ and the roll out of ‘step down beds’ has become the model for all Governments to pay lip service to. There is no doubt that both are part of the solution, but the creeping and continual closure of beds in our acute hospitals has brought our health service to the brink. Further improvements to reduce the length of time patients remain in Hospital can be made, but not without actually delivering that community care model we hear so much about. Simply, our hospitals are maxed out. We have to invest in additional beds, buildings, and the staff to go with them.

  3. Consultants & Specialists

Ireland needs a further 1000 consultants minimum. Currently there are approximately 2,500 consultants with 230 vacant posts that cannot be filled. As far back as 2003, the Hanly report identified the need for 3,600 consultants by 2013 along with a shift from Consultant led care to Consultant delivered care. In reality, greater than predicted population growth means that figure is also short.

Little in the way of acute care can happen in a hospital without the input and guidance of the senior consultant. Ireland again heads the league tables in having close to the lowest number of hospital consultants per 1000 of population of all OECD countries. Spreading this vital human resource so thinly places a huge burden on Junior Hospital Doctors, damages the working conditions of those that remain in the system and results in longer working hours, longer on-call periods, and crucially for the patients; waiting lists that are spiralling out of control.

  4. The 7 Day Hospital

Ireland desperately needs the 7 day working hospital to become a reality.  We still have a situation where precious little activity happens beyond 8pm and across the weekend. We have to maximise the use of the resources available within our Hospitals and move to a situation where as much as possible, hospitals are operating at full tilt up to midnight and across the weekend. There is no doubt that consultants will have to be offered more attractive “public only” contracts to make this happen and there is no getting away from the fact that this means more money. A small number of English speaking countries offer experienced consultants a better deal both in terms of working conditions and remuneration, we have to compete.

  5. Nurses & Midwives

Nurses & Midwives are effectively the glue that holds the Health Service together and the recruitment embargo has left us with 4,000 fewer of them. Those that are left behind are struggling to cope in working conditions that are clearly unsafe. The HSE has recently embarked on a recruitment programme in an effort to attract Nurses home, but is struggling to fill the positions.  Irish nursing staff are head hunted all over the world, salaries and working conditions on offer here are too often second best.  We have to compete with our neighbours.   The combined impact of pay cuts, the pension levy and general tax increases to all incomes has meant that Irish Nurses working abroad, including in the UK, can earn more, in working environments that are much less pressurised. We need to review Nurses pay, the short term incentives currently on offer are simply not enough. We also need to maximise the role of Nurses by providing clear career paths and continuous training opportunities towards advanced clinical practice, with pay grades to match.  

  6. Junior Doctors : Career Paths

Cutting consultant pay for new entrants by 30% proved to be a huge mistake. Junior Doctors are still forced to work hours well in excess of the European working time directive, jeopardising patient safety. A significant number of Junior Hospital Doctors have left the system and left Ireland. Other countries reap the benefits from the huge investment the Irish State has made in their education. Ireland currently produces more Medical Graduates per head than any other OECD country, but the HSE employs many more medical staff from other countries than is the norm internationally (*6). We have to keep our Junior Doctors here and encourage those that have left to return. The career path to become a consultant is significantly longer and less certain in Ireland than provided for by our neighbours. It can take well over 15 years for a Non Consultant Hospital Doctor to make a Senior Post. The system extracts a penal work load from Junior Doctors who are forced to bridge the chronic deficit in Consultant numbers.

  7. Primary Care: Managing Chronic Diseases

Primary Care Centres are being built around the country in an effort to provide the infrastructure to deliver the long promised “care in the community”. However, many remain hopelessly understaffed and are operating on a very limited basis. There is a long way to go to convince the general population that a Primary Care Centre can be a real alternative to presenting at A&E in certain circumstances.

For example, more patients with Asthma are presenting at A&E in Ireland than virtually any other country in the OECD (7*).

There are real benefits for both the patient and our hospitals in managing chronic diseases in the community and only referring patients to acute hospitals when necessary. Implementing existing plans to deliver care locally for the 5 main chronic diseases; Asthma, Diabetes, COPD, Stroke & Heart Failure, would provide the patient with appropriate care in a local setting, significantly reduce pressure on Emergency Departments,  and result in substantial cost savings. 

  8. Target limited resources based on need

As we transition towards some sort of Universal Healthcare, any widening of eligibility should first be targeted at those with a clear Medical Need; a basic principle that we look after the sick first. From the outset, this Government committed to widen access to medical care based on need, not income.  Again, following the crisis that ensued from the removal of Discretionary Medical Cards last year, the Government once more gave a commitment that Medical Need would be a key determinant in any widening of eligibility. In the interim free GP care has been extended to all children under 6 with plans to extend this provision to all children up to the age of 12, regardless of the child’s medical need or parent’s income.

Given the gravity of the crisis in Health, we simply cannot afford such moves at this point. Both free GP schemes will cost in the region of €130m every year, money that is desperately needed to increase capacity in our Hospitals (*8).

We can and should however deliver on that commitment to first grant free care to those with the greatest Medical need. For example, rather than granting children free GP care based on their age and nothing else, it would make far more sense to grant free medical care to all children that meet the criteria for the Domiciliary Care Allowance. By meeting the criteria, the State already deems that these children have a “severe disability”. Providing for the relatively few children that have a real medical need would cost a fraction of the cost to roll out a universal entitlement to all based on age.

  9. Primary Care: The GP

Up to quite recently, general practice was one of the few areas of the Health Service that operated without waiting lists. Key pressures are now building up in the system, with some areas around the country unable to fill vacant GP positions or to re-open surgeries when they close down. Cuts made to General Practice fees and allowances as part of the financial emergency legislation were particularly severe, amounting to 40%. Again, many young Doctors are choosing to leave Ireland and set up practices in other countries. We have to compete.

  10. Still paying too much for Drugs

Despite efforts to reduce costs and increase the use of generic unbranded drugs, Ireland is still paying way over the odds, wasting hundreds of millions every year. Last year, Sunday Business Post journalist Susan Mitchell did a direct comparison on prices the HSE was paying for drugs vs the NHS – taking just 3 widely used medications alone as an example, the difference was €27m. If Ireland cannot get a fair deal on its own, we must look in the short term at reaching a deal with the NHS to procure and supply certain drugs on our behalf. Longer term, Ireland should push for an EU wide drugs purchasing programme to the benefit of all EU member states.

  11. HSE Structure

Any organisation the size of the HSE must be subject to a full staffing audit. Combining all former National Health Boards under the umbrella of the HSE without any reduction in non medical staffing numbers was one of the greatest mistakes of Bertie Ahern’s era. We hear a lot about how the HSE is top heavy with managers & administrators, let’s get the facts. We need to carry out a full audit of non medical staffing roles, benchmark against best international practice, implement a streamlined structure and introduce a voluntary redundancy or re-deployment programme where necessary. 

  The Cost of Doing Nothing

Temporary solutions are simply not good enough any more. If we continue to fail to address the route causes, another 1500 patients, predominantly older people, will die unnecessarily over the next 5 years.  It is a stain on our country – on this Government and every Government that has gone before over the last 20 years. 

(*1) The Irish Association of Emergency Medicine estimate that between 300 – 350 people will die, every year, if the overcrowding situation is not addressed. Their estimate is based on comprehensive Australian research and the findings extrapolated to ensure relevance to the Irish situation. 

(*2) Open Democracy.net – https://www.opendemocracy.net/ournhs/john-lister/england-has-relatively-few-hospital-beds-so-why-are-there-calls-to-close-more

(*3) Data available from the OECD – http://stats.oecd.org/index.aspx?DataSetCode=HEALTH_STAT

(*4) Figures from ‘Acute Hospital Bed Capacity – A National Review.’ Department of Health & Children 2002 and Current bed numbers quoted in Sunday Business Post with data provided by the HSE on 8.11.15. 

(*5) Bed Occupancy Rates – Irish Times Report 23.09.14 referring to OECD data from 2012.

(*6) Graduate number data available from the OECD – http://stats.oecd.org/index.aspx?DataSetCode=HEALTH_STAT

(*7) Data available from the OECD – http://stats.oecd.org/index.aspx?DataSetCode=HEALTH_STAT

(*8) 270,000 children granted free GP care as part of under 6’s scheme, representing 64% of all under 6’s that did not already have a Medical Card, at a cost of €67m p/a or €248 per child. 378,000 children between the age of 6 & 12. 64% of 378,362 = 242,151. 242,151 x €248 = €60,053m.