Clinical Features

End of Year Review: IHCA

Health Service at a ‘Critical Juncture’

Written by Professor Robert Landers, President, Irish Hospital Consultants Association.

The Irish Hospital Consultants Association continues to highlight the deteriorating capacity deficits in our public hospitals to the Health Service Management and the Government. There is a pressing need for practical, sustainable solutions that will address the record waiting lists. The Government must agree solutions with the Association to fill the 900 permanent Consultant posts that are not filled and address the severe shortage of public hospital beds, theatres, diagnostic and other facilities. These priority actions are essential to ensure more timely care for patients and the almost 1 million people on waiting lists. All sectors of Irish life have gone through extreme challenges in the past three years, but none more so than our public hospitals.

Our frontline Consultants, doctors and other staff have carried an enormous burden, as have patients. They have performed exceptionally well in the face of once-in-a century global health challenges. The pandemic came against a background of major capacity deficits in our public hospitals, which successive governments over the past two decades have failed to address. Ireland has one of the lowest levels of acute hospital beds and Consultant numbers on a population-adjusted basis in the EU. On both parameters, we have about 40% less than the EU average.

This includes an even greater deficit in the number of ICU beds, despite an HSE/Department of Health report, commissioned over a decade ago, which recommended a doubling of ICU capacity by 2020. In the interim, the population has increased by over 600,000 and the number of people aged 65 and over has increased substantially, by approximately 53% since 2008. Flawed, costly and damaging Government policies over the past decade have been instrumental in driving our highly trained medical specialists abroad. In particular, the ongoing pay discrimination imposed by Government on Consultants in October 2012 has resulted in a ‘decade of despair’ for Irish patients because they are denied timely hospital treatment due to the increasing shortage of hospital Consultants.

The number of people awaiting an outpatient appointment has increased by 240,000 over the past decade since the pay inequity was imposed – an increase of 62%. It is important to remember that behind every waiting list statistic is a person and a family seeking healthcare, often while experiencing pain, suffering, and the psychological distress at not knowing when they will be able to receive treatment. Sadly, this can also be a matter of life and death. Despite the immense pressures placed on those on the frontline at the height of Covid, there was a semblance of hope that its impact would be a catalyst to finally tackle the obvious problems.

Instead, another year and momentum has been lost, resulting in worsening patient wait times that could deteriorate further over the winter months. It is still unclear how bad this year’s flu season will be, on top of growing Covid challenges. The concern is that we could see an increase in people coming to hospital with severe symptoms, resulting in further increased pressure on an already overstretched public hospital service. This could result in the cancellation of thousands of planned appointments and procedures, further exacerbating the ever-growing waiting lists, which nationally stand at over 900,000 people, and leading to poorer outcomes for patients.

The provision of ¤169 million announced in the Winter Plan is welcome, but much of this funding had been previously included in existing allocations. The Association has grave concerns that it will not be nearly sufficient to address the magnitude of deficits in our public hospitals and the enormity of the challenges they face in the coming months. There needs to be a laser like focus on the two things every patient relies upon most: hospital beds and hospital Consultants. Unfortunately, this Winter Plan is unlikely to make in-roads in delivering the significant numbers required of both resources. Attempts by Government to tackle the waiting lists crisis also continue to fail because their plans do not address the core issue of the overwhelming capacity deficits including the severe shortage of Hospital Consultants and public hospital beds and other frontline facilities which are needed to provide timely, safe care to patients.

The  €350 million Waiting List Action Plan for 2022 has spectacularly failed to reach any of its targets and shows the Government has run out of ideas when it comes to tackling the record public hospital waiting lists. The fact that just half of this  €350 million allocation could be spent was not a surprise to the Association, as the Action Plan was based on the false premise that as much as 25% of the backlog of care could be outsourced to the private system. This was always questionable in view of the capacity limits in the sector. Funding should be provided to expand the capacity of public hospitals to ensure sustainable, workable solutions to waiting lists and trolley problems, which are now a yearround problem. This summer record numbers of admitted patients had to be treated on trolleys while waiting for admission to a hospital bed because our wards were full.

This was the worst June and August for ED overcrowding in the past 16 years, and the second worst September on record. It is now expected the situation could get significantly worse as we face into a potential ‘twindemic’ of flu combined with further expected Covid cases. Talk of ‘prioritising’ the opening of outstanding hospital beds already promised but not delivered will not address the problem or the impact of bed shortages on patients in our wards this winter.

There are still 250 inpatient beds to be opened as part of the additional 1,146 hospital beds which were funded and committed to two years ago in Budget 2021. In fact, what we need is an additional 5,000 hospital beds by 2030 to meet current and future demand. Plans to recruit an additional 50 Consultants in Emergency Medicine will also have little to no impact this year given the average timeline of over 500 days to recruit a Consultant. This means if any candidates are found, they may not even be in post to deliver on next year’s Winter Plan. We have a chronic Consultant recruitment and retention crisis in all specialties and regions with over 900 (22% of the total) permanent posts across the country not filled as needed.

We know what the problems are, and we know what it takes to fix them: fill these vacant permanent Consultant posts, open the required number of public hospital beds and other facilities on a properly resourced and staffed basis. The Consultant contract negotiations, which were ongoing at time of writing, need to result in a contract that will work in practice. Those negotiations must restore trust by honouring the ‘unambiguous commitment’ made by the Minister for Health Stephen Donnelly to end the 2012 pay discrimination. It is astonishing that the Government keeps trying to impose decade-long discriminatory terms on new Consultants and expects a different outcome.

Such action is in stark contrast to the collaborative and supportive terms which consultants experience in other countries which are successfully competing in attracting an increasing number of our highly trained specialists to pursue their careers abroad instead of in our public hospitals. Unless an attractive contract is agreed with the Association, our public hospitals will not fill the 900 existing vacant posts, not to mention the thousands of new Consultant positions that are needed. The onus is now on the Government and the Health Service Management to provide attractive working conditions in our health service, for our existing Consultants, our Consultants in training and the new medical talent we need to attract into permanent posts.

If the opportunity is not availed of it will be lost to the detriment of the population that depends on public hospital services. The health service is at a critical juncture as we approach 2023, with decisions made around both the Cabinet and the negotiation table pointing it in one of two directions. One direction involves implementing the practical, sustainable solutions as proposed by the Association; the other ignores the practical, workable solutions resulting in unacceptable waiting times and poorer patient outcomes.

It is time to restore trust through collaborative engagement by the Government and the health service management with the Association and its frontline members who provide medical and surgical care to over 6 million people annually in our public hospitals. Agreement on a new Consultant Contract that is as attractive as possible for current and future cohorts of Consultants is vital for these 6 million patients and for the additional 1 million people awaiting care.

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