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Government must avoid mistakes of the past and fund promised health service expansion

By Mr Martin Varley - 24th Sep 2023

health service expansion

There is now a real opportunity to address longstanding capacity deficits in our health service, writes Mr Martin Varley, Secretary General of the IHCA

Mr Martin Varley

The State’s coffers may be in very good health, but it is uncertain whether the forthcoming Budget will provide the health service with the funding it needs to end decades long, growing capacity deficits. Funding and clear time-bound plans to rapidly increase public hospital and mental health service capacity are required to ensure timely care for patients. Not to do so at a time of historic exchequer surpluses would be a major mistake. 

The Government must use some of the exchequer surpluses of €26 billion this year and next year to provide funding in the October Budget for the Minister for Health’s promised 1,500 additional acute beds, four elective hospitals, and six surgical hubs.

Public hospitals are suffering from decades of underfunding and deficits that are preventing the provision of timely care to patients. These deficits involved both physical capacity and consultant staffing levels.

The population has grown by 15 per cent since 2008 – or by an additional 664,000 people – and now surpasses 5.1 million. The most significant growth has been in the 65-plus age cohort, which has increased by 60 per cent since 2008. This growth in the number of over-65s is more than three times the average level of growth of this cohort in the EU.

These demographic changes are increasing the demand for inpatient, day case and outpatient hospital care and mental health services. In contrast, over that same period since 2008, our hospital and inpatient bed capacity has increased by just 4 per cent (+587 beds), which is in fact a decrease of nearly 10 per cent on a population adjusted basis in this 14-year period, from 3.03 beds per 1,000 population in 2008 to 2.75 beds in 2022.

The overall problem is that the public health sector is very slow to get anything done in terms of providing the capacity that is needed in our hospital and community facilities. Deficits have been ongoing and growing for years and the difficulty is that the problems are not declining, but effectively being rolled over into larger and larger problems year after year. This is adversely impacting consultants, reducing the efficiency and effectiveness of their practice. As a result, patients are suffering, staff are burning out, there are an increasing number of patients being treated on trolleys, waiting lists are increasing, and hospital appointments being cancelled.

€4 billion for capital projects

Now is the opportunity for politicians and the Government to expand capacity and deliver on their promises. Earlier this year, in a very welcome move for the patients of the country, the Minister for Health, Stephen Donnelly, announced his commitment to the rapid building of 1,500 additional acute beds, the opening of four elective hospitals and six surgical hubs. With the current exchequer surplus, the funding is there to implement these changes. As outlined in our pre-Budget submission in July, based on health service management broad indications, these projects could cost approximately €4 billion.

These projects would deliver a lot of extra beds, which are badly needed, provide additional theatre operating space and result in the provision of more timely care and a reduction in waiting lists. The acid test for the Government now is whether it provides funding for the Minister’s commitment in the October Budget. If it does not, then these announcements will be meaningless and there will be no progress.

It is also widely acknowledged that the public health sector is far too slow in implementing capacity expansion because there are too many steps and officials in the current decision-making process, from design to planning, contracting to commissioning, etc. The Minister himself has acknowledged this and indicated the need to reduce these steps and speed up the process, but up to now there has been no significant evidence of a change in the pace of decision-making, which is a concern.

In contrast, the private hospital system is capable of significantly expanding its facilities and opening fantastic new services in as little as two years. The public sector in many cases takes multiples of that time, and it can be up to a decade or more from the initial announcement to provide a new facility to its opening. An extreme example of that is the planned New Children’s Hospital.

This very inefficient system needs to be changed and seriously overhauled, otherwise the capacity deficits we have been living with will continue to grow and grow, to the detriment of patients and those working in our health service.

50 per cent increase in consultant numbers

The other significant capacity deficit in our health service is the shortage of hospital consultants. Ireland has the lowest number of medical specialists per 1,000 of the population in Europe. The number of medical specialists here is 34 per cent below the EU average. The HSE has acknowledged that a 50 per cent increase in the number of consultants is required by 2028 to address current shortfalls and meet increased patient demand. At our Annual Conference last year, Minister Donnelly also confirmed we need a 50 per cent increase in consultant numbers, to bring the overall number of consultants in post to around 6,000.

In addition to the above shortfalls, over 900 permanent consultant posts are not filled as needed, which is an increase of over 200 posts (28 per cent) in the past two years.  They are either vacant or filled on a temporary basis. This shortage of consultants is a key capacity deficit, resulting in longer delays for patients awaiting treatment. The deficit in consultant staffing makes Sláintecare waiting time targets unachievable. We must fill these vacant posts and recruit and appoint additional consultants without delay. The Association has called on the Government to appoint 2,000 additional consultants by 2030 – around an extra 300 annually.

The fact that so many consultant posts remain vacant should be an unequivocal signal to Government and health service management that the current conditions in our public hospitals do not create an environment in which skilled medical and surgical specialists want to work and which is driving our trained specialists abroad to pursue their careers elsewhere. The pandemic and hospital overcrowding crises have placed even more extreme work demands on consultants and other frontline staff. A survey of IHCA members in March this year found that seven-in-10 (69 per cent) consultants experienced symptoms of burnout due to work pressures in the past 12 months.

Consultant recruitment crisis

Doctors are migrating abroad due to excessive workloads and understaffing in our hospital services. New official figures from the Australian Department of Home Affairs show a total of 298 skilled visas granted to Irish doctors over the nine months, between 1 July 2022 and 31 March 2023. The number of visas granted to Irish doctors in a full year has more than doubled in the past decade, increasing from 173 in 2012-2013 to a record 442 in 2021-2022 – a 155 per cent increase. 

Evidence of the consultant recruitment crisis include the fact that no appointments were made in 86 out of 252 completed competitions run by Public Appointments Service (PAS) in 2022. These difficulties in filling consultant posts have continued this year. The number of advertised completed PAS posts up to mid-June 2023 indicated only 13 of 31 posts had been filled – that is 42 per cent of the advertised posts.

Mental health service deficits

The deficits in the mental health service are also extremely challenging, with the services operating with an insufficient number of beds and with mental health teams in many areas only staffed to approximately 50 per cent of the level recommended in A Vision for Change, which was published in 2006.

The number of beds for child and adolescent services needs to be more than doubled from the current 50 to at least the 130 recommended in 2006, and adult psychiatric beds also need to be increased significantly.

The consultant recruitment and retention crisis has continued to deteriorate with almost one-in-three (174 posts or 32 per cent) approved consultant psychiatry posts currently vacant or filled on a temporary basis. The increased number of unfilled child and adolescent psychiatry posts has contributed to around 4,400 children on the child and adolescent mental health services (CAMHS) waiting lists at the end of May. This is almost a quarter (865 or 24 per cent) more children waiting for treatment compared with the start of 2022 and almost double (+2,094 or +90 per cent) the number on the CAMHS waiting list at the start of 2020. The recent Mental Health Commission CAMHS reports underlined once more the scale and severity of the deficits faced day-to-day in our child and adolescent mental health services.

In addition to addressing the capacity deficit outlined above, there is a pressing need to re-structure the provision of public health services. This includes the need to put in place ICT equipment and software systems which are fit for purpose, in comparison with the current antiquated systems operating throughout our acute public hospital and mental health services.

New Health Regions

The Association supports the restructuring of healthcare services to ensure greater alignment between community and hospital healthcare services, based on common geographic areas with the full integration of these services. But the new HSE Health Regions, due to commence operation from next February, need to ensure that in addition to responsibility and accountability, authority is delegated to local hospitals and mental health services. The HSE CEO has acknowledged the current system is top-heavy with cumbersome processes. 

It is worth reiterating that public health services are facing enormous challenges due to lack of investment over several decades. There is now a real opportunity for the Government to address these deficits, especially in the light of the large exchequer surpluses at its disposal this year and forecasted for future years.

Our Association is actively engaging with health service management and politicians to have the practical and workable solutions outlined in our pre-Budget submission implemented.

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