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The bed debacle

Anyone who holds the view that there are enough beds in the Irish health system should not be allowed to be involved in any part of healthcare organisational planning. There is evidence from every quarter that bed shortages in all areas of the service are one of the main factors contributing to the problems that bedevil our health service. There is insufficient bed capacity in emergency care, ICU and high-dependency care, care of patients with aged-related complex diseases, rehabilitative care after disabling illness and injuries, step-down convalescence care and long-term nursing home care.

Bed capacity reviews are important and should be carried out yearly or biannually to ensure that the correct number of beds is available for current and future needs. If previous bed capacity reviews had been fully implemented, the Irish health service would not be in the awful position that it is in year-on-year.

If there is an emergency trolley queue, which varies between 200 and 600, then every day there is a corresponding acute bed shortage. If there are delayed discharges of between 400 and 800 patients every day, then there is a shortage of ongoing care beds outside the acute hospital setting. If the population is increasing and people are living longer, there is going to be a necessity to match this demographic change with yearly corresponding increases in bed capacity. When you calculate the unmet need of patients waiting for planned admissions, now at almost 100,000 and increasing, you can begin to appreciate the bed capacity deficit that exists. The effective bed shortage is increasing annually and the knock-on effects this has on delayed treatment and poorer-quality outcomes are obvious. However, additional beds need to be resourced and staffed by doctors, nursing staff and support workers.

How could this bed capacity deficit develop? The answer is multifactorial and should have been predictable. The reconfiguration of hospitals, which resulted in smaller hospitals suffering bed closures and loss of services, was not matched by opening additional beds in the centres of excellence. Demographic age increases were ignored. The HSE policy of reducing their pool of community beds in public nursing homes, while encouraging the expansion of private nursing homes, substantially reduced the capacity of the HSE to appropriately place patients in ongoing care beds as needed. Thus bottlenecks have been created at entry to and exit from acute care beds. Ireland has now 33 per cent less beds than the OECD average.

Insufficient bed capacity is compounded by the HSE failing to invest in primary community healthcare provision, including effective home care support in terms of public health nurses, community occupational therapy, physiotherapy, chronic care provision by primary care teams and development of the ‘hospital at home’ concept supported by the expansion of community intervention teams. Under-resourced community services lead to increased avoidable admissions of mainly elderly patients, who have longer admissions and delayed discharges.

Patient flow through the hospital system is additionally prolonged by nursing staff shortages, limited access to diagnostics where demand outstrips supply, access to operating theatres, and a shortage of senior decision-makers with the experience to make effective and efficient decisions.

Most patients spend just a small fraction of their lives in hospital. What happens before and after their hospital stay is far more relevant to their long-term health. Yet hospital care, because it is acute care, attracts most of the funding and headlines, while community care, which has greater importance, commands less resources and attention.

A given population whose demographics are known will have a statistically predictable incidence of illness every year. We will not know who will become ill but we can predict the numbers affected by differing categories of illness. Thus, we can reasonably accurately predict the healthcare needs for acute unplanned illnesses, anticipated planned admissions for treatment, mental health illness, chronic complex illness, rehabilitation, cancer, and long-term care at home or in long-term care settings.

We know with predictable certainty that respiratory infections and influenza occur every winter and we can plan for that by freeing-up beds to cater for the short-term surge of admissions. Required bed capacity, staff and support services to deal with mostly predictable volumes of illness should be relatively easy to calculate. Building in a safety margin that can be adjusted yearly will give an accurate target for service provision.

Irish hospitals work at 95 per cent capacity, while maximum efficient capacity is deemed to be 85 per cent and the OECD average hospital capacity is 77 per cent. Excess capacity leads to poorer outcomes, increased hospital-acquired infection rates, increased re-admission rates, overall inefficiency, poor working conditions and job satisfaction, increased staff burnout, and recruitment and retention difficulties.

A vicious circle is created where every poor planning decision has a knock-on effect on other parts of the health service, resulting in paralysis and stagnation.

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