Running to stand still

My column from Medical Independent on 9 October 2014.

Minister Leo Varadkar has admitted that many key health service indicators “are going in the wrong direction”. He must have had sight of the July HSE Performance Report before it was published in the third week in September when he made that point.
This latest update on HSE performance confirms the dire state of the health service. It reveals that there were 10 per cent more people waiting on trolleys for hospital admissions in July 2014 compared with July 2013.

Figures already in the public domain show that this situation worsened in August, with a 19 per cent increase year-on-year of those waiting on trolleys in Irish public hospitals. There have been persistent problems with chronically high numbers of patients left on trolleys over the last decade. In fact, it is 10 years since Mary Harney published her 10-point plan to tackle the ‘A&E crisis’ and nine years since she declared ‘A&E’ a national emergency and set up a task force to find solutions.
It is not possible to call something a crisis or a national emergency if it has been a persistent problem for over a decade.

Trolley waits have become a perennial challenge of the Irish health system, a phenomenon largely unheard of in other health systems. There have been many efforts to address the issue during the decade, including the setting-up of medical assessment units and minor injury clinics to take the pressure off emergency departments, the formalising of homecare packages and under this Government, the establishment of a Special Delivery Unit — yet it is a problem that won’t go away.

EDs are a bellwether of the health system — people get stuck on trolleys in EDs due to problems and cutbacks across the health system. The July HSE report acknowledges the 2 per cent increase in emergency admissions, an increase in the numbers of people referred for outpatient appointments and hospital elective procedures, as well as persistently high numbers of delayed discharges.

In mid-September, there were 695 delayed discharges in Irish hospitals. The July report at least has the decency to acknowledge in its second paragraph that these people remained inappropriately in hospital and were not discharged to residential care, respite or transitional care “as the level of additional funding required to enable these discharges is currently not available”. It also recognises that this impacts on increased waiting lists and quality of care in hospitals, as well as clearly citing the huge budget and staff cuts imposed on the HSE through austerity measures.

In July 2014, there were 7,727 people waiting more than this Government’s own target of eight months for hospital treatment. This is 1,497 more than the same month last year but a whopping 7,724 more than in December 2013. Of course, it makes no sense to compare the July figures with the December ones, as money was thrown at public and private hospitals towards the end of 2013 so that the then Minister, James Reilly, could claim to have reached his own target.

But this was a false economy as Reilly’s chaotic reign failed to address the underlying causes of the waits and therefore, inevitably they went right back up. With many hospitals operating at over 100 per cent capacity, with a growing ageing population with a greater burden of disease, fewer staff and smaller budgets, hospitals simply do not have the capacity to meet need.

These hospital wait times do not include outpatient waiting times, which are also going in the wrong direction. In July 2014, 360,753 people were waiting for an outpatient appointment. Of these, 37,876 were waiting more than a year, up hugely from the beginning of 2014, when under 5,000 people were waiting that long. But again, that was just more unsustainable gaming by James Reilly, who instructed health managers to buy appointments for long-waiting public patients wherever they could.
The July outpatient figures are an improvement year-on-year, with a 57 per cent reduction of those waiting more than 52 weeks. However, critically, there are 60,000 more people waiting for an outpatient appointment and a 5 per cent increase in outpatient attendances when January to July 2013 is compared with 2014.

Meanwhile, delayed discharges have reached a standstill, at persistently in or around 600-700 beds. This is nearly 7 per cent of all hospital beds not available for use at any time in the system because there is not the money to place those people in the community or in nursing home beds. Some progress is detailed in the reports, such as absenteeism, which is at an all-time low.

This HSE report paints a stark picture of James Reilly’s legacy, the perfect storm that the Irish health service is stuck in and the enormous challenges facing Leo Varadkar.