At the root of the problem
See below column from Medical Independent on 22 January 2015
As the numbers of people on trolleys in emergency departments reached a record high in the first week of January, there was much commentary on the causes and consequences of so many people waiting too long on trolleys.
Among the causes identified was the persistently high numbers of delayed discharges in public hospitals. These are people who are clinically well enough to be discharged but do not have a place to go, so they stay unnecessarily in hospital. The absence of adequate community support services, step-down and rehab facilities, as well as nursing home places, all contribute to the high numbers of delayed discharges.
In the last budget, Minister Varadkar and the HSE secured extra money to deal with the critically high numbers of delayed discharges, which came into effect on 1 December, 2014. At the beginning of December 2014, there were 828 delayed discharges. By the end of the month there were 719 delayed discharges, a decrease of 109 from earlier in the month. Good progress but not enough.
So are there sufficient home care packages and nursing home places to meet the needs of those who have to move out of their hospital beds?
There were 850 home care packages provided nationally in November 2014, of which approximately 45 per cent were for people being discharged home from hospital. Figures are not available for December but global figures are.
There was an increase in the numbers of people receiving home care packages between 2010 and 2014, from just under 12,000 to 13,800. However, there was a reduction in the numbers of hours provided from 11.98 million to 10.3 million, thus spreading less care across more people.
It is more difficult to count nursing home beds, as the HSE only publishes figures on public beds, while Nursing Homes Ireland (NHI) — the representative organisation for voluntary and private nursing homes — publishes surveys of all beds. However, its public bed figures differ from the HSE figures. Using HSE figures for public beds and NHI figures for voluntary and private beds, there were 30,223 nursing home beds in 2010 and 29,773 at the end of 2014, a decline of 550. They also show an increase in voluntary and private capacity of about 2,000 and a decline in public beds of over 2,500.
So despite our growing ageing population, between 2010 and 2015 the provision of publicly-funded home care packages and nursing home beds declined. No wonder there are 700-800 people stuck in hospital beds.
While the HSE is focusing on reducing the numbers of delayed discharges, other measures such as cancelling elective surgery, moving trolleys from the EDs up onto wards, better discharge planning, as well as encouraging patients to seek care outside of hospital, are being progressed.
This matter of accessing care outside hospital is a long game. In order to keep people out of hospital, some services currently provided in hospitals need to be provided in the community. This will require a significant change in how services are provided, as well as investment in primary, community and social care services.
In the meantime, the INMO was looking for additional beds in hospitals and extra staff to look after the patients in extra beds. Hospitals were already opening additional beds and wards to meet demand.
Yet if we look at the figures, they tell a different story. HSE figures for 2010 show public acute hospital bed numbers at 11,872, whereas figures from the most recent HSE Acute Hospital Report say there are 12,504 public hospital beds — an increase of 632 beds.
Significant health warnings must be given to these figures, as the HSE stopped counting hospital beds in 2011. The Executive explained at the time that different hospitals were counting beds differently, and that it was going to do an audit of hospital beds and start counting them consistently. Hospital bed numbers reappeared in the 2015 HSE Acute Hospital Divisional Plan. Also in 2010, figures were broken down by public and private beds, whereas in 2014/15 they are broken down by day case and inpatient beds, as there is no longer a distinction in public or private bed designations.
An examination of the closed beds, as articulated by the INMO, shows that many of these beds are not acute hospital beds but community, or what were district hospital beds, which in effect serve as step-down and long-term community nursing beds. The failure to invest in these old units means many of these places are nowhere near meeting HIQA requirements, while thousands of them have been closed by stealth over the last five years.
These HIQA standards have been well flagged and come into complete effect in June 2015. Unless urgent action is taken to invest in the existing public units and bring them up to standard, many more of them will close and the delayed discharge situation will get worse, not better.