Analysis: there are huge challenges involved in correcting the imbalance between supply of and demand for healthcare services in Ireland

As another year begins, a familiar problem has raised its head again. On January 3rd, the INMO Trolley Watch figures reached a new record of 931 patients waiting for beds in emergency departments (EDs) and on wards in Irish hospitals. Although the figures have reduced since then, EDs are still under pressure. So why were the figures so high this year - and how can this a perennial issue in the Irish health system be addressed?

Ultimately what we are seeing here is an imbalance between supply of and demand for healthcare services. If demand exceeds supply in most markets for goods and services, the price mechanism adjusts, leading to reduced demand and/or increased supply. However, there is no price mechanism in this case. In other areas of healthcare, rationing via, for example, waiting lists can be used to solve the problem, but this is not an appropriate mechanism when it comes to people requiring emergency care.

Looking at the supply side, the OECD figures from 2019 (the last set of pre-pandemic figures that we have) show that Ireland had 2.9 hospital beds per 1,000 population, compared with an OECD average of 4.4. Our acute care bed occupancy rate of 89.9% was also the third highest in the OECD, and above the recommended safe level of 85%. Although our doctor numbers per 1,000 population were only slightly below the OECD average, the proportion of specialists in Ireland was significantly below average (45% versus 65%).

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From RTÉ Radio 1's Morning Ireland, HSE says there is no certainty hospital situation won't 'get worse before it gets better'

Since then, Covid has had a number of effects. Firstly, many people delayed seeking care during the pandemic, or were unable to access elective care during some of the pandemic. There is therefore a pent-up demand that is now being felt as people seek that care, although in some cases their illnesses have progressed and require more intensive treatment. Secondly, new infection control measures in hospitals have impacted on capacity, and thirdly, the pandemic has affected healthcare staff through burnout and absenteeism (as many of them have caught Covid themselves).

This has led to a system under strain even at a baseline level. In recent weeks, this system has been put under even more pressure with a combination of another wave of Covid infections, combined with flu and RSV infections, leading to higher levels of presentations at EDs and other areas of the health services.

Ultimately, the solution to this problem will be increased capacity in our health service, some of which has been provided in recent years. Both Sláintecare and the Health Service Capacity Review called for significant capacity expansion, including 20% increases in hospital bed and consultant numbers (around 2,600 additional beds and nearly 600 additional consultants) and a 48% increase in the primary care workforce (one key reform proposal is to reorient the system more towards primary care).

But research from the ESRI, published since these proposals were launched and based on modelling of demand, suggests that even these numbers will not be sufficient. The ESRI forecasts that between 3,200 and 5,600 extra public hospital beds will be needed by 2030, along with additional private hospital bed capacity. Meanwhile, it also forecasts that significant additional workforce will be required, including increases of between 30 and 39 percent in consultant and non-consultant hospital doctor numbers by 2035.

One of the main reasons for these increased capacity requirements is that Ireland's population is growing and ageing more quickly than those in many other European countries. The 2018 Health Service Capacity Review projected a population of 5.139 million in 2026, and it was on this basis that its recommendations were made. However, the provisional Census figures show that our population in April 2022 was 5.124 million, so we almost certainly exceeded the 2026 projections by the end of 2022.

Bringing this capacity on stream will not be easy. In terms of physical infrastructure, the construction sector in Ireland is under strain, with a housing crisis, a massive public infrastructure programme and commercial property demand vying for scarce resources. This is reflected in an almost 50% increase in the tender price index between the first half of 2017 (when the Sláintecare report was published) and the first half of 2022 (before the full effects of the current round of inflation were felt).

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Meanwhile, recruiting and retaining staff will also be challenging. We are trying to attract medical staff in an ever more competitive market and international shortages of healthcare workers mean that they can be selective in where they choose to work. We have also seen examples in recent years of industrial unrest among healthcare staff surrounding pay and conditions in the Irish public health system.

In the absence of short-term increases in capacity then, the other alternative would be to try to reduce demand for services. In relation to the current ED pressure, one thing that we could do as a population is wear masks in crowded settings, something that the INMO has been calling for for some time now. This would reduce the spread of the airborne respiratory viruses and result in fewer ED presentations. While a small inconvenience for most people (acknowledging that some people have genuine difficulties wearing masks), this would be most welcome on the frontline of a very stretched health service.

The views expressed here are those of the author and do not represent or reflect the views of RTÉ