Hospital overcrowding: Is adding more beds really the solution?

Perhaps we should christen the first week of the year National Trolley Week, so constant a fixture has hospital overcrowding become.

This past week has exceeded all expectations, with Minister for Health Stephen Donnelly blaming a “perfect storm” of flu, Covid and other respiratory viruses as a new record for patients waiting for admission to hospital was set.

As the Minister blundered into a row with consultants over off-roster working, almost 2,000 patients waited for more than a day for a bed. They included 70-year-old Pat McCarthy, who spent 57 hours sitting on a chair, oxygen flow attached and using her coat as a pillow, before being admitted to Cork University Hospital. “I didn’t sleep a wink,” she told The Irish Times.

Patients’ misery is set to continue with weeks more of the current flu wave projected; the 1,000 trolley mark may even be breached.

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The flip side of the focus on trolleys in January is that the problem gets ignored for the rest of the year. Back in 2006 then minister for health Mary Harney said long waits on trolleys were “not acceptable”; Taoiseach Leo Varadkar said exactly the same this week. Little seems to have changed, and many of the solutions put forward this week have a familiar ring.

Adding more hospital beds is the most commonly touted solution, though it will do nothing to ease pressure in the short term.

We have fewer hospital beds than we had in the 1990s, despite a massive increase in population. But modern medicine reduced its reliance on traditional beds as high-volume procedures could be done quicker, often without the need for overnight stays. Countries across Europe have cut their bed numbers, with the lowest ratios seen in Scandinavia.

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According to Dr Brendan Walsh, senior research officer with the Economic and Social Research Institute (ESRI), there has been significant investment in beds and staffing since the Covid pandemic, but from a low base. “We’re back where we were in 2012, and still among the lowest in Europe.”

Considering over-65s, who now account for half of all bed-days in Irish hospitals, there has been a slight decline in provision relative to population, according to Walsh.

Yet the trolley problem varies hugely in scale across different hospitals. The worst-affected hospitals regularly claim they are shy of resources but HSE boss Stephen Mulvany said this week that not all the variations in performance could be explained by resource allocation.

Throughout this week of chaos, University Hospital Waterford (UHW) had not a single patient on a trolley, according to the HSE’s daily count. (It had eight trolley patients on Wednesday and three on Friday, according to the separate count by the Irish Nurses and Midwives Organisation.) UHW hasn’t registered a trolley patient with the HSE for more than 1,000 days.

The hospital is as crowded as many others – it housed 65 patients above bed capacity on Thursday, when I spoke to general manager Grace Rothwell. But none of these patients had to endure the indignity of waiting on a trolley bed or chair.

“I don’t think it’s appropriate to have an emergency admission on a trolley in ED. The minute you do that one day, it doubles in number over days and days and days.”

Rothwell says the hospital focuses on managing demand in its emergency department, ahead of all else. “We don’t have the beds to do everything. They are the emergency admissions. They are the people who need to be admitted.”

She freely admits there are losers with this approach; elective work gets cancelled, chemo is delayed and sometimes consultants get frustrated when they struggle to admit a patient.

The hospital’s day ward has been used for inpatients “for months”. “Our approach is to use every available bed. I don’t distinguish between beds for this, and beds for that. A bed is a bed and if a patient needs the bed, the patient gets it.

“We staff as best we can. We use overtime, we do whatever it takes. If there’s no dialysis on tonight we pull the dialysis nurse over to ED. If paeds are less than [full] occupancy, we might pull a paeds nurse. We supplement nursing staff with healthcare assistants.”

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A senior manager was on-site at UHW every day over Christmas. Rothwell says it contracted off-site nursing home beds two years ago and these have been “a lifesaver”.

“We’re not for one minute problem-free. But we put our hearts and soul into this space. And that takes huge effort and huge commitment on a personal level. But that’s what we do because to us it’s a patient safety issue.

“We drive all the things to make sure that there’s no delays in the patient journey,” she explains. “This morning, every ward is looking to see who they can send home, are they waiting on bloods, when will they finish their IV antibiotics, are they waiting on a physio review.”

She was asked this week about people waiting in ambulances to get to bed. “That’s another misnomer: people don’t arrive in ambulances to go to bed. They arrive in ambulances to be seen in ED. You can only see people in order of clinical need.”

Mr Donnelly responded to this week’s crisis by appealing to consultants to come in at nights and at weekends and the HSE later told hospitals to introduce seven-day working for this month.

“We do this anyway,” Rothwell responds. “Staff don’t need to be told to do it. Making people come in seven days a week will mean staff are going to be exhausted and will go sick.”

She says managers at UHW have no problem ringing consultants if the weekend is going to be busy. “We get the junior doctors to meet on a Friday, to identify persons potentially for discharge over the weekend. We get diagnostics to focus on inpatients, not outpatients. All of these things are common sense.

People are dying unnecessarily all the time; it just gets worse in winter

—  Dr Bill Tormey, veteran doctor and former politician

“What we do works for us,” she stresses. “It’s not a one-size-fits-all solution for every hospital. It’s leadership, management and teamwork. Everybody in the place works together to do the same thing.

“I wouldn’t get through a day here without the staff. We work really hard. We’re no different from any other place. But we manage things differently.”

Veteran doctor and former politician Dr Bill Tormey suggests “we need to do things that are unthinkable” to deal with the hospital overcrowding crisis. “People are dying unnecessarily all the time; it just gets worse in winter.”

Tormey believes county coroners should be “kicking up a stink” about deaths linked to delays in hospital treatment.

In the short term, the State should buy or lease hotels to accommodate the excess patient numbers, he suggests. (Hospitals in the southwest of England are discharging patients to private “care hotels”.)

Retired GPs could be brought back into the workforce to provide telemedicine sessions and relieve the pressure on primary care, according to Tormey, who is editor of the Irish Journal of Medical Science and has just written a book on the Irish health service.

Not everyone is convinced that extra beds is the way out of this crisis. “Acute hospital beds are very expensive. There’s a casual call for more of them, but I’m uncertain this is the right thing to do. We need to use our existing infrastructure more wisely,” says Dr Brendan O’Shea, a GP in Kildare and assistant adjuvant professor in public health at Trinity College Dublin.

“It would be far more preferable if I could admit a significant proportion of my patients to a local nursing home and then have them looked after by a GP with a special interest in nursing home care.”

O’Shea works in a three-doctor practice that typically sends three-six older people for admission to hospital each week, but he feels many of them would fare better in a local nursing home.

“If we had a little bit more time, we could look after the classic frail, elderly admissions such as COPD, heart failure or diabetes exacerbations, particularly if that could be supported by telemedicine from the department of gerontology in the local hospital. We have lots of nursing home beds, and we’re not using them as smartly as we could.”

While trolley numbers mounted this week, there were never fewer than 500 well patients waiting to be discharged but still occupying beds. Delays in finding nursing home places and other stepdown options are a major factor.

“Open up those facilities and we’d have an extra 500 beds tomorrow,” says one administrator. “Yet there’s never the same urgency about community services; they’re a Monday to Friday service.”

Tormey proposes a partial reversal of policy in relation to smaller hospitals in Ennis, Nenagh and Navan to allow sicker patients to be treated there, while rapid-build primary care centres could be constructed alongside the bigger hospitals.

He suggests doctors should be paid extra allowances to work in hospitals such as Sligo or Letterkenny, which traditionally struggle to attract staff.

Can we understand that a dry tickly cough going on for two weeks on its own is not a serious condition? Ask yourself seriously whether you’re seriously sick or not before professionalising the problem

—  Dr Brendan O’Shea, a GP in Kildare

Patients were hurting this week, but so were staff. “Bad stuff happened in EDs all around the country over the Christmas period. It didn’t need to be this bad. Real people suffered and died,” according to one Dublin hospital doctor.

“I despair for my nursing, medical and HCP colleagues in hospital currently – this is “trench medicine” at its worst,” says Cork GP Dr Mike Thompson.

“There are no easy answers, certainly no quick or cheap ones, but we need more beds, more social care and more rehab. Our population ‘pyramid’ is becoming a rectangle – demand is overwhelming, capacity is finite, we are still firefighting illness and we are so, so far from a wellness model.”

The simultaneous presence of flu, Covid and other respiratory ailments is the “new normal” that we have to adjust to, infectious diseases doctor Paddy Mallon said this week.

O’Shea says there is “nothing new” about the ailments he is seeing in patients at present. Patients can protect themselves through immunisation, treat basic symptoms by consulting reliable online information, and taking fluids and paracetamol. “Can we understand that a dry tickly cough going on for two weeks on its own is not a serious condition? Ask yourself seriously whether you’re seriously sick or not before professionalising the problem.”

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He says many people attending his clinic haven’t tried these options first. “Even more so with the emergency department: it’s not the department for minor illness but a significant proportion of the population tend to use it like that.”

The lack of IT in our hospitals is a bugbear for O’Shea. “In 2023, most of our hospitals are still administered on paper. This means we’re always dealing with today’s problems, informed by last year’s data. When you go into the hospitals, it’s a struggle to find data anywhere, so you can’t identify the inefficiencies or remedy them in a timely manner.”

Ireland has too many hospitals, he believes. “We have about 28 hospitals all claiming to be the best they can be as acute hospitals. If the smaller half of them were reconfigured as ambulatory care centres for the frail and elderly and were to set aside their ambitions to be centres of excellence for surgery, neurology, respiratory medicine, etc, you would see an immediate improvement.”

The number of GP training places is being ramped up but it will take some years for the additional workforce to come available. Before then, O’Shea says more general practice nurses and technicians could be provided to perform much of the testing and other work carried out by a GP.

Because of high occupancy rates – hitting 118 per cent in Sligo this week – hospitals lack “breathing space” to relieve overcrowding and minimise cancellations, Brendan Walsh points out.

“Until we reduce bed occupancy, we’re likely to see similar levels of overcrowding next winter and beyond.”