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Despite HSE claims of record staff numbers, unions say hospital levels are insufficient

Management says nearly 25,000 more health workers than in 2019 but unions argue posts vacant at the end of last year have effectively been suppressed

Unions, which have been demanding the end of a recruitment embargo, contend that the HSE’s approach means the suppression of posts vacant at the end of last year. Photograph: iStock
Unions, which have been demanding the end of a recruitment embargo, contend that the HSE’s approach means the suppression of posts vacant at the end of last year. Photograph: iStock
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Martin Wall
Mon Jul 22 2024 - 06:00

In an email to his managers last week, Health Service Executive chief executive Bernard Gloster said the health service never had as many staff.

He said in May, there were 127,325 whole-time equivalent personnel on the books – a net growth of 24,200 over those employed in 2019.

Gloster’s email was just the latest health service document to highlight an expanding workforce.

Last week, Minister for Health Stephen Donnelly published data showing the growth in numbers employed in individual hospitals.

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For example, between 2019 and 2023 in University Hospital Limerick – a facility beset by chronic overcrowding – staffing levels increased by nearly 40 per cent.

A Department of Health report in April said between 2016 and 2022 the number of nurses and midwives increased by 26 per cent from 20,902 to 26,494.

But some working in the health service argue that despite the Government’s claims of increased personnel, hospitals are still considerably understaffed.

The Irish Times spoke, on the basis of anonymity, to a nurse manager in a centre which sits high up in the table of hospitals which have seen significant increases in staffing.

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Asked whether it seems on the ground that staffing has risen by over 25 per cent, the nurse manager replied:

“Absolutely not. The Government may say that there are more staff. But our daily life as nurse managers is that we just do not have an adequate number to look after the number of patients that are coming in on a daily and annual basis. There are just not enough to provide safe, quality care to everyone that comes in.

“So if I say that I need 10 nurses on a shift tomorrow morning and when I go on duty there are just six, what happens to the patients that the other four were meant to be looking after?

“[This] means each nurse has more patients to look after, so therefore there’s going to be missed care. There’s going to be the patient that is deteriorating and who is not going to be noticed for a longer period of time.

“If somebody falls out of bed, you’re not going to notice they’ve fallen out of bed for a longer period of time. If somebody is bleeding or haemorrhaging, you’re not going to notice that for a longer period of time. All of the research tells us that the fewer nurses you have on duty, the less care and the worse the outcome is for the patient. ”

Gloster’s email said that a highly controversial embargo on recruitment, which had been in place since last November, was being ended.

The Government had a few days earlier agreed to provide a further €1.5 billion this year and a commitment for an additional €1.2 billion in 2025.

[ HSE recruitment ban to end soon, Bernard Gloster tells conference ]

This cleared the way for the HSE and the Minister to agree on its workforce plan for the year.

The six HSE regions can now manage their own staffing allocation within an overall ceiling.

But there will be tight controls. Only about 10 ten people will have authority to add staff to the HSE payroll.

Unions, which had been demanding the end of the recruitment embargo, contended that the HSE’s new approach actually meant the suppression of posts that were vacant at the end of last year.

Siptu asked: “Were the posts that went unfilled in 2023 fully funded? And, if they were, where was that money spent?”

Gloster said apart from new personnel for additional developments this year, the HSE staff ceiling would be 125,420 – the number of occupied posts at the end of December 2023.

The general secretary of the Irish Nurses’ and Midwives’ Organisation, Phil Ní Sheaghdha, said the HSE had simply guillotined posts that were vacant last December.

“We reckon cumulative vacancies were just under 2,000 in December 2023. And when you guillotine like that, you lose a lot more posts.”

Ms Ní Sheaghdha said that while there had been a growth in employment, there had also been a large growth in services. She said that since Covid there was a whole new outpatient-like service in the community.

[ HSE spends €4.2bn on outside agency staff since 2013 ]

“Hospitals have become really busy. We know that on wards every single day and night, there are huge [staff] shortages.”

Ms Ní Sheaghdha pointed to a Government-agreed framework on nurse staffing levels. She maintained that health service management “admit themselves that they have not been able to roll that out fully in the in the level-four hospitals, which are the large hospitals, because of the turnover and because of the vacancies arising”.

She said there should be one midwife for every 29.5 births but that recent figures suggested that in some cases the real number was one for every 45 births.

She said a recent study maintained that a ratio of one nurse to four patients on a general acute hospital surgical or medical ward was safe but that when ratio became one nurse to six patients or more, it was not safe.

“We breach that on a daily basis in our services.”

However the assertion that safety on the wards is determined by the ratio of nurses to patients is disputed in the Department of Health.

“The department does not focus on ratios,” one senior figure said.

“The evidence on ratios doesn’t actually include safety in its full context.

The department looks at a different system “which we have based on thousands of hours of observational studies on thousands of patients in a surgical and medical environment, where you look at what the nursing needs for those patients are.

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“So for Ireland and for our hospitals, the nursing-hours-per-patient day is a much safer way to estimate and determine nursing staffing levels in general and medical wards. And there is a much bigger proven bank of evidence behind it rather than just a blunt instrument of ratios.”

“So we know that the general surgical patient, on average, needs around five hours of nursing care in a 24-hour period. So if you have 20 patients on your ward, you can calculate that up so that you can staff your ward safely, knowing that you have that kind of nursing workload. If a patient deteriorates, and you need extra hours, you can factor in a calculation.”

So how many healthcare workers does Ireland need?

Two years ago, the Economic and Social Research Institute forecast that by 2035 Ireland would require up to 3,236 more doctors and up to 8,868 more nurses and midwives.

However, UCC health economist Brian Turner pointed to difficulties in projections keeping up with actual population growth.

He said the ESRI suggested that projections in the earlier Sláintecare reform document and a 2018 health capacity review would be insufficient to meet growing demand.

“The capacity review was based on population projections, projecting out from the 2016 census. However, in the 2022 census, by then we were pretty much where they had predicted for 2026. So our population has grown even faster than they were anticipating.”

[ Health regions to be allowed recruit staff up to new ceiling ]

He maintained the Irish population was not only growing but getting older.

“Another thing I’m not sure has been fully taken on board by policymakers, not just not just here, but internationally, is antimicrobial resistance.

“So basically, the antibiotics that we have are becoming less and less effective, and we don’t have a sufficient pipeline of new antibiotics.

“If we can’t rely on our antibiotics any more, things are going to have to change. So again, we saw during Covid the idea of trying to isolate patients from each other. So we may end up having to do that on a long-term basis, if and when antimicrobial resistance really kicks in. So again, that’s going to have implications in terms of the workforce.”