Such was its splendour when it first opened to patients 20 years ago that local wags dubbed it the Wilton Hilton. But now they look at Cork University Hospital in rather a different light.
If admitted now to the biggest hospital in Munster you're lucky to get a bed. You could spend 18 hours on a trolley, be delayed in going to surgery because there will be no bed on the return from theatre or be transferred from ward to ward due to lack of space.
It is a traditionally quiet time of year for hospitals, but most days at CUH, where there are 552 beds, staff are trying to cope with up to 40 extra patients. They just keep on coming. Unlike the big Dublin hospitals, this one is constantly on call, and every day brings an influx of new patients.
The hospital's general manager, Mr Tony McNamara, is proud that he oversees the most efficient hospital of its size and scale in the State, employing a staff of 2,000 and treating about 30,000 in-patients a year. However, he acknowledges that management faces an "exceedingly difficult" task in trying to solve the overcrowding problem.
The pressure on bed availability is similar to that experienced in virtually every other acute general hospital with a large accident and emergency department, treating 50,000 patients each year, and a widespread number of specialities dealing with trauma and elective admissions, he says. The hospital has an annual budget of £54 million.
The hospital is the only one in the board's area, he points out, with the range of specialities to meet the requirements of a Level 1 trauma service, including orthopaedics, plastic surgery and chest trauma facilities.
It is also the only centre dealing with cardiac surgery, neurosurgery and plastic surgery. All this places further pressures on the available beds.
"It is an overall testament to the success of the hospital that it continues to be the most efficient hospital of its size on the basis of the case-mix data available," says Mr McNamara.
There are many who feel the hospital gets a raw deal in budget terms, and lacks political clout. Mr McNamara says this is like "comparing apples with oranges", but agrees that, relatively speaking, the hospital is under-funded. Because of efficiencies relative to other big acute hospitals, it has, however, benefited from an additional £2.5 million from the Department of Health in recent years.
A 1996 Comhairle na nOspideal report showed that consultant staffing levels in the hospital were significantly lower than elsewhere, with some key departments, such as cardiac surgery, dependent on a single consultant. This has since changed, but a number of positions remain to be filled.
A lack of capital funding is apparent from the hospital's appearance. The secretary-general of the Irish Hospital Consultants' Association, Mr Finbarr Fitzpatrick, believes the hospital needs capital funding of £120 million, on a par with University College Hospital Galway. "Its current budget should be increased to allow it to play its role as the largest single hospital complex outside Dublin," says Mr Fitzpatrick.
As far as the nursing staff are concerned the overcrowding has gone far enough. They voted in recent weeks for industrial action. According to Ms Mary Power, industrial relations officer with the Irish Nurses' Organisation, the stresses on nurses just keep mounting.
"It's been going on for years really," she said. "It gets alleviated from time to time but that rarely lasts long." Measures have included the appointment of a bed management committee, which reported late last year, and in recent weeks a bed manager. "We always end up having to threaten some kind of action." Nurses believe, she said, that proper patient care cannot be delivered in such conditions. "Extra beds placed in treatment rooms in the middle of wards, in day clinics, on trolleys in the A&E department with no facilities, no privacy and no extra staff, is unacceptable and should not be occurring.
"Nurses cannot provide a first class service in a second-rate environment. Nurses do not like treating them in what are supposed to be sitting rooms, in cubicles or on trolleys. If you are going to have extra beds you need extra nurses," says Ms Power.
The nurses voted overwhelmingly in support of limited industrial action in June, designed, she says, to free them from non-nursing elements of their job. "We can't do everything," says Ms Power. They have now agreed to defer their action until October. Mr McNamara seems irritated by questions on how the overcrowding crisis can be solved. He prefers to describe it as a "bed management process". "Maybe you can show me how to solve it. How can it go away? Patients are presenting with problems which we must treat. Do we move back from new medical developments?" he asks. It is not, he points out, a simple problem. "As with many other things it is multidimensional."
While it is the hospital's policy to live within its bed complement, the professional judgment of the hospital consultant has to dictate when it is safe to admit or discharge patients. "Inevitably, circumstances arise where this can only be done by accommodating additional patients and providing the resources necessary to facilitate optimum patient care."
Despite the assertions of the INO, Mr McNamara says that where additional beds have to be erected in non-designated bed areas of the hospital, additional staff are employed "where existing staffing levels are inadequate to meet the needs".
One hundred new nurses will be appointed over the next two months. Mr McNamara says the unions have accepted that a "comprehensive" strategy is in place to deal with the problem. However, Ms Power says that on balance she believes the threatened industrial action will go ahead in October.
The problems are compounded by a number of factors, according to the INO. A number of beds - up to 30 at any one time - are taken up with chronic young sick and elderly people, awaiting transfer to appropriate facilities. Consultants, they say, are bringing in patients up to five days before their treatment or operation for tests which could be done on an out-patient basis. The appointment of additional consultants causes an increased demand for beds.
A patient's discharge should be planned as soon as the patient is admitted, they say, examining whether they will need community support or continuing residential care. They want consultants to delegate authority to discharge patients to their registrars. Mr McNamara said there was some anecdotal evidence about consultants blocking beds with their own patients, bringing them in days before a procedure for tests. In an effort to ascertain if this was true they carried out a review which would be completed at the end of next month. As far as the appearance of the hospital goes, Mr McNamara says criticism is valid but a significant improvement should be seen shortly. Much criticism has also been voiced in recent years concerning the conditions and staffing levels in the hospital's A&E department.
According to the general manager, approval has been given by the Department of Health for a new £5 million department and additional staff, which is at an advanced stage of planning.