The controversial issue of bed capacity was hotly contested during the fifth of the series of Irish Times/Pfizer health debates
TWO OUT OF EVERY five patients in public hospital beds could be treated more effectively in the community, according to a leading health management consultant.
“Over 4,000 people are currently in hospital beds who don’t need to be there,” Paul Pierotti, PA Consulting Group’s head of health, told the fifth Irish Times/Pfizer health debate in Galway last week.
“We need to acknowledge that hospitals are not particularly good places for certain patients, with infection rates of one in 20,” he said.
He was lead author of a report for the HSE on acute bed capacity, conducted in 2007 and published in January 2008.
Mr Pierotti was speaking against the motion that “this house believes that Ireland has insufficient bed capacity to meet our healthcare needs”.
Also speaking against the motion was HSE director for quality, safety and risk, Dr Joe Devlin, while speakers in favour were Irish Nurses Organisation (INO) deputy general secretary, David Hughes, and Irish Hospital Consultants’ Association (IHCA) assistant general secretary, Donal Duffy.
The debate in NUI Galway was chaired by Irish Timesassistant editor, Fintan O'Toole.
The HSE/PA Consulting report found Ireland could do with between 2,000 and 5,000 fewer acute hospital beds if an integrated plan involving expansion of community health services and reform of hospital management was implemented.
Such improvements in hospital management should include increasing day case rates and undertaking diagnostic services in the primary care/community settings – rather than using hospitals as “waiting rooms” for diagnostics, he told the debate. “We need to stop thinking more beds will mean better health services,” Mr Pierotti said.
“Inappropriate admission” to hospitals is a major contributory factor to the current problems in public healthcare, Dr Devlin agreed.
Having worked until recently as consultant rheumatologist at Waterford Regional Hospital, he concurred that the current situation faced by many patients in public hospitals was “not acceptable”.
However, providing more acute beds was “not the answer” when those available were not being used properly, he said.
Dr Devlin cited the administration of intravenous antibiotics, the admission of patients for scans, and admission the previous day for minor procedures, as examples of situations where beds were being occupied unnecessarily – or for longer than was necessary.
Admitting people on a Friday for treatment which would not begin till the following Monday, and delays in releasing or discharging patients were other examples cited by Dr Devlin.
Mr Hughes, speaking for the motion, recalled that a report published by former minister for health Micheál Martin in 2002 had forecast the need for an additional 3,000 acute beds and 10,000 continuing care beds by 2011.
Subsequent reports, such as the HSE/PA Consulting study, had estimated that the service could manage with between 2,000 and 5,000 fewer beds, provided that an integrated health service was initiated, he said. He questioned how such figures could differ, and noted that some 10 to 12 casualty departments were in “constant crisis”, with people waiting up to 36 hours for a bed.
Referring to arguments made by the previous speakers, Mr Hughes said that day case beds had increased enormously, and resources were required for expansion of community health services. In relation to discharges, some people could not be moved from acute beds when step-down facilities were not available.
Mr Duffy said much of the debate was centred on the accuracy of the HSE statistics and the separate INO “trolley watch” figures, but there was no dispute on the panel about the shortage of beds overall.
Some 73 per cent of patients admitted to hospitals were due to emergency, so the potential for substitution to day case admission, which would reduce bed demand, was very limited, he said.
While there was a need for reform, Mr Duffy said, he did not see the HSE spending the money that is “so badly needed”.
During questions from the audience, former IHCA president David O’Keeffe asked the speakers to define what “beds in the community” meant, given that a patient requiring a routine cataract procedure might be depending on a limited bus service between Clifden and Galway, which would require an overnight stay.
Mr Pierotti said he accepted that in some cases, community care would have to “include beds”. Other countries such as Scotland and Canada managed many day cases in rural areas, he noted.
Dr Devlin said the State had finite resources, but “we can liberate those resources for accommodation or transport by eliminating inappropriate use of beds”.
Galway University Hospital’s (GUH) clinical director, Jack McCann, asked if there was a definitive number of beds for a population such as that in the west of Ireland. It was an area with one tertiary referral centre, also designated as a national cancer treatment centre with no extra funding for same, and an older population.
Dr Devlin responded that this was an issue of “reconfiguration”, and noted that Ireland was “not good at moving staff around from areas where their service was no longer needed”.
Mr Pierotti said beds were a “heck of a bad way to judge a health service” and, moving away from this: “If there is more demand, I agree that we need more capacity – but it’s how we provide that capacity,” he said.
Mr Hughes said the reality from the INO perspective was that hospitals would be overcrowded between October 15th and March 15th, and the concept of developing community services was “not new”.
The biggest single improvement in hospital management had been the introduction of medical admission units, but even these had begun to fill up, he said. “We’ve tolerated plans to beat the band, and then it is the patients who continue to suffer,” he said.
Mayor of Sligo, Cllr Jim McGarry (Lab), outlined a situation he had experienced with his own daughter who had been taken to hospital and had to wait for a bed. When a bed did become available, it was in a geriatric ward, which was unsuitable. Sligo General Hospital had lost 70 beds since 2007, he said.
Former Galway mayor, Cllr Padraig Conneely (FG), also asked if the panel would agree that HSE chief executive Prof Brendan Drumm was now a “lame duck”, given he had signalled his intention to retire.
He also said that a memo published earlier in the year, written by the retiring GUH general manager, had expressed concern that cuts in funding would make it impossible to meet commitments to become a cancer centre of excellence. This was a “terrible indictment”, said Cllr Conneely, who is chair of the HSE West regional health forum.
Responding, Mr Hughes agreed that Sligo General Hospital had been run down in recent months and weeks. “If the economic recovery is going to be ridden on the backs of patients, it is totally wrong,” he said.
Dr Devlin said he could not agree with the “status quo”, but the reality was hospital beds were being used inappropriately, equipment was not available for use at certain times, and there were “people who are rigid in terms of employment conditions” in the health service.
Mr Duffy said the IHCA had no difficulty with reconfiguration, but all changes required seed money.
“It needs an incentive, and we see little incentive from the HSE . . . and that’s not to say I regard Brendan Drumm as a lame duck,”Mr Duffy added.
The motion was carried on a show of hands.
