If only I knew then what I know now. On St Brigid’s Day 2023, I spent 24 hours in the Emergency Department of Wexford General Hospital with an elderly relative who has dementia and suffered a significant medical event at home about 7pm on Sunday.
The ambulance came quickly, and the paramedics were excellent. All went well until we got to the hospital. That ambulance and its crew sat outside for about an hour, before we got in the door of the ED. We were lucky, up to a point. We got a trolley in a cubicle, which was a penthouse suite compared to sitting on a chair in harsh lighting on the open floor of an emergency room.
The short version of the story is that the patient first saw a doctor about 8am on Monday and was finally in a bed by teatime. Comfortable now in a ward, what happened next was worse. That acute hospital bed was occupied for three nights while only very few tests were performed sporadically over several days. Bad possibilities eventually ruled out, it was time to go home – reassured, but none the wiser. In an efficient system, the patient should not have been in that bed for more than one night, if at all. The knock-on misery of others still waiting was entirely avoidable. That vigil of St Brigid’s Day I repeatedly asked who was available from management and was told that no one was.
The irony is the health system across the board is increasingly doing more and better. The bad examples are highlighted by good work elsewhere. The culture I encountered that night in Wexford was of a place that didn’t welcome questions. It is a place that needs more investment. The question is whether that money would be spent effectively.
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Health funding increased from €13.7 billion in 2014 to €22.8 billion in 2024. Over 50,000 healthcare staff have joined the public service
Knowledge is power. What I now know is that Wexford ranks only after Limerick as the acute hospital with the greatest increase in expenditure, 2016-2022. After inflation, real expenditure there increased by 68 per cent over the period, only behind Limerick on 75 per cent. That and much more is available in a first report of its kind published last week on trends in Activity, Expenditure and Workforce in acute hospitals by the Department of Health and the HSE. It should be on every news desk in the country, the better to interrogate unfiltered pleadings for ever more resources.
Health funding increased from €13.7 billion in 2014 to €22.8 billion in 2024. Over 50,000 healthcare staff have joined the public service. In the period of the 2016-2022 study, which is a baseline for the future, there was a 3.8 per cent increase in overall activity, compared to an inflation adjusted rise in expenditure of 45 per cent and a 29 per cent increase in staffing numbers. We are not getting bang for our buck.
[ Hospitals are getting more money but why is this not resulting in more activity?Opens in new window ]
There is no systemic failure. Considerable waste and pressing need for further investment are simultaneous realities. What happens outside the hospital is as important as what goes on inside it. The development of community healthcare, and step-down facilities are obvious examples. On e-health, Ireland is in the stone age. And yes, we need more acute hospital beds.
What has now changed is how hospitals are funded. Previously there was a tried and trusted formula which ensured that the worse things were, the more money you got. It was shroud-waving as fundraising, and it worked. In an audacious move, the health minister Stephen Donnelly enforced with brutality the obligation on all hospitals to co-operate with the Health Performance Visualisation Platform (HPVP), which is similar to a Pulse system for hospitals. They had to hand over their data or lose further capital investment.
Imagine the prospect of having to turn up in a studio with talking points about what you have delivered on, relative to the budget you have, as the essential premise to asking for more. Granular detail is the antidote for codswallop
The real test of his mettle will be to carry through on a threat to reward virtue in next year’s funding. That would upset the modus operandi of Irish hospitals perfected over a generation. Imagine the prospect of having to turn up in a studio with talking points about what you have delivered on, relative to the budget you have, as the essential premise to asking for more. Granular detail is the antidote for codswallop.
This report is an imperfect beginning. It encompasses Covid, and there is more work to do. That will deliver data by wholetime equivalent and by speciality as well as by hospital. It is the first real attempt at achieving accountability for enormous amounts of money, the management of which is essential for the quality of life of every patient and in some cases, for life itself.
It would be progress if hospitals had to demonstrate delivery to secure funding increases, and many have progress to report. It is a sign of the cynicism of the system, however, that a health budget for 2024 that is a work of fiction will imminently require yet another bailout. This is a country that – windfall taxes aside – is running an underlying budget deficit. In the first quarter of this year current spending increased by an astonishing 12.9 per cent. It is La La land. It remains to be seen if knowledge empowers the public interest, not the providers of public services.