1 in 8 of the population awaiting medical treatment

The latest data available from the National Treatment Purchase Fund (NTPF)(end of May 2022) shows that 12.5 per cent of the population, 1 in every 8 of us, was waiting for outpatient treatment. That equates to 624,446 adults and children in need of healthcare. Of those, more than one in five (22.2 per cent, or 138,753 people) were waiting for 18 months or more.

 

The NTPF no longer breaks down this data by age group, however of the 624,446 people on the outpatient waiting lists, 537,208 (86 per cent) were adults and 87,238 (14 per cent were children).

Over two-fifths, 45.7 per cent, of people on the outpatient waiting lists were waiting for 0 to 6 months, some 285,246 people, one in five (135,126) were waiting for 6-12 months, one in ten (65,329) were waiting for 12-18 months and one in five were waiting for 18 months or more (Table 1). 

There is something fundamentally wrong with the health service when a third of people awaiting treatment are waiting for a year or more.

Table 1: Outpatient Waiting List, 26th May 2022

	Number	%
0-6 Months	285,246	45.7
6-12 Months	135,126	21.6
12-18 Months	65,329	10.5
18 Months +	138,753	22.2
Total	*624,446

Source: National Treatment Purchase Fund, OP Waiting List by Specialty 2022, www.ntpf.ie

*There is a slight discrepancy in the source data where the number in the "Total" column does not match the sum of the numbers in the time columns.

The pattern observed in Table 1 is also evident when the data is disaggregated into Adults and Children. The majority of the outpatient waiting lists (86 per cent) consist of Adults (537,208), with 14 per cent Children (87,238). More than two in five of both Adults and Children (45.7 per cent and 45.5 per cent respectively) were awaiting treatment for 6 months or less, while one in five were awaiting treatment for 18 months or more (Table 2).

Table 2: Outpatients Waiting List, 26th May 2022, Adult and Child breakdown

	Adults		Children
	Number	%	Number	%
0-6 Months	245,580	45.7	39,666	45.5
6-12 Months	117,165	21.8	17,961	20.6
12-18 Months	56,334	10.5	8,995	10.3
18 Months +	118,130	22.0	20,623	23.6
Total	537,208		87,238

Source: National Treatment Purchase Fund, OP Waiting List by Specialty 2022, www.ntpf.ie

Type of Treatment

Of the 537,208 adults awaiting treatment, 1 in 8 were awaiting Orthopaedic care, while almost one in ten (9 per cent) adults were awaiting treatment with an ENT. This is is followed by General Surgery (8 per cent of the adult waiting list), Gynaecology (5.7 per cent of the adult waiting list), and Cardiology (6.2 per cent of the adult waiting list). Radiotherapy, Radiology and Palliative Care had the lowest waiting lists.

The specialty with the highest proportion of adult patients waiting 18 months or more was Oral Surgery, with 55 per cent of the 2,486 adults awaiting treatment for this period. This was followed by Anaesthetics (52 per cent of the 333 adults were waiting 18 months or more); Maxillo-Facial (47 per cent of the 4,747 adults awaiting treatment); Pain Relief (37 per cent of the 14,214 adults were waiting 18 months or more); and ENT (36 per cent of the 48,560 adult patients were waiting 18 months or more).

Of the 87,238 children awaiting outpatient treatment, 1 in 5 were awaiting Paediatric care (17,659 children); while 1 in 8 (10,344 care) were awaiting ENT treatment; 7 per  cent (5,909 children) were awaiting Paediatric Dermatology; and 6 per cent (5,346 children) were awaiting Ophthamology care. Neurosurgery, Gastro-Enterology and Pain Relief had the lowest waiting lists for children.

The specialty with the highest proportion of children waiting 18 months or more was Clinical Immunology, with 55 per cent of the 1,049 children awaiting care waiting for 18 months or more. This was followed by Immunology (54 per cent of the 471 children awaiting treatment); Rheumatology (53 per cent of the 1,259 children awaiting treatment); and Dental Surgery (44 per cent of the 555 children awaiting treatment).

Two-Tiered System

Accessing our complex system depends on whether one has a medical card, a GP visit card, private health insurance, private resources to spend on health services, where one lives and what type of services one is trying to access; it is people who are poorest, sickest and those with disabilities who find it hardest to pay charges, to negotiate access, and who must wait longer for care (Burke, 2016). As well as undermining equity and efficiency in the health system, private health insurance represents a financial burden on households, accounting for around 3 per cent of household spending on average in 2015–2016, up from 2 per cent in 2009–2010 (Johnston et al. 2020). Furthermore, while 46 per cent of the population has private health insurance, about 20 per cent has neither private health insurance nor a medical card (OECD and WHO, 2021). The medical card system protects many households from financial hardship, but poorer households are still disproportionately likely to experience financial hardship, and protection has been eroded over time (Johnston et al, 2020). Even relatively low user-charges can operate as barriers to access and lead to financial hardship for very poor households, and there is a high degree of income inequality in unmet need for prescribed medicines in Ireland, with disparities between the richest and poorest being particularly large relative to dental care (Johnston et al, 2020). The European Health Interview Survey (EHIS) shows that unmet need for prescribed medicines in Ireland is on average more than twice as high as the EU average and more than twice as high among people with the least education than those with the most (Johnston et al, 2020). The pandemic also limited access to care for people with health conditions not related to COVID-19 and unmet needs for medical care because of delayed or missed consultations are likely to lead to poorer health outcomes in the future.

Healthcare Model

Problems with the Irish healthcare system are often apparent through difficulties of access (discussed already). However, that is not the whole story – as well as waiting times for access to hospital care, there are barriers in access to primary care and delays in Accident & Emergency Department admissions. When the financial crisis occurred in 2008, Ireland still had poorly developed primary and community care services (WHO & European Observatory on Health Systems and Policies, 2014) and austerity policies followed leading to continuous cuts to staff and budgets alongside increasing demand for care (Burke et al, 2016).

Problems with overcrowding in emergency departments are a regular feature of the Irish system. The Irish Nurses and Midwives Association (INMO, 2022) document that over 70,275 patients went without a bed in hospitals in 2021. In this situation outpatient appointments and surgeries can be cancelled and effects are felt throughout the system – not to mention the human suffering involved and the risks to safety. The 2019 national survey of patients found that 7,927 people (70 per cent of those answering this question) said they waited longer than six hours before being admitted to a ward; 331 people (4 per cent) waited 48+ hours (National Care Experience Programme, 2019).

Contributing to these problems is inability to discharge people, often older patients, due to lack of step-down facilities, nursing homes and other forms of support in communities. A study suggests that formal care is available to only 24 per cent of those needing care and (amongst the different groups examined) 38 per cent of people over 65 have unmet needs for care, as do 34 per cent of disabled adults (Privalko et al, 2019). The OECD (2019b) highlights how many hospital admissions could be avoided in Ireland (especially for chronic conditions like Asthma and COPD) if there were improvements in primary care. Thus, community services are not fully meeting growing demands associated with population change, reflected in inappropriate levels of admission to, and delayed discharges from, acute hospitals. With increases in the population, especially amongst older people, the acute hospital system will be unable to operate effectively without a shift towards primary and community services as a principal means of meeting patient needs.

Social Justice Ireland is concerned that the ageing of the population is not being properly planned for. Although Budget 2022 made some changes (e.g. increasing the fuel allowance and increasing the Social Welfare Pension), it took limited steps to begin planning for the future health and care needs of older people. An opportunity to resource and implement the proposed statutory right to home care was regrettably missed; so too was the restoration of Home Adaptation Grants to 2010 levels and a substantial increase in funding for the HSE National Safeguarding Teams. The Department of Health (2018) acknowledges that the current health service needs to evolve, noting that there is an over-reliance on hospitals, that community-based services are fragmented, and that there is a lack of integration within and across different services.  

Sláintecare makes proposals for a ten year strategy for health care and health policy in Ireland. Robust rollout of Sláintecare could strengthen the effectiveness of the health care system (OECD and WHO, 2021). However, as the OECD/European Union (2020) noted, while the Strategy and Action Plan commit to expanding eligibility for health care on a phased basis, they do not commit to legislating for entitlement to care and the expansion of services required to deliver universal health coverage. As noted already, the additional resources committed for the development of the healthcare system in 2021 should be  retained and now fully rolled out to implement Sláintecare. In order to deliver the modern, responsive, integrated public health system that the report envisages it is vital that the necessary investment is made. Reform will require investment before savings can be made.

Needed Reforms

We cannot return to a two-tier healthcare system and access to healthcare based on need, not income, should remain an important aim for Ireland’s healthcare system. Furthermore, investment in a reconfigured model of healthcare is overdue, one that emphasises primary and social care. In the context of our past mistakes, it is important that Ireland begins to plan for this additional demand and begins to train staff and construct the needed facilities. It is also necessary for leadership that communicates the need to invest in reform now so that the necessary services are in place to enable us to afterwards shift to a different model of care that emphasises primary care more. We need to ring-fence the COVID costs incurred in 2020 and 2021 for the investment required, financed with a very long-term low-interest loan (30 to 50 years) provided by the EU and the European Central Bank.

The following is a summary of key policy priorities and actions that Social Justice Ireland recommends:

• Ensure that announced budgetary allocations are valid, realistic and transparent and that they take existing commitments into account.
• Complete the roll-out of the Community Health Networks across the country and thus increase the availability and quality of Primary Care and Social Care services.
• Ensure medical card-coverage for all people who are vulnerable.
• Act effectively to end the current hospital waiting list crisis.
• Create a statutory entitlement to Home Care Services. This will require increased funding, but will save the State money long-term, as home support allows people to remain living in their own homes, rather than entering residential nursing care.
• Create additional respite care and long-stay care facilities for older people and people with disabilities and provide capital investment to build additional community nursing facilities.
• Implement all aspects of the dementia strategy.
• Increase educational campaigns promoting health, targeting particularly people who are economically disadvantaged, acknowledging that a preventative approach saves money in the long-run.
• Properly resource and develop mental health services, and facilitate campaigns giving greater attention to the issue of suicide.
• Adopt a target to reduce the body mass index (BMI) of the population by 5 per cent by 2025.
• Work towards full universal healthcare for all. Ensure new system structures are fit for purpose and publish detailed evidence of how new decisions taken will meet healthcare goals.
• Enhance the process of planning and investment so that the healthcare system can cope with the increase and diversity in population and the ageing of the population projected for the next few decades.
• Ensure that structural and systematic reform of the health system reflects key principles aimed at achieving high performance, person-centred quality of care and value for money in the health service.

References

Burke, S. (2016).  Opening Statement: Oireachtas Committee on the Future of Healthcare Inequality and Access to Healthcare, Sara Burke, Research Fellow, Centre for Health Policy and Management, TCD 6 October.

Burke, S, Normand, C., Barry, S., and Thomas, S. (2016) ‘From Universal health insurance to universal healthcare? The shifting health policy landscape in Ireland since the economic crisis.’ Health Policy. 120. 235-340

Johnston B, Thomas S, Burke S.(2020) Can people afford to pay for health care? New evidence on financial protection in Ireland. Copenhagen: WHO Regional Office for Europe.

Keegan, C., Brick, A., Walsh, B., Bergin, A., Eighan, J. and Wren, M-A. (2018) How Many Beds? Capacity Implications of Hospital Care Demand Projections in the Irish Hospital System, 2015-2030. Dublin: Economic and Social Research Institute

Keegan, C., Brick, A., Bergin, A., Wren, M-A., Henry, E., and Whyte, R. (2020) Projections of Expenditure for Public Hospitals In Ireland, 2018–2035, Based On The Hippocrates Model Dublin: Economic and Social Research Institute

National Treatment Purchase Fund (2022). National Waiting List Data Outpatient Waiting List [Online] https://www.ntpf.ie/home/nwld.htm [Jan-May 2022]

Privalko. I., Maître, B., Watson, and D., Grotti, R. (2019)  Access to Care Services Across Europe. Dublin: Department of Employment Affairs and Social Protection and Economic and Social Research Institute

Social Justice Ireland (2021) Budget 2022 Analysis and Critique. Dublin: Social Justice Ireland

Walsh, B., Wren, M-A, Smith, S., Lyons, S., Eighan, J. and Morgenroth, E. (2019) An Analysis of the Effects on Irish Hospital Care of the Supply of Care Inside and Outside the Hospital. Dublin: Economic and Social Research Institute

Wren, M-A., Keegan, C, Walsh, B., Bergin, A., Eighan, J., Brick, A., Connolly, S. Watson, D. and Banks, J. (2017) Healthcare in Ireland, 2015-2030. First Report from the Hippocrates Model. Dublin: Economic and Social Research Institute