Ailing hospitals on life support
THE latest health service cutbacks are rightly seen as — to use that infamous 1980s election slogan — an attack on the old, the sick, and the vulnerable.
But they’re not exactly a walk in the park for our hospitals’ accountants, managers, and medical staff, either. As part of Health Minister James Reilly’s controversial plan to save the system from financial ruin, already overstretched facilities are set to take the brunt of the economic pain.
While last week’s embarrassing €10m U-turn on personal assistance cuts for people with disabilities is to be welcomed, it is unlikely that equally controversial cuts to hospitals will also be rowed back, when they are inevitably imposed.
The latest HSE performance monitoring report update said the hospital sector was already €151m over budget at the end of June. The figure makes it the single biggest financial headache for the health system at that time, and a key target for cuts.
In Munster at least, it’s easy to see why bringing spending back into line is so badly needed — and what the potentially damaging impact of such a move could be.
Since the end of last year, none of the 18 hospitals in the HSE South and HSE Mid-West have been able to stay within their budgets, after combined cutbacks between 2011 and 2012 of €48.94m.
The Mid-Western Regional Hospital in Limerick (€11.91m over budget between Jan and Jun 2012), the Cork University Hospital Group (€8.28m), and Wexford General (€2.84m) have been among the biggest over-spenders.
However, the problem has occurred everywhere, with only the Mid-Western Regional in Ennis, Mallow General, Bantry General, and the Mid-Western Regional in Nenagh coming within €1m of their planned halfway point expenditure.
Coming after the 2011-2012 cutbacks, and a further €26.37m of debt rolled over from 2011 at 11 of the hospitals where the figure was available, hospitals have had to cut back even further.
As a result, agency and overtime spend has reduced, making it more difficult to plug staff absenteeism, retirement, and non-filled post gaps — including over 1,000 nurses who have departed the HSE South since Mar 2009.
Beds are being closed in attempts to save more money, with the Irish Nurses and Midwives Organisation stating that 456 of 4,287 beds were shut at the end of July — causing log-jams which increase waiting lists and overcrowding in the process.
Making matters even worse, is the fact patients and insurers are failing to repay their debts — with the non-payment of €67.09m of the 18 hospitals €162.2m income between Jun 2011 and Jun 2012 further adding to the financial woes.
Coupled with the latest round of health service cuts, the problems are making life increasingly difficult for hospitals, all of which will have to reduce services even more over the coming weeks.
Details of what cuts should be expected on a region- by-region basis, including those for hospitals, were meant to be outlined late last week by Dr Reilly and new HSE director general Tony O’Brien.
However, given the embarrassing row over the initial €130m cuts announcement, and the political storm caused by the way the news was released, this move has been temporarily delayed.
What is inevitable is that hospitals will see their budgets reduced further before the end of the year, with the HSE facing a €500m deficit if nothing is done this year and a further €850m overspend in 2013. While a draft copy of the Department of Health’s Securing the Future of Smaller Hospitals: A Framework for Development obtained by trade newspaper the Irish Medical Times has confirmed “no acute hospital will close”, changes will take place.
Chief among these, according to the leaked document, is that budgets will be moved along with services from the likes of Mallow, Bantry, Ennis, Nenagh, and St John’s in Limerick, among others.
The move is likely to further fuel anger in rural areas, with any reduction in the budgets of larger hospitals almost certain to cause the same response.
Money may not be everything. But as Dr Reilly, Mr O’Brien, and hospital bosses know all too well, the impact of not having any does at least effect everything.
Description: Services include general medicine and surgery, geriatric assessment, emergency department care, intensive/critical care, and day surgery.
The difference of opini-on between HSE management and patients over when reforms are in fact cuts is never clearer than when it involves rural hospitals.
From Sept 17, North Tipperary patients in need of emergency or heart care will have to travel to the Mid-Western in Limerick.
An 8am-8pm local injuries unit to be set up in Nenagh for broken bones, minor facial injuries, and easy to fix issues.
2011 and 2012 budgets: €17.97m and €16.71m.
2012 budget cut: €1.26m.
2011 overspend carried into 2012: Not provided by HSE.
Jan-Jun 2012 budget overspend: €105,000.
Money owed by patients and insurers: €2.57m; Jun 2011-Jun 2012 bill, €804,412 still unpaid.
Bed closures: 188 beds in total; 25 beds closed.
Staff absenteeism: 4.4%.
Waiting lists:
(In-patient appointments)
None waiting 0-12 months, 873 waiting 0-12 months for day case care.
(Out-patient consultant appointments)
2,022 waiting 0-12 months, 635 waiting 1-3 years, 237 waiting three years or longer.
Emergency department: Presentations down between first half of 2011 and first half of 2012 by 5.7%, from 5,290 to 4,987; admissions down 8.2%, from 1,009 to 926.
Description: Provides specialist maternity care to pregnant women, newborns, and new mothers in the Mid-West, including obstetrics, neonatology, and gynaecology.
Consultant obstetrician Dr Gerry Burke said this year that the loss of 47 midwives from the facility could cost lives, and in June that the management merger of hospitals in the region was putting economics before “the community’s need for decent clinical services”. The claims were criticised by the Government, with Taoiseach Enda Kenny describing the midwife statement as “outrageous”.
However, further cuts or loss of staff could lead to the issues returning to the fore.
2011 and 2012 budgets: €15.7m and €13.64m.
2012 budget cut: €2.06m.
2011 overspend carried into 2012: Figure not provided by HSE Mid West.
Jan-Jun 2012 budget overspend: €2.25m.
Money owed to the hospital by patients and insurers: €4.96m Jun 2011-Jun 2012 bill, €1.48m still unpaid.
Bed closures: 103 beds in total; closed bed figure not provided by HSE Mid West.
Staff absenteeism: 6.63%.
Waiting lists:
(In-patient appointments)
N/a
(Out-patient consultant appointments)
N/a
Emergency department: N/a.
Births: Down 0.8% between first half of 2011 and first half of 2012, from 2,536 to 2,515.
Description: Cork University Hospital and Cork University Maternity Hospital are two of Ireland’s largest general and maternity facilities, and as such when financial cutbacks come they are likely to strike this campus as much as any other.
Agency nurses have already been cut back at CUH and there is an ongoing row over junior doctor allowances, but the most likely service issues could happen at CUMH.
Last month, the INMO’s industrial relations officer, Patsy Doyle, pictured, warned that the hospital could not cope with further cuts, as it was 80 midwives short of the 380 recommended.
The HSE said “in order to ensure the planned delivery of services throughout 2012, the CUH Group must remain within budget so core activities, including emergency treatment and cancer services, are maintained”.
This means that while emergency department and cancer services will commendably remain untouched, other areas will have to take a financial hit.
2011 and 2012 budgets: €270.9m and €261.2m.
2012 budget cut: €9.7m cut.
2011 overspend carried into 2012: €9.13m.
Jan-Jun 2012 budget overspend: €8.28m.
Money owed to CUH by patients and insurers: €38.12m. Jun 2011-Jun 2012 bill, €13.9m still unpaid.
Bed closures: 851 beds in total; 57 closed (from INMO, accurate at end of July).
Staff absenteeism: 4.85%.
Waiting lists:
(In-patient appointments) 659 waiting 0-12 months, 1,697 waiting 0-12 months for day case care.
(Out-patient consultant appointments)
14,115 waiting 0-12 months and 5,190 waiting over 12 months, including 314 waiting over three years.
Emergency department: Presentations up between first half of 2011 and first half of 2012 by 14.7%, from 27,887 to 31,998; admitted patients up 15.1%, from 11,430 to 13,154.
Births: CUMH down between first half of 2011 and first half of 2012 by 2%, from 4,359 to 4,272
Description: Services include: General medicine, general surgery, emergency department care, geriatrics, urology, gynaecology, anaesthesia, radiology.
A 2009 Hiqa report said the hospital’s acute services were unsafe and detailed a series of needed reforms.
A €15m extension was built in light of the document’s findings. However, this new 50-bed unit remains idle because of a row between nurses and management over staffing numbers.
Staffing levels, and the risk further cuts bring to them, has been at the forefront of financial debates at the facility this year.
In addition, the hospital be re-targeted at day care and diagnostic services, with more complex work being sent to the Mid-Western Regional Hospital.
The smaller hospitals framework document will also see a linked fall in the money for Ennis.
2011 and 2012 budgets: €19.65m and €18.67m.
2012 budget cut: €980,000.
2011 overspend carried into 2012: Figure not provided by HSE Mid West.
Jan-Jun 2012 budget overspend: €155,000.
Money owed to Mid-Western Regional in Ennis by patients and insurers: €812,003 Jun 2011-Jun 2012 bill; €460,708 still unpaid.
Bed closures: 102 beds in total; 25 closed (from INMO, accurate at end of July).
Staff absenteeism: 7.39%.
Waiting lists:
(In-patient appointments)
No patients waiting 0-12 months, 709 waiting 0-12 months for day case care.
(Out-patient consultant appointments)
2,285 waiting 0-12 months, 1,390 waiting 1-3 years, 795 waiting three years or longer.
Emergency department: Presentations up 3.9% between first half of 2011 and 2012 by 3.9%, from 6,642 to 6,900; admitted patients down 1.3%, from 1,532 to 1,512.
Description: A voluntary hospital funded by the HSE, the 103-bed facility includes general medicine, surgery, and a 12-hour Monday to Friday emergency department/minor injuries clinic.
Referring to it and other hospitals, a leaked copy of the smaller hospitals framework report seen by Irish Medical Times states: “Our priority will be to increase the number of patients treated in smaller hospitals, but this may be done in a number of ways, including with reduced budgets. For example, by reducing staff cover at less busy times for elective work such as at nights and weekends.”
2011 and 2012 budgets: €17.62m and €15.84m.
2012 budget cut: €1.78m.
2011 overspend carried into 2012: Figure not provided by HSE Mid West.
Jan-Jun 2012 budget overspend: €1.52m.
Money owed by patients and insurers: €5.83m Jun 2011-Jun 2012 bill, €2.38m still unpaid.
Bed closures: 103 beds in total; 25 closed (from INMO, accurate at end of July).
Staff absenteeism: 2.31%.
Waiting lists:
(In-patient appointments)
175 patients waiting 0-12 months, 809 waiting 0-12 months for day case care.
(Out-patient consultant appointments)
1,207 waiting 0-12 months, 76 waiting 1-2 years.
Emergency departments: Presentations down 6.7% between first half of 2011 and 2012, from 8,071 to 7,351; admitted patients up 0.5%, from 1,104 to 1,110.
Description: St Luke’s provides acute hospital services in areas such as general medicine, general surgery, geriatrics, psychiatry and paediatrics to the South-East.
The linked Kilcreene facility looks after in-patient and out-patient orthopaedic care.
Due to the specialised nature of orthopaedic services offered by Kilcreene, there are few additional cuts which can be easily made at the facility.
At St Luke’s, staff will be keen to highlight how nearly 2,000 people are waiting up to 12 months for an outpatient consultant appointment, a log-jam which is not helped by high absenteeism levels.
While outpatient services at other hospitals are due to be transferred to larger facilities, further reduction in agency workers or staff at St John’s before this happens would risk exacerbating the current delays.
2011 and 2012 budgets: €55.72m and €53.54m .
2012 budget cut: €2.18m.
2011 overspend carried into 2012: €1.47m.
Jan-Jun 2012 budget overspend: €1.89m.
Money owed to the St Luke’s by patients and insurers: €8.79m Jun 2011 to Jun 2012 bill, with €4.82m still unpaid.
Bed closures: 336 beds combined; 26 discharge beds, 29 inpatient beds, 14 gynaecological beds and 14 medical beds closed (from INMO, accurate at end of July).
Staff absenteeism: 6.82% and 6.47%, respectively.
Waiting lists:
(In-patient appointments)
90 patients at St Luke’s and 216 at Kilcreene waiting 0-12 months, 889 and 153 waiting 0-12 months for day-case care.
(Out-patient consultant appointments)
1,951 patients at St Luke’s waiting 0-12 months, 11 waiting one to two years.
Emergency department: Presentations (to St Luke’s) up 8.3% between first half of 2011 and 2012, from 19,120 to 20,699; admitted patients down 13.3%, from 5,954 to 5,160.
Description: Provides acute services, including outreach clinics, obstetrics units, and an emergency department.
Among the pleas to help are those focussed on South Tipperary’s emergency dept, which regularly places highly on the INMO’s trolley count.
The decision to close beds in an attempt to save money has also led to criticism.
The most high-profile facility issue recently was May’s decision to postpone the closure of the St Michael’s acute psychiatric unit which had been due to stop admitting patients at the start of summer. The initial decision was heavily criticised. However, with a €2.26m overspend in the first half of this year, a €1.77m budget cut and a pre-existing deficit from 2011 of €1.11m, alternative savings will need to be found.
2011 and 2012 budgets: €45.6m and €43.83m .
2012 budget cut: €1.77m .
2011 overspend carried into 2012: €1.11m.
Jan-Jun 2012 budget overspend: €2.26m.
Money owed by patients and insurers: Figures not provided.
Bed closures: 255 beds in total; 40 surgical and medical beds and one intensive care unit bed (from INMO, accurate end July).
Staff absenteeism: 6.45%.
Waiting lists:
(In-patient appointments)
46 patients waiting 0-12 months, 224 waiting 0-12 months for day case care;
(Out-patient consultant appointments)
1,798 waiting 0-12 months, none waiting one year or more
Emergency department: Presentations up between first half of 2011 and first half of 2012 by 8.9%, from 19,116 to 20,826; admitted patients up 8.9%, from 4,511 to 4,914
Description: A key base for healthcare in the region, it provides a full range of services, including a 24-hour emergency department.
Medical unions claim overcrowding on the hospital’s wards has become a regular occurrence, meaning the need to keep beds open is considered a high priority.
In March the facility was also forced to temporarily cancel operation appointments after a sudden surge in the number of patients coming to its emergency department.
While the issue was quickly resolved, the difficulties behind what happened could return unless emergency department, bed and staffing funding levels are left untouched when north Tipperary emergency services are transferred to the facility later this month.
2011 and 2012 budgets: €138.05m and €123.18m.
2012 budget cut: €14.87m.
2011 overspend carried into 2012: Figure not provided by HSE Mid West.
Jan-Jun 2012 budget overspend: €11.91m.
Money owed to the Mid-Western by patients and insurers: €25.09m Jun 2011 to Jun 2012 bill, €12.88m still unpaid.
Bed closures: 522 beds in total; six paediatric and four intensive care unit beds closed (from INMO, accurate at end of July).
Staff absenteeism: 6.78%.
Waiting lists:
(In-patient appointments)
Four patients waiting 0-12 months, 481 waiting 0-12 months for day case care.
(Out-patient consultant appointments)
2,965 waiting 0-12 months, 74 waiting one to two years.
Emergency department: Presentations down between first half of 2011 and first half of 2012 by 0.8% from 32,272 to 32,026; admitted patients up 4.6%, from 10,318 to 10,795.
Description: Provides services across general medicine, general surgery, gynaecology, obstetrics, and paediatrics.
In the budget for this year, the facility suffered a near 4% cut in its budget and 15 frontline staff depart.
Out-patient consultant appointment lists are high, at nearly 3,000, and emergency department admittance rates were up 10% in the first half of this year compared to Jan-June 2011. However, in the first six months of this year its overspend was also higher, at €2.84m than the €433,000 deficit at the end of 2011, making cuts inevitable.
2011 and 2012 budgets: €47.77m and €45.88m .
2012 budget cut: €1.89m.
2011 overspend carried into 2012: €433,000.
Jan-Jun 2012 budget overspend: €2.84m.
Money owed to Wexford General by patients and insurers: €8.24m Jun 2011-Jun 2012 bill, €2.56m still unpaid.
Bed closures: 237 beds in total; 14 gynaecological beds and 25 ward beds closed (from INMO, accurate at end of July).
Staff absenteeism: 5.13%.
Waiting lists:
(In-patient appointments)
Four patients waiting 0-12 months, 481 waiting 0-12 months for day case care.
(Out-patient consultant appointments) 2,965 waiting 0-12 months, 74 waiting one to two years.
Emergency department: Presentations up between first half of 2011 and first half of 2012 by 2.8%, from 18,690 to 19,212; admitted patients up 9.8%, from 6,559 to 7,201
Description: Under the regional HSE South 2012 budget three of the hospital’s operating theatres have been closed, in addition to one of its surgical wards.
Among the services felt by staff to be untouchable when it comes to cuts is its cancer service. The hospital is one of Ireland’s eight national cancer control programme centres, one of just two NCCP centres in the HSE South providing care for Waterford, Wexford, Kilkenny, and South Tipperary.
2011 and 2012 budgets: €135.46m and €130.37m.
2012 budget cut: €5.09m
2011 overspend carried into 2012: €8.49m.
Jan-Jun 2012 budget overspend: €1.91m.
Money owed to Waterford Regional by patients and insurers: €21.36m Jun 2011-Jun 2012 bill, €11.35m still unpaid.
Bed closures: 429 beds in total; six paediatric and 25 surgical beds closed (from INMO, accurate at end of July).
Staff absenteeism: 6.45%.
Waiting lists:
(In-patient appointments) 55 patients waiting 0-12 months, 626 waiting 0-12 months for day case care.
(Out-patient consultant appointments) 15,694 waiting 0-12 months, 14,010 waiting one to three years and 6,138 waiting three years or longer.
Emergency department: Presentations up 1.5% between first half of 2011 and 2012, from 28,961 to 29,384; admissions up 3.7%, from 8,492 to 8,802
Description: The second largest acute hospital in the HSE South, it serves Kerry, West Limerick and north Cork. In April, its long-awaited €4m emergency department opened and is expected to treat 33,000 patients a year. Hospital management will be keen to ensure consultant posts are not reduced, considering the backlog of people waiting for out-patient appointments.
2011 and 2012 budgets: €71.3m and €68.84m.
2012 budget cut: €2.47m.
2011 overspend carried into 2012: €1.5m.
Jan-Jun 2012 budget overspend: €1.73m.
Money owed by patients and insurers: €7.28m Jun 2011-Jun 2012 bill, €2.93m still unpaid.
Bed closures: 377 beds in total; 29 surgical beds closed (from INMO, accurate at end of July).
Staff absenteeism: 5.25%.
Waiting lists:
(In-patient appointments) 55 patients waiting 0-12 months, 626 waiting 0-12 months for day case care.
(Out-patient consultant appointments) 4,427 waiting 0-12 months, 1,090 waiting one to three years and 23 waiting three years or longer.
Emergency department: Presentations up between first half of 2011 and 2012 by 15.5%, from 15,881 to 18,344; admitted patients up 8.3%, from 5,204 to 5,637
Description: The facility provides acute specialities, including in-patient, day patient, and out-patient services to Cork City. Under HSE reconfiguration moves, it no longer provides emergency department care.
Management has attempted to ensure the administrative and private patient side of the hospital takes up the financial slack. It emerged in July that the facility will no longer carry out blood tests for GPs or send payslips in the post in an attempt to save frontline services from cuts. Bed closures and agency/ overtime reductions are a possibility if more savings are needed.
2011 and 2012 budgets: €46.26m and €44.37m.
2012 budget cut: €1.89m.
2011 overspend carried into 2012: €1.87m.
Jan-Jun 2012 budget overspend: €1.54m.
Money owed by patients and insurers: €13.99m Jun 2011-Jun 2012 bill, €5.66m still unpaid.
Bed closures: 192.
Staff absenteeism: 4.9%.
Waiting lists:
(In-patient appointments) 560 waiting 0-12 months, 435 waiting 0-12 months for day case care.
(Out-patient consultant appointments) 8,449 waiting 0-12 months, 4,782 waiting one to three years and 742 waiting three years or longer.
Emergency department: N/a.
Description: Provides a range of acute specialities, including in-patient, day patient, out-patient, and emergency services to Cork City.
In Budget 2012, it lost 18 beds — 12 surgical and six paediatric — and one theatre. Administration staff were re-organised and an increase in occupancy of private beds was sought to help boost funds.
The changes were imposed after a €2m funding cut between 2011 and 2012. With the hospital in the red by €2.41m by the end of June this year more of the same can be expected.
2011 and 2012 budgets: €56m and €53.67m.
2012 budget cut: €2.36m.
2011 overspend carried into 2012: €2.03m.
Jan-Jun 2012 budget overspend: €2.41m.
Money owed to Mercy by patients and insurers: €17.52m June 2011-June 2012 bill, €5.72m still unpaid.
Bed closures: 350 beds in total; six adult surgical beds, and six paediatric beds closed (from INMO, accurate at end of July).
Staff absenteeism: 4.22%
Waiting lists:
(In-patient appointments) 158 patient waiting 0-12 months, 1,195 waiting 0-12 months for day case care.
(Out-patient consultant appointments) 3,157 waiting 0-12 months and 480 waiting 1-3 years.
Emergency department: Presentations up 12.1% between first half of 2011 and first half of 2012 from 13,294 to 14,906; admissions down 14.7%, from 3,665 to 3,126.
Description: While Bantry General continues to provide acute care to the West Cork community, like other rural facilities it has faced significant upheaval over the past 12 months.
Chief concerns will be any further changes to emergency medical care, both in the facility and on an ambulatory basis, which has in recent months undergone significant reconfiguration in the region.
Continuing moves to cut back on agency and overtime costs are being resisted by unions who insist the issues are effectively stop-gap measures to fill unstaffed positions.
The hospital has yet to appoint a permanent replacement consultant radiologist to a position which has been unfilled since June, or a senior dietician post empty since May.
It will also be one of the smaller hospitals in the region which will be re-focused on day care, ambulatory, and diagnostics such as blood tests and X-rays over the coming months.
2011 and 2012 budgets: €16.9m and €16.4m.
2012 budget cut: €566,000.
2011 overspend carried into 2012: €340,000.
Jan-Jun 2012 budget overspend: €253,000.
Money owed to Bantry by patients and insurers: €412,350 Jun 2011-Jun 2012 bill, €138,822 still unpaid.
Bed closures: 118 beds in total; 14 surgical ward beds closed (from INMO, accurate at end of July).
Staff absenteeism: 4.21%.
Waiting lists:
(In-patient appointments) No patient waiting 0-12 months, 120 waiting 0-9 months for day case care.
(Out-patient consultant appointments) N/a.
Emergency department: N/a.
Description: Provides specialised orthopaedic care to the Mid-West, while a rheumatology clinic is also available one day a week.
Like other specialist facilities, the services at Croom are unlikely to suffer significant cutbacks as major service change in the HSE Mid West takes place.
However, should any be mooted, hospital management are likely to point to the 5,606 patients waiting longer than three years for an outpatient consultant appointment as a sign of the damage further cuts could cause.
2011 and 2012 budgets: €9.82m and €9.08m.
2012 budget cut: €740,000.
2011 overspend carried into 2012: Figure not provided by HSE Mid West.
Jan-Jun 2012 budget overspend: €584,000.
Money owed to Croom by patients and insurers: €4.69m Jun 2011-Jun 2012 bill, €1.45m still unpaid.
Bed closures: 78 beds total; number of closed beds not listed.
Staff absenteeism: 2.05%.
Waiting lists:
(In-patient appointments)
107 waiting 0-12 months, 109 waiting 0-12 months for day case care.
(Out-patient consultant appointments)
1,725 waiting 0-12 months, 2,997 waiting 1-3 years, 5,606 waiting three years or longer.
Emergency department: N/a.
Description: The soon-to-be-published HSE smaller hospitals framework document will outline the changes to take place at Mallow over the coming months and years in detail.
A draft copy of the document says these will include a 20% cut in the number of emergency patients treated at the local injuries unit; and a 10% rise in outpatients as services are transferred to Mallow.
A total of 1,300 emergency and complex surgery cases per year will also leave Mallow for larger hospitals, while day case numbers are expected to rise from 6,500 to 7,400.
In early summer it emerged the facility had been criticised by the health watchdog for failing to act on changes recommended in a 2011 report. Among the issues raised was the continuing non-transfer of major and complex surgery to CUH. The unpublished framework plan is likely to seek similar changes take place.
2011 and 2012 budgets: €14.82m and €15.48m.
2012 budget increase: €660,000.
2011 overspend carried into 2012: Figure not provided by HSE South.
Jan-Jun 2012 budget overspend: €172,000.
Money owed to hospital by patients and insurers: €2.34m Jun 2011-Jun 2012 bill, €558,270 still unpaid.
Bed closures: 76 beds in total; 10 beds closed.
Staff absenteeism: 3.38%.
Waiting lists:
(In-patient appointments)
10 waiting 0-12 months, 72 waiting 0-12 months for day case care.
(Out-patient consultant appointments)
827 waiting 0-12 months, one waiting one to two years.
Emergency department: N/a.
* Read more:
Munster hospitals €40m over budget
