Acute Hospital Service: Inputs, Outputs and Waiting Lists

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Key Point:

Since 2015, total spending on acute hospital services has risen by €1.2billion or 27%, from €4.4bn to almost €5.6bn in 2019. The total number of staffing in acute hospital services has also increased by almost 8,000 or 14.5%, from over 54,000 in 2015 to 62,000 in 2019. However, recent data suggests that this has not led to a significant change in the outputs of acute hospital services. The total number of inpatient discharges increased by only 3% between 2015 and 2019. Moreover, data on the national waiting lists for acute hospital services shows that the total number of people on the outpatient waiting list[i] has increased substantially by almost 178,000 or 47%, from over 375,000  2015 to over 553,000 in 2019. In terms of inpatient/day case[ii] patients awaiting treatments, there has been an overall marginal decline of over 1,500 or 2% from 68,100 in 2015 to 66,600 in 2019. Although there has been a decrease in the number of adults on the waiting list-long term (15+ months) for day case treatment, there has been an increase in the number of adults waiting for inpatient treatments. The total number of children on the waiting list long-term for day case treatment has increased to 600 (+236) and the total number of children on the inpatient waiting list has increased slightly to 225 (+8).

Policy Context

In 2019, the Health Service Executive (HSE) Agency was allocated a budget of over €16.05bn, representing an increase of 5.6% on 2018. The acute hospital sector accounts for €5.4bn or 31% of the total health care spend in 2019. The network of acute hospitals provide a range of services throughout the country which include: scheduled care (planned care), unscheduled care (unplanned/emergency care) diagnostic services, specialist services, cancer services, maternity and children’s services and the National Ambulance Service.

Inputs: Acute Hospital Expenditure and Workforce

Figure 1 shows the trends in acute sector spending between the years 2015-2019. Total spending in the acute sector increased from almost €4.4bn in 2015 to €5.6bn in 2019: representing an increase of almost €1.2bn or 27%. Of this total spend, the acute hospitals sector increased by almost €1.2bn (+28%) from €4.2bn in 2015 to €5.4bn in 2019. The National Ambulance Service and Emergency Management spent amounted to €170.5m in 2019: representing an increase of almost €25m (+17%) on 2015.

Figure 1: Acute Sector Division Net Expenditure, 2015-2019

Source: HSE Performance Reports (2015a, 2016b, 2017b, 2018b 2019a). Note: expenditure figure for 2019 is based on allocation for year and not actual spend.

Figure 2 shows the distribution of acute hospital service staff by sector in 2019. The largest areas of staff resources are Nursing (37%), Management and Administration (15%) and the Medical and Dental sector (14%). Areas of the acute hospital services with the least staffing resources are Health and Social Care (12%), Patient and Client Care (12%) and General Support sectors (10%)[iii].

Figure 2: Proportion of Acute Hospital Staff by Sector, 2019

Source: HSE Employment Reports (2019b)

Table 1 shows the number of Whole Time Equivalent (WTE) staffing employed in the acute hospital sector between the years 2015 and 2019. Since 2015, the total number of WTE staff increased from over 54,000 to 62,000 in 2019 – an increase of almost 8,000 or 14.5% on 2015. The greatest proportional increase in staff resources was in the ‘Patient and Client Care’ and ‘Medical and Dental’ sectors: with the total number of WTE staff increasing by 1,200 (+20%) and 1,320 (+18%) respectively during 2015-19. Within the Medical and Dental area of acute hospital services, the number of consultants rose by almost 490 (+21%) and Non Consultant Hospital Doctors increased by almost 830 (+17%). Notwithstanding, there are significant staffing shortages in the sector with one in five consultant posts (500 posts) being either unfilled or temporarily filled in 2019. This has led to a decline in the working conditions of medical practitioners delivering frontline services due to factors such as: the inability of doctors to take annual leave; inadequate replacement cover; and it is also believed to have led to an increasing number of doctors leaving Ireland to work overseas (IHCA, 2019; Hayes, Prihodova, Walsh et al., 2019). Total WTE staffing resources also rose in the Nursing area by 2,800 (+14%) and the Health and Social Care sector by 890 (+13%). The smallest increase in acute hospital service staffing was in the General Support sector at 370 or 6%.

Table 1: Number of Acute Hospital Staff Employed by Service area, 2015-19

Source: HSE Employment Reports (2019b).

Outputs: Patient Discharges and Waiting Lists

Figure 3 shows the number of inpatient and day case discharges and emergency presentations between the years 2015-19. While there has been an increase in levels of acute hospital expenditure and staffing resources during these years, concurrent data from HSE Performance Management Reports suggests that this has not led to a significant increase in outputs. Between the years 2015 and 2019, the number of inpatient discharges (i.e. elective, emergency and maternity inpatients) has remained relatively flat: increasing by almost 11,000 (+3%) from 413,000 in 2015 to 424,000 in 2019. There has been a gradual rise in the number of day case discharges, with an increase of almost 60,000 (+9%), from 676,500 in 2015 to 736,300 in 2019. While the number of Emergency Department Presentations is a key hospital activity metric measuring the number of patients with urgent care needs receiving frontline services, increasing utilisation rates in this area can adversely affect patient outcomes, lead to a rise in health care costs and increase the workload pressures of medical practitioners. In 2019, there was a greater number of Emergency Department Presentations at 1.125m: with an increase of almost 150,000 (+15%) from almost 979,000 in 2015.  

Figure 3: Numbers of Emergency Department Presentations and Inpatient/Day Case Discharges, 2015-19 (August/September).

Source: HSE Performance Reports (2015b, 2016b, 2017b, 2018b, 2019a). Note: As full year data for 2019 is not yet available, the cumulative data presented in this graph for each year is from the month of January to September for Inpatient and Day Case discharge data and the month of January to August for Emergency Presentations data.

Figure 4 shows the total number of patients on an inpatient/day case and outpatient waiting list between the years 2015 and 2019 (0-18+ months). From this data obtained from the National Treatment Purchase Fund, the evidence highlights the total number of patients categorised as ‘Active’ – those individuals who are waiting for an appointment date for their treatment. In this context, the total number of inpatient/day case patients on the waiting list has remained relatively flat: with a marginal decline of 1,500 or 2% from 68,100 in 2015 to 66,600 in 2019. Despite the proportional increase in the number of consultants (+21%) and NCHDs (+17%) WTEs during these years, the total number of outpatients on the waiting list has risen substantially by almost 178,000 or 47%: from over 375,000 on the waiting list in 2015 to over 553,000 in 2019.

Figure 4: Total Inpatient/Day case and Outpatient Waiting Lists (0-18+ months), 2015-2019 (December)

Source: NTPF (2019)

Figure 5 shows the total number of adults and children waiting 15 months and over for a day case and inpatient treatment, 2016 and 2019. The total number of adults on the inpatient waiting list increased by over 600 from almost 1,840 in 2016 to over 2,440 in 2019. Conversely, the total number of adult patients waiting for day case treatment has fallen during these years to over 2,840 in 2019: representing a decrease of almost 670 on 2016.

Figure 5: Number of adults and children on the Long-Term waiting list (15 months and over) for day case and inpatient treatment, 2016 and 2019 (December).

Source: NTPF (2019)

The total number of children awaiting inpatient and day case treatment has increased between the years 2016-19. In 2016, the total number of children on the waiting list for day case treatment was 364, while 217 children were awaiting inpatient treatments. Four years later, the total number of children awaiting day case treatment has increased to 600 (+236) and the total number of children on the inpatient waiting list has increased slightly to 225 (+8).

References

Hayes, B., Prihodova, L., Walsh, G. et al. (2019) ‘Doctors don’t Do-little: a national cross sectional study of workplace well-being of hospital doctors in Ireland’ BMJ Open, 9:e025433.

Health Service Executive (2019a) Performance Profile July-September 2019 Quarterly Report [Online] Available at: https://www.hse.ie/eng/services/publications/performancereports/july-to-september-quarterly-report.pdf

Health Service Executive (2019b) National Reports – Workforce Reports Online] Available at: https://www.hse.ie/eng/staff/resources/our-workforce/workforce-reporting/national-reports.html

Health Service Executive (2018a) Performance Profile July-September 2018 Quarterly Report [Online] Available at: https://www.hse.ie/eng/services/publications/performancereports/july-to-september-2018-quarterly-report.pdf

Health Service Executive (2018b) Performance Profile October-December 2018 Quarterly Report [Online] Available at: https://www.hse.ie/eng/services/publications/performancereports/october-to-december-quarterly-report-2018.pdf

Health Service Executive (2017a) Performance Profile July-September 2017 Quarterly Report [Online] Available at: https://www.hse.ie/eng/services/publications/performancereports/july-september-2017-performance-report.pdf

Health Service Executive (2017b) Performance Profile October-December 2017 Quarterly Report [Online] Available at: https://www.hse.ie/eng/services/publications/performancereports/october-to-december-2017-performance-report.pdf

Health Service Executive (2016a) Performance Profile July-September 2016 Quarterly Report [Online] Available at: https://www.hse.ie/eng/services/publications/performancereports/august-september-2016-performance-report-.pdf

Health Service Executive (2016b) Performance Profile October-December 2016 Quarterly Report [Online] Available at: https://www.hse.ie/eng/services/publications/performancereports/october-december-performance-report-2016.pdf

Health Service Executive (2015) Performance Profile October-December 2015 Quarterly Report [Online] Available at: https://www.hse.ie/eng/services/publications/performancereports/dec15pr.pdf

Irish Hospital Consultants Association (2019) Hospital consultant shortages perpetueating a spiral of burnout, stress and doctor emigration [Online] Available at: https://www.ihca.ie/news-and-publications/hospital-consultant-shortages-perpetuating-a-spiral-of-burnout-stress-and-doctor-emigration  

National Treatment Purchase Fund (2019) National Waiting List Data [Online] Available at: https://www.ntpf.ie/home/nwld.htm


[i] In this context, an outpatient refers to a patient who is waiting for a first appointment at a consultant-led outpatient clinic. The majority of patients requiring admission are usually referred by their General Practitioner and attend an ‘outpatient consultation’. At this consultation, the clinical decision will be made as to whether or not an inpatient or day case admission is required (NTPF, 2017).

[ii] An inpatient admission is a patient who is not a day case admission and who will require the use of a hospital bed overnight. A patient placed on a waiting list for a day case is a patient who will be admitted to hospital on an elective basis for care and /or treatment which does not require the use of a hospital bed overnight (NTPF, 2017).

[iii] See Appendix one for list of Acute Hospital Service Staff working in each sector.

Appendix One

 Source: HSE (2019b)

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