An extraordinary aspect of the current capacity crisis in the health service is the failure of the media and public attention to reflect on the causes and solutions for the problem. This short attention span has focused on the final common pathway of the problem, the crowded emergency department, rather than those elements causing it, some of which could be resolved in the short term.

The longer-term issues include failure to invest for a growing population in both community and hospital services (glib comparisons with other countries are meaningless given the incorporation of social services in our health budget) and fractionation of emergency services and costs across too many centres without critical mass.

A helpful analogy for the trolley crisis is that of a bath overflowing, and what measures might be undertaken to stop it, apart from mopping the floor and wringing hands, or indeed shouting at the bath for not being efficient enough as is the wont of some politicians.

The first is to turn off the tap, ie the numbers of patients presenting to the service. Known as admission avoidance, the scope for this is limited, as most patients that I see on every post-take ward round need admission.

However, Tallaght Hospital, like many major hospitals, has undertaken strenuous efforts to lower the flow, developing an acute medical assessment unit, a chest pain service, engagement with services to provide intravenous medications at home, an integrated care team for older people, etc.

Time and month

The second option is to increase the size of the bath by increasing hospital bed numbers, which with the best will in the world takes time and money. While planning for this should start immediately, in the interim the bath will continue to overflow.

What is most disheartening is that the obvious solution – removing the bath plug – is off the table largely due to the effective freezing or severe rationing of homecare packages in some areas for those who require this service due to their disabilities, either as a factor in their admission to hospital or consequent to the illness precipitating admission. An additional factor is the failure to provide tailored dementia care in nursing homes for those with more complex needs.

In our own hospital more than 20 patients could be discharged if their homecare package was available, and multiplying this number by the weeks or months they are waiting is a clear major contributory factor to the trolley crisis. This is made worse by a freeze on new homecare packages to those living at home in our and other areas, not only causing suffering but also potentially contributing to hospital admissions.

That this outrageous situation (imagine if antibiotics or cancer therapies were cut off in this way) has not received due attention seems to be due to complex dysfunctional interactions between the Government, Department of Health, various sections of the HSE, and in the final analysis also due to us as well in terms of our signals to our TDs as to how we should prioritise healthcare spending.

Unfunded costs

As recent interactions between the department and the HSE have made clear, extra unfunded costs have been imposed on the HSE, whether through new expensive medications, increase in population or diffusing funding for 24-hour emergency services in a wide range of small centres.

The media and general public need to redirect their ire about trolley crises away from the hospital

Something had to give, and whether it was seen as strategic in terms of sparking a reaction (which it has not yet) or of establishing budgetary lines between the department, HSE central and its regions, it is predominantly vulnerable older people, and the many hundreds daily who end up on trolleys, who suffer from the freezing and restriction on homecare packages.

So, the next time you or a family member suffers the distress of being admitted to hospital on a trolley, or you hear debate in the media or apologies about stays on a trolley, remember this might well have been averted if homecare packages and tailored nursing-home care for dementia had been made available in a timely fashion in every community health area.

A focus on normalising access to homecare packages, a basic building block of care, would also afford an opportunity to review how homecare staff are funded and supported. In many areas, there have been difficulties in recruitment to the private-care agencies who generally provide the care.

Contrasting sharply

It would appear that a very high proportion of the HSE payment is retained by the agencies, with care worker payments set at around the minimum wage level contrasting sharply with much higher rewards for the owners of such agencies. Developing better pay and conditions for direct care workers must also become a priority element to support stated government policy of prioritising care at home.

The media and general public need to redirect their ire, outrage and political energy about trolley crises away from the hospital and towards the key remediable aspect of the situation: readily accessible and high-quality homecare packages and more sophisticated nursing-home options for those with complex needs.

Prof Des O’Neill is a geriatric consultant at Tallaght Hospital