11 minute read
Irish health system under pressure
A system under pressure
With the pandemic now stretching into its third calendar year in Ireland and waiting list numbers reaching all-time highs in 2021, the Irish health system has come under significant pressure of late, at a time when efforts were to be focused on the implementation of the Sláintecare reforms.
Covid-19
Yet again, the health system has come under pressure due to a spike in the number of Covid-19 cases. Having been as low as 200-300 new cases per day in June 2021, case numbers steadily rose from October onwards, peaking at 5,959 new cases on 21 November, with between 3,000 and 5,000 new cases recorded each day for most of November and into December.
While these numbers do not make for good reading, there is solace to be drawn from both testing numbers and hospitalisation rates that show a health system that has gotten to grips with the virus much more than in previous waves. The effectiveness of the vaccination campaign rolled out by the health system during 2021 is borne out in hospitalisation figures: on 5 December, a seven-day average of 4,885 new cases was recorded, with a seven-day average of 543 hospitalisations (11.1 per cent) and 115 (2.3 per cent) people in intensive care. In comparison, a seven-day average of 4,381 new cases per day was recorded on 15 January 2021, with a seven-day average of 1,623 hospitalisations (37 per cent) and 156 people in intensive care (3.6 per cent).
Testing capacity has also been greatly increased, with November and December consistently recording seven-day average records for tests taken. The average now exceeds 30,000 per day. This, of course, has led to an increase in the rate of positive tests, with positive rates over 10 per cent recorded in October for the first time since January, reaching as high as 15 per cent in November, though still not as high as the 25 per cent seen in January, when 5,000 less tests per day were being taken.
However, despite the relative success of the vaccination programme in keeping people out of hospitals and in the increased testing capacity in detecting cases, the health system has still been put under significant pressure due to a lack of capacity. HSE figures released in mid-November showed 288 ICU beds open and staffed in Ireland, with 279 of them (97 per cent) occupied, 119 by Covid patients. Projections for numbers of ICU beds needed for Covid cases alone during this current wave range from 300 to 500; while Budget 2022 committed to the delivery of 340 ICU beds in the State by the end of 2022. ICU capacity is an issue that has affected the health system well before Covid, with the
Covid-19 in the Republic of Ireland, 2021
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OECD reporting in 2019 that Ireland had 5.2 ICU beds per 100,000 of population, as compared to an average of 14.1.
Capacity in testing has also been put under great stress due to the increase, specifically in the Greater Dublin Area, with three new centres opened in November in an attempt to alleviate some of this pressure.
The Health in Ireland: Key Trends 2021 report stated that an expenditure increase of €3 billion had occurred between 2019 and 2020, with staffing increases due to the pandemic a major contributing factor. Separate HSE data published in November showed one-in-25 HSE staff to be off work at the time due to either being infected with Covid-19 or being deemed a close contact. 5,800 employees were absent at the time, a total of 4 per cent of the workforce, as compared to 1,800 a month previous.
Waiting lists
Unsurprisingly, the pressure placed on the health system by the pandemic has seen problems elsewhere in the system worsen since March 2020. National Treatment Purchase Fund data published in August 2021 showed a record 908,519 patients on some form of public hospital waiting list for assessment by a consultant or treatment at the end of July. 268,500 of these were waiting for over a year for assessment, a 15 per cent increase on July 2020 and a seven times increase over seven years. 20,513 patients were waiting over a year for hospital care, an increase at a rate of 88 times since 2012.
The Key Trends 2021 report, which was prepared by the Department of Health, found that there has been a 25 per cent increase in the number of people who have spent more than six months on inpatient waiting lists since the pandemic began. Over 28,000 adults and almost 4,000 children were found to be waiting more than six months for inpatient treatment in October 2021.
The Government had sought to reduce waiting list numbers by 18,300 between August and the end of October, but the final figure recorded was 10,700, or 60 per cent of the target. The Irish Hospital Consultants Association has said that it expects the target of 36,600 reduction by the end of 2021 to be missed.
Sláintecare
Sláintecare implementation has been thrown into doubt of late with the resignation of three members from the Sláintecare Implementation Advisory Council (SIAC), but progress towards the goals in the reform programme continues with the Winter Plan and 2021 National Service Plan placing pronounced emphasis on the building of capacity for healthcare to be delivered within local communities.
However, the Irish Fiscal Advisory Council has recently warned that basic financial information around the reforms is “severely lacking”, stating that no budgeting is available beyond one year, updated costing have not been produced since 2017; “little clarity on progress made is publicly available”; and public spending on health, pay and other cost issues “do not appear to have been factored into the original costings”.
With this likely to have driven up the final cost of the implementation of Sláintecare, the IFAC has warned that factoring in these pressures “should be carried out as a matter of urgency”.
I lead a small but dedicated multidisciplinary team in the HSE National Immunisation Office; we manage vaccine procurement and distribution and developing training and communication materials for the public and health professionals to allow safe and high-quality vaccination programmes to be delivered in line with Department of Health Immunisation Policy. During the Covid-19 pandemic we have also supported the implementation of the Covid-19 vaccination programme and its many changes.
The first Covid-19 vaccine was administered in the Republic of Ireland on the 29 December 2020 to Annie Lynch and up to the end of November 2021 over 7.4 million doses have been administered.
It’s important to remember that as millions of doses of Covid-19 vaccines were administered in Ireland during 2021, our routine vaccination programmes continued thanks to dedicated health professionals who know the value of preventing vaccine preventable diseases.
In Ireland, our vaccination programme offers protection against 13 diseases including influenza, rotavirus, meningococcal disease and measles. We offer vaccines throughout the life course; the primary childhood immunisation programme at two, four, six, 12 and 13 months of age through GP practices, our schools programmes to Junior Infants in primary schools and first year in second level schools delivered by HSE school immunisation teams, vaccines in pregnancy and to those in risk groups through GP practices and pharmacies and our vaccines for health professionals delivered through peer vaccination programmes in our CHOs and Hospital Groups across the country. In lots of cases the professionals who are delivering the Covid-19 vaccines also deliver our routine programmes.
Immunising the nation
Since the World Health Organization declared that Covid-19 was a pandemic on 11 March 2020, a lot has changed in our personal and professional lives but one thing that hasn’t changed is my team’s dedication to preventing vaccine preventable diseases, writes Lucy Jessop, Director of Public Health, National Immunisation Office within the HSE.
Reflecting on 2021
My multi-disciplinary team have a wealth of experience in public health, medicine, pharmacy, procurement, ICT, communications and project management. With these skills we have supported our colleagues across the HSE working across different work streams to safely implement a population wide Covid-19 vaccination programme and maintain our support for the routine programmes.
The National Immunisation Office has taken the lead on the training of vaccinators for the Covid-19 vaccination programme and in providing clinical information on the vaccine programmes. Frequent updates from the European Medicines Agency (EMA) and the National Immunisation Advisory Committee (NIAC) have meant that we have had to respond quickly to ensure all our clinical and public facing materials always contained the most up to date advice which has been by no means easy.
For example, so far this year we have:
• developed over 40 different clinical materials to support our vaccinators across the country and updated them as needed for example our Clinical Guidelines are currently on Version 29, reflecting the amount of clinical changes to the programme since it began;
• dealt with over 6,000 queries covering topics like intervals between Covid-19 vaccines, cold chain and clinical questions about vaccines;
• provided up to date e-learning training which has so far been completed by 20,000 learners across the country;
• worked with HSE communications to ensure information provided to people before and at the time of vaccination is clinically accurate;
• we worked with colleagues in HSE
Social Inclusion to provide information in over 26 languages using print, audio and visual materials; and
• worked with the HSE Office of the Chief Information Officer (OoCIO) to test software releases and sanity testing before updates are made to the CoVax system being used to record Covid-19 vaccination records across the country.
I have attended Department of Health NPHET briefings on four occasions and presented at Joint Health Select Committees, HSE press briefings, the European Congress of Clinical Microbiology, BIPA Committee B along with multiple TV and radio appearances to provide updates and answer questions about the Covid-19 vaccination programme.
It hasn’t been all smooth sailing; the cyberattack in May meant we had to rethink the work processes we had put in place to run an efficient team. Our email, education, shared files and all
other HSE IT systems went off line overnight but our vaccination programmes continued, so we needed to adapt to continue to support them.
My team developed a solution that allowed health professionals to contact us if they had clinical queries and they developed a bespoke training and education programme similar to that provided by the HSE HSELand platform to ensure vaccinators and vaccine advocates could continue to access up to date clinical training materials for the Covid-19 vaccination programme. This was up and running within days of the HSE systems going offline.
During the time of the cyberattack we dealt with over 2,000 clinical queries and over 6,000 people completed the Covid19 Vaccination Training Programmes.
Throughout 2021, we also continued to work on our routine immunisation programmes and adapt our messaging in line with Covid-19 measures. We encouraged people to avail of vaccines for their babies, school children and themselves to not only protect them from vaccine preventable disease now but when they are older too using traditional and digital channels.
Planning ahead
As we approach the end of 2021, we are reflecting on the work we have completed so far this year and putting plans in place for our routine work in 2022. We are also very aware that we will need to continue to adapt to support the Covid-19 vaccination programme and whatever changes are required in line with Department of Health policy.
Although Covid-19 public health measures like social distancing and reduced foreign travel have supressed the number of vaccine preventable disease being reported in Ireland temporarily, they have not gone away. Some people have not taken the opportunity to complete the recommended vaccination schedule for themselves or their children. It is never too late to catch-up on vaccinations so I would encourage people to contact their GP or other healthcare professional to arrange any vaccines they have missed. The mission of the National Immunisation Office has not changed through the pandemic and beyond. We will continue to work with key stakeholders and support healthcare providers to maximise the uptake of all national immunisation programmes and provide strategic direction in support of a best practice based, equitable and standardised delivery of publicly funded immunisation programmes.
Lucy Jessop worked in paediatrics before training in Public Health Medicine in London. She worked as a consultant in both England and Northern Ireland. In 2019 she took up the position of Director of Public Health, National Immunisation Office. She was previously the Northern Ireland member of the Joint Committee for Vaccinations and Immunisations in the UK and is now a member of the National Immunisation Advisory Committee.
W: www.immunisation.ie Social: @hseimm on Twitter and Instagram and National Immunisation Office on YouTube.
