Health service staffing under the microscope

We are entering what is traditionally the busiest and most testing time for the health system.

Along with a rise in colds, flu and other viruses, the winter season exposes weakness in the health services, especially in staffing and capacity bottlenecks.

Hospital overcrowding is on the rise again.

This week, health unions warned that the Health Service Executive is understaffed and that there are restrictive ceilings and caps on recruitment, which means unsafe staffing and delays in patient care.

Industrial action

Industrial action is looming over the issue with ballots due to begin later this month.

This week, healthcare unions held lunchtime protests to highlight the issue. The HSE said the protests were regrettable, against the background of extra funding for the service.

Both sides seem set for confrontation.

The Government has countered that Ireland has never had as many health staff and that an extra 28,000 people have been employed in the system during its lifetime.

Next year, the HSE will have €24.3 billion for day-to-day services, the highest sum ever. It will also be allowed to employ an extra 3,300 staff to meet a total staff ceiling cap of 133,300 people. Is this not sufficient?

Now that the six new HSE regions have gone 'live', each has been provided with its own specified number of staff and the senior executives in the regions can replace and recruit staff, within that ceiling.

Population increase

Ireland’s population has been growing significantly, the proportion of older people is rising and people are living longer. All these elements increase demand on the health service.

One of the major bones of contention is the HSE Pay and Numbers strategy of July 2024. It also dealt with staffing that had not been approved by Government and set a ceiling on overall staff numbers for the service.

According to the Irish Nurses and Midwives Organisation (INMO), what happened in July of this year with the HSE Pay and Numbers strategy, was that all posts that were not physically filled in December 2023, last year were axed.

INMO General Secretary Phil Ní Sheaghdha said the system has been told that these posts cannot be filled because they no longer exist. She said the service is regularly dealing with ratios of one nurse to 12 or 14 patients, when it should one to four.

She also argued that in 2022 although weekly nursing hours had reduced from 39 hours to 37.5 hours, the HSE staffing strategy did not account for this in its workforce planning.

As part of the changes introduced with the HSE Pay and Numbers strategy, several thousand posts that had not been approved were retrospectively approved by the Government.

Under a two-year deal, the Government agreed to cover a projected HSE overrun this year of €1.5bn, plus the health service was given €1.2bn for the existing level of services in 2025.

On top of that, over €150m was allocated in the Budget last week for new or expanded services next year.

Pressure points

Minister for Health Stephen Donnelly has accepted that there are some clinical teams in the community that are under significant pressure and who need extra staff.

But he insisted that when it comes to nursing, Ireland has the second highest level of nurses per head of population in Europe, second to Finland.

He also pointed to a significant increase in consultant numbers - the Budget provides for an extra 49 new consultants next year. He added that Ireland has never had as many healthcare staff for the population.

Reliance on agency staff

The health service is still heavily reliant on agency staff, which cost almost €650m last year. While this is an expensive way to run the HSE, a certain amount of agency staff will always be needed, given the nature of the service.

Health unions would like to see the many thousands of agency staff places converted to full-time staff, which would mean staff would be permanent and be eligible for pension, sick pay and other benefits. There is also the argument that permanent staff are more likely to provide better continuity of care for patients.

The HSE’s Pay and Numbers Strategy promised 418 agency conversions towards safe staffing levels, plus 542 agency conversions to reduce costs and increase stability. Conversions are where these posts are filled by permanent staff, and no longer by agency personnel.

The College of Psychiatrists of Ireland has expressed major disappointment in the health funding for next year. Its assessment is that the measures will not go far enough to recruit and retain the number of staff needed for services.

Creeping privatisation

Social Democrats Spokesperson on Health Róisín Shortall raised concerns during the week, that there is a deliberate, creeping privatisation of health services. She said the scale of outsourcing of services that are supposed to be public was shocking.

She also noted that there were now 68 fewer public health nurse wholetime equivalent posts in the health system, than in December 2019.

Health unions have also warned that caps on recruitment can take a long time to recover from. Skilled workers will go to the private sector, sometimes with better pay and conditions, and many will go abroad. This is where the recruitment and retention of staff comes under pressure.

It can take about six months to fill a nursing post here, and many Irish recruitment programmes have to look abroad to try and attract people to come to the Irish system. There has been some success in attracting consultants from the NHS in Northern Ireland, to work in the Republic of Ireland, where pay is significantly better, under the new public only contract.

Cancer care

Staffing shortages are also affecting cancer care here, according to the SIPTU union.

Up to 120 cancer patients a day are not getting the treatment they need because of a shortage of radiation therapists, the union told the Oireachtas Committee on Health this week.

It said the staffing crisis has led to at least four cancer treatment machines not being utilised, meaning expensive equipment is lying idle.

Deborah Kelleher, SIPTU member and a radiation therapist, said that staffing levels are 30% below what is needed across the five public radiotherapy centres.

She added that along with four cancer treatment machines closed, there are three CT scanners not in use.

As a result, she said that around €10m has been spent on outsourcing to private centres.

In a survey SIPTU carried out in August among mostly acute hospitals, 86% of respondents said that the recruitment embargo was having either a 'very negative' or 'somewhat negative' impact on services and staff.

The survey also found that the use of agency staff had increased as a result.

New services

The Government has promised extra investment in a range of areas next year. These will require extra staff.

The National Ambulance Service will get 180 more wholetime equivalent staff to expand services.

More GP training places are promised, along with the continued expansion of Advanced Practitioners in health and social care.

There are to be 209 internship places provided for student nurses.

Added to that, 45 staff are to be employed to open the remaining beds at the National Forensic Mental Health Service Hospital in Portrane, in north Dublin.

The HSE said that overall staff numbers are rising and for people to suggest there are cuts is a misrepresentation of the situation.

By its nature, health is a very labour-intensive service. Inevitably, there will always be pressure for extra staff. Of the total health budget, over €11.7bn will go on pay and pensions next year.

Ensuring that the correct mix of staff is in place for patient needs is a complex but critical job.

Health unions insist that the HSE has got its staffing policy badly wrong and warn that this will pose dangers.

The HSE and the Government disagree.

The wider public, and health service patients are left in the middle, trying to understand this widening gulf between the sides, and how it might affect them.