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The crisis in Irish hospitals

Jon Morris

13 February 2023

Patients lying on trollies.

While the crisis that engulfed Irish hospitals in January has eased to some degree this is only in a relative sense when compared to its most acute point.  The new year opened with the familiar story of overcrowding in public hospitals across the state. Trolley numbers hit record levels with 931 and 838 people lying on trollies, waiting on a hospital bed, on January 3rd and 4th respectively.  The situation was so acute that health officials were warning people to stay away from hospital A&E departments.  However, this crisis didn’t come out of nowhere. It had been building throughout the previous year.  In early December 2022 another record was reached when it was announced that 118,662 patients had been on trollies at some stage since the beginning of the year.  When we consider that annually, up to 400 people die in A&E units as a result of overcrowding, we get a sense of how dangerous such conditions are.


Despite claims that the hospitals’ crisis was impossible to foresee, the reality is that the crisis of January was entirely predictable and indeed had been predicted by medical professionals.  They were scathing about the Winter Plan, to deal with the expected capacity problems in hospitals, that was published by the government in October.  The Irish Medical Organisation, which represents doctors, said that it was “meaningless to those working in our health services and those who need care.”  The group said that the budget was insufficient to tackle the enormity of the challenge facing the health service over the winter months claiming that the plan was “more about branding than a meaningful intervention to deal with the capacity issues, workforce crisis and patient waiting lists.”  Back in September Dr. Fergal Hickey, president of the Irish Association of Emergency Medicine, warned that winter would be “hell on earth” due to the lack of acute beds, the lack of critical care beds and the difficulty in recruiting staff.  These staffing issues (such as the 900 consultant vacancies) arise from relatively poor wages and working conditions, and are consistently cited as one of the primary causes of problems within the health service.


Various government officials have made the point that in recent years, largely in response to the pandemic, the capacity of the health service has been expanded, with a figure of a thousand extra beds often being cited.  However, such claims are thoroughly disingenuous as they ignore the decline that preceded it, and more than offsets this modest expansion.  For example, over the last 15 years eight A&E departments have been closed by the Health Service Executive.  The number of beds in the state has fallen by over a third since 2008, falling from 21,789 to 14,412.  This is despite the fact that the population of the state has risen by 200,000 in the same period.  What needs to be factored into this is that Ireland has an ageing population which also leads to increased demand on health services. By international comparisons Ireland is below average when it comes to hospital bed provision.  It is below the EU average of 387 beds per 100,000 people; the Irish figure is 269 beds per 100,000.  Ireland’s bed to people ratio is also well below the OECD average and is lower now than it was 14 years ago.

This deterioration in the capacity of the Irish health service is well documented as are the warnings of the likely consequences. What has also been on the public record are the projections from various professional bodies on what capacity is required to address the current and future healthcare needs of the population.  for example, in 2017, the GP committee of the Irish Medical Organisation insisted one thousand additional hospital beds were needed immediately and 325 additional beds would be needed annually "for the next two decades". It also pointed out that there would be about 20,000 more people over the age of 65 every year until 2040. Earlier this year the Irish Hospital Consultants Association stated that an additional 5,000 hospital beds are needed by 2030 “to meet current and expected demand."  While these figures can be considered the bare minimum, they are well beyond anything that is planned by the government.  The clear implication is that the situation in the health service will continue to deteriorate and that the crisis point over the winter months will become more acute.

Recurring crisis

The big myth being pushed by the government around the crisis that engulfed Irish hospitals this year was that it was the consequence of a unique set of circumstances, the by-product of a “perfect storm” of rising flu, RSV and Covid cases. This was summed up in the claim by health minister Stephen Donnelly that “what we're seeing this year, unfortunately, is new.”  However, this is simply not true.  The reality is that crises, of this type, have been a regular feature of the Irish health service over many years.

The recurring and long-term nature of the failings of hospitals was set out in an article in the Irish Times by the historian Diarmuid Ferriter.  He illustrated this by drawing from the “abundant archive of trolley stories and related tales of distress in hospital settings”.  As one of the earlier examples he quoted an address to the Fine Gael Ard Fheis in 1994, by then party leader John Bruton, in which he singled out the issue as indicative of the failure to provide quality public services and, crucially, cater adequately for "the rights of those who are ill".  Moving forward in the timeline to January 2005 he cites a figure of 422 patients on trolleys at that time representing a record level.  Advance to 2011 when the number of patients on trolleys was now over 500; a situation the Irish Association of Emergency Medicine claimed was putting patients' lives at risk.  The critical point made by the professional body was the failure to provide adequate bed capacity "cannot and should not be blamed on seasonal influenza".  In December 2014, up to 20 patients a night were being treated on chairs at Beaumont Hospital.  By January 2015 a "record high" of 601 patients on trolleys was reported.  In January 2018 a "record figure" of 677 patients were on trolleys. In January of 2023 the number on trolleys reached more than 900: a situation described by the Irish Nurses and Midwives Organisation (INMO) as an "out and out crisis".

Profit driven system

While the challenges faced by Ireland’s health service aren’t unique, they are exacerbated by a system that is heavily skewed towards for profit health care whether that is private practice, private medical facilities or private insurance.  The public elements of health care are very weak and are really no more than a collection of mitigations (such as medical cards) to protect the poorest people in society.  In the history of the state there has never been any proposals for the reform of health care that have gone beyond the extension of current mitigations.

Successive governments have continued with the for-profit system despite the high cost to the public purse.  Recent examples of this include the hugely inflated costs of the new Childens’ Hospital and the plan to hand the management of the new National Maternity Hospital over to a multinational healthcare business.  Before this, there was the policy of “co-location” which saw private medical facilities arise within the grounds of public hospitals.  Despite the cost and inefficiency of this so-called “two tier system”, which even the Taoiseach Leo Varadkar has decried as “not right and not normal”, the commitment of the government to the protection of profiteering and rent seeking is unwavering.  Its most immediate response to the beds crisis was to call for the further expansion of private healthcare. This was made most explicit by Minister of State at the Department of Transport and Environment Jack Chambers who claimed that there had been an under-utilisation by the Health Service Executive of bed capacity in private hospitals.  He demanded that the HSE “scale up" its use of private beds and co-ordinate its efforts with the Private Hospitals Association.  Similar sentiments were expressed by the Taoiseach and the Minister for Health.

On the face of it the health policy of the government is illogical, contradictory and even hypocritical.  But that’s not what matters. What matters is that it is in keeping with a state and government whose whole programme is subordinated to rent seeking and profiteering, not just in Ireland but on an international scale.  The policies being pursued in relation to health, housing or anything else can only be understood within this framework.

Wealthy republic?

In the comment piece by Diarmuid Ferriter, referenced earlier in this article, he makes the observation that “it is remarkable that a small, wealthy republic creaks annually on the hinge of this issue.”  While this may appear passing and superficial, and whether the author was conscious of its import or not, this actually cuts to the heart of the matter on health and a whole range of other issues.  The widely held assumption, including on the left, is that Ireland is a republic (that as a nation it has achieved political independence) and that it is generating enough wealth (income) to adequately fund a wide range of public services. Within this schema it is baffling that Ireland should be experiencing persistent crises within sectors such as health and housing.  The blame for this is put down to misguided government policies.  There is an assumption that an alternative government (most likely led by Sinn Fein) would pursue a different programme that would produce a different outcome.

The underlying premise of the “wealthy republic” concept is the possibility of reform i.e. an Irish variant of social democracy.   However, the foundations for such a hope are dubious.  Firstly, Ireland has not fulfilled its national democratic tasks.  Rather than being a capitalist state (albeit a small one) in which questions around self-determination and independence have been settled Ireland retains its colonial status.  The most obvious manifestation of this is partition with part of Ireland’s national territory being under the direct control of a foreign power. Less remarked upon is the domination of the island of Ireland as a whole by international capitalism and imperialism.  We see this in the political sphere (most recently in relation to the war in Ukraine) by the Irish state aligning itself closely with the EU and the US and also with NATO.  We also see it in the economic sphere with the Irish economy completely geared towards servicing the needs of international capital.  This was revealed most clearly in the wake of the financial crash of 2008 when the Irish state was prepared to bankrupt itself in order to bailout bondholders.  For a long period, the Irish state’s signature economic strategy has been to function as a tax haven for multinationals.  In more recent years it has completely opened up the housing market to international landlordism represented by the vulture funds.

While it is true that there is wealth flowing through (and being extracted from) the jurisdiction of the Irish state this does not mean that Ireland as a nation is wealthy.  Ireland’s status as a neo-colony makes it impossible to build up national income and accumulated wealth that could be used by a reformist government to fund public services.  It is this structural problem, rather than the incompetence of successive governments, that is the biggest barrier to reforms in Ireland.

The hospitals’ crisis is a good example of how this operates.  At the time as hundreds of patients were waiting on trolleys it was announced that the Irish state had collected a record level of corporation tax for the year (over €5bn more than projected).  When the obvious point was raised about this surplus being used to ease the crisis in the health service the reply from the government was a blunt “no”. Taoiseach Leo Varadkar stated that the first call on any surplus was the servicing of the debt incurred by the bailout rather than increasing public spending.

Working class

The Irish state’s broad programme - which has been in place for forty years - rests on the premise that there can be no concessions to labour in the workplace or in public policy.  Every political party (including those that purport to be on the left) accept that they are working within this programme. The trade unions also accept it and are fully committed to the framework of social partnership which enforces the demands of employers and the government upon workers.  This is why quite modest demands from workers in relation to issues such as housing and health are continually knocked back.  It is also the reason why a future Sinn Fein led government, which many people have invested hope in, is likely to disappoint. The crisis in the health service, and across a range of issues, is not going away.  Surging inflation and the economic fallout from the escalating war in Ukraine has made them even more acute.

A serious challenge to the status quo requires the creation of an independent working-class movement that understands that pressing for even modest demands means coming into conflict not only with employers and the government but also with the current leadership of the trade unions. Given Ireland’s place in the international capitalist system such a movement will inevitably be anti-imperialist as well as anti-capitalist.

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