At the same time, meeting this demand for rehabilitation beds and care options is fraught with challenges. From limited bed capacity, regional distribution disparities and staffing shortages to aging infrastructure, collectively there are significant barriers to scaling up supply.

HSE data indicates that delayed discharges can lead to more than 200,000 lost bed days a year. In simple terms, patients who are medically well enough to leave hospital cannot leave, because there is nowhere suitable for them to go. While this is in part due to a shortage of available spaces at community hospitals or nursing homes, or delays in facilitating home care packages, it is often owing to fragmented care delivery systems and insufficient collaboration which impedes effective rehabilitation pathways. While such challenges are not unique, the scale in Ireland is greater than average equating to 43 days per 1000 people compared to 5 days per 1000 people in Denmark, 16 days per 1000 in Norway and 34 days per 1000 in the UK[1].

There are, of course, both direct and indirect consequences of delayed discharges. The recovering patients themselves are directly impacted by having to stay in an acute bed in an acute care environment, being exposed to the risk of hospital-acquired infections. Patients waiting for a hospital bed are then often left on a trolley in a corridor, until a bed becomes available. Indirectly, the pressure to find beds in a crowded hospital can often lead to the cancellation of elective procedures. This, in turn, leads to ever-growing waiting lists. The financial, health and social costs of delayed discharge are felt across the health system. But the question is, what are the possible solutions?

Improving integration with primary care and community services is essential for reducing delayed discharges and optimising patient outcomes. Looking further afield, we can learn lessons from several countries including Sweden, the Netherlands and Denmark all of whom have implemented successful models of investing in rehabilitation services at system level. Sweden is a notable example, emphasising early rehabilitation and patient-centred care. In 2019, Sweden had the lowest number of hospital beds per capita in the EU, at 2.1 beds per 1,000 population (compared to the EU average of 5.4). This is partly because most hospital activities in Sweden focus on acute care, whereas most rehabilitation services and all long-term care are provided outside of hospitals. Their average length of stay in hospital has come down over the past decade and was about 25 % lower than the EU average in 2018 (5.7 versus 7.5 days)[2]. Importantly, countries who have been successful in achieving improvements through targeted investment in rehab services are those which have focussed on the whole continuum of care from acute treatment within a hospital setting, to community rehab beds, and through to home-based care, thus ensuring the flow of patients out of the acute setting.

In Ireland, the HSE Early Supported Discharge (ESD) programme[3] was rolled out in 2012 and is now working from nine major hospitals across the country. The programme has demonstrated that it reduces length of stay for appropriate clients, saving nearly 8000 bed days during the COVID-19 years of 2020/2021. However, up until 2021, only 25% of stroke survivors have been able to access the programme, and the programme itself has had significant difficulties with reaching full staffing levels, partly due to the temporary funding attached. The intention of the HSE is that there will be 21 ESD services across the country by the end of 2025, but it is unclear how they intend to manage the recognised challenges with staffing, meaning that it is unlikely that they will meet their target of 5480 saved bed days per annum[4].

Access to quality data is a key requirement in tackling the issue of delayed discharges. The use of manual reporting and fragmented software systems means that timely access to data across the Irish health system can be difficult and clinicians and managers do not have visibility of system capacity across the acute, community and continuing care sectors. An up-to-date national map of rehab beds, community and continuing care services would provide a comprehensive baseline, highlighting where gaps may exist. This baseline could then be used to develop a whole-of-region and/or national dashboard, outlining live system capacity across acute, community and continuing care. This type of integrated approach could provide a robust evidence base for future clinical and infrastructure planning for rehab services, supporting cost effective and clinically driven care pathways for patients across the country.

Ultimately, successfully addressing challenges in Ireland’s rehab capacity will require a coordinated approach involving providers, policymakers and stakeholders to ensure that infrastructure, workforce, and integrated care models can meet demand. The recent appointment of Regional Health Executive Officers within the HSE now provides a key opportunity to allow all sectors of the health and social care system to optimise capacity and highlight where gaps or barriers exist, enabling a fresh approach to improving the continuum of care for patients across the Irish health system.

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About the author

Deborah Hutton is an Associate Director in Strategic Advisory. Alongside a clinical background as a speech therapist and multi-disciplinary health service manager, she has significant experience of health planning, implementing service redesign and managing complex projects within health and social care environments.

References:

[1] Health at a Glance: Europe 2018, OECD

[2] OECD/European Observatory on Health Systems and Policies (2021), Sweden: Country Health Profile 2021, State of Health in the EU, OECD Publishing, Paris/European Observatory on Health Systems and Policies, Brussels.

[3] Early Supported Discharge for Stroke, 2020 & 2021 Report, HSE

[4] Early Supported Discharge for Stroke, 2020 & 2021 Report, HSE