The single most newsworthy and most persistent healthcare issue in Ireland is the constant overcrowding in emergency departments. This is a problem throughout the year and is invariably at its worst at the beginning of each year. In January of 2017 the number of patients on trolleys in emergency departments awaiting an inpatient bed in Irish hospitals peaked at an all-time high of 612. At the same time in the UK the media were also reporting a crisis and the Red Cross cautioned that emergency departments in hospitals in England would be unable to deal with a major disaster, should one occur. Interestingly, the problem is much less in Scotland.

When private health insurance and direct personal spending on healthcare is included, the cost of healthcare is Ireland is probably of the order of €20 billion, or €5,000 per person. It is depressing to think that this is not sufficient to allow a reasonable level of comfort and dignity for those, mainly elderly, people who need acute hospital care.

Solutions proffered by representatives of various stakeholders and by politicians include more inpatient beds, better resourcing of primary care, better social supports, healthier living and so on. What is lacking is any evidence to support any of these suggestions. A few things are clear, however:

The problem is in the emergency departments but the solution is not. Building bigger emergency departments, as has been done in recent years, makes the problem bigger

Most of the patients awaiting hospital admission are frail and elderly and many have problems that require care that could be provided outside hospitals but which they cannot access.

Appeals to discourage attendance at emergency departments may have a small effect but in this case patients with minor problems must be offered alternatives and those with serious treatable problems must not be deterred. In any case, patients with minor problems are easily dealt with and do not require hospital admission.

Perhaps some intelligence may be gleaned by looking not so much at those hospitals that have the greatest overcrowding, as at those that do not. Small hospitals that have replaced emergency departments with medical assessment and local injury units are rarely among those mentioned as overcrowded – are they simply less busy or are they more efficient? Not all of the larger hospitals appear to suffer to the same extent. Is this due to better resources, different demographics in the catchment population or different practices in dealing with acute medical cases?

Since most inpatient medical beds are occupied by elderly patients, examination of the role of elderly medicine departments in hospitals might give some insight into reasons why some hospitals fare better than others. It is unlikely that there is only one cause (lack of beds) and only one solution (more beds).

Finally, crisis interventions such as cancelling elective surgery, cancelling nurses’ annual leave, putting pressure on patients to move to nursing homes and discharging patients who have a clinical need for inpatient care are not part of any long-term solution.