Ireland may have 1,000 bed capacity deficit in public hospitals


Focusing on scenarios that assume an 85 per cent occupancy rate, Ireland may have a bed capacity deficit of approximately 1,000 inpatient beds in public acute hospitals this year, according to a paper drawn up by the ESRI.

In addition to the 1,000 in-patient deficit, the paper said over 300 additional inpatient beds were required per annum to keep up with demand pressures arising from an increasing and ageing population.

It said this bed capacity deficit was likely a key contributor to recent overcrowding issues experienced in public acute hospitals.

It also revealed that patients aged 65 and over used over 55 per cent of all inpatient bed days in 2021.

The paper, on inpatient bed capacity requirements in 2023,   includes a number of caveats which should be taken into consideration in interpretating the paper,  The number of beds required depended on population increases, ALOS and avoidable hospitalisations.  Reducing ALOS by 10 per cent  and avoidable  hospitalisations by 33 peer cent would considerably reduce in patient bed requirements.  However, ALOS has actually been increasing.  Including a more recent base year data (e.g. 2022) might result in differing demand profiles and therefore different bed capacity estimates. The impact of COVID-19 on population health and hospital demand was not incorporated in the estimates, as all projection analyses exercises preceded the pandemic. The lasting effects in terms of infection control measures, COVID-19 outbreaks in hospitals, and increases in public hospital waiting lists might mean estimates underestimated the bed capacity shortfall in 2023. Then, it was necessary to estimate 2022 and 2023 inpatient bed figures as at the time of writing no published data existed on current bed numbers.

The ESRI paper found that  while absolute, and per capita, public acute hospital inpatient bed capacity had increased in recent years, large bed capacity deficits remained.   An estimated 1,385 inpatient beds were opened between 2015 and 2022.  The majority of these – 1,000 – were opened since 2018.  However, these increases came off historically low bed capacity levels.

It stated that the OECD and European Union statistics consistently found the public acute hospital system in Ireland to have amongst the lowest inpatient bed per capita rate compared to comparator countries (Walsh et al., 2020a; OECD and European Union, 2022).

“In 2019, Ireland reported the highest average occupancy rate, 90 per cent, in the OECD, which is much higher than the frequently referenced 85 per cent occupancy rate above which patient safety risk can arise (Bagust et al., 1999).

“This report further reiterated low levels of capital investment in health infrastructure and capacity constraints, including low numbers of hospital beds associated with inpatient bed occupancy rates above international safety standards. Winter 2022/2023 also saw severe overcrowding experienced by the public hospital system; on 3 January 2023, there were 749 people waiting on trolleys in public acute adult hospitals. It has been acknowledged by the HSE that this overcrowding was caused in part by insufficient bed capacity in public acute hospitals  and may continue for a number of years as the ‘process to build beds is a long one.’”

In the current ESRI paper, only projection scenarios that assumed a maximum of 85 per cent average bed occupancy were examined.

The authors said there was growing evidence that insufficient bed capacity and high bed occupancy rates were linked to higher patient mortality, poor in-hospital outcomes, and risks to hospital staff welfare (Keegan, 2010; Madsen et al., 2014; Bosque-Mercader and Siciliani, 2022). High bed occupancy also resulted in overcrowding on hospital corridors and in Emergency Departments (as regularly experienced in Ireland, particularly in Winter 2022/2023) (Morley et al., 2018; Turner et al., 2020). The 85 per cent average occupancy rate threshold had been adopted by the OECD and other systems as an upper average threshold for hospitals to aim for. In Ireland, the Irish Paediatric Critical Care Audit (Healy et al., 2022), and recent Department of Health research (Shine and Hennessy, 2022) have used 85 per cent as a recommended limit when examining bed occupancy rates. The HSCR stated Ireland’s ‘occupancy rate is abnormally high’ and estimated their bed projection based upon ‘a more acceptable occupancy rate of 85 per cent.’

The estimates in this paper of public acute hospital inpatient bed requirements in Ireland in 2023 are based on earlier ESRI research published by Keegan et al. (2018), the Department of Health’s Health Service Capacity Review (2018) and the National Development Plan (2018-2027). Each of these analyses projected hospital bed capacity requirements in Ireland, based on a variety of projection scenarios.

The paper concluded that population increases, especially at older ages, would continue to increase demand for hospital care. It said the Irish population was projected to increase by 1 per cent on average per annum out to 2035, with the population aged 65+ projected to increase by 3.5 per cent on average per annum.

“This means that additional public acute hospital capacity will be required. Where appropriate, transferring care from hospitals into the community and lower acuity care settings (e.g. step-down and rehabilitation facilities) in line with Sláintecare is also needed. For instance, on 10 January 2023, there were 524 people in public acute hospitals categorised as delayed in the transfer of care (DTOC) awaiting discharge. Previous ESRI evidence has shown that increases to post-acute care supply, such as home support, can reduce length of hospital stays, especially for those who are likely to be DTOC patients (Walsh et al., 2020b). Adopting Sláintecare proposals to reduce DTOC numbers will also reduce hospital bed capacity needs. However at least in the medium term, and in the context of Ireland’s rapidly changing demographic position and long waiting lists for care, policymakers should be realistic about the need to invest in the acute hospital system. Optimistic projection scenarios listed in the HSCR and NDP may underestimate bed capacity needs, especially without substantial improvements in primary and community-based care, and patient flow into post-acute settings, occurring. Meanwhile additional bed capacity will also require sufficient workforce to provide care.  The paper found that while inpatient beds per capita had increased, they remained amongst the lowest in the OECD and despite the population aged 65+ using more than half of all inpatient bed days, the number of beds per 1,000 population aged 65+ had decreased considerably in recent years


This QEC Research Note was subject to refereeing prior to publication. The authors are solely responsible for the content and the views expressed.

March 29, 2023

Financial support for this work was provided by the Department of Heath  through the ESRI/Department of Health Research Programme in Healthcare Reform. The views expressed in this paper are those of the authors and not necessarily he Department of Health.