Dr. Brendan Walsh presented on health and social care spending in Ireland. Key points include: - Mortality rates in Ireland have improved since 1995 and are lower than the EU-15 average. However, Ireland has high health spending per capita that has increased substantially since 1995. - Demand for care is high as evidenced by long waiting lists and high bed occupancy rates. Projections show demand will increase substantially over the next decade due to an aging population. - Resource allocation in Ireland lacks a systematic process, resulting in regional inequities in supply. Data on community care spending is poor. The ESRI plans to further develop its healthcare expenditure model to better project costs and understand cost drivers over time.

1. www.esri.ie
Planning for Health and Social
Care
DATE
14/9/2019
VENUE
Dublin Economics Workshop
AUTHOR
Dr Brendan Walsh

2. HEALTH AND HEALTHCARE SPENDING IN
IRELAND SINCE 1995

3. Mortality Rates in EU15: 1995 – 2014
60070080090010001100
Age-StandardisedMortality
1995 1998 2001 2004 2007 2010 2013
EU-15 Countries EU-15 Average Ireland
All Cause - Male
300400500600700
Age-StandardisedMortality
1995 1998 2001 2004 2007 2010 2013
EU-15 Countries EU-15 Average Ireland
All Cause - Female
Source: Eighan & Walsh et al. (Forthcoming)
• 15,300 fewer deaths in 2014 as mortality improved post-2000

4. Health Spending in EU15: 1995 – 2018
0100020003000400050006000
US$PPP
1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015 2017
EU-15 Countries EU-15 Average Ireland
Total Health Spend Per Capita
0100020003000400050006000
U$PPP
1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015 2017
EU-15 Countries EU-15 Average Ireland
Government Health Spend Per Capita
Source: OECD (2019)
$837
$3,583
$1,129
$4,869

5. DEMAND FOR CARE & WAITING LISTS

6. Hospital Capacity & Waiting Lists
• Inpatient beds per capita amongst lowest in OECD
• Ireland has the highest inpatient bed occupancy in the OECD at 95%
• Waiting list figures amongst worst in OECD (Sicilliani et al., 2014)
175,662
218,589
0 50,000 100,000 150,000 200,000 250,000
Waiting >12 months
Waiting 3-9 months
Outpatient Waiting (Assessment) – July 2019
10,665
30,039
0 5,000 10,000 15,000 20,000 25,000 30,000
Waiting >12 months
Waiting 3-9 months
IP/DC Active Waiting (Treatment) – July 2019
0.0% 10.0% 20.0% 30.0% 40.0% 50.0%
Waiting >24 Hours
Waiting 6-24 Hours
Emergency Department Discharge Thresholds
All Ages Aged 75+
• 333 Waiting for a Hospital Bed
(‘Trolley’) – 11/09/2019

7. Community Care Waiting Lists
40,716
50,121
11,154
10,523
75,616
56,804
-
16,329
0 10,000 20,000 30,000 40,000 50,000 60,000 70,000 80,000
Physiotherapy
Occ. Therapy
S&L Therapy
Psychology
Community Care Waiting Numbers (Assessment) – 2017
Waiting 3-9 months
Waiting >12 months
• 1 out of every 16 inpatient bed filled by delayed discharges
• Waiting for community care also high, and increasing over time

8. Projected Demand for Care
• ESRI HIPPOCRATES Model report found increases in projected health
& social care demand from 2015-2030 (Wren et al., 2017)
• Projected Increases:
• Inpatient bed days: 32% – 37%
• GP Visits: 20% – 27%
• LTRC places: 40% – 54%
• Home Care: 38% – 66%
• Projections driven by population increases and ageing (pop. aged 65+
to increase by 60%)
• Sláintecare outlines moving care from hospital into the community
• This will increase projected community demand
• Health Service Capacity Review and NDP have outlined projects to
increase capacity and workforce

9. Health Service Capacity Review & NDP
10,500
11,500
12,500
13,500
14,500
15,500
16,500
2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031
Inpatient Bed Supply
Base Case Optimistic Case Actual (Open Beds Report, April 2019)
• Optimistic case based upon large investments in non-acute care
• NDP plans for 2,600 additional acute hospital beds by 2027 with
€620m allocated (post-2022)
• Are plans sufficient from the beginning?

10. RESOURCE ALLOCATION
(Are we spending money efficiently?)

11. Allocation of Spending and Resources
• Is health and social care spend efficient?
• Unique for a largely tax-funded system, Ireland lacks a systematic
allocative decision process
• Activity-Based Funding now incorporated in public hospitals
• No single correct way to allocate health resources exists (Vega et al.,
2010; Brick et al., 2010). Other systems:
• Match population need to supply and resources
• Allow for substitution and integration of care across sectors
• Aid Workforce Planning
• Ensure equity across regions and population groups

12. Resource Allocation – Regional Inequities
Source: Smith & Walsh et al. (2019)
• Lack of allocation mechanism has resulted in
regional inequalities in supply exist
• Supply difference do not related to population
need differences
• Dublin commuter belt have low supply across
all ten services examined
• Allocation mechanism would allow for supply
to follow population increases, age difference,
disability, deprivation etc. (Sláintecare)

13. DATA LIMITATIONS

14. Data Limitations - Overall
No unique Individual Health Identifier (IHI)
• Comparing simple outcomes such as hospital length of stay is difficult
Data on community-based care severely poor. Little information on
• # visits, age/sex of patient, follow-up care, etc.
NB: Lack of unit cost information
Ireland lacks consistent and comprehensive health cost data
• E.G. Ireland, Greece and Romania only EU28 countries with no age-
related public healthcare expenditure profile (Euro. Commission 2018)
International expenditure comparisons are fraught
• OECD System of Health Accounts is a work in progress (where does home
care and nursing home care fit?)

15. Data Limitations - Private Care
• 31% of day cases and 15% inpatient bed days occur in private
hospitals. Information on the following is lacking:
 # ED att.
 # outpatient att.
 # day patient visits
 # inpatients stays
 Average length of stay
 Bed occupancy
 # day case/inpatient beds
 Patient casemix
 Nurse & doctors WTEs
 # public patients treated
(NTPF)
 Salaries
• Over 50% of non-acute physiotherapy care is privately provided
(Eighan et al, 2019). Unknown for other therapies
• Large proportion of publicly-funded care is privately provided:
• >75% of long-term residential beds (including NHSS) in private facilities
• 56% of publicly-financed Home Care provided by voluntary/for-profits
• Workforce planning: Public and private ‘fishing from the same pool’

16. FUTURE WORK ON HEALTH AND SOCIAL CARE
EXPENDITURE AT THE ESRI

17. ESRI HIPPOCRATES Model - Expenditure
• Currently incorporating health and social care expenditure
• Plan to project health and social care expenditure to 2030+
• Developing Expenditure Projections
• Requires unit cost analysis by service and components
• What drives individuals component of cost?
• Allows decomposition of price and volume drivers
• It is hoped this work will allow for better understanding of the
impact different components of healthcare expenditure

18. THANK YOU