Maev-Ann Wren

The 2011 proposal for Universal Health Insurance in Ireland: potential implications for healthcare expenditure

The Irish healthcare system has long been criticised for a number of perceived weaknesses, including access to healthcare based on ability-to-pay rather than need. Consequently, in 2011, a newly elected government committed to the development of a universal, single-tier system based on need and financed through Universal Health Insurance (UHI). This article draws on the national and international evidence to identify the potential impact of the proposed model on healthcare expenditure in Ireland. Despite a pledge that health spending under UHI would be no greater than in the current predominantly tax-funded model, the available evidence is suggestive that the proposed model involving competing insurers would increase healthcare expenditure, in part due to an increase in administrative costs and profits. As a result the proposed model of UHI appears to be no longer on the political agenda. Although the Government has been criticised for abandoning its model of UHI, it has done so based on national and international evidence about the relatively high additional costs associated with this particular model.

Unmet healthcare needs in Ireland: Analysis using the EU-SILC survey

The analysis used the 2013 Survey of Income and Living Conditions to examine the extent and causes of unmet need for healthcare services in Ireland. The analysis found that almost four per cent of participants reported an unmet need for medical care. Overall, lower income groups, those with poorer health status and those without free primary care and/or private insurance were more likely to report an unmet healthcare need. The impact of income on the likelihood of reporting an unmet need was particularly strong for those without free primary care and/or private insurance, suggesting a role for the health system in eradicating income based inequalities in unmet need. Factors associated with the healthcare system - cost and waiting lists - accounted for the majority of unmet needs. Those with largely free public healthcare entitlement were more likely than all other eligibility categories to report that their unmet need was due to waiting lists (rather than cost). While not possible to explicitly examine in this analysis, it is probable that unmet need due to cost is picking up on the relatively high out-of-pocket payments for primary care for those who must pay for GP visits; while unmet need due to waiting is identifying the relatively long waiting times within the acute hospital sector for those within the public system.

A European late starter: lessons from the history of reform in Irish health care

The Irish health care system is unusual within Europe in not providing universal, equitable access to either primary or acute hospital care. The majority of the population pays out-of-pocket fees to access primary health care. Due to long waits for public hospital care, many purchase private health insurance, which facilitates faster access to public and private hospital services. The system has been the subject of much criticism and repeated reform attempts. Proposals in 2011 to develop a universal health care system, funded by Universal Health Insurance, were abandoned in 2015 largely due to cost concerns. Despite this experience, there remains strong political support for developing a universal health care system. By applying an historical institutionalist approach, the paper develops an understanding of why Ireland has been a European outlier. The aim of the paper is to identify and discuss issues that may arise in introducing a universal healthcare system to Ireland informed by an understanding of previous unsuccessful reform proposals. Challenges in system design faced by a late-starter country like Ireland, including overcoming stakeholder resistance, achieving clarity in the definition of universality and avoiding barriers to access, may be shared by countries whose universal systems have been compromised in the period of austerity.

A profile of physiotherapy supply in Ireland

BackgroundThe lack of information on public and private physiotherapy supply in Ireland makes current and future resource allocation decisions difficult.AimThis paper estimates the supply of physiotherapists in Ireland and profiles physiotherapists across acute and non-acute sectors, and across public and private practice. It examines geographic variation in physiotherapist supply, examining the implications of controlling for healthcare need.MethodsPhysiotherapist headcounts are estimated using Health Service Personnel Census (HSPC) and Irish Society of Chartered Physiotherapists (ISCP) Register data. Headcounts are converted to whole-time equivalents (WTEs) using the HSPC and a survey of ISCP members to account for full- and part-time working practices. Non-acute supply per 10,000 population in each county is estimated to examine geographic inequalities and the raw population is adjusted in turn for a range of need indicators.ResultsAn estimated 3172 physiotherapists were practising in Ireland in 2015; 6.8 physiotherapists per 10,000, providing an estimated 2620 WTEs. Females accounted for 74% of supply. Supply was greater in the non-acute sector; 1774 WTEs versus 846 WTEs in the acute sector. Physiotherapists in the acute sector were located mainly in publicly financed institutions (89%) with an even public/private split observed in the non-acute sector. Non-acute physiotherapist supply is unequally distributed across Ireland (Gini coefficient = 0.12; 95% CI 0.08–0.15), and inequalities remain after controlling for variations in healthcare needs across counties.ConclusionThe supply of physiotherapists in Ireland is 30% lower than the EU-28 average. Substantial inequality in the distribution of physiotherapists across counties is observed.

Measuring healthcare expenditure: different methods, different results

BackgroundAccurate information on healthcare expenditure is essential; however, a number of issues arise when healthcare expenditure is being measured. Traditionally healthcare expenditure data in Ireland have been limited, especially data that facilitate comparable analysis through time and across particular programmes or services. Recently however, a major development in Irish healthcare expenditure estimates was the publication of Irish healthcare current expenditure estimates for 2013 according to the international standard of the OECD System of Health Accounts (SHA).AimsThe aim of the analysis presented in this paper is to examine how alternative methodologies for measuring healthcare can influence the estimate(s) of healthcare expenditure.MethodsThe methods and results (in terms of healthcare expenditure) of the Central Statistics Office (CSO) application of SHA methodology will be compared and contrasted with an alternative methodology for measuring healthcare expenditure developed by Wren et al. [1].ResultsThe two approaches to measuring healthcare expenditure in Ireland reached a very similar figure for total current healthcare expenditure in 2013. However, there were considerable disparities in the components of expenditure.ConclusionsThere is no one absolute definition or estimate of healthcare expenditure, and different methodological approaches to estimating expenditure will likely yield different results. Therefore, care is required when assessing healthcare expenditure to ensure that there is a clear understanding about what is and is not included in the estimate.

Managing cognitive impairment following stroke: protocol for a systematic review of non-randomised controlled studies of psychological interventions

Introduction Stroke is one of the primary causes of death and disability worldwide, leaving a considerable proportion of survivors with persistent cognitive and functional deficits. Despite the prevalence of poststroke cognitive impairment, there is no established treatment aimed at improving cognitive function following a stroke. Therefore, the aims of this systematic review are to identify psychological interventions intended to improve poststroke cognitive function and establish their efficacy. Methods and analysis A systematic review of non-randomised controlled studies that investigated the efficacy of psychological interventions aimed at improving cognitive function in stroke survivors will be conducted. Electronic searches will be performed in the PubMed, Embase and PsycINFO databases, the search dating from the beginning of the index to February 2017. Reference lists of all identified relevant articles will be reviewed to identify additional studies not previously identified by the electronic search. Potential grey literature will be reviewed using Google Scholar. Titles and abstracts will be assessed for eligibility by one reviewer, with a random sample of 50% independently double-screened by second reviewers. Any discrepancies will be resolved through discussion, with referral to a third reviewer where necessary. Risk of bias will be assessed with the Risk of Bias in Non-randomized Studies of Interventions tool. Meta-analyses will be performed if studies are sufficiently homogeneous. This review will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The quality of the evidence regarding cognitive function will be assessed according to the Grading of Recommendations Assessment, Development and Evaluation. Ethics and dissemination This systematic review will collect secondary data only and as such ethical approval is not required. Findings will be disseminated through presentations and peer-reviewed publication. This review will provide information on the effectiveness of psychological interventions for poststroke cognitive impairment, identifying which psychological interventions are effective for improving poststroke cognitive function. PROSPERO registration number CRD42017069714.

016Examining Frail Older People’s Use and Experience of the Irish Healthcare System: A Mixed Methods Study

Background: Frail older people are vulnerable to adverse outcomes and require a multimodal, integrated package of healthcare services. Planning such care requires robust evidence about the frail population and their current patterns of service utilisation in order to identify the nature and scale of problems in the current model of care. This study describes the community-living frail older Irish population and examines their patterns of service utilisation and their experiences seeking, securing and managing services. Methods: A sequential explanatory mixed methods design was operationalised. Data was obtained from wave one of the Irish Longitudinal Study on Ageing (TILDA) for those aged ≥65 years (n = 3,507). Multivariate regression techniques examined the impact of frailty, measured by the Frailty Index, on utilisation of hospital and community services adjusting for need, predisposing and enabling factors. Latent class analysis identified profiles of service-use among frail TILDA participants (n = 745). Data from semi-structured interviews with a qualitative sample of frail older people (n = 12) explored why serviceuse patterns occur. Results: 24% (95%CI: 23–26) of the Irish older population were classified as frail. In adjusted models, frailty remained a significant predictor of utilisation across many types of services. Four diverse patterns of service use were identified among frail older people. Misaligned referral routes, hospital consultant waiting lists and inadequate budgeting all contributed to impeding access to services. However, the Public Health Nurse Service enabled navigation and referral to community services. Discussion: The findings indicate a supply-constrained, hospital-centric healthcare system which fails to proactively manage the needs of the majority of the frail older population. Receiving community services is a rarity rather than the norm, and these are utilised mainly by the very-frail (FI > 0.40, p < 0.01). Conclusions: Since the frail older population comprises a diverse set of service users, new models of care should be designed to reflect that diversity.