From ‘more with less’ to ‘less with less’ – The Performance of the Irish Health System during the Economic Crisis

Dr Steve Thomas, Associate Professor, Centre for Health Policy and Management in Trinity who led the Resilience Project spoke about the economic context within which this study was conducted, saying: “A new government came to power in March 2011 with the most radical proposals for health system reform in the history of the Irish state, including improving access to healthcare, free GP care for all by 2015 and the introduction of Universal Health Insurance after 2016. All this was to be achieved amidst the most severe economic crisis experienced by Ireland since the 1930s, resulting in severe cuts to the health budget.”

The team of academic researchers on the Resilience Project have assessed how well the Irish Health system has coped with a downsizing of resources by an analysis of a range of performance indicators. These show a system that managed ‘to do more with less’ from 2008 to 2012 using increased efficiencies such as clinical care programmes; agreements between health service management and unions which allowed for increased flexibility and productivity; reduced professional fees and drug cost savings. They also found that some of the efficiencies were achieved by transferring the cost of care onto people and through significant resource cuts.

Significantly, from 2013, the indicators show a system that has no choice but ‘to do less with less’. They indicate diminishing returns from crude cuts, evident in declining hospital cases, increased wait-times, as well as cuts to home care hours and increasing costs of agency staffing. A final paper from the Resilience Project, Measuring, Mapping and Making Sense of Irish Health System Performance in the Recession, is available in full here: http://www.medicine.tcd.ie/resilience4health

Key Figures about the Irish Health System:

• Approximately €2.7 billion has been cut from the Irish health system since 2009.
• There is over 12,000 fewer Health Service Executive (HSE) staff in December 2013 than there were at the height of public health sector employment in 2007.
• By December 2013 there were 1,890,465 with medical cards, the highest number in the history of the state, (over 600,000 more now than in pre-crisis 2007) reflecting lower incomes and higher levels of unemployment.

Key Findings: From ‘More with Less’ to ‘Less with Less’

• Despite a declining budget and staff numbers, during the period 2008 to 2012 public hospitals managed to do more with less evidenced by increased numbers of inpatient, day case, outpatient appointments and emergency admissions.
• Inpatients cases increased by 10,000 between 2010 and 2012, day cases increased by 193,000 between 2008 and 2012
• However, from the end of 2012 and through 2013 and 2014, there was a decrease in inpatient activity, a levelling off of day cases despite increased demand and an increase in Emergency Admissions.
• Inpatient admissions declined by 21,000 between 2012 and 2014; day cases 30,000 between 2012 and 2014.
• While these are only a fraction of all hospital cases they demonstrate the change in the trend. Similarly, Emergency Admissions are due to increase by 45,000 between 2012 and 2014.
• The cost of drugs in the demand led, publicly funded health schemes decreased by €434 million between 2009 and 2014, due in part to increased efficiencies around costs of medicines and changed prescribing practices.
• The cost of the Drugs Payment Scheme more than halved from €311 million in 2008 to€?127 million in 2012, driven by declining numbers using the scheme due to hefty increases on the reimbursement threshold (from €85 per month in 2008 to €144 per month in 2013), in effect a direct transfer of costs from the State onto patients.
• Some progress has been made on the most persistent problems in the Irish health system – very long waiting times in Emergency Departments, for elective treatment and for out-patient appointments with a specialist. Specifically:
• The numbers of people waiting on trolleys in Emergency Departments has been reduced by 36% between 2011 and 2013. However, when figures from 2008 are compared to 2013, a 3.6% reduction is counted.
• There has been progress on the numbers of people waiting for inpatient and day-case hospital treatment, specifically, in eliminating those waiting over two years (a key 2011 Programme for Government Commitment).
• However, between November 2012 and November 2013, there has been a trebling of those waiting over six and twelve months for treatment.
• These hospital wait times indicate increased demand on the public health system resulting from fewer people with private health insurance alongside an increasing, ageing population with a greater burden of chronic diseases.
• Despite there being 941 fewer public hospital beds in 2012 compared to 2008, the numbers of delayed discharges remained chronically high, with the most recent figures showing 718 delayed discharges (people in hospital beds who do not clinically need to be there).
• There has been a steady decline in home care hours (designed to support people to live independently) since 2008. In 2013, there were under nine million home care hours provided, compared to over 11 million hours in 2006.
• The priorities for HSE Service Managers and decision makers in the HSE relate to running the health care system more effectively in the current constrained resource environment rather than headline priorities in the Programme for Government. One-quarter of their time is taken up with living within the budget and managing change.

Speaking about the overall impact of the recession on the Irish healthcare system and subsequently, on individuals, Dr Steve Thomas said: “The Irish system demonstrated reasonable resilience in the early years of austerity, with some good efficiency gains. However, as Ireland experiences prolonged austerity recent indicators demonstrate a system under increasing pressure with unavoidable cuts and increased rationing risking patient care. In addition, during austerity Government has quietly shifted the burden of paying for healthcare back on to the sick and the elderly. Increased charges and lower subsidies now amount to almost €100 per person more each year for health care.”

Speaking about the significance of these findings in the context of the Government’s current health reform priorities Dr Sara Burke, Research Fellow, Centre for Health Policy and Management in Trinity said: “Interviews with senior policymakers indicate a greater coherency in health policy at leadership level. However, the system’s ability to pull off the reform programme is in question. Differences between Health and Public Expenditure and Reform may be putting the sustainability of the public health system in jeopardy if more money is taken out of health in the year ahead’.

 “The change process, in terms of hospital groups and divisional directorates, is biting on the ground – but with confusion, uncertainty, and a lack of clarity, timeliness and communication. This is inhibiting the pace of change, the confidence managers feel about it and their ability to bring others along. The significant demands of delivering a safe, functional, within budget, and efficient service are suffocating the implementation of headline reforms which remain remote from managers’ day-to-day reality,” said Dr Sarah Barry, Research Fellow, Centre for Health Policy and Management in Trinity.

Reflecting on the value and impact of the research Graham Love, Chief Executive at the Health Research Board said: ‘Providing high-quality, affordable, health services is a challenge – especially in a recession. This project provides insight and understanding about how the Irish health system has dealt with the recent financial crises and outlines solutions to help the service be resilient, or become stronger, in face of future crises. The national benefit and international reach of this project reinforces the importance and impact of HRB investments for Health Services Research.”

 
For media queries please contact:

Yolanda Kennedy, Press Officer for the Faculty of Health Sciences, Trinity College Dublin at yokenned@tcd.ie or Tel: + 353 1 8963551.

About Resilience:

The Resilience Project is a three year research programme (2012-2014) assessing the resilience of the Irish health system during the economic crisis. Dr Stephen Thomas of the Centre for Health Policy in Trinity College Dublin is the principal investigator (PI) and it is funded by the Irish Health Research Board. From the work, guidelines will be developed to suggest how health systems can withstand and be strengthened during times of significant cuts and disturbances to the health system.

 

Media Coverage:

• Irish Times, March 31st, 2014 
• Irish Independent, April 1st, 2014
• Irish Independent opinion, April 1st, 2014
• Irish Examiner, April 1st, 2014
• TheJournal.ie, April 1st, 2014