Geographic inequalities in non-acute healthcare supply: evidence from Ireland

Background: measuring geographic equity in healthcare supply

Access to healthcare is a broad concept that encompasses availability and accessibility, affordability, and acceptability of services, and the degree of fit between individuals and these different dimensions^10–12. Many empirical studies on access focus on one aspect of this multifaceted concept, and there is a large body of work that interprets access as a supply concept (the focus of this paper), concentrating on geographic availability of services using provider–population ratios^11,13–16. For example, UK researchers used this approach to examine the geographic distribution of general practitioners (GPs) from the mid-1970s to the 2000s, with modifications to the supply ratios to take account of geographic variations in healthcare needs^14–17. We use supply ratios to examine geographic patterns of supply of non-acute services in Ireland, drawing on the methods used in the UK to adjust for healthcare needs.

Simple comparisons of supply-to-population ratios across different geographic regions provide a good indication of patterns of geographic inequality. This is the most common way in which geography is used in assessing equality and/or equity in healthcare access¹⁸, allowing international organisations (e.g., Eurostat) to undertake cross-country comparisons of health and social care supply. Supply ratios are useful for broad comparisons of supply across large areas, and are used by policymakers to set minimal standards of supply and to identify underserved areas¹⁹.

Other studies have focused on what has been referred to as spatial accessibility¹⁹. These studies involve models (e.g., Two-step floating catchment area, 2SFCA) that move beyond simple provider–population ratios to incorporate both healthcare availability (i.e., level of supply) and accessibility (i.e., distance/time between patient location and healthcare facility). The 2SFCA method and other related techniques have been applied to a wide range of countries and healthcare services: for example, variations in geographic accessibility of different aspects of primary care in Wales²⁰, Texas, US²¹, Ontario, Canada²², and ambulatory and inpatient services in Germany²³. Analysis of spatial accessibility in healthcare in Ireland has been focused on GPs and long-term residential care (LTRC)^24–27 but extending this type of analysis to other non-acute healthcare services is hindered by the absence of adequately geocoded data.

This paper makes four core contributions to the literature for healthcare policymakers. First, the analysis demonstrates how the persistence of historic budgeting can lead to considerable inequities in supply of non-acute care. Second, in the absence of detailed geocoded data, simple provider-to-population ratios, with adjustments for healthcare need factors, can be used to give a comprehensive description of non-acute care in a country, and identify notable regional patterns. Third, while localised decision-making facilitates better matching of supply with local demand, the Irish experience underlines the importance of appropriate data and guidance from the national level to help address any geographic imbalances in supply. Fourth, the analysis highlights important regions requiring attention from Irish policymakers undertaking comprehensive healthcare reforms.

Institutional context

Healthcare organisation in Ireland has undergone several changes in the past 15 years, with implications for how local non-acute care services are allocated. The nationally based Health Service Executive (HSE) replaced (in 2005) 11 former regional Health Boards that had considerable autonomy in developing local services, with local political representation on the boards. The HSE replaced an older system comprised of local services that had developed in different ways²⁸. Since 2005, the HSE has overseen numerous changes in the organisation of local non-acute services from 32 Local Health Offices (LHOs), to 17 Integrated Service Areas (never fully implemented), to nine Community Health Organisations (CHOs), comprising 96 Community Health Networks (CHNs). CHNs cover an average population of 50,000 and provide the structure for integrating primary and social care. In 2019, six Regional Health Areas (RHAs) were proposed, merging hospital groups with CHOs to ensure integration across acute and non-acute care, with each RHA having its own budget and greater autonomy at local level²⁹. We examined the 10 most central non-acute healthcare services in Ireland³⁰, representative of the key professions that make up CHNs.

The extent of healthcare affordability for patients is an important element in facilitating access to healthcare. Ireland is unusual amongst other high-income European countries because it does not offer universal access to primary care⁵ and there is a lack of clarity around entitlement to other non-acute care⁴. For GP care, approximately 33% of the population have a Medical Card (MC) which covers free GP visits (and cover for other primary care and acute care including prescription medicines³¹). A further 11% have a GP Visit Card (GPVC) that covers free GP care only³². MCs are granted mainly on the basis of an income-based means test but some are also granted on a discretionary basis to patients with health needs for whom paying for healthcare would cause ‘undue financial hardship’³¹. Since 2015, GPVCs are available for children under six years of age and adults aged 70+. The rest of the population pays out-of-pocket for GP care (average €52.50 per visit³³). More than 40% of the population have supplementary private health insurance which mainly covers acute care³⁴. For other non-acute care, it is acknowledged that there is ‘huge variety’ in access ‘depending on geographic location and existing supply in that area’, and in practice priority is often given to MC holders^{4: p45,35}. This paper provides a more rigorous analysis of available data to move beyond this anecdotal understanding of variable access to non-acute care services in Ireland.

Geographic setting

There are 26 administrative counties in the Republic of Ireland, ranging in population size from 0.32m (Leitrim) to 1.35m (Dublin), with a total population of 4.8 million people³⁶. Ireland has a low population density, with a large dispersed rural population. Per capita non-acute supply is described for 28 counties (Tipperary and Dublin are divided into North and South) using 2014 ESRI population estimates (described in detail in previous applications^37,38). This level of aggregation has the advantage that counties are stable across time (aligning well with, but independent of, potentially changing HSE administrative structures) and reflect definitions of catchment areas for non-acute services, which are designed to be community-based services serving clients in their immediate locality.

Supply and needs data

This paper draws on several data sources on the supply of 10 mainly publicly employed non-acute services, including private supply where available:

General practitioners: GPs in Ireland are self-employed private practitioners. A large proportion hold a state General Medical Services (GMS) contract to provide GP care that is free at the point of use to MC and GPVC holders^39,40. Data on GP supply are based on extracts from the Irish College of General Practitioners database and the Irish Medical Directory in September 2014^24,41. GPs in training (668) were not included due to a lack of information on location and whole-time equivalent (WTE) activity⁴². Headcounts were converted to WTEs using recent survey data on self-reported full-time/part-time practices, disaggregated by sex, by a representative sample of GPs in Ireland⁴³.

Community nurses (CNs) and allied health professionals: the HSE employs community nurses (Public Health Nurses (PHNs) and community Registered General Nurses) to provide a wide range of non-acute services to individuals within a geographic area^44,45 in health centres and in individuals’ homes. Allied health professionals including physiotherapists, occupational therapists, speech and language therapists and others (podiatrists & chiropodists, counsellors & psychologists, social workers) deliver services in health centres or individuals’ homes. These can include private as well as publicly employed professionals. Data on the WTE supply (by grade, LHO, agency) of publicly employed community nurses and allied health professionals were obtained from the Health Service Personnel Census (HSPC), December 2014⁴⁶.

Private physiotherapists: data on private and state-subsidised voluntary physiotherapists were taken from the register of members of the Irish Society of Chartered Physiotherapists (ISCP). WTEs were estimated using data from an online survey of ISCP members, as previously described⁴⁷.

Care for older people: home carers provide domestic support and more intensive care where needed, to older people in their own home. Approximately 75% of formal home care is publicly financed and provided by a mix of state-run, not-for-profit, and for-profit organisations³⁰. LTRC is mainly provided in private nursing homes although the majority of care is publicly financed³⁰. Data on the number of publicly financed home care hours provided under the two home care schemes running in 2014 (Home Help and Home Care Package schemes) were obtained from the HSE. The 2015 data on the supply of LTRC beds were based on combined datasets maintained by the Health Information and Quality Authority (HIQA) (responsible for regulation in long-term care), and the Department of Health (DOH).

Needs data: To adjust county populations for need, data on the population aged 65+ and 85+ were available in the 2014 ESRI population estimates; data from the Central Statistics Office (CSO) were used to estimate mortality and disability rates by county; data on the number of people with MCs and GPVCs by LHO were provided by the Primary Care Reimbursement Service (PCRS); and data from the PCRS and the Department of Pharmacology and Therapeutics, Trinity Centre for Health Sciences in St. James's Hospital, Dublin were used to estimate chronic illness levels amongst MC holders.

Methods

Supply data were assigned to counties based on address (e.g., a GP surgery, a nursing home), using boundary files for counties provided by the CSO. Where the address was unavailable and the supply data were assigned to aggregate areas that cross county borders (e.g., some LHOs), the supply data (e.g., number of nurses) were redistributed from the aggregate areas to counties based on share of population. The population in each LHO disaggregated by county was received from the Health Intelligence Unit of the HSE. Data on MC and GPVC numbers by LHO were assigned to counties in the same way.

Metrics presented: supply per capita, location quotients (ratio of area supply per capita to national supply per capita^17,18), and Gini coefficients were estimated. Supply was measured in terms of WTEs for personnel (GPs, community nurses, etc), beds for LTRC, and hours for home care supply.

Needs adjustment: to examine potential sources of inequity in the geographic distribution of non-acute services, the raw population in each county was adjusted for each of the following needs indicators independently: age (65+ and 85+), mortality, disability, MC status and a measure of morbidity among MC holders. The choice of indicators can be categorised using Andersen’s Behavioural Model of Health Services Use¹² and include predisposing characteristics (i.e., age), need (i.e., mortality, disability, chronic illness levels) and enabling factors (i.e., MC coverage). For ease of presentation these are collectively referred to as ‘needs’ indicators. The needs adjustment methods are based on analysis of GP distribution in the UK^14–16. The general approach involved adjusting the population in each study area by a specific need indicator, and then re-calculating the ratios of supply per capita on the basis of the adjusted population (e.g., number of GPs per person with disability in each area). A range of needs adjustments were applied, reflecting the complexity of, and the challenges in measuring healthcare need⁴⁸.

Inequality in supply

Table 1 shows national average supply per capita, together with the Gini coefficient, for each of the 10 non-acute services in Ireland in 2014, prior to adjustment for need. The Gini coefficient ranges from 0.091 for LTRC to 0.615 for publicly employed podiatrists and chiropodists, indicating substantial geographic inequality in non-acute supply, but also that the degree of inequality varies across the services.

Figure 1 presents the distribution of each of the non-acute services by county, detailing the variability in supply across counties and the variability in the shape of the distributions across services.

Figure 1. Estimated supply of non-acute care, Ireland, 2014.

Figure 1a also shows that there are some counties with consistently low levels of per capita supply for many of the services. Table 2 provides further detail on this aspect. For each non-acute service, Table 2 presents the counties where per capita supply is at least 10% higher than the national average (white circles), counties where per capita supply is at least 10% lower than the national average (black circles), and counties where per capita supply is within 10% of the national average (grey circles). Focusing on those areas with a location quotient that is lower than 0.90, a number of counties had low levels of supply relative to the national value for nearly all of the 10 non-acute services. These counties are mainly located in the East of the country, including: Kildare, Wicklow and Meath, which are the three main commuter counties around the capital city (Dublin); Wexford, Kilkenny and Waterford in the Southeast. As an exception to this eastern trend, the western county of Clare had seven non-acute services with a location quotient lower than 0.90. There was also consistency across services in terms of the areas that have high levels of supply relative to the national value. Sligo, Leitrim, Westmeath all have seven or more non-acute services, with location quotients greater than 1.10. Sligo and Leitrim are located in the north west of the country, while Westmeath is in the midlands.

The main exception to this regional pattern is the supply of LTRC. Areas with the lowest levels of supply for most of the non-acute services had relatively high levels of supply of long-term care (e.g., Kildare, Kilkenny, and Wicklow) and vice versa (e.g., Sligo).

Inequity in supply

Following adjustment for need, the geographic distribution of each non-acute service remained unequal and overall, there was very little change in the distributions following adjustment.

The scatterplots in Figure 2 summarise how the geographic distribution of the supply of publicly employed CNs changes after adjustment for each need indicator. The graphs plot each county’s location quotient before adjustment (y axis), and after adjustment for the need indicator (e.g., MCs) (x axis). For example, a data point in the upper left quadrant indicates a county where per capita supply is higher than the national value based on the unadjusted population, and lower than the national value based on the needs-adjusted population. If needs-adjustment does not change a county’s location quotient (i.e., ratio of county to national supply), then the data point will lie on the diagonal ‘line of no change’.

Figure 2. Scatter plot of location quotients of the number of WTE community nurses per 10,000 total population, and per 10,000 needs-adjusted populations by county, Ireland 2014.

For the supply of publicly employed CNs, the location quotients for the majority of counties lie close to the line of no change for each need indicator. There are exceptions to this pattern. For example, in Figure 2e, Kildare, Dublin North and Dublin South are located inside the bottom right quadrant where the location quotient was below the national average prior to adjustment for MCs (used as a proxy for healthcare need as well as socioeconomic status) (0.83, 0.93, 0.93) and higher than the national average after adjusting for the MC population (1.04, 1.08, 1.21). Conversely, Mayo is located in the top left quadrant where the location quotient fell from 1.07 prior to adjustment to 0.85 after adjustment, for the MC population. However, the analysis adopts a conservative approach of assuming that location quotients that fall within 10% of the national value are similar to the national average. Thus, these exceptions, while notable, are not considered very significant changes given that the values did not all fall outside the 10% interval.

When comparing across the different adjustment factors, for each type of supply, controlling for the population aged 85+ is most likely to influence rankings, illustrated in Figure 2 for community nursing (and Figure 3 and Figure 4 for GPs and LTRC). For each type of supply, the majority of the counties did not move from their respective quadrants following adjustment for the need indicators (although they may move within that quadrant). Kildare, Mayo and Roscommon were the most frequent exceptions to these patterns, mainly after adjustment for age 85+, but the changes in quadrants were only significant in a limited number of instances. These findings indicate that the analysis is picking up on genuine geographic inequities in supply that cannot be explained by needs.

Figure 3. Scatter plot of location quotients of the estimated number of WTE GPs per 10,000 total population, and per 10,000 needs-adjusted populations by county, Ireland 2014.

Figure 4. Scatter plot of location quotients of the number of long-term residential care beds per 1,000 population aged 65+ years, and per 1,000 needs-adjusted populations by geographic area, Ireland 2014.

Core findings

This paper provides the most comprehensive picture of the geographic distribution of non-acute care in Ireland to date. Despite Ireland being a small country with a mainly centralised health system, the findings show considerable geographic inequalities in the supply of non-acute care across Irish counties. There are some counties that have low levels of supply of not only one, but several types of non-acute care, which include publicly employed, but also some privately provided services (GPs and private PTs). Similarly, some areas have high levels of relative supply of multiple types of non-acute care. The findings remain largely unchanged after adjusting for different needs indicators, suggesting that the unequal patterns of supply are also inequitable and have been determined by non-need factors.

With the exception of LTRC, the supply of non-acute services in Ireland is consistently lower in the east of the country compared with other regions. This pattern holds after needs adjustment. In contrast, there is more regional variation in the areas that have consistently high levels of supply (before and after needs adjustment).

While explaining the reasons behind the observed inequalities is beyond the scope of this paper, population change provides some explanation for the observed ‘eastern’ effect. There have been sizeable changes in the distribution of the population by county over the past 30 years. In particular, there have been increases in population in Dublin and the greater Dublin commuter counties. Kildare and Meath populations increased, as a proportion of national population, by more than 40% from 1986 to 2016⁴⁹. Wicklow (12%) and Wexford (9%), in the east, also experienced large increases in population. The relatively low levels of per capita supply in these counties could be explained, at least in part, by supply distribution not keeping up with changes in population distribution. Over the same time period, some of the largest declines in population, as a proportion of national population, occurred in Sligo and Leitrim (12–13% reduction) which may explain why per capita non-acute supply is consistently higher than in other counties.

However, there are exceptions to these general patterns, with other factors also likely to be at play, and because of the persistence of historical budgeting it is important to keep in mind influences from former administrative structures.

The difference in the geographic distribution of LTRC compared with the other non-acute services is assumed to be influenced by location decision factors. More than 75% of LTRC beds in Ireland are now privately provided^50,51. This may make equal distribution of these services more difficult because supply is likely to be influenced by market factors such as land prices, profit margins, and availability of staff.

Limitations

Equity in access to healthcare is a core objective in many healthcare systems including Ireland⁴, and it is acknowledged that supply is just one element within the broad concept of ‘access’¹¹. The focus on supply in this paper is a feature of the data available for non-acute services in Ireland. In contrast, data collection on acute care and lifestyle survey data^52,53 has been more extensive. For some non-acute services such as GPs and LTRC, where data can be geocoded, more detailed analysis of spatial accessibility has been undertaken^24,25,27,41. The need for timely access to information to support an integrated healthcare system has been underlined in international policy³. The emphasis in this paper has been on collating and cleaning data from disparate sources, using simple provider-to-population ratios (raw and needs-adjusted) for a broad spectrum of services to give a comprehensive picture of regional inequity in non-acute supply in Ireland.

Supply in each county is assessed against national average supply but the latter is not equivalent to adequate supply. Analysis was focused on those counties that are more than 10% different from the national average, ensuring a conservative approach is adopted to measuring variations across counties. To judge whether or not a given level of supply is adequate would require assessment against a set of agreed criteria. International supply benchmarks are challenging to determine, given the varying roles and definitions of care providers in different countries. Alternative benchmarks could include clinical standards outlining optimal care levels. For example, Wren et al.⁵⁴ examined the quality of rehabilitation care for stroke survivors in Ireland against international best practice protocols. Optimal supply may be higher than the national average for some of the non-acute services examined here, given clear evidence of unmet need and long waiting times for public community therapy services and home care³⁰.

Data gaps remain, including on the supply of private health professionals (e.g., SLTs, P&Cs, HCHs) and GP practice nurses. New data sources are coming on stream, which could be used for future analysis (e.g., the multi-profession regulator (CORU) responsible for the registration of health and social care professionals⁵⁵). There may also be local variations in non-acute service delivery that are not apparent in WTE data. For example, in some areas the delivery of selected non-acute services is contracted out to private providers, or there can be differing degrees of role substitution/overlapping (e.g., overlapping roles of community nurses, PTs and OTs) across counties.

Finally, the needs adjustment methods do not control for collinearity across needs indicators. However, the MC can be considered a multi-dimensional need indicator because, as well as being a key enabling factor for receiving publicly funded healthcare, the MC is also frequently considered a control for socio-economic status (since eligibility is largely based on income means-testing)^56,57 and a proxy for healthcare need, given the well-established link between lower socio-economic status and poorer health^58–60.

Lessons for Ireland and other countries

Formal resource allocation models for healthcare have been in use for decades⁹, yet in Ireland, historical budgeting in non-acute care persists. The analysis in this paper shows that in the context of important population changes and the influence of non-need factors (e.g., hangovers from previous administrative structures), persistence of historical budgeting can lead to considerable geographic inequities in non-acute healthcare supply. In the Irish case, there are notable regional patterns to the observed inequities, with supply in the east consistently lower relative to the rest of the country. While such inequities can remain under the radar under normal conditions of demand (particularly in the absence of systematic analysis of supply), they come into sharp relief in the context of a crisis such as the COVID-19 pandemic where non-acute supply plays a crucial role in ensuring that acute services can be preserved for treating COVID-19 and other patients with acute care needs. A key objective in Ireland’s current health reform programme, Sláintecare⁴, is the development of a community-costing programme for non-acute care. This, together with building capacity in non-acute care in the areas where it is most needed, is now more important than ever.

For Ireland, keeping pace with population change is critical. Future migration within and into Ireland, as well as population growth patterns, may exacerbate the regional disparities in non-acute supply, especially because projected population increases are for those areas with already relatively low levels of non-acute supply⁶¹.

The Irish case also has lessons for policymakers seeking to find the appropriate balance between local autonomy and national oversight in healthcare planning. With the persistence of historical budgeting, there remains an institutional legacy with regard to the regional-based Health Boards that were in place prior to the HSE. In addition to the factors already discussed, some of the geographic differences in supply may be a consequence of the historical regional Health Board structures. Local autonomy for service planning led to divergences in non-acute supply, with some of these divergences persisting and underpinning the inequities in supply across Ireland. As part of Sláintecare, the proposed establishment of RHAs means that aspects of localised decision-making will remain. This should facilitate better matching of supply with local patient demand, but it is important that there is national oversight to ensure that data infrastructure, data analysis and resource allocation mechanisms are systematic and consistent across regional structures.

Underlying data

This paper is based on the analysis of secondary datasets, and no other data were collected as part of this research. Details on those datasets and their host institutions are outlined below: