Tracking aspects of healthcare activity during the first nine months of COVID-19 in Ireland: a secondary analysis of publicly available data

Study design

Secondary analysis was undertaken on existing published and publicly available data that were: 1) related to primary care, community-based healthcare and hospital care in Ireland; 2) considered relevant for addressing this study’s research objectives; and 3) reported during the first nine months of the pandemic. Secondary analysis is a process whereby data collected by one or more researchers or administrative systems are re-analysed to pursue an alternative perspective on the same topic or a new research interest entirely.

Data sources

1.   Primary care

There is a dearth of publicly available data on GP activity in Ireland. Prior to COVID-19, the need for a centralised data registry for GPs was recognised (Health Service Executive, 2015; Walsh et al., 2019). To describe GP activity nationally, this paper drew on selected data retrieved from:

2.   Community-based healthcare

Waiting list and activity data were extrapolated from HSE monthly Performance Reports and quarterly Performance Profiles (Health Service Executive, 2018a; Health Service Executive, 2018b; Health Service Executive, 2018c; Health Service Executive, 2018d; Health Service Executive, 2018e; Health Service Executive, 2018f; Health Service Executive, 2018g; Health Service Executive, 2018h; Health Service Executive, 2018i; Health Service Executive, 2018j; Health Service Executive, 2018k; Health Service Executive, 2018l; Health Service Executive, 2018m; Health Service Executive, 2018n; Health Service Executive, 2018o; Health Service Executive, 2019a; Health Service Executive, 2019b; Health Service Executive, 2019c; Health Service Executive, 2019d; Health Service Executive, 2019e; Health Service Executive, 2019f; Health Service Executive, 2019g; Health Service Executive, 2019h; Health Service Executive, 2019i; Health Service Executive, 2019j; Health Service Executive, 2019k; Health Service Executive, 2019l; Health Service Executive, 2019m; Health Service Executive, 2019n; Health Service Executive, 2019o; Health Service Executive, 2019p; Health Service Executive, 2020b; Health Service Executive, 2020c; Health Service Executive, 2020d; Health Service Executive, 2020e; Health Service Executive, 2020f; Health Service Executive, 2020g; Health Service Executive, 2020h; Health Service Executive, 2020i; Health Service Executive, 2020j; Health Service Executive, 2020k; Health Service Executive, 2020l; Health Service Executive, 2020m) to facilitate a comparison of the 2020 figures with those reported in 2018 and 2019. We present analysis on the following:

It is important to note that in both cases, these figures relate only to the public (State-run) health services. To this end, data on access, wait times and activity levels in the private sector remain unavailable and thus excluded from this research.

3.   Hospital care

Hospital waiting list data were extracted from reports published by the National Treatment Purchase Fund (NTPF) (National Treatment Purchase Fund, 2021). There are three major waiting list categories defined by the NTPF Waiting List Management Protocol (National Treatment Purchase Fund, 2017):

Within each of these categories, hospital waiting lists are subdivided into ‘active’ (those awaiting a treatment appointment date), ‘suspended’ (those who are ‘temporarily unfit or unable to attend due to clinical or personal/social reasons’), and ‘to come in (TCI)’ (those who have received an appointment for their treatment) (see Table 3). The complexity of these numerous subcategories creates difficulty both in capturing the full burden of patient wait times and in enabling comparisons with other jurisdictions (Brick & Connolly, 2021).

Analysis

Once these selected data were extracted, cleaned and prepared for analysis, descriptive statistics were computed using Microsoft Excel 2016.

Primary care

Eligibility categories. As shown in Figure 1, the proportion of the Irish population eligible for free-at-point-of-use GP care, due to their medical card or GP Visit Card, was analysed from PCRS data for 2019, 2020, and the months of 2021 for which data were available.

Figure 1. Share of population eligible for either medical card or GP Visit Card, per month (2018-2021) (from Primary Care Reimbursement Service).

For all months studied, the proportions of the population eligible for a GP visit card or a medical card remained stable, between 10.3–10.6% and 31.0–31.9% respectively. Accordingly, the proportion of the population entitled to GP care without charge remained between 41.6% and 42.4% across the study period, including after onset of the pandemic in 2020.

Out-of-hours GP care. Data on patients accessing out-of-hours (OOH) GP care are published at monthly intervals. As seen in Figure 2, the number of patients availing of OOH GP care in the early months of 2020 is similar to those seen in 2018 and 2019. However, a sharp decline emerged in April 2020, when 57,945 patients were seen nationally by an OOH GP service compared to 92,369 in April 2019 – a reduction of 37.3%, or 34,424. This decline was maintained until July 2020. In August and September 2020, OOH GP care activities returned to pre-pandemic levels.

Figure 2. Monthly use of GP out-of-hours services (2018–2020) (from HSE Performance Reports).

It should be noted that these data may under-state the full extent of activity as reported to the HSE, particularly for private patients paying out of pocket at the time of the consultation.

COVID-19 telephone consultations. Since the onset of the pandemic, GPs have been reimbursed by the HSE via the PCRS to conduct telephone-based triaging consultations with patients with possible COVID-19 symptoms. These consultations are provided without financial charges for patients. Figure 3 presents the monthly number of telephone triages at the national level (left axis), alongside national case totals (right axis).

Figure 3. Number of COVID-19 telephone triages by GPs (running totals shown) with national COVID-19 cases (2020–2021) (from Primary Care Reimbursement Service).

As shown, there were three distinct peaks in COVID-19 telephone consultation activity by GPs: in March, September and December 2020. These peaks preceded the national peaks in COVID-19 cases, seen in April 2020, October 2020, and January 2021, respectively.

In March 2020, the ‘spring peak’ manifested as 219,548 telephone consultations by GPs triaging COVID-19 symptoms nationally. Activity level then fell during the summer months, before reaching the ‘autumn peak’ of 260,329 COVID-19 telephone triages in September 2020. This was exceeded in December 2020, when 416,607 telephone triages occurred. This high-point preceded the surge in case numbers seen in January 2021, when 103,015 new cases of COVID-19 were identified and the national incidence was temporarily the highest in the world (Ritchie et al., 2020). In total, from February 2020 to February 2021, 2.31 million of these consultations occurred.

COVID-19 testing by GPs. Figure 4 presents the number of COVID-19 PCR tests conducted for the hospital sector and the community.

As of March 2021, 3.76 million COVID-19 tests were performed by Ireland’s public healthcare system, 2.48 million (66%) of which were referred from the community. The largest monthly number of COVID-19 tests was seen in January 2021, with 705,531 performed, of which 491,772 (69.7%) arose from the community.

Figure 4. COVID-19 testing nationally by location (hospital or community/GPs) with percentage of tests from community/GPs (from Ordnance Survey Ireland open-source data).

As shown by the red line in Figure 4, the proportion of tests in which GPs played at least some role – that is, ordering them, following up on them, or both – was between 60% and 70% for most months of the pandemic, averaging 66%, with a peak of 73.8% in October 2020.

Of note, for the purposes of this study and in the absence of more robust data, it is assumed that COVID-19 tests performed in hospitals were ordered by a hospital-based clinician, while those performed outside of hospitals were either ordered by GPs, followed up by them, or both. However, a small proportion of out-of-hospital COVID-19 tests may have originated from other sources, such as from public health doctors referring close contacts of confirmed cases for testing, as part of a response to a specific outbreak or cluster. As such, these data may over-state GPs’ role in referrals for testing.

In addition, these data do not include COVID-19 tests performed in the private sector or in ‘walk-in’ testing centres which began to operate in early 2021.

Community-based healthcare specialties

Activity levels. As mentioned earlier, analysis on activity levels and waiting lists was undertaken using data on eight community-based healthcare specialties, including: physiotherapy; occupational therapy; speech and language therapy; audiology; psychology; podiatry; community ophthalmology; and dietetics.

As shown in Figure 5, there was a 35% reduction in publicly provided care across all eight allied health specialties in the community when the first nine months of 2020 are compared to the same period in 2018 and 2019, suggesting a significant impact of COVID-19 on these essential services. The divergence appeared in March 2020, when the HSE introduced widespread restrictions on non-urgent healthcare.

Figure 5. Cumulative patient numbers seen across eight allied healthcare specialties.

Totals for September 2018 (middle figure), 2019 (top) and 2020 (bottom) are labelled. (from HSE Performance Reports).

By September 2020, 771,322 patients were seen by all eight specialties, compared to 1,157,154 and 1,187,734 patients by the same date in 2018 and 2019, respectively. This 2020 figure represents a reduction of 416,412 (35.1%) compared to 2019 (data for the last three months of 2020 are unavailable at time of writing).

There was heterogeneity observed between specialties regarding the degree of reduction of activity seen in 2020 when compared to the 2019 figures (see Table 1). The greatest reductions in patient numbers were seen in speech and language therapy (49.0%) and audiology (46.1%), while dietetics (13.6%) and psychology (18.1%) exhibited the lowest proportional increase over the observation period.

Community waiting lists. Waiting lists for the eight community specialties were also analysed at three-month intervals from 2018 to 2020. These are represented in Table 2 and Figure 6. As shown, this period was characterised by three phases. First, there was a gradual, sustained increase in waiting list numbers across the specialties in 2018 and 2019. Second, an abrupt decline in the waiting list numbers for all specialties combined was reported in the first quarter of 2020, falling from 162,629 in December 2019 to 100,708 in March 2020, a reduction of 61,921 or 38.1%. Thirdly, a marked increase was seen in waiting list numbers from March to September 2020 for all specialties, offsetting the decline seen earlier that year.

Figure 6. Total waiting list figures across all eight community-based specialties (2018–2020) (from HSE Performance Reports).

As shown in Table 2, while waiting lists for all specialties increased markedly in the period from March to September 2020, speech and language therapy and dietetics recorded the greatest increases during this time, rising by 176.8% (11,129 to 30,810) and 95.3% (8,498 to 16,593), respectively.

(Of note, distinct waiting lists for assessment and treatment are published by the HSE for speech and language therapy [Health Service Executive, 2018a; Health Service Executive, 2018b; Health Service Executive, 2018c; Health Service Executive, 2018d; Health Service Executive, 2018e; Health Service Executive, 2018f; Health Service Executive, 2018g; Health Service Executive, 2018h; Health Service Executive, 2018i; Health Service Executive, 2018j; Health Service Executive, 2018k; Health Service Executive, 2018l; Health Service Executive, 2018m; Health Service Executive, 2018n; Health Service Executive, 2018o; Health Service Executive, 2019a; Health Service Executive, 2019b; Health Service Executive, 2019c; Health Service Executive, 2019d; Health Service Executive, 2019e; Health Service Executive, 2019f; Health Service Executive, 2019g; Health Service Executive, 2019h; Health Service Executive, 2019i; Health Service Executive, 2019j; Health Service Executive, 2019k; Health Service Executive, 2019l; Health Service Executive, 2019m; Health Service Executive, 2019n; Health Service Executive, 2019o; Health Service Executive, 2019p; Health Service Executive, 2020b; Health Service Executive, 2020c; Health Service Executive, 2020d; Health Service Executive, 2020e; Health Service Executive, 2020f; Health Service Executive, 2020g; Health Service Executive, 2020h; Health Service Executive, 2020i; Health Service Executive, 2020j; Health Service Executive, 2020k; Health Service Executive, 2020l; Health Service Executive, 2020m]; these are combined in this section.)

Developmental screening checks. The proportion of infants receiving developmental screening checks on time – that is, by 10 months of age – from a PHN is shown at monthly intervals in Figure 7 (data after September 2020 were unavailable at time of writing).

Figure 7. Percentage of infants receiving PHN 10-month developmental screening check on time (2018–2020) (from HSE Performance Reports).

As can be seen, throughout 2018 and 2019, the proportion of children receiving this screening check on time was consistently between 90% and 94%. There was a marked decline in achieving this target in the first half of 2020, reaching a nadir of 25.5% in May 2020 before recovering slightly to 54.8% in September 2020, the latest month for which data are available.

Hospital care

In January 2021, there were 869,676 people waiting on some form of Irish public hospital waiting list across all NTPF waiting list categories, as shown in Figure 8 and in greater detail in Table 3. This total refers to the number of patients across the three major hospital waiting list categories – outpatients, in-patient/day-case admissions and planned procedures – including those grouped as ‘TCI’ or ‘suspended’.

Figure 8. National hospital waiting list numbers from January 2019 to January 2021, by category (from National Treatment Purchase Fund).

All three categories underwent an increase during this two-year period. Outpatient waiting lists increased by 20.4%, reaching 629,919 in January 2021; in-patient and day-case waiting lists increased by 13.5%, reaching 146,680; and planned procedure waiting lists increased by 20.1%, reaching 93,077. In total, the national hospital waiting list figure was 139,739 in January 2021, 19.1% higher than two years prior.

Outpatient waiting lists. Figure 9 and Table 4 present national outpatient hospital waiting list data at three-month intervals from January 2019 to 2021, by length of wait. Most notably, outpatient waiting list numbers rose nationally from 523,225 in January 2019 to 629,919 in January 2021, representing an increase of 106,694, or 20.4%.

Figure 9. National outpatient waiting list figures, by length of wait (January 2019 - January 2021) (from National Treatment Purchase Fund).

In addition, the proportion of patients experiencing very long waits for care increased during this time, with 170,983 (27.1%) of those on the outpatient waiting list waiting longer than 18 months as of January 2021 (Table 5). The hospital specialties with the longest outpatient waiting lists in January 2021 were orthopaedic surgery (77,257); ear, nose and throat surgery (68,073); and ophthalmology (47,075), comprising 30.5% of the total national outpatient waiting list (Table 6).

In-patient/day-case waiting lists. Waiting lists for the IPDC admissions were analysed with respect to length of wait and are presented in Figure 10. As stated, this category refers to patients awaiting admission on an elective basis for care or treatment, some of whom require overnight admission after their treatment (in-patient admissions), together with those who do not (day-cases). Of note, NTPF figures for the IPDC and planned procedure waiting list categories are published with patients awaiting endoscopy considered separately; as shown in Figure 10 and Figure 11, data in this paper are depicted in the same manner.

Figure 10. Number of patients on in-patient/day-case (IPDC) waiting lists (January 2019 - January 2021) (from National Treatment Purchase Fund).

Figure 11. Planned procedure waiting lists (January 2019 – January 2021) (from National Treatment Purchase Fund).

As shown, there was a marked increase in both endoscopic and general IPDC waiting lists in the early months of 2020 (January to April), coinciding with the ‘first wave’ of COVID-19 and attendant disruptions in planned routine healthcare. From January 2019 to 2020, the number awaiting an IPDC admission rose by 3.7% from 129,243 to 134,079; from January 2020 to 2021, it rose by 9.4% from 134,079 to 146,680. As of January 2021, the three specialties with the largest IPDC waiting lists were general surgery (13,537 waiting), orthopaedic surgery (11,092) and urology (10,348).

Planned procedures. As mentioned earlier, planned procedures refer to those patients who have had an initial episode of care and require recall for further treatment subsequent to that episode. Patients in this category include those awaiting second-eye cataract surgery, follow-up skin grafts, or follow-up GI endoscopy. As shown in Figure 11, patients awaiting GI endoscopy constitute the majority of this category.

Endoscopy. Notably, as shown in Figure 10 and Figure 11, both the IPDC and planned procedure waiting list categories include a cohort of patients awaiting GI endoscopy. These cohorts are combined in Figure 12, to provide an estimate of total national patient numbers awaiting GI endoscopy.

Figure 12. Total GI endoscopy waiting list figures in Ireland (January 2019 – January 2021) (from National Treatment Purchase Fund).

Of 121,505 patients awaiting GI endoscopy in January 2021, 45,529 (37.5%) were in the IPDC category, and 75,976 (62.5%) were in the planned procedure category. This total represents a 27.4% increase from January 2019, when the number of those awaiting an endoscopy was 95,386. An increase was seen every three months over the two-year period, with the largest single increase recorded from January 2020 to April 2020, a period coinciding with the first national ‘lockdown’, when 7,223 patients were added to the list.

As well as increasing in absolute terms, the proportion of patients in the ‘active’ IPDC waiting list category waiting long periods for an endoscopy rose in the two-year period analysed (Figure 13), in particular after the onset of the pandemic. Having been relatively stable in 2019, the proportion of those on the IPDC endoscopy waiting list waiting more than 12 months rose from 6.0% in January 2020 to 19.0% in January 2021, and the proportion waiting more than 18 months from 1.2% to 5.6% in the same period.

Figure 13. Percentages of IPDC GI endoscopy list waiting longer than 12 and 18 months (from National Treatment Purchase Fund).

Notably, at time of writing, length-of-wait data for endoscopy were only available for patients in the IPDC category and classified as ‘Active’, and not for patients in the planned procedure category. As such, the length of wait for around 70% of patients awaiting a scope nationwide remains uncharacterised. This constitutes a limitation of the data in this section.

Primary care

The findings indicate that GPs played an instrumental role in Ireland’s COVID-19 response given that a majority (two-thirds) of all COVID-19 PCR tests were either referred by GPs, followed up on by GPs, or both. Moreover, the figures show that large numbers of telephone-based consultations were held with patients presenting with COVID-19 symptoms, with three peaks in this activity, each preceding the successive ‘waves’ of COVID-19. However, the number of patients availing of out-of-hours GP care fell significantly in 2020 coinciding with the first ‘lockdown’. This reflects other Irish and international literature that has highlighted changes in care-seeking activity during the pandemic, such as in emergency departments (Brick et al., 2020; Lazzerini et al., 2020; Marron et al., 2021).

Ireland’s primary care system has been described by international observers as inequitable (Organisation for Economic Co-Operation and Development, 2019; Thomson et al., 2014). Yet these trends represent significant changes in routes of access to healthcare, including in primary care, and speak to the extraordinary dedication and professionalism of healthcare workers. They also demonstrate the potential of the Irish healthcare system successfully to implement entirely novel approaches to healthcare at scale that are underpinned by universalism: the foundation stone of Sláintecare. Critically, all COVID-related healthcare in Ireland has remained free at the point of use (Brick et al., 2020); the public health benefit of minimising monetary barriers to healthcare access has been emphasised (World Health Organisation, 2020b).

Community-based healthcare

The analysis revealed that activity declined significantly in 2020 across multiple allied healthcare professions in the public system. Notably, the extent of the decline in activity varied between specialties. There may be several factors causing this variance, such as differences in adaptability to video-based or tele-consultations (Tack et al., 2021); workforce redeployment to tasks such as contact tracing (Raidió Teilifís Éireann, 2020a; Raidió Teilifís Éireann, 2020b); and socioeconomic effects of the pandemic such as those related to childcare, particularly given that a majority of allied healthcare workers are women (Del Boca et al., 2020; Shannon et al., 2019; U.S. Bureau of Labor Statistics, 2021).

Moreover, the proportion of infants receiving 10-month developmental screening checks on time from their PHN fell significantly in 2020. Further research documenting the long-term impact of the disruption to this element of early-childhood healthcare would be of value.

In addition to reduced activity, the findings point to significantly increased waiting list figures for the eight allied health specialties examined during the early months of the pandemic. Notably, these increases were immediately preceded by a significant reduction in total waiting list numbers in the first quarter of 2020 (see Figure 6). The reason for this decline is not clear. It may represent a true decline in numbers awaiting treatment, a statistical artefact arising from methodological change in list management, or a combination of both.

The pandemic appears to have compounded a pre-existent crisis in community services. In 2018, a quarter or more patients were waiting longer than a year to be seen by several allied health specialties (see Table 2). During the pandemic, activities were cancelled and an unquantified number of allied health professionals were redeployed to other areas. The ramifications of this remain to be seen.

A core tenet of Sláintecare is the transition of healthcare from the acute hospital to the community. The reduced activity levels and increased waiting list figures documented here suggest that COVID-19 had a substantially negative impact on the levels of community-based healthcare delivered by the public healthcare system in Ireland in 2020. This lends considerable support to the assertion that the capacity for community-based healthcare should be bolstered and enhanced now and in the future; however, it also makes a strong case for ensuring that specialists are enabled, where possible, to remain in community settings if another wave of COVID-19 (or, indeed, a new health system crisis entirely) occurs in the future.

Hospital care

The findings point to a significant disruption of scheduled hospital care during the COVID-19 pandemic, manifesting as increased waiting lists and longer wait times in the Irish healthcare system. The harms incurred to those experiencing exceptionally long waits for healthcare, in terms of delayed diagnosis and worsened health outcomes, have long been recognised as a policy concern globally (Organisation for Economic Co-Operation and Development, 2019; Siciliani et al., 2014; Wren, 2003). Indeed, reducing public hospital waiting list numbers in Ireland has been a stated priority of healthcare policy for decades and is a key imperative of Sláintecare (Besley et al., 2009; Burke et al., 2019; Health Service Executive, 2021a; Health Service Executive, 2020a; Siciliani et al., 2014).

However, this research indicates that the onset of COVID-19 has exacerbated already long hospital waiting lists for essential care in the Irish context, emphasising existing deficits in the current healthcare system that will need to be considered and addressed by policymakers. There are likely several factors at play here: most obviously, service suspensions leading to cancellations (Government of Ireland, 2020b; National Public Health Emergency Team, 2020b), but also staff absences due to exhaustion and burn out (Riley et al., 2020), challenges to providing surgical care (Bresadola et al., 2020) and altered health-seeking behaviour patterns within the population, such as reduced rates of presentation to hospital related to fear of contracting the virus (Brick et al., 2020; Marron et al., 2021).

It appears that the health system sustained a ‘double hit’. Waiting lists grew during 2020, due to curtailed activity in hospitals. However, referral rates in real terms probably dropped, because of reduced availability of preventative care from GPs. This points to significant unmet need at community level. This has important policy implications.

If the implementation of Sláintecare is to be successful, measures to counteract or reduce the impact of these adverse effects in the longer-term, as well as protective mechanisms to prevent or mitigate similar consequences in the future, will need to be conceptualised, developed and put in place.

Limitations and directions for future research

As mentioned at the outset, we performed a secondary analysis of publicly available data to examine trends in healthcare activity in Ireland during the first nine months of the COVID-19 pandemic. While secondary data analysis has clear value, this approach is not without limitations, the most notable of which is that researchers have to ‘make do’ with what they have (or what is available), rather than being able to gather tailored data.

Because of this, the findings presented here only represent activity in the public health system and not the private sector. Furthermore, as stated accordingly throughout, the findings likely provide an incomplete picture of healthcare activity as it relates to GPs, GI endoscopy waiting lists and community-based COVID-19 tests. In particular, the data pertaining to general practice mostly describe COVID-19-related work, while data from other community-based services largely describe non-COVID-related work. This is because the PCRS reimbursement system – by which GPs were paid for COVID-related services such as testing – does not capture many other elements of general practice.

Moreover, it is likely that gaps exist between our presented figures on COVID-19 consultations and COVID-19 testing referrals. For example, Figure 3 shows that GPs were reimbursed for 413,000 telephone consultations in December 2020 and 174,000 consultations in January 2021. Meanwhile, GPs were responsible for more than 300,000 tests in December 2020 and 500,000 tests in January 2021 (Figure 4). It is difficult to identify where the ‘additional’ patients originate. Of note, out-of-hours GP care was reimbursed and recorded differently during this period. This is an important avenue for future research.

It also appears likely that the NTPF data used to describe the hospital sector contains flaws. For example, in Figure 9, a sudden jump in patients in the 15–18 month category in January 2020 seems inconsistent with trends from preceding three-month periods. Patients may have been reclassified. A clearer and more transparent method of collating waiting list data would be of benefit to policymakers and the public alike. The ‘Referral To Treatment’ (RTT) metric used across the UK’s National Health Service is noteworthy in this regard (NHS Statistics, 2023).

Nevertheless, critical insights have been gleaned that warrant further research to improve our understanding of the impact of COVID-19 on Ireland’s health services and the potential implications for the implementation of Sláintecare.

Finally, certain consequences of the pandemic may take years to manifest fully. Moreover, the data utilised by this research were collected before several public health developments took effect, such as the introduction of walk-in COVID-19 testing centres and the roll-out of the national vaccination campaign. Further analyses of Irish healthcare activity should therefore endeavour to incorporate a longer observation period to enable stronger inferences to be made about the effect of the pandemic in the longer-term.