The Sláintecare report by the all-party Committee on the Future of Healthcare¹ and the Sláintecare Implementation Strategy² are the key policy documents outlining the Irish Government’s commitment to a system of universal healthcare and the mechanisms by which it is to be implemented.

A key part of this reform is a radical shift in the allocation of resources to support an integrated model of care in place of the current heavy reliance on acute hospitals. This shift must also be matched by greater equality in the geographical distribution of resources. Historically, health resources in Ireland are allocated based on existing level of service patterns, which makes it difficult to match the quality of care provided with those countries that apply more robust mechanisms of resource allocation. The Irish health reform programme has driven considerable academic and research interest in identifying the most appropriate mechanisms of resource allocation to create a more equitable health system. This article looks at some Irish research and commentary in this area.

Regionalisation and resource allocation

As part of Ireland’s development of a universal healthcare system, health policymakers are considering the approach to population-based resource allocation (PBRA) based on the six regional health areas (RHA) established under the Sláintecare health reform programme in 2017. RHAs will be regional divisions within the Health Service Executive (HSE) with the objective of aligning hospital and community care services and promoting innovation, integrated care, efficiency, clinical and corporate governance, and accountability. PBRA policies can facilitate the decentralisation process by allocating healthcare resources in a way that is sensitive to local population profiles and regional variation. Implementing a population-based health funding model would link expenditure to population characteristics to estimate future need for healthcare and could improve transparency and predictability in the allocation of funding. This could allow for greater ability to forecast required healthcare expenditure over the medium and longer term.

Resourcing non-acute hospital health services in Ireland

Implementing an effective system of resource allocation needs careful consideration of current resourcing of health services, particularly in the non-acute area. A 2019 report by Smith et al. on the supply of, and the need for, non-acute care in Ireland found that there were significant inequalities in the supply of primary, community, and long-term care services across Irish counties.³ The authors state that this inequality can partially be explained by the absence of any formal resource allocation system and the persistence of historical budgeting for community-based care. The report was commissioned to inform policymakers planning non-acute services and building capacity in the context of the Sláintecare reforms. When judging whether there was an inequitable supply of care across regions, the report took into account demographic differences, such as age, disability, and chronic illness rates, as these have a significant bearing on healthcare need. The supply per capita, based on identifying services in a particular area, is adjusted based on healthcare need indicators in that area. Inequity can be established by the extent to which supply did not meet need in some areas, or exceeded it in others. The results of the report’s analysis consistently show that needs adjustment does not remove inequities in supply. Some regions are significantly under-resourced in terms of supply of non-acute healthcare services.

Availability of information and health service reform

Smith et al. collated and combined available data to provide a detailed profile of the supply of non-acute health services across regions. This represents the most comprehensive account of non-acute care supply in Ireland that has been prepared to date. While this is a valuable new information resource, reform of allocation mechanisms will be impeded if there are not improvements in the accuracy and timeliness of data on both the demand for and the current supply of health services. Greater integration in the Irish health and social care system faces the challenges of insufficient evidence on the capacity of the non-acute sector to meet current and future demand. The report identifies a historic failure to invest in surveillance and survey-level data. Developments such as the Growing Up in Ireland survey, The Irish Longitudinal Study on Ageing (TILDA), and the Healthy Ireland Survey have aided health policy decision-making, but significant gaps remain.

Resource allocation models

Despite a lack of consensus on the approach to modelling, many health systems favour PBRA models as they are seen to promote equity in outcomes, support reform, and encourage stakeholder involvement and support. Two reviews published in 2021 looked at the impact and implementation of PBRA models in a number of countries. In the models studied in these reviews, resource allocation is determined largely by the profile of local populations, based on the entire range of determinants of health and wellbeing, and on the measurement of the population’s health needs.

Review of international PBRA models

The first review by Johnston et al. summarised recent evidence and found that all the models studied used population size as a starting point for determining resource allocation requirements, adjusting in different ways for direct and indirect factors such as age, gender, morbidity or, less commonly, ethnicity and rurality.⁴ These models used different variables to account for population need. However, they shared several guiding principles with regard to the nature of the variables selected. The review found that PBRA models promote technical efficiency and equity in terms of health outcomes and access, but care must be taken to ensure that funding aligns with policy objectives especially when undergoing a regionalisation or decentralisation process. PBRA is viewed as a valuable policy lever to promote equity in health outcomes and access to services. It is essential that the selection of the model be based on clearly defined objectives, whether it is equity in outcomes, matching needs or regional equality. Important contextual considerations for the implementation of a PBRA model in Ireland include the proportion of funding covered by the model, the range of services covered, compensation for regional differences, and determinants of costs.

Reliable data on the factors relevant to modelling health needs and robust information on cost are essential for describing this context accurately. The collection, management, and analysis of these data in turn require expertise in several disciplines and well-supported analytical capacity. Successful implementation of a PBRA model will require decisions to be made regarding regional delegation, including workforce planning and recruitment and support in using funding effectively.

Department of Health spending review

Building on the Johnston et al. review, a Department of Health spending review considered what is the most appropriate PBRA model to be implemented as part of the Sláintecare reform programme.⁵ The Department of Health report investigated reviewing policy and technical documents related to PBRA in a sample of formulae from six countries, selected partly on the basis that they use a similar funding for their health systems as Ireland is hoping to implement under Sláintecare.

One of the study’s considerations is how the different systems established the relationship between need indicators and healthcare costs, which can then be used to account for differences in geographical areas and estimate expenditure. Population size, age and sex, socioeconomic status or deprivation, ethnicity, and standardised mortality ratio (SMR) or mortality were indicators common to all the formulae studied. Less common were geographical area/place of residence (geographical) (rural versus urban), ethnicity, and cross-boundary flows.

Selecting indicators is a complex and potentially contentious process. It is also contingent on the extent and quality of data available, for instance on morbidity, which is an indicator closely related to healthcare needs, and the availability of relevant and recent research on needs factors. The linkage between needs factors is often difficult to determine and there are usually historical political and administrative practices that should be considered. Age, with the higher need for healthcare in early and later stages in life, and sex, because of the different healthcare needs of men and women, are demographic indicators common to all the PBRA formulae examined. Methods of disaggregation of ages vary between countries. Various measures of socioeconomic status or deprivation are included in all of the models examined, with ethnicity used in countries with large indigenous populations such as Canada and New Zealand, and unmet needs sometimes used as an indicator to divert resources to population centres that have a high level of poor health outcomes. Geographical impacts on the cost of delivering health services and rurality or remoteness are common indicators.

Role of data in designing PBRA models

Data availability on healthcare costs, the distribution of needs, and healthcare supply is the factor that most limits the choice of resource allocation model. Some countries support comprehensive data systems that record individual healthcare costs which can be linked to other databases providing information on other indicators. However, most countries rely on non-administrative sources of information such as health surveys. The lack of a unique health identifier means that Ireland is not yet in a position to pursue the type of approach taken in countries that can match utilisation and costs with other indicators such as socioeconomic status.

Linberg et al.’s investigation of a sample of PBRA formulae from the countries reviewed helped to inform the selection of Irish data sources to support a potential PBRA model.⁵ The Central Statistics Office (CSO) Census of Population and the Department of Health’s Healthy Ireland Surveys were found to be the most useful and reliable data sources for the purposes of designing a PBRA model. Census data provide valuable demographic information and support the examination of regions by socioeconomic, ethnicity, health status, and rurality/urbanity variables. There are limitations to using Census data for this purpose but initiatives like the HP Deprivation Index, a combination of 10 key indicators, serves as a proxy for deprivation across regions. The Department of Health’s Healthy Ireland Survey of health and health behaviours is conducted annually and provides data for several of the indicators typically used by PBRA models. The review presents comparable data under a number of variables as a demonstration of the potential of both of these information sources to support the development of a PBRA in Ireland.

Conclusion

In this supplement to the 2023 Winter issue of Drugnet Ireland, geographical analyses of indicators of drug use are presented in various articles. Treatment demand mapped to Small Areas (SA)⁶ and population prevalence to Electoral Divisions (ED) demonstrates the geographical distribution of these indicators and current need for responses in these areas. In addition, by mapping treatment data to the levels of deprivation in Small Areas, which is calculated using the HP Deprivation Index, the socioeconomic determinates of drug use are clearly demonstrated. Treatment demand is a response to problematic drug use, but also serves as a reliable proxy indicator of prevalence. It will be possible to extend the range of these indicators to include data on consequences of substance use, such as drug-related deaths, and on problematic drug use to develop more detailed population-based pictures of the drug situation.

The reviews referred to above emphasise the difficulties presented by the lack of availability of the data required to build a regional profile of healthcare needs, an essential part of an effective resource allocation model. Ireland has a well-resourced and highly efficient system for monitoring substance use and a supply of timely, comparable, and detailed data in this area. By integrating data from this system with the kind of detailed population-based information and analysis provided by the deprivation model, it is possible to more accurately devise a measurement of needs for interventions designed to prevent, treat or reduce the harms associated with drug use.

1    Houses of the Oireachtas Committee on the Future of Healthcare (2017) Houses of the Oireachtas
Committee on the Future of Healthcare: Sláintecare report. Dublin: Houses of the Oireachtas.
https://www.drugsandalcohol.ie/27369

2    Department of Health (2018) Sláintecare implementation strategy and next steps. Dublin: Government of Ireland. https://www.drugsandalcohol.ie/29415

3    Smith S, Walsh B, Wren M-A, Barron S, Morgenroth E, Eighan J, et al. (2019) Geographic profile of healthcare needs and non-acute healthcare supply in Ireland. Research Series No. 90. Dublin: Economic and Social Research Institute. https://www.drugsandalcohol.ie/30828

4    Johnston BM, Burke S, Kavanagh PM, O’Sullivan C, Thomas S and Parker S (2021) Moving beyond formulae: a review of international population-based resource allocation policy and implications for Ireland in an era of healthcare reform. HRB Open Res, 4: 121. Available from: https://hrbopenresearch.org/articles/4-121

5    McCarthy T, Lindberg C, & O’Malley C (2022). Towards population-based funding for health: evidence review & regional profiles. Spending review 2022. https://www.drugsandalcohol.ie/40893/

6    Small Areas are areas of population comprising between 80 and 120 dwellings created by the National
Institute for Regional and Spatial Analysis (NIRSA) on behalf of Ordnance Survey Ireland (OSi) in consultation with the CSO. Small Areas were designed as the lowest level of geography for the compilation of statistics in line with data protection and generally comprise either complete or part townlands or neighbourhoods. There is a constraint on Small Areas that they must nest within Electoral Division boundaries. Small Areas were used as the basis for the enumeration in Census 2016. Available from: https://www.cso.ie/en/census/census2016reports/census2016boundaryfiles/