Implicaciones de la investigación

Table 4.20 summarises the Gini coefficients for each of the non-acute supply variables outlined in Sections 4.4–4.6. It is important to note that this is just a summary index that hides some of the detail on how each of the services is distributed around the country. Nevertheless there is value in comparing the indices to give some indication of the scale within which the geographic distribution of these services vary.

Comparison across services

A priori, the location of publicly employed services would be expected to be more evenly distributed across areas, particularly once adjusted for need, given that decisions on location are made by the public employer (in the Irish case, the HSE) and are expected to be governed by plans for delivering co-ordinated services in line with local needs.

The Gini coefficients based on the unadjusted total population in Table 4.20 do not follow expected patterns. The Gini coefficients for GP and LTRC beds would be expected, a priori, to be higher than those for publicly employed services. GPs are private practitioners with more flexibility to choose where to locate in accordance with a number of factors (desirability of location, potential GMS contract, potential for private income stream, etc.), and over 75 per cent of LTRC beds are in privately run nursing homes (DOH, 2015b). The Gini coefficient for GPs (0.096) and for LTRC beds (0.091) based on the unadjusted population, while large, is lower (more equal) than that for the publicly employed services included in Table 4.20. Interestingly after controlling for need, the Gini coefficients for LTRC increase, indicating a more uneven distribution after adjustment for each of the need indicators. Similarly, the Gini coefficient for PTs, which includes both public and private practitioners, increases following adjustment for need (e.g. from 0.116 to 0.142 after adjustment for age 85+). The Gini coefficient for GPs shows a more mixed response to need adjustment.

In contrast, the Gini coefficients for the publicly employed CNs, OTs, SLTs and P&Cs generally fall following adjustment for each of the needs, indicating a more equal distribution once needs have been taken into account. Nevertheless, the Gini coefficients for these services are still higher than those for GPs and LTRC for most of the need adjustments. The effect of needs adjustment on the Gini coefficients for SWs and CO/PSYs is mixed.

It is also important to note that for some of these services, the distributional profile is incomplete and private supply needs to be examined where feasible (e.g. P&Cs, SLTs, HCHs).

Comparison across adjustment indicators

Adjustment for disability reduces the Gini coefficient for each non-acute service presented in this report except for long-term and home care. Adjustment for mortality, age 65+ and 85+ reduces the Gini coefficient for most of the services (the main exceptions are PTs and CO/PSYs, and LTRC and home care).

Adjustments for Medical Card holders and for Medical Card holders with a prescription for a chronic condition have similar impacts on the Gini coefficient, and this is not surprising given that the latter ‘morbidity’ adjustment is based on a subset of the Medical Card population.

TABLE 4.20 GINI COEFFICIENTS FOR THE GEOGRAPHIC DISTRIBUTION OF SELECTED NON-ACUTE

HEALTHCARE SERVICES, IRELAND 2014

Supply variable Total

population Age 65+ years Age 85+ years

Mortality Disability Medical Card Medical Card plus prescription General practitionersa 0.096 0.093 0.122 0.093 0.082 0.115 0.103 Community nursinga _{0.125 0.105 0.117 0.106 0.115 0.114 0.110} Physiotherapistsa _{0.116 0.119 0.142 0.119 0.107 N/A N/A} Occupational

therapistsa 0.171 0.166 0.153 0.162 0.169 0.169 0.167

Speech and language

therapistsa 0.120 0.104 0.104 0.101 0.109 0.134 0.125 Podiatrists and chiropodistsa 0.615 0.594 0.571 0.596 0.610 0.605 0.601 Counsellors and psychologistsa 0.168 0.178 0.189 0.175 0.159 0.170 0.172 Social workersa _{0.214 0.215 0.205 0.215 0.211 0.220 0.218} Long-term residential care bedsb

N/A 0.091 0.119 0.146 0.095 N/A N/A

Home care hoursb _{N/A 0.101 0.116 0.122 0.129 N/A N/A}

Legend: Decrease in Gini coefficient relative to the baseline Gini (i.e. based on total population) across adjustment indicators (suggests decreased inequality).

No change in Gini coefficient relative to the baseline Gini (i.e. based on total population) across adjustment indicators. Increase in Gini coefficient relative to the baseline Gini (i.e. based on total population) across adjustment indicators (suggests increased inequality).

Notes: (a) The Gini coefficient for the total population is the base to which the other Gini coefficients are compared. (b) The Gini coefficient for the population aged 65+ years is the base to which the other Gini coefficients are compared.

CHAPTER 5

Discussion and conclusions

5.1 INTRODUCTION

The previous chapter presents findings on the geographic profile of ten key non- acute services in Ireland in 2014 with and without adjustment for healthcare need indicators. These findings are discussed in this chapter, where we draw out key conclusions and highlight areas that require further consideration in the current policy context of improving resource allocation and expanding non-acute primary, community and long-term care services in Ireland.

This analysis was undertaken using data from 2014 (and 2015 in the case of long- term residential care (LTRC)). Due to the lack of a comprehensive database on care supply in Ireland, the identification and collation of the data supply included, specifically surveying private physiotherapists (PTs), was in itself a major contribution of the report. Changes in regional supply and population since 2014 may have altered some of the supply rankings summarised in the findings. However, due to the absence of a systematic resource allocation system in Ireland that relates supply to population need, it is likely that inequalities persist and the counties ranked as having low relative supply of care remain insufficiently served. This report does not therefore propose which areas require greater supply of which services, or which services may require particular attention to increase supply. Instead, it shows that considerable regional inequality in the supply of non-acute services exists and, importantly, this cannot be explained on the basis of need. In the context of a national policy objective of moving care from acute hospitals into the community and the establishment of Regional Integrated Care Organisations (RICOs) such under-supply in certain regions may present hospitals and healthcare administrators in these regions with greater challenges than in other areas which are better resourced.

Section 5.2 draws on the findings from Chapter 4 on supply of non-acute primary, community and long-term care across counties in Ireland to provide a high-level synthesis of the results across counties and services. Section 5.3 discusses the sensitivity of these results to adjustments for needs. Section 5.4 considers how our results relate to optimum supply. Section 5.5 situates the findings in the context of the Irish health and social care system, and examines the implications for policy, future planning and resource allocation decision making. Section 5.6 discusses limitations of the report and data challenges encountered. Section 5.7 concludes.