RECOMENDACIONES

Expanding care and service provision in the primary, community and long-term care sectors is a current priority for policymakers in Ireland (Department of Health, 2019; Government of Ireland, 2018b; Houses of the Oireachtas Committee on the Future of Healthcare, 2017). However, as discussed by Smith et al. (2019), there is only limited documented evidence on the patterns of supply of non-acute services across the counties in Ireland. Smith et al. (2019) built upon previous analyses of non-acute services and generated a more comprehensive picture of the geographic distribution of non-acute services in Ireland.

This expansion of care in the non-acute sector is envisaged to allow for care to be provided more appropriately outside of hospitals, and to remove much of the pressure on the overburdened hospital sector in Ireland. Expenditure on acute hospital care accounts for the largest proportion of healthcare spending in OECD countries (OECD, 2018). In 2016, hospital care accounted for 60 per cent of total healthcare expenditure in the OECD, with inpatient services alone accounting for 30 per cent of total spend (OECD, 2018). In Ireland, 55 per cent of current healthcare expenditure was accounted for by the hospital sector in 2017 (CSO, 2019).3_{Ireland is often seen as having a ‘hospital-centric’ service delivery model.}

This overburdening of the acute sector in Ireland has in part resulted in inpatient bed occupancy rates being the highest in OECD countries (OECD, 2018) and some of the longest waiting lists for elective care of developed countries (Siciliani et al., 2014). The overburdened public hospital sector is ill-equipped to meet the pressures on it, with one of the lowest bed-to-population ratios in the OECD (OECD, 2018). The Irish public hospital system has achieved a number of efficiency improvements in recent years, including a high proportion of procedures as day

cases (Wren et al., 2017) and one of the lower lengths of stay within the OECD (OECD, 2018); however, pressures on the acute sector remain.

Delivering care at the most appropriate level is a fundamental principle in the Sláintecare proposals for reform (Houses of the Oireachtas Committee on the Future of Healthcare, 2017). The Sláintecare report acknowledges the importance of developing non-acute care capacity in order to facilitate integrated care, as well as move away from a hospital-centric system. A key ‘strategic action’ of the Sláintecare Implementation Strategy focuses on expanding non-acute care services to provide adequate care supply closer to home (Department of Health, 2019). The Sláintecare report, the Department of Health’s Capacity Review and the National Development Plan (2018–2027) set out a proposed future Irish health and social care system, and each report acknowledges that greater provision of acute services, such as inpatient beds, is required. This is largely due to the current inadequacy of acute service provision, as well as to projected growth and ageing of the population in coming decades (Wren et al., 2017). However, each plan’s acute care projections are heavily dependent upon substantial expansion in non- acute care, especially in sectors that largely provide care for older people. These projections of acute care requirements are therefore dependent upon two very important elements: the ability of patients and health professionals to substitute care into the community; and the system’s ability to expand workforce and capacity of non-acute services quickly. While the latter element is a vital component of healthcare reforms, in this report we focus on the former element – substitutability. We focus on two specific areas when examining substitutability between acute and non-acute care: home care and LTRC.

The report focuses on home care and LTRC for a number of reasons. First, these services are two of the largest components of non-acute care in Ireland more generally (Wren et al., 2017). In 2015, there were over 65,000 uses of public and private home care in Ireland. The State financed 10.46 million home help hours, with an additional estimated 3.86 million hours privately purchased. The State also provided 15,300 home care packages. Furthermore, there were an estimated 29,000 LTRC residents in 2015, with the majority (over 21,000) covered by the Nursing Home Support Scheme (NHSS, known as the ‘Fair Deal’ scheme). These residents used 10.6 million LTRC bed days – over twice as many inpatient bed days as in the public and private acute hospitals systems combined. While the ESRI report projected large increases in projected demand across the board, the largest projected increases were seen for these two services, and even accounting for healthy ageing in the older population in the future, demand for home care and LTRC care was projected to increase by 40–54 per cent between 2015 and 2030. In this context, any substitution of care from acute hospitals to home care and LTRC will likely result in even higher projected demand.

Second, there is a dearth of granular data on healthcare utilisation in Ireland. There is a sufficient level of data to examine substitution effects in Ireland in acute public hospital care using the administrative Hospital In-Patient Enquiry (HIPE) data, as well as home care and LTRC, for which administrative data has been collected at regional level over a number of years.

Third, while there is limited national and international evidence on substitutability between acute and non-acute services, a small but revealing body of literature has developed around examining substitution effects between hospital care demand and expenditure and long-term care demand and expenditure. This literature is outlined in Section 2.3.

In this report, we also examine an oft-overlooked but key aspect: how acute capacity, changes in acute capacity and hospital reconfiguration can impact access to hospitals and hospital utilisation. The relationship between acute care and non- acute care is complicated and impacted by a range of demand-side and supply-side factors. In order to accurately examine the substitution effects of acute and non- acute care, where non-acute care may ‘pull’ patients out of hospitals into more appropriate care settings (such as an LTRC centre), we must also clearly understand that acute capacity constraints can ‘push’ patients out of hospital early, thereby reducing their LOS.

It is acknowledged that acute capacity at this moment in Ireland is insufficient; 2,600 additional hospital beds (day patient and inpatient) are now explicitly planned for within the National Development Plan (Government of Ireland, 2018a), with three elective care-only hospitals to be developed in Dublin, Cork and Galway by 2027. In this context, by examining the relationship between bed capacity and hospital use, we also shed light on how the provision of a defined number of acute beds that will be in a system at a given point in time may impact hospitalisations and inpatient LOS. In this report, we provide a detailed overview of the acute system, including the reconfiguration of services seen in recent years, and compare Ireland to international peers with regard to acute capacity. We also discuss the literature that examines how bed capacity impacts hospital use. Chapter 5 is dedicated to highlighting how inpatient bed capacity is also a key determinant of inpatient LOS.