Variation in resource allocation in urgent and emergency Care Systems in Ireland

Many international studies have highlighted geographical variation in survival from emergency conditions [1‐6]. Rural areas are associated with a higher risk for poor outcomes from emergency conditions for a number of reasons including older and more socioeconomically disadvantaged populations, longer travel times to tertiary treatment centres and concerns about the quality of care delivered at smaller rural hospitals [2, 6, 7]. Measures to address this problem are controversial. One approach is to concentrate services in a smaller number of specialist services. In theory, this transports patients directly to a setting that is appropriate to the severity of their condition, but also exacerbates the underlying risk associated with rurality by lengthening journey times [8].

Emergency care services have been reconfigured across the Republic of Ireland since 2006, with notable regional variation in planning and implementation [9‐12]. Reform initiatives, where implemented, have focused on directing patients to settings that are appropriate for their care needs. These programmes typically featured reduced access to emergency care in local hospitals, centralisation of specialist emergency services in ‘hub’ hospitals, and development of integrated, condition-specific referral protocols for both ambulance and general practice services. The majority of service reconfiguration was carried out in the southern and western regions of the country, which are also the most sparsely populated areas of the country.

The Republic of Ireland is an island of 70·2 thousand km² with a population of 4·5 million, divided into 26 counties. At the time of the project design, there were eight operational regions in the Irish health care system (Fig. 1). The characteristics of each region and measures taken to reconfigure services are presented in Table 1. Two regions (South and Mid-West) have implemented significant reconfiguration of urgent and emergency care [9, 11]. Four regions (West, North-East, Dublin South, and South-East) have introduced some measures designed to reconfigure care but these do not cover all services [9‐11]. Two regions (Dublin Midlands and Dublin North-East) have undertaken no major changes to the configuration of urgent and emergency care since 2006 [9‐12].

It is unclear whether the composition of regional funding for emergency care has responded to these initiatives. Populations in some areas now have to travel much further to access an emergency department, and this should imply a commensurate increase in pre-hospital resources such as out-of-hours general practice and ambulance services. However, the reconfiguration of services coincided with a deep financial crisis for Ireland’s public health system: it has been estimated that public funding for health was reduced by 22% over the period 2009 to 2013 [14]. This crisis may have made it difficult for policy makers to properly match emergency care resources to population need; thus, it is possible that both horizontal and vertical inequities have arisen or been exacerbated across geographical areas in Ireland. By horizontal inequities, we mean that urgent and emergency care systems may not provide the same services for people with similar needs, regardless of where they come from geographically. Vertical inequities arise when people with worse economic circumstances do not get better access.

The aim of this research is to examine variation in resource allocation to urgent and emergency care systems and utilisation of such resources across Ireland. This is evaluated by comparing overall resource levels across counties and analysing county-level resource composition in relation to population need. The key research questions are:

A cross-sectional study design was used to collect data on resourcing and utilisation in urgent and emergency care in Ireland. This comprises services provided in either the community (pre-hospital) or in hospitals (in-hospital). Pre-hospital expenditure includes spending on GP and practice nurse services (in and out of hours) and ambulance services. In-hospital expenditure includes spending on Emergency Departments (ED) and Local Injury Units (LIU) in public and private hospitals. Data on activity, staffing and expenditure were gathered from a range of sources, including government agencies, individual facilities and service providers, health professional bodies and private firms, and the Health Service Executive (HSE) (Table 2). Information on county and regional populations, as well as geographical area, were taken from the most recent census information provided by the Central Statistics Office [13].

Ethical approval was granted by the Clinical Research Ethics Committee of the Cork Teaching Hospitals prior to study commencement.

The results highlight wide disparities in the funding of care across counties, and to a lesser extent regions, with quite different models of care and unequal utilisation of hospital resources. It is interesting, and perhaps unexpected, to see that Louth with €207 per capita has the highest per capita spending for Urgent and Emergency Care followed by Offaly, Cavan and Sligo. These are all small counties with small populations and yet with significant hospital spending on emergency care. These results more than likely reflect the fact that hospitals located in counties with lower population density have a smaller base to spread fixed costs over than those in more densely populated counties. Overall, those counties with the lowest spending per capita either have no local hospital or are largely reliant on ED and/or LIU services from neighbouring counties.

It is not surprising that more rural counties have higher spending on pre-hospital care, particularly where there is no local hospital or where the population is dispersed and travel times to facilities are often substantial. In such cases ambulance costs will be higher and perhaps GP costs. Nevertheless, there is no consistency of funding in relation to rurality, particularly for ambulance care.

A key question is whether any of the variation identified have been the result of deliberate health care policy and a systemic approach to planning urgent and emergency care. Certainly 2014 marked the end of a prolonged austerity period for the Irish health care system with substantial pressure on government to cut public resources for health care [13].

The picture that emerges though in relation to funding urgent and emergency care is one of fragmentation. Hospital budgets have no specific cost centre for emergency care and there has been no mechanism for activity based funding for EDs. Instead funding for emergency departments comes from general funds through budgeting which is both institutional and incremental. This means that history and past politics have been important to the development of emergency care in hospitals. Nevertheless, it is hoped that activity based funding will be introduced at some stage in this area. Although activity based funding is commonly used to fund acute hospital care, there is not a large body of research about the impact of this funding mechanism on efficiency, particularly in emergency and urgent care [25], and the findings vary between countries and contexts [26] . Further research on costs, cost-effectiveness and the implications of various staff-mix configurations are needed to ensure that activity based funding captures the complexity of cases treated in ED and urgent care settings appropriately [25]. There may also be potential for more integration of services through the relatively new hospital networks. Ambulance services are funded separately for National Ambulance Services (outside of Dublin) and the Dublin Fire Brigade (within Dublin). GPs are entirely private sector agents but are funded by Government through a contract for those patients who have medical cards. Their contract is based on a mix of per capita payments and fee for services [27]. The out of hours and emergency care that they provide for medical card patients is funded on a fee for service basis by Government. Private patients (around 60% of the population) who wish to receive such care, must pay the full costs. Individuals who wish to seek private emergency care may do so in the major cities, according to their own means and private insurance status.

This array of funding mechanisms has resulted in a piece-meal approach to the resourcing of urgent and emergency care. There is a clear case for more integration in decision-making around funding, and consideration of key principles, such as equity, to guide that process. Only then might there be scope for moving toward a system appropriately resourced for universal access to quality emergency care.

The approach taken to evaluate variation in resource allocation in urgent and emergency care systems is unique by aggregating geographic funding to different elements of the system and evaluating resource utilisation by different populations. The results show inequities in overall resource allocation by county, and to some extent, by region. There are also strong inequities in utilisation of resources provided for emergency hospital services between residents in the North East region of the country and those in the South and West. The results showed some resource compensation in counties and regions with few or centralised hospital services with higher pre-hospital funding. However, such higher funding appears to only partially compensate for utilisation of effective specialised care especially in relation to those regions that have been reconfigured. There is need for a more integrated resource allocation process to ensure appropriate and more equitable resourcing across the different elements of the system.