Healthcare in the Republic of Ireland

The HSE is responsible for providing health and personal social services to everyone living in Ireland.

Health care in Ireland is two-tier: public and private sectors exist. The public health care system is governed by the Health Act 2004,[1] which established a new body to be responsible for providing health and personal social services to everyone living in Ireland – the Health Service Executive. The new national health service came into being officially on 1 January 2005; however the new structures are currently in the process of being established as the reform programme continues. In addition to the public-sector, there is also a large private healthcare market.

In 2010 Ireland spent €2,862 per capita on health, compared to a European Union average of €2,172 per capita,[2] of this spending approximately 79% was government expenditure.[3]

Health care system

Total health spending as a percentage of GDP for Ireland compared amongst various other first world nations from 2005 to 2008

All persons resident in Ireland are entitled to receive health care through the public health care system, which is managed by the Health Service Executive and funded by general taxation. A person may be required to pay a subsidised fee for certain health care received; this depends on income, age, illness or disability. All maternity services and child care up to the age of six months are provided free of charge. Emergency care is provided at a cost of €100 for a visit to the Accident and Emergency department.

The Medical Card – which entitles holders to free hospital care, GP visits, dental services, optical services, aural services, prescription drugs and medical appliances- is available to those receiving welfare payments, low earners, and in certain other cases. The only medical conditions carrying automatic entitlement to a Card are having thalidomide syndrome, having a surgical symphysiotomy, and children with cancer.[4] Many political parties support extending the availability of the Medical Card to eventually cover everyone resident in Ireland – they currently cover 31.9% of the population. Those on slightly higher incomes are eligible for a 'GP Visit Card' which entitles the holder to free general practitioner visits. Persons over 70 years who are not entitled to a medical GP visit card can instead receive an annual cash grant of €400 up to a certain income.

People who are not entitled to a Medical Card (i.e. 68.1% of the population) must pay fees for certain health care services. There is a €100 A&E charge for those who attend an accident and emergency department without a referral letter from a family doctor (a visit to which usually costs €45–75, though some practices offer rates as low as €25-35 for over-65s and students[5]). Hospital charges (for inpatients) are a flat fee of €80 per day up to a maximum of €800 in any twelve-month period, irrespective of the actual care received. Specialist assessments and diagnostic assessments (such as X-rays, laboratory tests, physiotherapy, etc.) are provided free of charge. If a person cannot afford to pay hospital charges, the HSE will provide the services free of charge. Under the Drugs Payment Scheme, prescription drugs, individuals and families are eligible for subsidies for approved prescription drugs, medicines, and certain appliances, and pay only a maximum of €144 per month per household. To qualify a patient must hold a Drugs Payment Scheme Card, for which everyone who does not hold a Medical Card is eligible.[6]

Everyone living in the country, and visitors to Ireland who hold a European Health Insurance Card, are entitled to use the public healthcare system. Under Common Travel Area (CTA) arrangements, British citizens do not require an EHIC card and can instead present their NHS number, NHS card, driving licence or other proof of residence within the CTA. Outpatient services are also provided without charge. The majority of patients on median incomes or above are required to pay subsidised hospital charges.

Hospitals and health outcomes

The Rotunda Hospital in Dublin is the world's oldest maternity hospital, founded in 1745. It is also one of its largest, dealing with over eight thousand births in 2007.

Many hospitals in Ireland, such as Connolly Hospital at Blanchardstown, are operated directly by the HSE. There are also hospitals run on a voluntary basis by organisations who receive public funding but operate with some degree of autonomy. Included in this latter group are teaching hospitals (such as University Hospital Galway) operated in conjunction with a university and hospitals with a long-standing religious ethos e.g. Adelaide and Meath Hospital in Dublin. There are also many private hospitals. Ireland has a lower than OECD-average number of hospital beds according to the 2013 OECD Health at a Glance Report[7] The same report also noted that Ireland has fewer doctors (2.7 doctors per 1,000 population) and more nurses (12.2 nurses per 1,000 population) than average in other OECD countries.

Hospitals in Ireland generally offer a full range of healthcare including accident and emergency services. There have been dramatic reductions in mortality from the three principal causes of death in Ireland - heart disease, cancer and stroke - in recent years[8] age-standardised mortality rate for heart disease has fallen by 59% between 1990-2011 and now stands just above the OECD rate at 136 deaths per 100,000 population per annum. Similarly, the age-standardised mortality rate for stroke has fallen by 51% in the same period to below the OECD average (61 deaths from stroke per 100,000 population per annum). Deaths from cancer have fallen by 21% between 1990-2011 to 217 per 100,000.

Waiting lists

Ireland has reduced its spending on health care by 6.6% since the onset of the Global Financial Crisis according to the OECD's 2013 Health Report. In consequence, waiting times for treatment have increased.

According to the Euro health consumer index waiting times for emergency treatment, minor operations, and CT scans, in Irish hospitals in 2015 were the worst in Europe, though the Irish health system was ranked 21st out of 35 European countries.[9] The Health Service Executive accepted that it lacked the capacity to provide sufficiently accessible health services. It was working to ensure that no one had to wait more than 18 months for an outpatient appointment, or inpatient treatment. According to the index, reports by patients on waiting times were considerably more pessimistic than official Irish waiting-time statistics.[10]

In 2007,[11] 76% of inpatients were admitted to hospital for operations immediately, 11% had to wait up to one month, 4% had to wait up to three months, 1% had to wait up to six months and 4% had to wait for over six months for operations. Waiting times at the National Rehabilitation Hospital, the only such facility in the country, can be one year. For outpatients, 23% were seen on time, 44% were seen within 30 minutes, 18% waited more than an hour and 7% waited two hours.

University Hospital Galway is one of Ireland's largest hospitals, dealing with over two hundred thousand patients in 2007.

In 2007,[11] for GP services, 31% were seen without an appointment, 38% received an appointment the same day, 28% received a next day appointment and 3% had to wait over two days to be seen.

The National Treatment Purchase Fund (NTPF) was set up in 2002 for those waiting over three months for an operation or procedure, and as a result over 135,000 patients on waiting lists have been treated so far. The NTPF involves the government paying for public patients to be treated for free in a private hospital in Ireland, or sometimes abroad if necessary. The NTPF has reduced waiting times for procedures to an average of between two and five months (the average in 2009 is 2.4 months), compared to between two and five years in 2002. There are cases where essential care is needed urgently but not made available by the HSE under their NTPF, and contrary to relevant judgements by the European Court of Justice.

HSE figures quoted in April 2012[12] show that at least 178,000 people in Ireland were on waiting lists to see specialists at an outpatient clinic, and that more than 300 patients had been waiting for over four years to be seen by a consultant after being referred by their GP.

Health centres

A BreastCheck centre in Galway.

Health centres provide a wide range of primary care and community services in towns and villages throughout Ireland, and are run by the HSE. Services available at these clinics include GP services, public health nurses, social work and child protection services, child health services, community welfare, disability services, older people services, chiropody, ophthalmic, speech therapy, addiction counselling and treatment, physiotherapy, occupational therapy, psychiatric services, and Home Help. These services are available for free, or at a subsidised rate.

In 2012 a programme of developing 35 primary care centres was announced. By July 2017 only one was operational. 14 are to be constructed by public-private partnerships.[13]

General practitioners

Primary health care in Ireland is mostly provided by general practitioners (GPs), who generally operate as sole traders or in health centres with other GPs and sometimes nurses. Most GPs also offer house visits to their patients, with emergency "out-of-hours" GP services available in all parts of the country. GPs generally charge on a per consultation fee basis, usually charging anything up to €80, depending on the region. People with Medical Cards or GP Visit Cards are exempt from charges. Many GPs also provide free services to those with hepatitis C and maternity and infant services. Those with private health insurance can, depending on their plan, have their GP costs paid or refunded, either fully or partially, by the insurance company. People can also claim tax relief for GP visit costs.

Drugs

Prescription drugs and medical appliances are available to all for a small fee (medical card holders), reduced cost (Drugs Payment Scheme) or in certain circumstances free (under the Long Term Illness Scheme) to residents of Ireland. The Drugs Payment Scheme ensures that every household only has to pay a maximum of €134 per calendar month for up to one month's supply of prescribed medicines and medical appliances.[14] Some private health insurance plans provide partial reimbursement up to the Drugs Payment Scheme threshold.[15] Those who are entitled to a medical card pay a government levy for each item dispensed. The levy is €2.00 up to a maximum of €20 per family per calendar month. Those who are suffering from one of a list of 16 long-term illnesses do not have to pay for medicines or medical appliances related to their conditions.[16] Ireland has below average use of generic medication according to the OECD, despite being a major exporter.

All immunisation vaccines for children are provided free of charge, in schools, health clinics and hospitals.

Recovering heroin addicts can receive methadone treatment free of charge under the Methadone Treatment Scheme.[17]

Other services

The HSE provide dental, optical (vision) and aural (hearing) health care. Medical Card holders and their dependents, Health Amendment Act Card holders and children get these services free. Other people can get these services free or at a reduced cost from the Treatment Benefit Scheme or private insurance. People who pay the full price to private practitioners can claim tax relief.[18]

The HSE also provide mental health services, and treatment and rehabilitation services for alcohol and drug addicts. The Irish healthcare system is often criticized for not providing sufficient services for those with mental health issues,[19] leading to a rapidly growing suicide rate,[20] and ineffective services delivered to young people.[21]

Payment schemes

Those without a Medical Card or private health insurance, and their dependants can receive medical services free or at a subsidised rate from the Treatment Benefit Scheme, which takes into account the compulsory Social Insurance Fund (PRSI) contributions they have made. People can also claim tax relief on medical expenses not covered by the State or by private health insurance. Those with private health insurance are provided with tax credits, which are passed directly to the insurance company and lower the customer's premium.

Visitors to Ireland who hold a European Health Insurance Card do not have to pay for emergency treatment from a general practitioner or specialist, emergency dental, oral or aural treatment, inpatient or outpatient hospital treatment or prescription medicines. Those who need dialysis, oxygen therapy or other specialised treatments can arrange for them before their visit.

Satisfaction with the health service

A survey, commissioned by the HSE in 2007, found that patient satisfaction with the health service was quite high, with 90% of inpatients and 85% of outpatients saying they were satisfied with their treatment. In addition to this, 97% said they were satisfied with the care provided by their GP.[22]

The 2008 Health Consumer Powerhouse Euro Health Consumer Index report ranked Ireland's public healthcare system 11th out of 31 European countries.[23] This is an improvement on the 2007 report which ranked the Ireland 16th out of 29 countries,[24] and a drastic improvement on the 2006 report, in which Ireland was ranked 26th out of 26 countries.[25]

Health Service Executive

The Health Service Executive (HSE) manages the delivery of the entire health service as a single national entity.

There are four HSE administrative areas (HSE Dublin Mid-Leinster, HSE Dublin North-East, HSE South and HSE West), which are in turn divided into 32 Local Health Offices (LHOs).

The HSE is Ireland's largest employer with over 100,000 workers; and has an annual budget of €16 billion, more than any other public sector organisation.

The HSE's organisational structure is divided into three main areas:

  • Health and Personal Social Services, which in turn is divided into three service delivery units:
    • The National Hospitals Office (NHO), which manages acute hospital and ambulance services.
    • Primary, Community and Continuing Care (PCCC), which delivers health and personal social services in the community and other settings.
    • Population Health, which promotes and protects the health of the entire population.
  • Support Services, which enables the HSE to function efficiently and cost effectively.
  • Reform and Innovation, which drives the HSE's strategic and corporate planning processes.

Minister for Health

The Minister for Health has responsibility for setting overall policy with regard to the health service.

Private health insurance

Private health insurance is available to the population for those who want to avail of it. Vhi Healthcare (which is part-owned by the government), Laya Healthcare, and Aviva provide health insurance, among other services. Quote Devil were set up in 2006 to provide health insurance amongst other insurance types. On 2 July 2012, GloHealth entered the market to become Ireland's fourth private health insurer.

In 2005, 47.6% of people were covered by private health insurance. The regulatory body for private health insurance is the Health Insurance Authority. In 2015 the proportion of people buying private health insurance had fallen to 40%, but this is still the highest proportion of any European country.[26]

The Hospital Saturday Fund (HSF) is also available to give customers cash towards a range of every day health care costs.

Reform initiatives

Due to the high share of out-of-pocket payments under the existing health service system, the Republic of Ireland represents the only state within the EU, which does not provide universal healthcare based on the criteria by the WHO.[27] The newly elected Irish government committed itself in March 2011 to reform the two-tier structure of national health service in response to public discontent with austerity measures from 2008 onwards.[28] Since public funding of health provision was reduced between 2009 and 2013 to meet payment obligations regarding the state’s budget deficit, citizens faced higher medical charges and extended waiting lists.[29] In reaction to this development, the coalition government of Fine Gael and the Labour Party declared to introduce “a universal single-tiered health service, which guarantees access based on need, not income… through Universal Health Insurance.”[30] The published government plan outlined in the 2014 document “The Path to UHC – The White Paper” foresaw introducing compulsory private health insurance based on managed competition between insurance companies to abolish the distinction between public and private patient status.[29] Key features of the policy entailed mandatory health insurance for every citizen under free choice of insurer as well as entitlement to the same package of care, covering primary and acute hospital services.[31] Further, patients should be charged in turn insurance premium irrespective of age or risk profile and additionally have the right to change their insurance membership on an annual basis.[32] Those citizen, who are unable to afford the amount of premium would have qualified for subsidies to cover the required premium payments by a National Insurance fund.[33]

The implementation of the proposed model of universal health insurance was supposed to be conducted by 2019.[28] However, after a public consultation procedure regarding the reform initiatives the plan of universal health insurance was abandoned by the Irish administration in November 2015 due to projections that the envisaged system would be too costly and would still require the highest share of funds by general taxation.[34] According to the state department of health, the implied costs of universal health insurance would have led to approximately 11% higher expenditures than the existing system.[35] After the Irish parliamentary election of 2016, Fine Gael formed a minority government supported by independent parliamentarians. Social Democrat TD Róisín Shortall founded in June 2016 an all-party “Committee on the Future of Healthcare” following an initiative by the health department with the aim to identify an appropriate approach for establishing universal healthcare in Ireland.[36] The committee was supported by an academic team from Trinity College Dublin to analyse submissions made within 30 public hearings in the course of the public consultation process.[37] In May 2017 the committee published its final report entitled “Committee on the Future of Health, Sláintecare Report”, which specified universal healthcare based on the following definition:

The document entails a proposed ten-year plan for reforming the Irish health system towards universal healthcare.[38] It consists of five sections, covering Population health profile, Entitlements and Access to Healthcare, Integrated care, Funding and Implementation.[38] The report foresees the provision of health cards called Carta Sláinte to every citizen, granting access to primary care free of charges at specified local entities preferably outside of hospitals.[37] This system is planned to be funded by taxation, requiring an increase of public health spending and further infrastructure investment of approximately 3 billion Euros.[38] The submitted plan was debated twice in the parliament in 2017 and the Irish government decided to found an official implementation office to appoint a head of the organisation as well as to develop a drafted implementation plan by December 2017.[37] However, as of June 2018 neither the document was published nor the lead to the office was appointed.

See also

References

  1. ↑ "Health Act 2004". Irish Statute Book. Office of the Attorney General. Retrieved 5 October 2010.
  2. ↑ "Ireland's spend on health above EU average - OECD". Rte.ie. 2012-11-16. Retrieved 2017-03-27.
  3. ↑ "GHO | By theme". Who.int. Retrieved 2017-03-27.
  4. ↑ "Am I eligible [for a Medical Card]?". Ireland's Health Service. Retrieved 25 September 2017.
  5. ↑ "Inchicore Family Doctors | Primary Care Centre". Inchicoredoctors.ie. Retrieved 2017-03-27.
  6. ↑ "Your Guide to the Drugs Payment Scheme - Ireland's Health Service".
  7. ↑ "Archived copy" (PDF). Archived from the original (PDF) on 6 December 2013. Retrieved 2013-12-11.
  8. ↑
  9. ↑ "Irish emergency care waiting times rated worst in Europe". Irish Times. 26 January 2016. Retrieved 30 January 2016.
  10. ↑ "Numbers awaiting outpatient assessment unacceptable - HSE". RTE. 26 January 2016. Retrieved 30 January 2016.
  11. 1 2
  12. ↑ "HSE: 178,000 waiting to see a consultant at an outpatient clinic". Thejournal.ie. 2012-04-06. Retrieved 2017-03-27.
  13. ↑ "Here's what stage 35 primary care centres announced for 20 counties in 2012 are currently in". The Journal. 22 July 2017. Retrieved 25 May 2018.
  14. ↑ "Drugs Payment Scheme". Citizensinformation.ie. 2016-10-25. Retrieved 2017-03-27.
  15. ↑ "Health Insurance Comparison | HIA: Health Insurance Authority". Hia.ie. Retrieved 2017-03-27.
  16. ↑ "Prescriptions - government schemes explained".
  17. ↑ "Archived copy". Archived from the original on 7 April 2014. Retrieved 2014-04-06.
  18. ↑ "Taxation and medical expenses". Citizensinformation.ie. Retrieved 2017-03-27.
  19. ↑ McNamara, McNicholas, Ford, Paul, Gavin, Coyne, Cullen, O'Connor, Ramperti, Dooley, Barry, Singh (2002). "Early Intervention in the Real World-Transition from child and adolescent to adult mental health services in the Republic of Ireland: an investigation of process and operational practice". Early Intervention in Psychiatry. 53 (9): 466–468.
  20. ↑ Hegarty, K (2014). "Suicide in Ireland". The Furrow. 22 (8): 291–297.
  21. ↑ Illback, Bates (2011). "Transforming youth mental health services and supports in Ireland". Early Intervention in Psychiatry. 5 (1): 22–27.
  22. ↑ 28/09/2007 - 11:51:58 (2007-09-28). "Survey finds widespread satisfaction with health service". BreakingNews.ie. Retrieved 2017-03-27.
  23. ↑ "Irish healthcare system winesses improvement in European health consumer ranking" (PDF). Healthpowerhouse.com. Archived from the original (PDF) on 3 March 2016. Retrieved 27 March 2017.
  24. ↑ "Omslag_EHCI_2007_cover02" (PDF). Healthpowerhouse.com. Archived from the original (PDF) on 19 March 2017. Retrieved 27 March 2017.
  25. ↑ "Euro Health Consumer Index 2006" (PDF). Healthpowerhouse.com. Archived from the original (PDF) on 22 February 2011. Retrieved 27 March 2017.
  26. ↑ "Outcomes in EHCI 2015" (PDF). Health Consumer Powerhouse. 26 January 2016. Archived from the original (PDF) on 6 June 2017. Retrieved 27 January 2016.
  27. ↑ Tamas, Evetovits,; Policies, European Observatory on Health Systems and; Europe, WHO Regional Office for (2012-11-16). "Health system responses to financial pressures in Ireland: policy options in an international context"
  28. 1 2 Burke, Sara Ann; Normand, Charles; Barry, Sarah; Thomas, Steve (March 2016). "From universal health insurance to universal healthcare? The shifting health policy landscape in Ireland since the economic crisis". Health Policy. 120 (3): 235–240. doi:10.1016/j.healthpol.2015.12.001. ISSN 0168-8510.
  29. 1 2 Byers, Vivienne (March 2017). "Health Care for All in Ireland? The Consequences of Politics for Health Policy". World Medical & Health Policy. 9 (1): 138–151. doi:10.1002/wmh3.217. ISSN 1948-4682.
  30. ↑ "Universal Health Insurance".
  31. ↑ "White Paper on Universal Health Insurance" (PDF).
  32. ↑ "White Paper on Universal Health Insurance" (PDF).
  33. ↑ "White Paper on Universal Health Insurance" (PDF).
  34. ↑ Wren, Maev-Ann; Connolly, Sheelah (2017-12-26). "A European late starter: lessons from the history of reform in Irish health care". Health Economics, Policy and Law: 1–19. doi:10.1017/s1744133117000275. ISSN 1744-1331.
  35. ↑ Clements, Richard (October 2016). "3. Prime Minister and Cabinet". Law Trove. doi:10.1093/he/9780198745259.003.0003.
  36. ↑ "Committee on the Future of Healthcare".
  37. 1 2 3 Burke, Sara; Barry, Sarah; Siersbaek, Rikke; Johnston, Bridget; Ní Fhallúin, Maebh; Thomas, Steve (May 2018). "Sláintecare – A ten-year plan to achieve universal healthcare in Ireland". Health Policy. doi:10.1016/j.healthpol.2018.05.006. ISSN 0168-8510.
  38. 1 2 3 4 "Committee on the Future of Healthcare".
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