Spending on the health services has gone up across a range of areas in recent years, writes Prof Miriam Wiley. But the question remains: can any government continue funding expectations without apparent limit?
In 2002 the allocation of gross current expenditure from Exchequer funds to the health services is projected to exceed €8.027 billion, which is over twice the allocation of €3.648 billion estimated for 1997.
While gross current health expenditure accounted for 6.3 per cent of GNP in 1997, for the first time since 1984 it is projected that this will account for 7.7 per cent of GNP in 2002.
Even though capital expenditure is outside the scope of this review, to provide some indication of scale it is worth noting that in 1997 €166.9 million was allocated to capital health expenditure yet in 2002 this has increased to €497 million.
In addition, the National Development Plan proposes to allocate over €2.5 billion to health service development over 2000-2006.
An increase of 120 per cent in current public health expenditure levels is estimated for the 1997-2002 period. After adjusting for inflation, this translates into an increase of over 70 per cent (in 1995 prices) in real terms.
The Government's health strategy estimates that in 2001 for the first time per capita health spending in Ireland (excluding personal social services and including expenditure from private sources) exceeds the combined average for total per capita health spending for all other EU countries. This again represents a substantial change from 1997, when Irish per capita health expenditure only reached 82 per cent of the average for all other EU countries (excluding Ireland).
While specifying changes in health expenditure levels may be relatively straightforward, tracking the return on this investment is more challenging, particularly given the limitations on the data available.
Approximately two-thirds of all health expenditure is devoted to pay costs. Since1997 health sector employment is estimated to have increased by 28 per cent to the current level of 87,000 available posts.
Around one-third of health sector employees are nurses, with the support services accounting for 30 per cent of those employed. Medical, dental and paramedical personnel together account for 16 per cent of employment. Those working in management, administration, clerical and maintenance/technical duties account for the remaining 17 per cent of health sector employees.
While those providing services in the clinical context may often be the most visible face of the health services, substantial input from the support services is required to ensure the provision of services.
The health strategy estimates that two-thirds of those working in areas like management and administration are involved in frontline services for patients.
Given constraints on the scope of this review, it is proposed here to focus on highlighting change in those areas accounting for substantial resource investment and on areas of innovation.
Accounting for 48 per cent of current expenditure, the general hospital programme has attracted proportionately the largest allocation of health care funding and in 2002 is projected to consume €3.8 billion of the allocation for gross non-capital expenditure.
Since 1997 it is estimated that current expenditure on the public hospital system has grown by 112 per cent, while expenditure in real terms on this programme has increased by close to 66 per cent.
Over the period 1997-2001, there was an overall increase in total discharges from general hospitals of 17 per cent, while inpatient discharges increased by 4.3 per cent. The number of day cases treated increased by 45 per cent. The number of outpatients treated within the hospital system has increased by 11 per cent since 1997, while the growth in accident and emergency attendances is estimated at around 1 per cent.
The number of patients waiting for treatment within the hospital system was estimated at 26,126 in December 2001, a reduction of 19 per cent from the estimated 32,206 patients on the waiting list in December 1997.
The implementation of the National Cancer Strategy has attracted substantial investment since development and to date it is estimated that around €103 million has been allocated to the implementation of the proposals put forward.
The community health service programme is the next most significant in expenditure terms, accounting for 17 per cent of current health expenditure. Since 1997, current expenditure on this programme has increase by 122 per cent, while expenditure in real terms (1995 prices) has increased by 74 per cent.
The GMS service (including GP fees and drug costs), together with the subsidisation of drug costs, accounts for the largest items of expenditure within this programme.
While the costs of the Choice of Doctor scheme within the GMS have more than doubled between 1997 and 2002, the numbers covered by the scheme have declined. Even taking account of the extension of the medical card scheme to the over 70s in 2001, since 1997 the numbers covered by the GMS scheme have dropped by close to 2 per cent and now account for 32 per cent of the population compared with over 33 per cent in 1997.
THE programme providing funding for care of the handicapped is the third most significant in expenditure terms and now accounts for 12 per cent of current health expenditure, compared with an estimated 11 per cent of health funding in 1997. Between 1997 and 2002, current health expenditure on this programme increased by 148 per cent, while expenditure in real terms increased by 94 per cent.
For those with physical and sensory disability, data from the Department of Health and Children indicate that developments in this area between 1997 and 2001 include the availability of an additional 51 long-term residential places, 95 residential respite places, 400 new day-care places, 54 additional occupational therapy posts, 37 additional speech and language therapy posts and 33 additional physiotherapy posts.
The developments in services for those with intellectual disability and autism over the same period include the provision of around 1,600 additional residential places, 395 dedicated respite places and 2,400 new day places. The community welfare programme now accounts for 8.8 per cent of current health expenditure, compared with 7 per cent in 1997. Since 1997 this programme shows the second highest level of growth (compared with all other health programmes) and in current terms rose by 170 per cent and in real terms increased by 112 per cent.
The advancement of the policy of deinstitutionalisation for the treatment of those with psychiatric conditions to some extent accounts for the fact that the psychiatric programme now accounts for just over 7 per cent of current health expenditure compared with 9 per cent in 1997.
The number of admissions to psychiatric hospitals and units has declined by close to 4 per cent between 1997 and 2000, and the number of inpatients has declined by 12 per cent over the same period.
In keeping with the policy of developing more mental health services in the community, since 1997 the number of places available in day hospitals has increased by 7 per cent.
With regard to service-related expenditure, however, while representing the smallest proportion of current expenditure the community protection programme has accounted for proportionately the biggest increase in investment since 1997. This programme funds such services as immunisation against infectious diseases, food safety and health promotion, and in 2002 accounts for 3.4 per cent of current health expenditure.
It must be recognised, in conclusion, that the unprecedented increase in funding for the health services which has been forthcoming since the late 1990s has to a great extent been made possible because of the exceptional growth in the economy over this period.
The increase in the proportion of GNP being devoted to health, which has become evident in the past two years in particular, is a function both of increased funding levels and also of the economic slowdown.
We are now at a point where the levels of health investment relative to GNP are approaching those which were in evidence in the early to mid-1980s. Given the difficulties experienced in the latter part of that decade, both within the wider economy and the health sector in particular, it does not seem unreasonable to expect that some hard decisions lie ahead, particularly with regard to what level of resources we are prepared to commit to the development and support of the Irish public health system.
Prof Miriam Wiley is head of the health policy research centre in the Economic and Social Research Institute.
Tomorrow: Sean Barrett examines what happened to infrastructure during the boom, with commentary by Frank McDonald