Ireland Healthcare System International Benchmark

The recent publication of the OECD Health Statistics, brings with it a renewed interest in the performance of each State and the quality of care that is provided to their citizens, compared to their international peers.  Domestically, an acute focus has been placed on the Irish healthcare system and in particular, the under supply of hospital beds.  With the health budget in Ireland, as in so many other countries continuing to rise and healthcare expenditure is becoming a growing challenge for the government, it is worth noting that in many healthcare metrics, Ireland is among the best in the world.

Life expectancy

The US spends more on healthcare than any other nation on this earth, and by some margin. So if you measure its healthcare expenditure as a percentage of GDP, or much more importantly as a per capita spend (adjusted for purchasing power parity – PPP) it spends more than double the OECD average. One would expect that health outcomes in the US would be superior to other OECD countries, but this is not the case. Surprisingly, the life expectancy in the US fell in both 2017 and 2016. Life expectancy for men in the US fell by 0.2 years in 2017, and the life expectancy for males now stands at 76.1 years. By comparison, in Ireland the male life expectancy is 79.6 years. The female life expectancy metrics in the US are similarly adverse.

In a period, where the health service has been the centre of adverse news, it might surprise readers to see that Ireland fares well on one of the most important healthcare metrics according to the OECD analysis of 35 countries healthcare systems. The OECD average life expectancy at birth for all of its member countries (35 developed nations) is 77.9 years. In Ireland this metric is 79.6 years. Of the 35 members of the OECD, 10 have a life expectancy of 80 years of over, while 21 countries have a lower life expectancy than Ireland. A snapshot of the OECD average and some other countries where there are significant amounts of Irish emigrants are as set out hereunder:

	Life Expectancy (M)	Life Expectancy (F)
	Years of lie at birth. males	Years of lie at birth. females
OECD Average	77.9	83.1
Ireland	79.6	83.4
United Kingdom	79.2	82.8
Australia	80.4	84.5
Canada	79.6	83.8
New Zealand	79.9	83.4
United States	76.3	81.2

 

Among OECD countries, Iceland tops the life expectancy table for males with an expectancy at birth of 81.2 years. Japan tops the life expectancy for females with a life expectancy at birth of 87.1 years. At the opposite end of the table, Latvia and Hungary have the lowest life expectancy levels for males (69.7 years) and females (79 years) respectively.

Key risk factors to wellbeing

The OECD analyses the key risk factors to wellbeing, which includes smoking, alcohol consumption, obesity and air pollution. Ireland is adverse, albeit close to the average on three of the four metrics, while it is positive but again close to the average on the fourth metric being levels of air pollution. What this demonstrates, is that there is particular room for improvement on three of the four metrics. Ireland smokes more than the OECD average. Ireland drinks more alcohol than the OECD average. Ireland is also more obese than the OECD average.

These need to be real areas of focus for Ireland’s health promotion agenda, as favourable movements in these metrics will lead to better wellbeing and greater availability of health resources for an increasing and aging population. Securing better healthcare outcomes is the combined responsibility of the individual and the state. If society adopts poor lifestyle choices, then even if our health service is given more resources we will have worse outcomes. Undoubtedly, more older Irish persons will need to avail of the health and social care services, but the health system and country can’t also afford a growing number of persons presenting with type 2 diabetes and cardiovascular disease from rising levels of obesity.

Hospital bed supply

The recent OECD analysis of hospital bed supply is very interesting and is one of the metrics which displays the greatest level of variation around the average, of any one of the many metrics in the annual OECD analysis of health systems in its 35 members. The average number of hospital beds per 1,000 of the population in the OECD is 4.7, while this varies from a low of 1.5 hospital beds in Mexico to a high of 13.2 hospital beds in Japan. Of course societal and budgetary factors vary from country to country and this obviously has an impact on the need and affordability of hospital beds. A country such as Japan has one of the oldest average ages of its population, and as is to be expected, it is one of the key factors in driving the need for hospital beds in any country. Greater levels of illness follows aging and so it is an expected correlation, that hospital bed needs will rise in such countries.

It was recently acknowledged by the Minister for Health that Ireland needs more hospital and community care beds in the coming years and prima facia this is backed up by the evidence which emanates from the OECD analysis. The bed capacity review will form part of the advice to Government in that regard. However it is again useful to look at Ireland’s hospital bed supply in the context of other countries (Table 2).

Ireland has 3 beds per 1,000 of the population. This is well below the OECD average of 4.7 beds. If one were to simplistically extrapolate the OECD average to Ireland, then the necessity for hospital beds is of the order of 8,200 beds and this is significant in terms of both capital and revenue expenditure.

Are there ways that will still deliver good health outcomes that will allow a country like Ireland not to have to move towards the OECD norm?

Could Ireland in fact plan its health resources like New Zealand for instance, which can achieve strong health and wellbeing metrics while in fact having less hospital beds per capita than Ireland? New Zealand has a population of 4.7 million which is very much like Ireland. Its public and private hospital bed stock is about 1,200 beds less than Ireland.

In addition, as a nation New Zealand has a much greater geographic spread to cover (which is a challenge when delivering healthcare), and yet can have a well-regarded health system which has well below average waiting times for a variety of surgical procedures. Its health system also has a patient satisfaction level of 84 per cent and is ranked as the 12^th best health system globally. In New Zealand their focus is on:

1. Integrating care – care is integrated so the patient gets care in the right setting with the principle of care being in the community and nearest to the patient. This means not doing what we do in Ireland which is allocating blocks of resources to acute care, another block of budget to primary care and another budget allocation to for instance the Fair Deal. The allocation of resources in blocks encourages the silo mentality which does not result in the patient being the focus.
2. Community care is at the centre of the New Zealand model. This is particularly necessary is a country which is over 2,000 km in length. The principle applies to Ireland and should be easier to deliver in this country because our country is so much smaller.
3. Resources are available on an out of hours basis and over the weekend. In effect the asset e.g. hospital and community clinics are sweated better in New Zealand as compared to Ireland and provide care for the public when required as opposed to when available.
4. Health metrics in New Zealand have gotten better because personal responsibility for one’s health has been the focus of government policy.

The answer at least in part, seems to point to how Ireland chooses to organise its health system and currently it is the BDO view that our health system is too heavily dependent on the hospital setting. This is evidenced by the rate of hospital admissions for treatment and is well demonstrated for asthma and COPD admissions which amount to 411 per 100,000 of population in Ireland, which is markedly above the OECD average of 236 per 100,000 of population.

What does this mean for Ireland?

Even if the Irish health system were to become less dependent on the hospital setting, it is still almost certain that the Minister is correct in saying thousands of additional beds are needed. The key objective of leaders in the Irish health system is to ensure this the number of thousands is minimised, because the capital cost of development is one off, but the cost of staffing and operating the facility is recurring. Any which way, the health budget in Ireland, as in so many other countries is going to continue to rise and healthcare expenditure is going to become a growing challenge for governments and societies all around the world.

It is important to recognize however that despite the despair about our health system, some of our current metrics are among the best in the world. It’s not all bad!