NCHDs 2,193 2,320 2,451 2,582 2,775 3,238 3,932 2,600 Consultants 1,122 1,158 1,186 1,270 1,327 1,440 1,731 5,200 Consultant/ NCHD 1 / 1.95 1 / 2.00 1 / 2.07 1 / 2.03 1 / 2.09 1 / 2.25 1 / 2.27 1 / 0.5 SourceHanly (2003: 40, 188)
Notes 1. NCHD = Non-Consultant Hospital Doctor.
2. FIN = Finland. The average basic salaries of consultants and NCHDs in the public sector in Finland were c45,500 and c30,960 respectively (a ratio of 1.45/1.00), butc133,051 and c43,231 in Ireland (a ratio of 3.08/1.00) [Hanly, 2003: 188].
issued medical cards. The inclusion of persons aged 70 or over began in 2001, but does not include their dependants. Otherwise, the identification of persons eligible for the medical card is based on social welfare receipt or on falling below an income guideline set by the government.44
They are then entitled to visit their family doctor and pharmacist and receive prescribed drugs free of charge. In addition, they do not have to contribute to their maintenance in public wards of hospitals, and receive free specialist out-patient services at public clinics, and dental, ophthalmic and aural services.
The medical card scheme was first introduced in 1972 and the proportion of the population covered by it peaked soon after, at 39 per cent in 1997. By 2002, 29.4 per cent of the total population had medical card cover and the cost of administering the scheme per eligible person was d679.45
The erosion of the percentage of the population covered is mainly because the income guidelines have been adjusted over time with an eye to inflation but not to the rise in earnings (Health Statistics, 2002). The extension of the medical card to older people regardless of income pushed the proportion of the population up slightly (to 31.2 per cent), but the trend decline reasserted itself thereafter. By employment status, the vast bulk of the population now covered by the medical card are outside the labour force or unemployed members of it: 55 per cent of all people aged 18 or over who were not economically active had medical card cover in 2001 and 48 per cent of all people who were unemployed, as against only 11 per cent of those in employment (QNHS, Third Quarter, 2001).
The differential rewards to family doctors of seeing patients — receiving an annual capitation grant for someone who may not come to them at all during the year (a medical card holder) versus charging a fee per visit to someone else — has problematic aspects. At one extreme, the medical card-holder has no incentive to consult the doctor only when necessary and is likely to consume a higher volume of services than their health status justifies. At the other extreme, a low paid worker with children, may be deterred by the significant cost involved from consulting a doctor even where it is necessary. On the other side, the family doctor has a large incentive to practice in areas where the number of medical card- holders is low and the likely pool of private patients high.46
The costs of medicines can impact on people much more than the cost of consulting a doctor. The Drugs Payment Scheme introduced in 1999 set a cap to the maximum that any individual or family must pay in a month for approved drugs, medicines or appliances for themselves or their families.47
The Long Term Illness
Social Protection in Ireland: A Hybrid System 65
44. By 2005, the income guidelines were a gross weekly income [net of PRSI and the Health Contribution] of c153.50 for a single person aged under 66 living alone and of c220 for a married couple. Further allowances for children, adult dependants without an income, some house expenses and travel to work expenses introduce a considerable element of discretion at the local (formerly Health Board) level where eligibility is determined.
45. General Medical Services (Payments) Board, report for year ended 31st December 2002. Excluding those aged over 70 newly admitted to the Scheme, just under 28 per cent of the population qualified for medical card cover in 2002.
46. Wren observes that, in 2002, the going rate for a visiting family doctor was between c40-c45, almost equivalent to the entire annual capitation grant the doctor received for an adult male medical card holder (c45.44) (Wren, 2002: 208).
47. Raised to c85 a month in 2005. To benefit from this scheme, a person must register themselves and their dependants with the health authorities; in 2002, 1,319,395 persons were registered and the net cost of the scheme per person was c148.50 and per claimantc935.73.
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Scheme means that persons suffering from one or more of a schedule of illnesses are entitled to obtain, free of charge and irrespective of their income, the drugs, medicines and appliances that they need.48
Caring services
Several forms of caring, some involving significant medical services and others not, constitute part of Ireland’s health budget. The public health authorities have, to a significant extent, had to respond to the major diminution of families’ capacities to carry out unpaid caring for housebound and incapacitated members as the number of women remaining in the home has fallen sharply. The expansion of publicly funded caring has also been in response to a greater insistence by society on the rights of children and of persons with disabilities and a concern that public provision for them should embody higher standards. The growing number of elderly people living alone, many with the health and capacity to enjoy a wide range of activities if minimal supports are forthcoming, is also creating a strong demand for new forms of domiciliary care and supports to facilitate ‘active ageing’. All these services have the significant added dimension that they enable people of working age more easily to reconcile employment with responsibility for ageing parents or other kin.
Overall, the two major influences on health spending are ageing and the expecta- tion of and demand for higher standards. For example, it is clear that older people use hospitals more than younger people. In 2000, they had admission rates to hospital (per 1000 in their age group) much higher than younger people and average lengths of stay four times longer than people of active age (16-54) (DHC, 2002). Estimates, in fact, suggest that the growing number of older people in Ireland’s population alone will require a 14 per cent increase in the number of acute hospital beds over the period 2000 to 2011, while the generally rising demand for health care will add a further 11 per cent to the increase necessary. The factors behind a generally rising demand for health services can be summarised as:49
s Previously unmet need. Medical conditions that lower social groups, in
particularly their older members, and other people discouraged by lengthy waiting times and the expense of treatment ‘put up with’ is translated into demand for heath services accordingly as the services improve;
s The availability of new services (technological advances in diagnosis and
treatment; the development of new services [e.g., magnetic resonance imaging, non-invasive surgery, etc.]; the availability of new drugs and medicines);
s Increasingly accessible health information through public bodies, the media
and the internet;
s The increasing demand for the active treatment of chronic conditions;
48. In 2002, 92,754 persons were eligible under his scheme. The cost per eligible person was c677.73 and per claimaintc1,961.55.
s Higher per capita income. As people become wealthier, they place more priority
on avoiding discomfort as well as alleviating pain, on preventative health measures as well as on curative, on personally tailored and immediate health services rather than on standardised treatments for which they may have to wait; and
s A larger, more educated, more self-confident and assertive population.
This is largely a positive development as increased awareness and vigilance by patients contributes to driving up standards. However, it also entails a more litigious health system and rising medical insurance premiums.
Each of these factors has already played a part in increasing the demand for health services in Ireland. However, it should be noted that the major increases in public expenditure which Charts 3.5 and 3.6 illustrate have taken place over a period when the Irish population profile did not age significantly. Ageing will become a further factor raising health spending in the years ahead in addition to the factors outlined above. In addition to older people’s greater recourse to hospitals already mentioned, consumption of medicines and the likelihood of living with a disability increases sharply with age. Factoring out the increased demand coming from a wealthier and more demanding population, one estimate of the impact of population increase and population ageing alone on health spending is that it will rise by 1 per cent per annum between 2002 and 2050, implying that the non-capital expenditure of the Department of Health and Children will rise from some 6 per cent of GDP in 2002 to 8.8 per cent in 2050. It would then absorb 26.5 per cent of the workforce’s aggregated salaries (Bennett
et al, 2003).
The cumulative impact of a much larger elderly population on both health care and pensions will be formidable, as Table 3.5 demonstrates.
Social Protection in Ireland: A Hybrid System 67
Table 3.5
Projected Costs of Health Care and Pensions
2002 2025 2050
Costs as Per Cent of GDP
Health care 6.0 6.3 8.8
Pensions 2.9 4.5 7.9
Costs as Per Cent of Working Population Salary
Health care 18.1 19.0 26.5
Pensions 8.9 13.6 23.8
These projections are based on several assumptions which only the future can test for accuracy. For example, it is becoming apparent that the degree of usage of health services by people aged, for example, 66-74 today may prove to be a poor guide to the level of usage by people aged 66-74 in the future (Seshamani, 2004). As people live longer, they are also living healthier. A large part of older persons’ usage of health services is concentrated in their final years and, if this pattern holds into the future, then the age to which they live will be less significant for health spending than the range and sophistication of the health services that attend them in their final years.5o
It is also the case that if a growing proportion of people aged over 65 in the future remain in employment because their health allows them to and they want to (pension policy could be redesigned to provide them with a higher pension in return for postponing their entitlement), then the current estimates of future pensions costs as a percentage of GDP will prove to have been on the high side.
As illustrated above, current public spending on health has soared since 1997. There has been extensive dismay that user’s experience of public health services (e.g., public patients’ waiting times for elective surgery and other treatments, conditions in A&E casualty departments, conditions within hospitals, the level of charges, instances of medical malpractice, etc.) has not only not improved in line with the rise in spending but, in key instances, deteriorated. In 2005, what is described as the ‘biggest change process ever undertaken in the state’ (Health Services Executive, HSE, 2004) got underway in the health services which are to be managed, for the first time, as a single national system. An evaluation of the extent to which reform and additional resources have proceeded sufficiently in tandem must wait for some years. It is clear that the effective and efficient development of a major part of Ireland’s welfare state is at stake and, with it, to a significant degree, public confidence in public services generally.
3.5.2 Education
As a share of GNP, current public expenditure on education over the period, 1985- 2002, has trended downwards from a high of 5.8 per cent in 1987 to 4.6 per cent in 2002 (Chart 3.3 above). When the absolute level of spending is distinguished by the level of the educational system where it is incurred, it has more than doubled at primary and secondary levels and tripled at third level (Chart 3.6). There have been markedly different developments in the number of students at each level; it has fallen significantly at primary level, increased marginally at second level and risen rapidly at third level. The net result is that spending per studenthas increased by a multiple of 2.8 at primary level, 2 at secondary level and 1.3 at third level between 1985 and 2002 (Table 3.6 and Chart 3.7).
68
50. It is even possible that, as the very old (in excess of 85 or 90 years) have less capacity to put up a long fight against new illnesses that interrupt their otherwise good health, the coming older generation may consume less health costs in their final months than the current older generation. The new Population Directorate in the Health Services Executive is to acquire the expertise and competence to improve Ireland’s ability to anticipate these types of development.
Social Protection in Ireland: A Hybrid System 69
Chart 3.6