Drug prescribing patterns in the General Medical Services Scheme in Ireland and projected costs to 2026

The primary objective is to investigate the main factors contributing to GMS expenditure on pharmaceutical prescribing and projecting this expenditure to 2026. This study is located in the area of pharmacoeconomic cost containment and projections literature. The thesis has five main aims: 1. To determine the main factors contributing to GMS expenditure on pharmaceutical prescribing. 2. To develop a model to project GMS prescribing expenditure in five year intervals to 2026, using 2006 Central Statistics Office (CSO) Census data and 2007 Health Service Executive{Primary Care Reimbursement Service (HSE{PCRS) sample data. 3. To develop a model to project GMS prescribing expenditure in five year intervals to 2026, using 2012 HSE{PCRS population data, incorporating cost containment measures, and 2011 CSO Census data. 4. To investigate the impact of demographic factors and the pharmacology of drugs (Anatomical Therapeutic Chemical (ATC)) on GMS expenditure. 5. To explore the consequences of GMS policy changes on prescribing expenditure and behaviour between 2008 and 2014. The thesis is centered around three published articles and is located between the end of a booming Irish economy in 2007, a recession from 2008{2013, to the beginning of a recovery in 2014. The literature identified a number of factors influencing pharmaceutical expenditure, including population growth, population aging, changes in drug utilisation and drug therapies, age, gender and location. The literature identified the methods previously used in predictive modelling and consequently, the Monte Carlo Simulation (MCS) model was used to simulate projected expenditures to 2026. Also, the literature guided the use of Ordinary Least Squares (OLS) regression in determining demographic and pharmacology factors influencing prescribing expenditure. The study commences against a backdrop of growing GMS prescribing costs, which has risen from e250 million in 1998 to over e1 billion by 2007. Using a sample 2007 HSE{PCRS prescribing data (n=192,000) and CSO population data from 2008, (Conway et al., 2014) estimated GMS prescribing expenditure could rise to e2 billion by2026. The cogency of these findings was impacted by the global economic crisis of 2008, which resulted in a sharp contraction in the Irish economy, mounting fiscal deficits resulting in Ireland's entry to a bailout programme. The sustainability of funding community drug schemes, such as the GMS, came under the spotlight of the EU, IMF, ECB (Trioka), who set stringent targets for reducing drug costs, as conditions of the bailout programme. Cost containment measures included: the introduction of income eligibility limits for GP visit cards and medical cards for those aged 70 and over, introduction of co{payments for prescription items, reductions in wholesale mark{up and pharmacy dispensing fees. Projections for GMS expenditure were reevaluated using 2012 HSE{PCRS prescribing population data and CSO population data based on Census 2011. Taking into account both cost containment measures and revised population predictions, GMS expenditure is estimated to increase by 64%, from e1.1 billion in 2016 to e1.8 billion by 2026, (ConwayLenihan and Woods, 2015). In the final paper, a cross{sectional study was carried out on HSE{PCRS population prescribing database (n=1.63 million claimants) to investigate the impact of demographic factors, and the pharmacology of the drugs, on GMS prescribing expenditure. Those aged over 75 (ẞ = 1:195) and cardiovascular prescribing (ẞ = 1:193) were the greatest contributors to annual GMS prescribing costs. Respiratory drugs (Montelukast) recorded the highest proportion and expenditure for GMS claimants under the age of 15. Drugs prescribed for the nervous system (Escitalopram, Olanzapine and Pregabalin) were highest for those between 16 and 64 years with cardiovascular drugs (Statins) were highest for those aged over 65. Females are more expensive than males and are prescribed more items across the four ATC groups, except among children under 11, (ConwayLenihan et al., 2016). This research indicates that growth in the proportion of the elderly claimants and associated levels of cardiovascular prescribing, particularly for statins, will present difficulties for Ireland in terms of cost containment. Whilst policies aimed at cost containment (co{payment charges, generic substitution, reference pricing, adjustments to GMS eligibility) can be used to curtail expenditure, health promotional programs and educational interventions should be given equal emphasis. Also policies intended to affect physicians prescribing behaviour include guidelines, information (about price and less expensive alternatives) and feedback, and the use of budgetary restrictions could yield savings.

"On our way": identities and representations of African women seeking asylum in Ireland

This thesis provides the first explicit Postcolonial study of asylum in the Irish context that integrates Black Feminist analyses of intersectional identity with Postcolonial Feminist theories of representation. African women seeking asylum in the Republic of Ireland were key political instruments used by the state to re-draw racial lines. The study examines how, for a group of African women “On their Way” through asylum, identity and representation work hand in hand to force identities, subaltern spaces and bodies to occupy them. Rich biographical data is gathered through mixed art and drama methods over two intensive participatory research projects conducted in a small Irish city. Data analysis critically examines the poetics (practices that signify) and politics (the powers that govern these practices) and affective economies of global and local NGO visual representations, exposing how they consume, fragment, and appropriate African women’s identities and bodies. Though hypervisible, the women themselves “cannot speak”. The women in the study reported feeling “tired” and “used”. Asking “What work are they doing as they do asylum?” the study finds that black female identities and bodies are forced to perform political, cultural, emotional and material labour on their way through this context of Irish asylum. The author argues that Postcolonial Asylum is a performative encounter that re-scripts colonial race/class/gender discourse through a humanitarian alibi to naturalize European/white supremacy, reinscribe patriarchal power and justify racialised incarceration of bodies seeking asylum in the North. This study takes an interdisciplinary approach that centralizes Black and Postcolonial Feminist theory and innovates Participatory Art-Based Action methodology. Black and Postcolonial feminisms can recognize, theorize and replenish black female political and intellectual agency. Participatory Action research, if grounded in Black feminist epistemology and ethics, can allow participants to “speak back” to what is already said about them in spaces of convivial self-representation.

Child care proceedings in non-specialist courts: the experience in Ireland

It is widely accepted that court proceedings concerning child protection are a particularly sensitive type of court proceedings that warrant a different approach to other types of proceedings. Consequently, the use of specialized family or children’s judges or courts is commonplace across Europe and in common law jurisdictions. By contrast, in Ireland, proceedings under the Child Care Act 1991 are heard in the general courts system by judges who mostly do not specialize in child or family law. In principle, the Act itself and the associated case law accept that the vulnerability of the parties and the sensitivity of the issues involved are such that they need to be singled out for a different approach to other court proceedings. However, it is questionable whether this aspiration has been realized in a system where child care proceedings are mostly heard in a general District Court, using the same judges and the same physical facilities used for proceedings such as minor crime and traffic offences. This article draws on the first major qualitative analysis of professional perspectives on child care proceedings in the Irish District Court. It examines evidence from judges, lawyers, social workers, and guardians ad litem and asks whether non-specialist courts are an appropriate venue for proceedings on an issue as complex and sensitive as child protection, or whether the establishment of specialist family courts with dedicated staff and facilities provides a better solution.

Uncomfortable 'truths' and the centenary anniversary of the 1916 Rising in Ireland

How to deal with uncomfortable ‘truths’ from the past has long posed problems for historians and politicians alike and this is exemplified by attempts to ‘deal with’ the centenary anniversary of the 1916 Easter Rising in Ireland. How do we recognise the revolutionary ‘heroes’ of the past and their contribution to the building of the new ‘nation’ state to which we may pledge allegiance, without exposing the contradictions inherent in the way that ‘nation’ state has transformed, subverted and indeed corrupted many of the ideas for which they fought? More controversially, how do we honour the actions of revolutionaries in the past which led to death and destruction in pursuance of a grand ideal, while at the same time condemning others today who claim to have been likewise engaged, using similar methods, during the recent ‘Troubles’ (1969-98 and counting)? Attempts by the Irish state to deal with the centenary seem to illustrate the point.

The effects of agglomeration economies on the productivity of manufacturing local units in Ireland

The purpose of this study is to examine the effects of agglomeration economies on the productivity of manufacturing local units in Ireland. Four types of agglomeration economies are considered in this study. These are internal economies of scale, localization economies, related variety and urbanization economies. This study makes a number of contributions to the literature. Firstly, this is the first study to conduct an investigation of the effects of agglomeration economies on the productivity of manufacturing local units operating in Ireland. Secondly, this study distinguishes between indigenous and foreign-owned local units which is important given the dual nature of the Irish economy (Krugman, 1997). Thirdly, in addition to considering the effects of agglomeration economies, this study examines the impact of spurious agglomeration on the productivity of foreign-owned local units. Using data from the Census of Industrial Local Units and a series of IV GMM estimators to control for endogeneity, the results of the analysis conducted in Chapter 6 reveal that there are differences in the effects of agglomeration economies on the productivity of indigenous and foreign-owned local units. In Chapter 7 the Census of Industrial Local Units is supplemented by additional data sources and more in-depth measures are generated to capture the features of each of the external agglomeration economies considered in this analysis. There is some evidence to suggest that the availability of local inputs has a negative and significant impact on productivity. The NACE based measures of related variety reveal that the availability of local inputs and knowledge spillovers for related sectors have a negative and significant impact on productivity. There is clear evidence to suggest that urbanization economies are important for increasing the productivity of indigenous local units. The findings reveal that a 1% increase in population density in the NUTS 3 region leads to an increase in the productivity of indigenous local units of approximately 0.07% to 0.08%. The results also reveal that there is a significant difference in the effects of agglomeration economies on the productivity of low-tech and medium/high-tech indigenous local units. The more in-depth measures of agglomeration economies used in Chapter 7 are also used in Chapter 8. A series of IV GMM regressions are estimated in order to identify the impact of agglomeration economies and spurious agglomeration on the productivity of foreign-owned local units operating in Ireland. There is some evidence found to suggest that the availability of a pool of skilled labour has a positive and significant on productivity of foreign-owned local units. There is also evidence to suggest that localization knowledge spillovers have a negative impact on the productivity of foreign-owned local units. There is strong evidence to suggest that the availability of local inputs has a negative impact on the productivity. The negative impact is not confined to the NACE 4-digit sector but also extends into related sectors as determined by Porter’s (2003) cluster classification. The cluster based skills measure of related variety has a positive and significant impact on the productivity of foreign-owned local units. Similar to Chapter 7, there is clear evidence to suggest that urbanization economies are important for increasing the productivity of foreign-owned local units. Both the summary measure and each of the more in-depth measures of agglomeration economies have a positive and significant impact on productivity. Spurious agglomeration has a positive and significant impact on the productivity of foreign-owned local units. The results indicate that the more foreign-owned local units of the same nationality in the country the greater the levels of productivity for the local unit. From a policy perspective, urbanization economies are clearly important for increasing the productivity of both indigenous and foreign-owned local units. Furthermore, the availability of a pool of skilled labour appears to be important for increasing the productivity of foreign-owned local units. Another policy implication that arises from these results relates to the differences observed between indigenous local units and foreign-owned local units and also between low-tech and medium/high-tech indigenous local units. These findings indicate that ‘one-size-fits-all’ type policies are not appropriate for increasing the productivity of local units operating in Ireland. Policies should be tailored to the needs of either indigenous or foreign-owned local units and also to specific sectors. This positive finding for own country spurious agglomeration is important from a policy perspective and is one that IDA Ireland should take on board.

The impact of user charges on patient choice of healthcare services in Ireland

This research assesses the impact of user charges in the context of consumer choice to ascertain how user charges in healthcare impact on patient behaviour in Ireland. Quantitative data is collected from a subset of the population in walk-in Urgent Care Clinics and General Practitioner surgeries to assess their responses to user charges and whether user charges are a viable source of part-funding healthcare in Ireland. Examining the economic theories of Becker (1965) and Grossman (1972), the research has assessed the impact of user charges on patient choice in terms of affordability and accessibility in healthcare. The research examined a number of private, public and part-publicly funded healthcare services in Ireland for which varying levels of user charges exist depending on patients’ healthcare cover. Firstly, the study identifies the factors affecting patient choice of privately funded walk-in Urgent Care Clinics in Ireland given user charges. Secondly, the study assesses patient response to user charges for a mainly public or part-publicly provided service; prescription drugs. Finally, the study examines patients’ attitudes towards the potential application of user charges for both public and private healthcare services when patient choice is part of a time-money trade-off, convenience choice or preference choice. These services are valued in the context of user charges becoming more prevalent in healthcare systems over time. The results indicate that the impact of user charges on healthcare services vary according to socio-economic status. The study shows that user charges can disproportionately affect lower income groups and consequently lead to affordability and accessibility issues. However, when valuing the potential application of user charges for three healthcare services (MRI scans, blood tests and a branded over a generic prescription drug), this research indicates that lower income individuals are willing to pay for healthcare services, albeit at a lower user charge than higher income earners. Consequently, this study suggests that user charges may be a feasible source of part-financing Irish healthcare, once the user charge is determined from the patients’ perspective, taking into account their ability to pay.

Survey on demand side sensitivity to power quality in Ireland

Power systems require a reliable supply and good power quality. The impact of power supply interruptions is well acknowledged and well quantified. However, a system may perform reliably without any interruptions but may have poor power quality. Although poor power quality has cost implications for all actors in the electrical power systems, only some users are aware of its impact. Power system operators are much attuned to the impact of low power quality on their equipment and have the appropriate monitoring systems in place. However, over recent years certain industries have come increasingly vulnerable to negative cost implications of poor power quality arising from changes in their load characteristics and load sensitivities, and therefore increasingly implement power quality monitoring and mitigation solutions. This paper reviews several historical studies which investigate the cost implications of poor power quality on industry. These surveys are largely focused on outages, whilst the impact of poor power quality such as harmonics, short interruptions, voltage dips and swells, and transients is less well studied and understood. This paper examines the difficulties in quantifying the costs of poor power quality, and uses the chi-squared method to determine the consequences for industry of power quality phenomenon using a case study of over 40 manufacturing and data centres in Ireland.

Trends in blindness due to diabetic retinopathy among adults aged 18-69 years over a decade in Ireland

Aims: To describe trends in the incidence of visual impairment and blindness due to diabetic retinopathy among adults aged 18–69 years in Ireland between 2004 and 2013. Methods: Data on visual impairment due to diabetic retinopathy in adults aged 18–69 years or over who are registered with the National Council for the Blind of Ireland, (2004–2013) were analysed. Annual incidence rates were calculated for the adult population and the population with diagnosed diabetes. Poisson regression was used to test for changes in rates over time. The relative, attributable and population risk of blindness and visual impairment due to diabetic retinopathy were calculated for 2013. Results: Over the decade, the prevalence of diagnosed diabetes increased from 2.1% to 3.6%. Among people with diagnosed diabetes, the incidence of visual impairment due to diabetic retinopathy increased from 6.4 (95% CI 2.4–13.9) per 100,000 in 2004 to 11.7 (95% CI 5.9–21.0) per 100,000 in 2013. The incidence of blindness due to diabetic retinopathy varied from 31.9 per 100,000 (95% CI 21.6–45.7) in 2004 to 14.9 per 100,000 (95% CI 8.2–25.1) in 2013. Conclusions: Our findings indicate the need for increased attention to preventive measures for microvascular complications among adults with diabetes in Ireland. Retinopathy screening has been standardised in Ireland, these findings provide useful baseline statistics to monitor the impact of this population-based screening programme.

Progress and the Lack of Progress in Addressing Infant Health and Infant Health Inequalities in Ireland during the 20th Century

There is a growing literature which documents the importance of early life environment for outcomes across the life cycle. Research, including studies based on Irish data, demonstrates that those who experience better childhood conditions go on to be wealthier and healthier adults. Therefore, inequalities at birth and in childhood shape inequality in wellbeing in later life, and the historical evolution of the mortality and morbidity of children born in Ireland is important for understanding the current status of the Irish population. In this paper, I describe these patterns by reviewing the existing literature on infant health in Ireland over the course of the 20th century. Up to the 1950s, infant mortality in Ireland (both North and South) was substantially higher than in other developed countries, with a large penalty for those born in urban areas. The subsequent reduction in this penalty, and the sustained decline in infant death rates, occurred later than would be expected from the experience in other contexts. Using records from the Rotunda Lying-in Hospital in Dublin, I discuss sources of disparities in stillbirth in the early 1900s. Despite impressive improvements in death rates since that time, a comparison with those born at the end of the century reveals that Irish children continue to be born unequal. Evidence from studies which track people across the life course, for example research on the returns to birthweight, suggests that the economic cost of this early life inequality is substantial.

Policy Transfer and the Sustainability of Public Private Partnership in Ireland::A conceptual analysis

There has been private sector involvement in the delivery of public services in the Irish State since its foundation. This involvement was formalised in 1998 when Public Private Partnership (PPP) was officially introduced. Ireland is a latecomer to PPP and, prior to the credit crisis, was seen as a ‘rapid follower’ relying primarily on the UK PPP model in the procurement of infrastructure in transport, education, housing/urban regeneration and water/wastewater.  PPP activity in Ireland stalled during the credit crisis, and some projects were cancelled, but it has taken off again recently with part of the Infrastructure and Capital Investment Plan 2016 – 2021 to be delivered through PPP showing continuing political commitment to PPP.  Ireland’s interest in PPP cannot be explained by economic rationale alone, as PPP was initiated during a period of prosperity. We consider three alternative explanations: voluntary adoption – where the UK model was closely followed; coercive adoption – where PPP policy was forced upon Ireland; and institutional isomorphism – where institutional creation and change was promoted to aid public sector organisations in gaining institutional legitimacy. We find evidence of all three patterns, with coercive adoption becoming more relevant in recent years. Ireland’s rapid uptake of PPP differs from other European countries, mostly because when PPP was introduced in 1998, the Irish State was in an economic position where it could have directly procured necessary infrastructure. This paper therefore asks why PPP was adopted and how this adoption pattern has affected the sustainability of PPP in Ireland.  This paper defines PPP; examines the background to the PPP approach adopted in Ireland; outlines the theoretical framework of the paper: transfer theory and institutional theory; discusses the methodology; reports on findings and gives conclusions.   

The Un-Politics of New Public Management in Ireland

Many of the principles and indeed the rhetoric of New Public Management proved attractive to both politicians and senior bureaucrats across the developed world as a remedy for problems in policy processes. Ireland shares many features of its constitutional structures and political practices with Britain, Canada, Australia, New Zealand, all of them early and enthusiastic adopters of NPM. Some of the organizational and procedural changes in Irish public administration do indeed bear similarities to those we would expect to see as a result of adopting principles of NPM. However, we contend that surface impressions are misleading. Drawing on a time-series database of Irish state institutions, we show that organizational changes were not necessarily driven by NPM. The absence of strong political drivers meant that reform initiatives did not fundamentally alter the configuration of the Irish public administration. Many of the problems that NPM was intended to address are only now coming under scrutiny.