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.

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.

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.

Caught in the conundrum: neoliberalism and education in post-conflict Northern Ireland: Exploring Shared Education

Northern Ireland (NI) is emerging from a violent period in its troubled history and remains a
society characterized by segregation between its two main communities. Nowhere is this more
apparent than in education, where for the most part Catholic and Protestant pupils are
educated separately. During the last 30 years there has been a twofold pressure placed on the
education system in NI - at one level to respond to intergroup tensions by promoting
reconciliation, and at another, to deal with national policy demands derived from a global neoliberalist
economic agenda. With reference to current efforts to promote shared education
between separate schools, we explore the uneasy dynamic between a school-based
reconciliation programme in a transitioning society and system-wide values that are driven by
neo-liberalism and its organizational manifestation - new managerialism. We argue that whilst
the former seeks to promote social democratic ideals in education that can have a potentially
transformative effect at societal level, neoliberal priorities have the potential to both subvert
shared education and also to embed it.

Building public policy on shifting sands: the case of the National Asset Management Agency

Over the last thirty years, there has been an increased demand for better management of public sector organisations (PSOs). This requires that they are answerable for the inputs that they are given but also for what they achieve with these inputs (Hood 1991; Hood 1995). It is suggested that this will improve the management of the organisation through better planning and control, and the achievement of greater accountability (Smith 1995). However, such a rational approach with clear goals and the means to measure achievement can cause difficulties for many PSOs. These difficulties include the distinctive nature of the public sector due to the political environment within which the public sector manager operates (Stewart and Walsh 1992) and the fact that PSOs will have many stakeholders, each of whom will have their own specific objectives based on their own perspective (Boyle 1995). This can
result in goal ambiguity which means that there is leeway in interpreting the results of the PSO. The National Asset Management Agency (NAMA) was set up to bring stability to the financial system by buying loans from the banks (which were in most cases, non-performing loans). The intention was to cleanse the banks of these loans so that they could return to their normal business of taking deposits and making loans. However, the legislation, also gave NAMA a wide range of other responsibilities including responsibility for facilitating credit in the economy and protecting the interests of taxpayers. In more recent times, NAMA has been given responsibility for building social housing. This wide-range of activities is a clear example of a PSO being given multiple goals which may conflict and is therefore likely to lead to goal ambiguity. This makes it very difficult to evaluate NAMA’s performance as they are attempting to meet numerous goals at the same time and also highlights the complexity of policy making in the public sector. The purpose of this paper is to examine how NAMA dealt with goal ambiguity. This will be done through a thematic analysis of its annual reports over the last five years. The paper’s will contribute to the ongoing debate about the evaluation of PSOs and the complex environment within which they operate which makes evaluation difficult as they are
answerable to multiple stakeholders who have different objectives and different criteria for measuring success.

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.

Who needs evidence? Radical Feminism, the Christian Right and sex work research in Northern Ireland

This chapter describes my experiences of conducting research on commercial sex in Belfast, Northern Ireland which was conducted as part of a larger British Academy – Leverhulme Trust funded study that examined the policing and legal regulation of commercial sex in Belfast (Northern Ireland) along with three other cities: Manchester (England), Berlin (Germany) and Prague (Czech Republic). This study provided the first empirical analysis of commercial sex in the jurisdiction and was instrumental in shedding light on prevalence rates for those involved in the industry as well as providing demographic information on the age, nationality and sexual orientation of sex workers along with the sector worked in, whether on-street or off-street. In the chapter I consider my role as a researcher and highlight some of the difficulties that I experienced conducting what was seen as controversial research in the politically, socially and culturally conservative context of Northern Ireland.

Economic impacts of seafood production growth targets in Ireland

This paper examines the potential economic impact of the Irish government strategy for the development of the seafood sector in Ireland, Food Harvest 2020 (FH2020). The seafood industry accounts for a large proportion of income and employment in peripheral coastal areas. Many of these regions are predominantly rural and they are largely dependent on the primary fisheries sector. Moreover, the services and retail businesses in these areas are heavily dependent on direct spending from the fisheries, aquaculture and seafood processing sectors. A social accounting matrix (SAM) approach with (1) set to zero purchase coefficients for all directly impacted industries and (2) changes in output converted to final demand shocks is used to calculate the economic and employment impact on the rest of the economy from an increase in the output in the fisheries, aquaculture and seafood processing sectors in Ireland. The results suggest fisheries sectors have strong links with the rest of the economy hence an important economic impact from a policy perspective.

The evolution of public–private partnership in Ireland: a sustainable pathway?

Ireland is a latecomer to Public Private Partnership (PPP) having only adopted it in 1998. Prior to the credit crisis, Ireland followed the UK model with PPPs being implemented in transport, education, housing/urban regeneration and water/wastewater. Having stalled during the credit crisis, PPP has been reactivated recently with the domestic infrastructure stimulus programme . The focus of this paper is on Ireland as a younger participant in PPP and the nexus between adoption patterns and sustainability characteristics of Irish PPP. Using document analysis and exploratory interviews, the paper examines the reasons for Ireland’s interest in PPP which cannot be attributed to economic rationales alone. We consider three explanations: voluntary adoption – where the UK model was closely followed as part of a domestic modernisation agenda; coercive adoption – where PPP policy was forced upon public sector organisations; and institutional isomorphism – where institutional creation and change around PPP was promoted to help public sector organisations gain institutional legitimacy. We find evidence of all three patterns with coercive adoption becoming more relevant in recent years, which is likely to affect sustainability adversely unless incentives for voluntary adoption are strengthened and institutional capacity building is boosted.

Measuring the sustainability of a national economy. The application of three measures of sustainability to Ireland

An assessment of the sustainability of the Irish economy has been carried out using three methodologies, enabling comparison and evaluation of the advantages and disadvantages of each, and potential synergies among them. The three measures chosen were economy-wide Material Flow Analysis (MFA), environmentally extended input-output (EE-IO) analysis and the Ecological Footprint (EF). The research aims to assess the sustainability of the Irish economy using these methods and to draw conclusions on their effectiveness in policy making both individually and in combination. A theoretical description discusses the methods and their respective advantages and disadvantages and sets out a rationale for their combined application. The application of the methods in combination has provided insights into measuring the sustainability of a national economy and generated new knowledge on the collective application of these methods. The limitations of the research are acknowledged and opportunities to address these and build on and extend the research are identified. Building on previous research, it is concluded that a complete picture of sustainability cannot be provided by a single method and/or indicator.

The Family Model - A transgenerational approach to mental health in families: personal, clinical, educational, research, systems and policy perspectives

The Family Model – A transgenerational approach to mental health in families This workshop will provide an overview on The Family Model (TFM) and its use in promoting and facilitating a trans­generational family focus in Mental Health services, over the past 10­ - 15 years. Each of the speakers will address a different perspective, including service user/consumer, clinical practice, education & training, research and policy. Adrian Falkov (chair) will provide an overview of TFM to set the scene and a ‘policy to practice’ perspective, based on use of TFM in Australia. Author: Heide Lloyd. The Family Model ­ A personal (consumer/patient) perspective | United Kingdom Heide will provide a description of her experiences as a child, adult, parent & grandparent, using TFM as the structure around which to ‘weave’ her story and demonstrate how TFM has assisted her in understanding the impact of symptoms on her & family and how she has used it in her management of symptoms and recovery (personal perspective). The Family Model ­ Education & training perspective ­ Marie Diggins | United Kingdom PhD Bente Weimand | Norway Authors: ­ Marie Diggins | United Kingdom PhD Bente Weimand | Norway This combined (UK & Norwegian) presentation will cover historical background to TFM and its use in eLearning (the Social Care Institute for Excellence)and a number of other UK initiatives, together with a description of the postgraduate masters course at the University Oslo/Akershus, using TFM. The Family Model ­ A research perspective PhD Anne Grant | Northern Ireland Author: PhD Anne Grant | Ireland Anne Grant will describe how she used TFM as the theoretical framework for her PhD looking at family focused (nursing) practice in Ireland. The Family Model ­ A service systems perspective ­ Mary Donaghy | Northern Ireland Authors: PhD Adrian Falkov | Australia ­ Mary Donaghy | N Ireland Mary Donaghy will discuss how TFM has been used to support & facilitate a cross service ‘whole of system’ change program in Belfast (NI) to achieve improved family focused practice. She will demonstrate its utility in achieving a broader approach to service design, delivery and evaluation.

Should the fiscal powers of the Northern Ireland Assembly be enhanced?

Northern Ireland has been characterised by an inability to narrow the persistent economic gap relative to Britain. Some commentators have suggested that regional Corporation Tax variation may be the “game changer” in closing this gap. This paper draws on a range of papers that help us better understand the historical and institutional context. However, the analysis of tax variation is broader than this. Consideration is given as to which taxes might be the most suitable candidates for devolution. While greater tax variations could certainly complement an emphasis on increased competitiveness aimed at improving economic outcomes, they are no substitute for such a focus. As is often the case in institutional and economic development, issues of sequencing and policy capacity are salient.

Exploring the influences on classroom-based contact via shared education in Northern Ireland

Initiatives in intercultural education have frequently involved the promotion of contact between members of different groups as a means of improving intergroup relations. Experience from Northern Ireland suggests, however, that such schemes have often been organised and delivered in such a way that opportunities for sustained, high-quality contact are limited. This paper considers processes of contact in one relatively recent initiative, “shared education”, which involves collaboration between separate schools to deliver classes to Catholic and Protestant pupils in mixed groups. Employing qualitative methods of observation and interviewing to capture participants’ experiences of contact, the research explores the influences on the quality and frequency of cross-group interaction in the shared class. With findings highlighting the subject and pedagogy, teacher’s approach and classroom arrangement as key factors, the study offers suggestions for policy and practice to enhance opportunities for contact and relationship-building in mixed classes.