An analysis of Population-Based Resource Allocation for health and social care in Ireland

Walsh, B endan; Hill, Leonie
Resea ch Repo
An analysis o Popula ion-Based Resou ce Alloca ion o
heal h and social ca e in I eland
Resea ch Se ies, No. 194
P o ided in Coope a ion wi h:
The Economic and Social Resea ch Ins i u e (ESRI), Dublin
Sugges ed Ci a ion: Walsh, B endan; Hill, Leonie (2024) : An analysis o Popula ion-Based Resou ce
Alloca ion o heal h and social ca e in I eland, Resea ch Se ies, No. 194, The Economic and Social
Resea ch Ins i u e (ESRI), Dublin,
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AN ANALYSIS OF POPULATION-BASED
RESOURCE ALLOCATION FOR HEALTH
AND SOCIAL CARE IN IRELAND
BRENDAN WALSH AND LEONIE HILL
RESEARCH
SERIES
NUMBER 194
OCTOBER
2024
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AN ANALYSIS OF POPULATION-BASED RESOURCE
ALLOCATION FOR HEALTH AND SOCIAL CARE IN
IRELAND
B endan Walsh
Leonie Hill
Oc obe 2024
ESRI RESEARCH SERIES
NUMBER 194
A ailable o download om www.es i.ie
© The Economic and Social Resea ch Ins i u e
Whi ake Squa e, Si John Roge son’s Quay, Dublin 2
h ps://doi.o g/10.26504/ s194
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ABOUT THE ESRI
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Depa men o Public Expendi u e, NDP Deli e y and Re o m.
Fu he in o ma ion is a ailable a www.es i.ie.
THE AUTHORS
B endan Walsh is a Senio Resea ch O ice a he Economic and Social Resea ch
Ins i u e (ESRI) and an Adjunc Associa e P o esso a T ini y College Dublin (TCD).
Leonie Hill was a Resea ch Assis an a he ESRI.
ACKNOWLEDGEMENTS
Financial suppo o his esea ch was p o ided by he Depa men o Heal h. The
au ho s would like o hank he membe s o he Depa men o Heal h/ESRI
Resea ch P og amme on Heal hca e Re o m S ee ing G oup o hei inpu in an
ea ly e sion o he epo . In pa icula , he au ho s would like o hank Cono
O’Malley, Ch is ophe Ryan, Tiago McCa hy, Te ence Hynes and Michael Cou ney
om he Depa men o Heal h, and Sheelah Connolly and Aoi e B ick om he
ESRI o hei aluable insigh s. We hank h ee anonymous e iewe s and Anne
Nolan om he ESRI o hei e iews and sugges ions. We hank all hose who
p o ided con ibu ions while acknowledging ha he au ho s bea sole
esponsibili y o he analysis and in e p e a ions p esen ed.
This epo has been accep ed o publica ion by he Ins i u e, which does no
i sel ake ins i u ional policy posi ions. The epo has been pee e iewed p io
o publica ion. The au ho s a e solely esponsible o he con en and he iews
exp essed.

Table o con en s | i
Table o con en s
ABBREVIATIONS ..................................................................................................................................... iii
EXECUTIVE SUMMARY ............................................................................................................................
CHAPTER 1 INTRODUCTION .................................................................................................................... 1
1.1 Resou ce alloca ion in heal hca e ......................................................................................... 1
1.2 Heal hca e esou ce alloca ion in I eland ............................................................................. 2
1.3 Resou ce alloca ion p oposals ............................................................................................... 5
1.4 Objec i es o epo ............................................................................................................... 7
1.5 S uc u e o he epo .......................................................................................................... 7
CHAPTER 2 POPULATION-BASED RESOURCE ALLOCATION OPTIONS IN IRELAND ................................. 8
2.1 In oduc ion ........................................................................................................................... 8
2.2 In e na ional esou ce alloca ion mechanisms ..................................................................... 8
2.3 Popula ion-based esou ce alloca ion o mula cha ac e is ics ........................................... 16
2.4 Conclusion ........................................................................................................................... 20
CHAPTER 3 PROPOSED HSE HEALTH REGIONS AND PBRA FORMULA .................................................. 21
3.1 In oduc ion ......................................................................................................................... 21
3.2 Resou ce alloca ion and unding mechanisms in I eland .................................................... 21
3.3 HSE Heal h Regions .............................................................................................................. 32
3.4 P oposed popula ion-based esou ce alloca ion o mula ................................................... 35
3.5 O he popula ion-based esou ce alloca ion o mula conside a ions ................................ 44
CHAPTER 4 CONCLUSIONS .................................................................................................................... 61
4.1 Impo ance o popula ion-based esou ce alloca ion ......................................................... 61
4.2 Conside a ions o u u e popula ion-based esou ce alloca ion ....................................... 62
4.3 Conclusion ........................................................................................................................... 67
REFERENCES .......................................................................................................................................... 69
APPENDIX A ADDITIONAL TABLES AND FIGURES .................................................................................. 77
ii | Lis s o ables and igu es
LIST OF TABLES
Table 3.1 Public heal hca e expendi u e included and no included in p oposed PBRA mechanism
......................................................................................................................................... 54
Table A.1 Local heal h o ices wi hin HSE Heal h Regions .............................................................. 77
Table A.2 Lis o heal h condi ions in Heal hy I eland Su ey ......................................................... 77
Table A.3 Medical ca d a es wi hin HSE Heal h Regions ............................................................... 78
LIST OF FIGURES
Figu e 2.1 Fundings om esou ce alloca ion o mula in Sco land .................................................. 13
Figu e 3.1 The impac o home suppo supply on inpa ien leng h o s ay ..................................... 27
Figu e 3.2 De e minan s o men al illness diagnosis among adul s in I eland ................................. 30
Figu e 3.3 De e minan s o heal hca e u ilisa ion among adul s in I eland ..................................... 31
Figu e 3.4 HSE Heal h Regions .......................................................................................................... 33
Figu e 3.5 Pe cen age o popula ion by HSE Heal h Region ............................................................. 36
Figu e 3.6 Acu e public hospi al unding alloca ion, popula ion adjus ed ....................................... 36
Figu e 3.7 Pe cen age o popula ion in each age g oup by HSE Heal h Region ................................ 38
Figu e 3.8 Acu e public hospi al unding alloca ion, age and sex adjus ed ...................................... 38
Figu e 3.9 Dep i a ion by HSE Heal h Region ................................................................................... 40
Figu e 3.10 Acu e public hospi al unding alloca ion, dep i a ion adjus ed ...................................... 41
Figu e 3.11 Acu e public hospi al unding alloca ion, dep i a ion adjus ed using DEIS o mula ....... 42
Figu e 3.12 Pe cen age o acu e hospi al and p ima y ca e heal hca e expendi u e by ac ual and
PBRA scena ios ac oss HSE Heal h Regions, 2021 ............................................................ 44
Figu e 3.13 Sel - epo ed heal h s a us, ch onic illness and mul imo bidi y by HSE Heal h Regions 46
Figu e 3.14 Heal hca e u ilisa ion pe annum by HSE Heal h Region ................................................. 49
Figu e 3.15 Medical ca d and PHI a es by HSE Heal h Region ........................................................... 50
Figu e 3.16 Medical ca d co e ge, PHI s a us and GP and inpa ien ca e demand ............................ 51
Figu e 3.17 Pe cen age o hospi al discha ges om pa ien s ou side a HSE Heal h Region .............. 58
Figu e A.1 Supply o p ima y, communi y and long- e m ca e se ices in I eland, 2014 ................. 78
Figu e A.2 The impac o men al illness diagnosis on heal hca e u ilisa ion among adul s ............. 79
Figu e A.3 Men al illness a es by HSE Heal h Region ....................................................................... 80
Figu e A.4 Medical ca d and PHI a es by local heal h o ice and HSE Heal h Region ...................... 80
Figu e A.5 Medical ca d a es ac oss dep i a ion quin iles by local heal h o ice ............................ 81
Abb e ia ions | iii
ABBREVIATIONS
ABF Ac i i y-based unding
ACRA Ad iso y Commi ee on Resou ce Alloca ion
CCG Clinical Commissioning G oup
CHN Communi y Heal h Ne wo k
CHO Communi y heal hca e o ganisa ion
CIPC Counselling in P ima y Ca e
COPD Ch onic obs uc i e pulmona y disease
CSO Cen al S a is ics O ice
DEIS Deli e ing Equali y o Oppo uni y in Schools
DHB Dis ic Heal h Boa d
DRG Diagnosis- ela ed g oup
ESRI Economic and Social Resea ch Ins i u e
EU Eu opean Union
GP Gene al p ac i ione
HIPE Hospi al In-Pa ien Enqui y
HIS Heal hy I eland Su ey
HNI Heal h Need Index
HR Heal h Region
HRB Heal h Resea ch Boa d
HSE Heal h Se ice Execu i e
ICB In eg a ed ca e boa ds
IHA In eg a ed heal h a eas
KPI Key pe o mance indica o
LHO Local heal h o ice
LOS Leng h o s ay
LTRC Long- e m esiden ial ca e
MFF Ma ke o ces ac o
MLC Mo bidi y and li e ci cums ances
NHS Na ional Heal h Se ice (UK)
NHSS Nu sing Home Suppo Scheme
NRAC Na ional Resou ce Alloca ion Commi ee
NSW New Sou h Wales
NTPF Na ional T ea men Pu chase Fund
ONS O ice o Na ional S a is ics
i | Popula ion-based esou ce alloca ion in I eland
OOP Ou -o -pocke
PBR Paymen by Resul s
PBRA Popula ion-based esou ce alloca ion
PCRS P ima y Ca e Reimbu semen Scheme
PHI P i a e heal h insu ance
PN P ac ice nu se
PPSN Pe sonal Public Se ice Numbe
RICO Regional In eg a ed Ca e O ganisa ion
SAPS Small A ea Popula ion S a is ics
SIMD Sco ish Index o Mul iple Dep i a ion
TILDA The I ish Longi udinal S udy on Ageing
UK Uni ed Kingdom
WHO Wo ld Heal h O ganiza ion
WTE Whole ime equi alen
In oduc ion | 3
h ough which unding o inpa ien and day pa ien ca e in la ge acu e public
hospi als was alloca ed (Keegan e al., 2020). This shi owa ds ABF, away om
block unding, in I ish acu e public hospi als, can be seen as an impo an shi in
how heal hca e se ices a e unded in I eland (HSE, 2015). As we discuss in Chap e
3, he adop ion o ABF has ep esen ed a subs an ial change and o e s
policymake s guidance o u u e esea ch alloca ion and unding mechanism
op ions. Howe e , he expansion o simila me hods o o he sec o s, and he
in eg a ion o unding decisions ac oss sec o s, has no ye occu ed.
A sys ema ic esou ce alloca ion sys em assis s local and na ional heal hca e
planne s in e icien ly alloca ing budge s and se ices o mee popula ion needs.
The lack o a esou ce alloca ion sys em designed o accoun o he popula ion’s
heal hca e needs conside ably hinde s heal hca e planne s. The absence o a
esou ce alloca ion sys em, simila o sys ems ha exis ac oss many
con empo aneous coun ies, also con ibu es o o he cons ain s ha pose
subs an ial challenges and di ec ly a ec he quali y o heal hca e deli e y wi hin
he I ish heal hca e sys em. P e ious esea ch has highligh ed ha key cons ain s
– such as he lack o heal hca e wo ke s (Keegan e al., 2022), physical acili ies and
in as uc u e (Walsh e al., 2023), coo dina ed ca e pa hways and heal h
in o ma ion sys ems (Walsh e al., 2021) – all impede he e iciency o he I ish
heal hca e sys em. While se e al ac o s unde pin hese issues, hese s udies ha e
highligh ed ha he lack o a esou ce alloca ion sys em designed o accoun o
he popula ion’s heal hca e needs is pa ly o blame.
Many issues a ise as a esul o he cu en lack o a sys ema ic esou ce alloca ion
mechanism in I eland. No ably, as heal hca e unding in I eland is o en
de e mined by his o ical spending, any p e ious inequi able alloca ion o unme
need (due o wai ing lis s, educed access o ca e o cos ba ie s) will be ein o ced
(Vega e al., 2010). This can esul in unding no being di ec ed o mee he heal h
needs o he popula ion, o i no being used o maximise heal h ou comes gi en
he a ailable esou ces (Vega e al., 2010). Ra he , he cu en sys em ein o ces
and exace ba es any s uc u al inequali ies ha may exis . Mo eo e , as illus a ed
in Sec ion 3.2.2 on u gen and eme gency ca e, he de elopmen o di e en
unding s uc u es ac oss egions and by dep i a ion le els is agmen ed and
inconsis en , wi h no iden i iable unding alloca ion me hod.
The lack o a esou ce alloca ion sys em has esul ed in ine icien dis ibu ion o
esou ces and s a ing ac oss egions in I eland. P e ious esea ch by he Economic
and Social Resea ch Ins i u e (ESRI) examined he supply o p ima y, communi y
and long- e m heal hca e se ices in I eland in 2014 (Smi h e al., 2019). The key
indings, illus a ed in Figu e A.1 in Appendix A, show no able inequali ies in he
dis ibu ion o heal h and social ca e se ices ac oss coun ies. A ecu en end o
unde supply in ca e was seen ac oss nume ous coun ies. The g ea e Dublin
commu e bel (Kilda e, Mea h, Wicklow) and he sou heas e n coun ies

4 | Popula ion-based esou ce alloca ion in I eland
consis en ly exhibi ed a lowe supply o p ima y and communi y ca e se ices
compa ed o he na ional a e age. Kilda e and Mea h, in pa icula , showed a
signi ican ly lowe supply, alling a leas 10 pe cen below he na ional a e age
o all non-acu e communi y and p ima y ca e se ices examined. Addi ionally,
Wex o d and Wicklow displayed an unde supply ha was a leas 10 pe cen lowe
han he na ional a e age o 7 ou o he 8 non-acu e communi y and p ima y ca e
se ices e alua ed. The au ho s also adjus ed he supply o accoun o need-
ela ed ac o s, such as age, mo ali y a es, a es o disabili y, medical ca d usage
and ch onic illness a es. E en a e hese adjus men s, he indings epea edly
demons a ed ha adjus ing o needs did no elimina e he obse ed dispa i ies
in supply.
In gene al, apa om some key excep ions (such as ABF in public hospi als), he
HSE s ill alloca es heal h and social ca e esou ces based on his o ic pa e ns o
demand o se ices (Johns on e al., 2021). This app oach aises se e al issues, as
cu en se ice use pa e ns may no accu a ely e lec ei he cu en o u u e
popula ion needs, due o he omission o unme need, he eby ein o cing
s uc u al inequi ies (Johns on e al., 2021). Addi ionally, gi en he apidly g owing
and ageing popula ion in I eland, and he clea impo ance o demog aphics on
heal hca e demand and expendi u e equi emen s (Keegan e al., 2020; Casey e
al., 2021; Walsh e al., 2021), elying on his o ic pa e ns may embed sys ema ic
unde es ima ions o heal hca e esou ce needs when de e mining he annual HSE
budge . To accoun o his, in he absence o a esou ce alloca ion sys em in he
sho e m, conside a ion should be gi en o cos ba ie s and long wai s o access
ca e, as well as changes o he s uc u e o he popula ion when de e mining he
heal hca e sys em’s equi emen s.
The absence o a esou ce alloca ion mechanism was also ou lined in he
Sláin eca e epo as impeding many o he changes equi ed o expand uni e sal
heal hca e in I eland (Houses o he Oi each as Commi ee on he Fu u e o
Heal hca e, 2017; Bu ke e al., 2018). Since he publica ion o he Sláin eca e
epo , and subsequen Sláin eca e implemen a ion plans, he e has been
inc eased p epa a ion o PBRA and egional de olu ion o heal h and social ca e
planning and go e nance. The Depa men o Heal h ha e ou lined he
app op ia eness o a PBRA app oach based upon he egionalisa ion o heal h and
social ca e (McCa hy e al., 2022; O'Malley e al., 2023). These epo s ou lined
he app op ia eness o a PBRA app oach based upon he egionalisa ion o heal h
and social ca e. The app oach ollows ha aken in Aus alia, England, he
Ne he lands, New Zealand and Sco land, all o which ha e de eloped PBRA
sys ems o help dis ibu e heal hca e esou ces e icien ly o mee he demands o
hei popula ion.
This epo , unded h ough a esea ch p og amme by he Depa men o Heal h,
p o ides an o e iew o PBRA, de ailing impo an ac o s included in
In oduc ion | 5
con empo aneous sys ems wi hin pee coun ies. Building upon his e iew, he
epo o e s insigh s om o he heal hca e sys ems abou he app op ia e
e olu ions PBRA in I eland should ake in he coming yea s. Expanding upon he
analyses unde aken p e iously (McCa hy e al., 2022; O’Malley e al., 2023), his
epo iden i ies obs acles o he success ul in eg a ion o PBRA in I eland and
sugges s how he sys em can be imp o ed mo ing o wa d, by modi ying elemen s
o he cu en p oposed PBRA o mula and adop ing app oaches implemen ed
ac oss in e na ional PBRA sys ems.
1.3 RESOURCE ALLOCATION PROPOSALS
1.3.1 HSE Heal h Regions
In 2020 he Minis e o Heal h ou lined plans o de elop six HSE Heal h Regions
(HRs – p e iously e e ed o as Regional In eg a ed Ca e O ganisa ions and
Regional Heal h A eas a a ious s ages o he p oposal p ocess). These HRs would
inco po a e communi y heal hca e o ganisa ions (CHOs) and Hospi al G oup
s uc u es in a co e minous geog aphical s uc u e (i.e., ha ing he same
geog aphic bounda ies). Howe e , he eme gence o he COVID-19 pandemic
s alled he es ablishmen o egional bodies, wi h much o he esponse o he
pandemic unde aken a a cen alised le el.
The p oposed es uc u ing o he heal hca e sys em is he la es in a long lis o
ans o ma ions in i s s uc u al and egional con igu a ions in ecen decades
(Tussing e al., 2006; Bu ke e al., 2016; W en e al., 2017; B aun e al., 2023).
Following he Heal h Ac 1970, a sys em o egional heal h boa ds was de eloped,
which p o ided a mo e localised go e nance o heal hca e se ices. In 2003, he
epo o he Commission on Financial Managemen and Con ol Sys ems in he
Heal h Se ice (also known as he B ennan epo ) ecommended he ending o he
heal h boa d s uc u e, and he es ablishmen o a na ional body esponsible o
deli e ing and managing ca e (Depa men o Heal h and Child en, 2003). This
esul ed in he es ablishmen o he HSE in 2005. Since hen, a numbe o
o ganisa ional changes ha e been made (and p oposed). The sho -li ed
in eg a ed se ice a eas (ISAs) aimed o s eamline se ices and imp o e pa ien
ca e con inui y. Fu he eo ganisa ion led o he c ea ion o CHOs, which a e
esponsible o deli e ing communi y-based heal h and social ca e se ices.
Concu en ly, Hospi al G oups we e o med, clus e ing hospi als o wo k oge he
as a single en i y o deli e acu e ca e, ensu ing highe s anda ds and mo e
e icien use o esou ces. CHOs and Hospi al G oups we e bo h ope a ional by
2015.
In 2017, he Sláin eca e epo p oposed majo changes o he s uc u e o
I eland’s heal h and social ca e se ices (Houses o he Oi each as Commi ee on
he Fu u e o Heal hca e, 2017). The p ima y goals o Sláin eca e include ensu ing
a o dable uni e sal heal hca e o all, ans e ing mo e ca e in o p ima y and
6 | Popula ion-based esou ce alloca ion in I eland
communi y ca e se ings, and de eloping a mechanism o dis ibu e unding,
wo k o ce and capaci y o imp o e o e all popula ion heal h. A key aspec o his
app oach was he de elopmen o egional decision-making bodies ha would
include go e nance s uc u es o connec acu e hospi al, p ima y and communi y
heal h and social ca e se ices. The epo also ecommended ha s a
ec ui men (including ha o hospi al consul an s) should be unde aken a he
egional le el. Subsequen o he epo , he de elopmen o HRs was cen al o
he i s Sláin eca e Implemen a ion S a egy (Go e nmen o I eland, 2018). The
epo ou lined:
… he alue o geog aphical alignmen o popula ion-based esou ce
alloca ion (PBRA) and go e nance o enable in eg a ed ca e.
(Houses o he Oi each as Commi ee on he Fu u e o Heal hca e,
2017, p. 20)
In Ap il 2023, i was announced ha he implemen a ion o HRs would
commence in 2024 (HSE, 2023).
1.3.2 Popula ion-based esou ce alloca ion
In 2022 and 2023, he Depa men o Heal h published wo pi o al epo s
p esen ing op ions o a new PBRA mechanism o I eland (McCa hy e al., 2022;
O’Malley e al., 2023). These epo s ou lined a po en ial model o alloca ing HSE
esou ces. The p oposed PBRA o mula was based on models om o he coun ies,
including hose discussed in he nex chap e .
Using e idence om o he coun ies, and analysis wi hin p e ious epo s
(Johns on e al., 2021), he Depa men o Heal h published a p oposed o mula
o he ini ial PBRA in I eland (O’Malley e al., 2023). The p oposed PBRA o mula
is:
𝐴𝑑𝑗𝑃𝑜𝑝𝐻𝑅 = 𝑃𝑟𝑜𝑗𝑃𝑜𝑝𝐻𝑅 𝑥 𝐴𝑔𝑒_𝑆𝑒𝑥𝐼𝑛𝑑𝑒𝑥𝐻𝑅 𝑥 𝐷𝑒𝑝𝐼𝑛𝑑𝑒𝑥𝐻𝑅 𝑥 𝑅𝑢𝑟𝐼𝑛𝑑𝑒𝑥𝐻𝑅
whe e he adjus ed popula ion o each HR (𝐴𝑑𝑗𝑃𝑜𝑝𝐻𝑅) accoun s o he
(p ojec ed) popula ion o each HR (𝑃𝑟𝑜𝑗𝑃𝑜𝑝𝐻𝑅), he age and sex composi ion o
each HR (𝐴𝑔𝑒_𝑆𝑒𝑥𝐼𝑛𝑑𝑒𝑥𝐻𝑅), he le el o dep i a ion in each HR (𝐷𝑒𝑝𝐼𝑛𝑑𝑒𝑥𝐻𝑅),
and he u ali y o emo eness o each HR (𝑅𝑢𝑟𝐼𝑛𝑑𝑒𝑥𝐻𝑅).
The Depa men o Heal h epo s ecommended ha only HSE acu e and
communi y expendi u e, and some se ices o olde people, be subjec o he
PBRA o e he sho o medium e m. This would exclude o e 50 pe cen o 2019
HSE ope a ional expendi u e, amoun ing o €8.14bn. I is ecommended ha he
Nu sing Home Suppo Scheme (NHSS o ‘Fai Deal’), he P ima y Ca e
Reimbu semen Scheme (PCRS – e.g., GP and pha macy expendi u e) and disabili y
In oduc ion | 7
se ices no be included in he ini ial applica ion o he PBRA. I is in he con ex o
he o mula abo e ha his epo is unde aken.
1.4 OBJECTIVES OF REPORT
The main objec i es o his epo a e o p o ide policymake s wi h e idence o
in o m he es ablishmen o PBRA in I eland and o examine he p oposed o mula
de eloped by he Depa men o Heal h.
The esea ch in he epo examines he impac o egional, socioeconomic and
o he pe inen ac o s on he de elopmen o PBRA in I eland. To do his, he
epo also p o ides an o e iew o PBRA, as well as impo an ac o s included in
con empo aneous heal hca e sys ems wi hin pee coun ies. Building upon his
e iew, he epo p o ides insigh s om I eland and o he heal hca e sys ems
abou he app op ia e e olu ions PBRA in I eland should ake in he coming yea s.
I also iden i ies obs acles o he success ul in eg a ion o PBRA in I eland. The
epo explici ly examines he mos ecen es uc u ing and PBRA plans ou lined
by he Depa men o Heal h and he HSE, and p o ides ecommenda ions on
changes and conside a ions ha could occu o imp o e he p oposals, d awing on
e idence om o he coun ies, and case s udies on p e ious esou ce alloca ion
and unding mechanisms om I eland.
1.5 STRUCTURE OF THE REPORT
The epo is s uc u ed as ollows. Chap e 2 de ails esou ce alloca ion sys ems
in e na ionally and he key e iew s udies o PBRA. Chap e 3 i s p o ides case
s udies om esou ce alloca ion and unding mechanisms in I eland. I hen
in oduces he HSE HR es uc u ing and p oposed PBRA o mulae, be o e
p o iding discussion poin s and ecommenda ions on how PBRA can be imp o ed,
using e idence om in e na ional PBRA mechanisms and he I ish case s udies.
Chap e 4 concludes and ou lines ba ie s o PBRA and imp o emen s o PBRA ha
may be needed.
8 | PBRA op ions in I eland
CHAPTER 2
Popula ion-based esou ce alloca ion op ions in I eland
2.1 INTRODUCTION
This chap e discusses he key cha ac e is ics o popula ion-based esou ce
alloca ion (PBRA) mechanisms used wi hin in e na ional heal hca e sys ems. The
chap e ou lines he di e en PBRA o mulae used in pee coun ies and, using
hese na ional le el e iews, poin s o he common cha ac e is ics ound in PBRA
o mulae. A numbe o o he conside a ions o PBRA in I eland a e also iden i ied,
and inally we discuss speci ic esou ce alloca ion and paymen mechanisms ha
a e used in I eland.
2.2 INTERNATIONAL RESOURCE ALLOCATION MECHANISMS
PBRA amewo ks aim o acili a e s a egic heal h and social ca e se ice planning.
This is achie ed by shi ing owa ds models ha inco po a e a mo e holis ic
assessmen o needs, a he han ocusing solely on speci ic diseases, se ings, o
se ice u ilisa ion pa e ns (Johns on e al., 2021). The PBRA me hod alloca es
unding acco ding o a ia ions in need, as well as he addi ional cos s equi ed o
p o ide se ices. PBRA mechanisms can also inco po a e unme need and
geog aphical ac o s such as u ali y, and hey may appo ion a highe le el o ca e
o ce ain demog aphic g oups. Fu he mo e, PBRA o mulae o en apply di e ing
weigh s o ce ain o mula inpu s, based on he judgemen s o decision-make s in
de e mining hei impo ance o hei popula ion’s heal hca e needs.
This sec ion e iews li e a u e on he de elopmen and applica ion o PBRA
mechanisms. Rele an li e a u e was iden i ied h ough app op ia e da abases and
e e ence sea ching. Ou selec ion c i e ia included pape s published in English and
s udies om coun ies wi h heal hca e sys ems akin o ha en isioned o I eland.
The selec ed coun ies a e Aus alia (New Sou h Wales), Canada (Albe a, On a io),
New Zealand, Sweden and he Uni ed Kingdom (UK – England and Sco land). These
coun ies we e included due o he in eg a ion o PBRA amewo ks wi hin hei
heal h sys ems, he ac ha each heal h sys em sha es some impo an simila i ies
wi h he I ish heal h sys em, and he iden i ica ion o li e a u e ha de ails he key
componen s wi hin each PBRA amewo k. The use o such c i e ia also means ha
mos o hese coun ies ha e been included in p e ious analyses commissioned by
he Depa men o Heal h (Johns on e al., 2021; O’Malley e al., 2023) o in o m
he po en ial u u e PBRA o mula o I eland.
2.2.1 Uni ed Kingdom
The Na ional Heal h Se ice (NHS) ope a es ac oss he cons i uen coun ies o he
UK. While he key pilla s o uni e sal heal hca e, ee a he poin o use, a e

Popula ion-based esou ce alloca ion in I eland | 9
consis en , he unc ions o he NHS ha e been de ol ed o each coun y. The e
a e also a ia ions be ween he UK coun ies ega ding he o mulae used o
dis ibu e esou ces. In England, NHS England o e sees heal hca e p o ision,
whe eas local au ho i ies a e esponsible o managing social ca e. The esou ce
alloca ion mechanisms in Sco land and Wales alloca e unding o heal h boa ds o
di e en ca e p og ammes, and a e o mula ed in a simila manne . In his s udy
we ocus on he Sco ish model. In con as , No he n I eland, simila o I eland,
adop s a join app oach o heal h and social ca e se ices, wi h bo h alling unde
he ju isdic ion o he Depa men o Heal h and Heal h and Social Ca e in No he n
I eland. Howe e , we do no examine he s uc u es o PBRA used in No he n
I eland as hey a e much less de eloped han hose used in England and Sco land.
England
The NHS in England was one o he i s heal hca e sys ems o es ablish s a egic
esou ce alloca ion based on popula ion needs in he 1970s (Buck e al., 2013).
Resou ces we e mainly alloca ed based upon popula ion size, and age and sex
di e ences ac oss egions. A mo e de ailed o mula ha inco po a ed o he
ac o s such as dep i a ion was p oposed by Ca -Hill e al. (1994). The ‘Ca -Hill
o mula’ has been in ope a ion since he 1990s and has been adap ed o gene al
p ac i ione (GP) and o he ca e se ices (Fishe e al., 2022). The o mula, which
was ini ially de eloped o alloca ing esou ces o GP se ices, has since unde gone
a se ies o e inemen s and adap a ions, expanding i s use o all key heal hca e
se ices.
In 2023, NHS England unde wen a signi ican o ganisa ional change wi h he
ansi ion om clinical commissioning g oups (CCGs) o in eg a ed ca e boa ds
(ICBs). This shi led o he c ea ion o a smalle numbe o la ge egional bodies
o decision-making and ma ked a mo e owa ds a mo e in eg a ed heal hca e
sys em, emphasising collabo a ion and coo dina ion among a ious heal hca e
p o ide s. Compa ed o he CCG s uc u e, he ICB amewo k en isages g ea e
in eg a ion o heal hca e p o ide s and local au ho i ies, who p o ide social ca e
se ices such as long- e m ca e.
As a esul o his ansi ion om CCGs o ICBs, he esou ce alloca ion o mula
unde wen adap a ions o align wi h he new s uc u e. These changes, ou lined in
a echnical no e by NHS England (2023), aimed o ensu e ha he dis ibu ion o
esou ces con inued o e lec he a ying needs and cos s associa ed wi h
p o iding heal hca e ac oss di e en egions, main aining he p inciple o
‘weigh ed capi a ion’ ha has exis ed o decades. The upda es ook in o accoun
demog aphic, mo bidi y and economic ac o s speci ic o he a eas o e seen by
he new ICBs, ensu ing ha he alloca ion o unding emained equi able, e icien
and esponsi e o he unique cha ac e is ics and equi emen s o each a ea. This
suppo s he o e a ching goal o he ICBs o deli e mo e pa ien -cen ic and
in eg a ed ca e.
10 | PBRA op ions in I eland
The NHS England model aims o esou ce alloca ion o be based on heal hca e
needs, ope a ing on he p inciple o weigh ed capi a ion. This me hod is used o
calcula e a ge unding alloca ions o each ICB o co e esponsibili ies,
specialised se ices and p ima y medical ca e. Sepa a e o mulae a e es ima ed o
di e en heal hca e se ice models (e.g., acu e hospi al ca e, disabili y ca e),
hough he pa ame e s a e e y simila ac oss he o mulae. The o mulae a e
among he b oades and mos da a-in ensi e in e na ionally. Howe e , he key
pa ame e s a e simila o hose used in o he coun ies and hose p oposed by
O’Malley e al. (2023). The weigh ed capi a ion o mula includes:
• Popula ion size: Censuses in England occu only e e y en yea s. Due o
p e ious di icul ies in popula ion es ima es, he size o he popula ion o
each ICB is based on he numbe o egis e ed pa ien s a GP p ac ices
loca ed wi hin he ICB’s bounda y a ea.
• Age and sex: Adjus men s a e made o age and sex wi hin each ICB,
ecognising ha heal hca e needs a y signi ican ly ac oss di e en age
and sex g oups.
• Addi ional heal hca e needs: The ICB o mula accoun s o addi ional
heal hca e needs ha canno be explained by age and sex di e ences
alone. These include ac o s ha inc ease heal hca e needs, such as he
incidence a es o mo bidi ies in he popula ion.
• Unme need and heal h inequali ies: Adjus men s a e made o add ess
heal h inequali ies and unme heal hca e needs wi hin popula ions. This is
c ucial o ensu ing ha a eas wi h his o ically unde se ed o
disad an aged popula ions ecei e adequa e unding. These pa ame e s
ha e been key o NHS esou ce alloca ion o mulae in he pas . P e ious
au ho i ies ha e ejec ed new esou ce alloca ion o mulae ha we e
pe cei ed as ailing o educe heal h inequali ies (Iacobucci, 2012).
• Ma ke o ces ac o s (MFF, o ‘cos ac o s’): The o mulae also include
adjus men s o he highe cos s o deli e ing heal hca e in some a eas.
Fo example, he e a e gene ally highe inpu cos s in ci ies o densely
popula ed a eas, such as London. Addi ionally, adjus men s a e made o
speci ic ci cums ances like he highe cos s o unning small hospi als in
u al a eas o eme gency ambulance se ices in emo e egions.
Combining each o hese ac o s, s a is ical modelling is used o selec he ‘bes i ’
d i e s o ela i e cos s a he pe son le el and he ela i e weigh s o each d i e .
The e a e a numbe o mo e nuanced aspec s o he o mula:
Weigh ing: Speci ic ac o s a e also weigh ed di e en ly ac oss heal hca e
models. Fo example, in he gene al and acu e ca e o mula, o accoun o
he highe hospi al needs o he olde popula ion, indi iduals aged 65–69
yea s a e assigned a weigh o 4 compa ed o hose aged 20–24 yea s, while
Popula ion-based esou ce alloca ion in I eland | 11
indi iduals aged 85+ a e assigned a weigh o 10 (NHS England, 2023).
Fu he mo e, weigh s a e applied o o he pa ame e s, such as unme need.
Regions ha a e his o ically unde se ed o disad an aged a e a ge ed wi h
a highe sha e o unding, using a ixed pe cen age o eweigh he
con ibu ion hey ecei e.
T ansi ions: The o mulae accoun o key ansi ions, pa icula ly he shi
om CCGs o ICBs, by implemen ing s a egies o ensu e inancial s abili y and
equi able esou ce dis ibu ion du ing his s uc u al change pe iod. A
con e gence p ocess is c ea ed whe eby ICBs a e g adually mo ed om hei
ini ial unding le els (based upon he p e ious CCGs) o a ge alloca ions
de e mined by he upda ed o mula. This ansi ion, which is managed o
a oid sudden inancial impac s, helps o ensu e con inui y o heal hca e
se ices. In a small numbe o cases, adjus men s a e also made o e lec new
geog aphic bounda ies and popula ion bases o ICBs, as well as mo e gene al
popula ion upda es (NHS England, 2023).
Ru ali y: The new ICB o mulae o communi y ca e se ices include a new
a el ime adjus men . This adjus men ecognises ha addi ional a el
imes a e o en necessa y o deli e communi y ca e se ices (e.g., communi y
nu sing isi s) o pa ien s li ing in emo e a eas.
In eg a ed ca e: The decision o c ea e ICBs and ansi ion esou ce alloca ion
o he ICB le el was la gely mo i a ed by policymake s’ goal o c ea ing be e
in eg a ed ca e pa hways o popula ion g oups. I e lec s a s a egic shi
owa ds mo e coo dina ed and pa ien -cen ed heal hca e se ices. Fi s , as
wi h o he mode n PBRA mechanisms, he NHS England o mulae ake in o
accoun a wide ange o ac o s, like popula ion demog aphics, heal hca e
needs and local cos a ia ions, when de e mining esou ces. In his sense, he
o mulae ensu e ha unding is no only alloca ed based on he numbe o
indi iduals in an a ea bu also on hei speci ic heal h equi emen s and he
complexi ies o deli e ing se ices in di e se se ings. This app oach is
conduci e o in eg a ed ca e as i enables ICBs in his ins ance o ha e he
esou ces necessa y o add ess he holis ic heal h needs o hei espec i e
popula ions, conside ing bo h p ima y and specialised ca e se ices. Second,
ICB s uc u es os e g ea e coo dina ion be ween NHS and heal hca e
p o ide s and he local au ho i ies esponsible o commissioning social ca e
(Wenzel e al., 2019). The shi also o e s an oppo uni y o commissione s
o heal h and social ca e o embed and a ionalise he p ocess o in eg a ed
ca e p o ision (Gongo a-Salaza e al., 2022).
T anspa ency and in o ma ion: An impo an aspec o he NHS England
esou ce alloca ion o mula is he ex ensi e le el o da a and in o ma ion
a ailable o in o m he decision-making p ocess. Rela ed o his, he Ad iso y
Commi ee on Resou ce Alloca ion (ACRA) was es ablished o p o ide
12 | PBRA op ions in I eland
guidance on he o mula and o ensu e anspa ency in he p ocess. In his
con ex , all guides and da a sp eadshee s used o es ima e he o mulae a e
a ailable o he public.
1
Howe e , o in eg a ed ca e especially, some ha e
a gued o he u he s eng hening o b oade da a collec ion and he
adop ion o an e idence-based p io i y amewo k (Gongo a-Salaza e al.,
2022).
Sco land
The Sco ish PBRA o mula, known as he Sco ish Na ional Resou ce Alloca ion
Commi ee (NRAC) o mula, alloca es unding o 6 ca e p og ammes o 14 NHS
heal h boa ds. To begin, he popula ion is weigh ed by age and sex p o iles (NHS
Sco land, 2020). Subsequen ly, he model is weigh ed by a mo bidi y and li e
ci cums ances (MLC) index ha conside s a ious indica o s ha a ec heal h,
o e and beyond wha can be explained by age and sex. This index includes
dep i a ion a es om he Sco ish Index o Mul iple Dep i a ion (SIMD) and
s anda dised mo ali y a io included a he egional le el (NHS Sco land, 2020).
Finally, he PBRA o mula accoun s o he addi ional cos s o p o iding ca e in u al
a eas (NHS Sco land, 2020).
The NRAC o mula is no oo dissimila o he app oach adop ed in England, and
he e a e many commonali ies be ween he English and Sco ish PBRA o mulae.
Howe e , he NRAC places a hea ie emphasis on adjus men s o u ali y and
emo eness, which is likely o be due o he geog aphic dis ibu ion o he
popula ion in Sco land compa ed o ha in England.
One o he dis inc ion be ween England and Sco land ela es o in eg a ion o ca e.
In Sco land, In eg a ed Join Boa ds (IJBs) we e es ablished o be e in eg a e
heal h and social ca e se ices. IJB membe ships include membe s om NHS heal h
boa ds, local au ho i ies and o he s akeholde s (e.g., olun a y p o ide s).
Howe e , in Sco land, hese IJBs unc ion as sepa a e legal en i ies, wi h he
au onomy o make decisions abou he unc ions and esponsibili ies o heal h and
social ca e commissione s (Collins e al., 2023). The e o e, he IJBs a e no
embedded wi hin he NRAC o mula, hough hey likely do help wi h he mo e
equi able dis ibu ion o esou ce o in eg a ed ca e.
Figu e 2.1 p esen s he pe cen age sha e o he unding p o ided o he Ay shi e
& A an NHS Heal h Boa d in 2020/2021 and 2024/2025. The igu e illus a es ha
while popula ion is he key componen o he NRAC o mula, he o he
adjus men s (especially he age–sex index) do impac he pe cen age o unding
p o ided o each NHS boa d. Fu he mo e, he e is a g ea deal o consis ency in
alloca ion ac oss yea s. This igu e con eys ha anspa ency on how esou ce
1
A echnical guide and all echnical annexes and da a sp eadshee s used o es ima e he esou ce alloca ions can be
ound he e: h ps://www.england.nhs.uk/publica ion/suppo ing-sp eadshee s- o -alloca ions-2023-24- o-2024-25/.
Popula ion-based esou ce alloca ion in I eland | 19
measu es by heal hca e sec o o accoun o a ying impac s o mo bidi y, heal h
s a us and u ilisa ion.
2.3.5 Regional ac o s
Regional-le el indica o s ha cap u e emo eness o u ali y accoun o he
una oidable cos o p o iding ca e in u al a eas. Such indica o s include a el
cos s and addi ional cos s associa ed wi h s a e en ion (Penno e al., 2013;
Johns on e al., 2021), and a e included ac oss mos PBRA mechanisms examined.
England adjus s o cos s associa ed wi h p o iding eme gency se ices in spa sely
popula ed a eas and diseconomies o scale associa ed wi h una oidably small
hospi als (NHS England, 2023). In No he n I eland, he o mula compensa es o
addi ional a el ca ied ou by s a o p o ide selec ed communi y se ices in
each a ea (s a ime and he a el cos ) and o di e en ial cos s aced by a eas
in mee ing a gi en le el o demand (economies o scale) (Depa men o Heal h,
2014).
Cos adjus men s a e no solely applied o u al a eas bu also o high-cos a eas.
To illus a e, England compensa es o una oidable geog aphical cos di e ences
h ough hei use o a MFF adjus e . The MFF inco po a es da a on s a wages, in
conjunc ion wi h building and land p ices, o e lec highe inpu cos s in densely
popula ed a eas (London and Sou heas England) (Ba e al., 2014; NHS England
2023). The adjus e also accoun s o highe cos s associa ed wi h a ac ing and
e aining wo k o ce supply in u al a eas. The MFF ocuses on supply-side ac o s
ha will in luence u ilisa ion and, consequen ly, need (NHS England, 2023). An
eme gency se ice cos adjus men was in oduced o e lec he una oidable cos
a ia ions o deli e ing se ices in u al a eas.
2.3.6 Unme needs
The e a e wo main app oaches o measu ing unme need in PBRA mechanisms.
The i s app oach is o use p e ious e idence on heal h ou comes o de ined
popula ion g oups. NSW applies addi ional weigh ings o Abo iginal and homeless
popula ions o ep esen g ea e heal h dispa i ies aced by hese g oups (New
Sou h Wales Heal h, 2005). New Zealand dis ibu es a pe cen age o hei budge
o heal h acco ding o he p opo ion o Māo i, Paci ic and dep i ed popula ions in
each DHB (Minis y o Heal h, 2004). Simila ly, Sweden p o ides an addi ional
weigh ing o hose who all in o he Ca e Needs Index wi hin hei mo e ma ke
o ien a ed alloca ion o mula. The index is inclusi e o ma e ial dep i a ion, amily
s uc u es, social ins abili y and e hnici y (Sundquis e al., 2003).
The second app oach has been o use epidemiological ma ke s o unme need. In
Sco land, alloca ions a e adjus ed o di e en ial a es o ci cula o y disease (NHS
Sco land, 2020). In England, p io o 2014/2015 he PBRA employed ‘disabili y ee
li e expec ancy’ as an indica o o heal h inequi y and unme heal hca e needs

20 | PBRA op ions in I eland
while dis ibu ing esou ces o p ima y ca e us s. Howe e , mo e ecen ly he
s anda dised mo ali y a io o indi iduals unde 75 yea s old (SMR<75) was
chosen as a mo e sui able choice o cap u e unme need. This was due o i s
ela i e s abili y a he CCG le el o e consecu i e pe iods and i s ease o
comp ehension.
4
2.4 CONCLUSION
The PBRA o weigh ed capi a ion mechanisms es ablished in compa a o coun ies
analysed in his chap e a e o en ema kably simila o each o he . The basic
adjus men s a e de e mined acco ding o popula ion size and he age and sex
p o iles o egional popula ions. While each coun y assigns conside able
au onomy in decision-making o egional o local heal h au ho i ies, each coun y
also in a iably includes an adjus men o socioeconomic s a us (mos likely
dep i a ion), u ali y and o he unme needs. O he coun y- o sys em-speci ic
pa ame e s a e also included. Fo example, in New Zealand, he size o he Māo i
and Paci ic peoples’ popula ion wi hin a egion is accoun ed o . The NHS models
may inco po a e qui e g anula dep i a ion in o ma ion and also accoun o
addi ional heal hca e needs (e.g., mo bidi y le els) wi hin hei o mulae.
This analysis, alongside simila analyses (Johns on e al., 2021; McCa hy e al.,
2022), highligh s ha I eland can lea n conside ably om in e na ional PBRA
sys ems. Howe e , he uniqueness o he I ish heal hca e sys em sugges s ha
sys em-speci ic pa ame e s may also be app op ia e o inclusion wi hin he PBRA
mechanism o I eland.
4
See h ps://www.england.nhs.uk/wp-con en /uploads/2022/04/ epo -on-ac a- e iew-o - he-heal h-inequali ies-
and-unme -need-adjus men -22-23.pd .
P oposed HSE Heal h Regions and PBRA o mula | 21
CHAPTER 3
P oposed HSE Heal h Regions and popula ion-based esou ce
alloca ion o mula
3.1 INTRODUCTION
This chap e in oduces he mos ecen p oposals o heal hca e sys em s uc u e
eo ganisa ion in I eland; Heal h Se ice Execu i e (HSE) Heal h Regions (HRs), and
he p oposed popula ion-based esou ce alloca ion (PBRA) o mula de eloped by
he Depa men o Heal h. As a way o p o iding con ex , he chap e i s p o ides
in o ma ion on esou ce alloca ion, unding mechanisms and in eg a ed ca e
s uc u es ha cu en ly exis in I eland, as well as lessons ha can be ga ne ed
om hem when in o ming PBRA. I hen in oduces he p oposed HRs and PBRA
o mula, highligh ing he key componen s o hese p oposed changes and
ecommending some changes o imp o e he p oposals. Discussions o po en ial
changes d aws on e idence om o he coun ies, as ou lined in Chap e 2, analysis
wi hin p e ious epo s (Johns on e al., 2021) and case s udies.
3.2 RESOURCE ALLOCATION AND FUNDING MECHANISMS IN IRELAND
While I eland lacks a sys em-wide esou ce alloca ion mechanism, ecen yea s
ha e seen changes in he use o paymen and unding mechanisms u ilised wi hin
a ious publicly unded heal h and social ca e se ices. Sec ion 3.3 and Sec ion 3.4
ou line op ions o egional le el esou ce alloca ion, based on sys ems de eloped
in o he coun ies. Fi s , we ou line examples o esou ce alloca ion and s a egic
unding mechanisms ha a e cu en ly being used in I eland and may emain
wi hin a u u e, wide heal hca e esou ce alloca ion mechanism. They also show
ha unding decisions designed o ensu e g ea e e iciency and equi y ha e
al eady been implemen ed by heal hca e policymake s in I eland, and a numbe o
ba ie s o hei e ec i e use ha e been iden i ied.
This sec ion iden i ies ou examples, e e ed o he e as case s udies, ha p o ide
e idence o esou ce alloca ion mechanisms being used wi hin he heal hca e
sys em. We highligh :
• he implemen a ion o ac i i y-based unding (ABF) wi hin acu e public
hospi als;
• esou ce alloca ion in u gen and eme gency ca e, as examined by Thomas e
al. (2019);
• implica ions o he sepa a e inancing o acu e hospi al ca e and social ca e,
using e idence om Walsh e al. (2020); and
• he po en ial need o o he pa ame e s, in pa icula men al heal h and
men al illness, o be accoun ed o wi hin PBRA mechanisms mo e gene ally.
22 | Popula ion-based esou ce alloca ion in I eland
Key p ac ical lessons om each mechanism ha e been iden i ied. These lessons
can also help o in o m he embedding p ocess o he p oposed PBRA mechanism.
3.2.1 Case S udy 1: Ac i i y-based unding in acu e public hospi als
ABF is a me hod o unding heal hca e ha alloca es unds o heal hca e p o ide s
(e.g., hospi als) based on he ac ual amoun and ype o ca e and se ices hey
p o ide. ABF allows o unding o e lec ca e deli e ed, a he han i being based
on p e-se budge alloca ions o his o ical spending pa e ns.
Since 2016, ABF has been he me hod h ough which he HSE has unded inpa ien
and day pa ien episodes o ca e wi hin he main la ge acu e public hospi als
(ca ego ised as Model 3 and Model 4 hospi als wi h 24/7 eme gency depa men s)
(Keegan e al., 2020; Valen ely e e al., 2021; Valen ely e e al., 2023). While ABF
is no ye used o und eme gency depa men s and ou pa ien ca e in acu e public
hospi als, his shi owa ds ABF, and away om block unding in acu e public
hospi als o inpa ien ca e, ep esen s an impo an shi in how heal hca e
se ices a e unded in I eland. The implemen a ion o ABF has made I eland
compa able in his ega d o o he coun ies ha employ ac i i y-based o
Paymen by Resul s (PBR) models o alloca ing heal h budge s. The mo e owa ds
ABF also showed ha he heal hca e sys em in I eland was capable o
implemen ing la gescale s a egic esou ce alloca ion and unding mechanisms.
ABF has been a ou ed as a mechanism by heal h economis s and planne s. The
key a ibu es o ABF a e as ollows.
• ABF pu s mo e esponsibili y on o he hospi als (and Hospi al G oups) o
p o ide accu a e in o ma ion on ca e p o ided o pa ien s.
• ABF p o ides a mechanism o mo e equi able dis ibu ion o esou ces
ac oss hospi als based upon he pa ien s who ecei e he ca e. In his
con ex , ABF is mo e pa ien -cen ed han block unding.
• ABF explici ly includes an e iciency elemen . Unde ABF, hospi als a e
eimbu sed o he ype and complexi y o ca e p o ided o pa ien s. This
means ha ABF incen i ises ea lie discha ge om hospi al, as hospi als
will be p o ided wi h he same le el o unding o pa ien s wi h he same
diagnosis- ela ed g oup (DRG), ega dless o hei leng h o s ay (LOS).
• The use o DRGs p o ides hospi als wi h a simple classi ica ion sys em ha
allows o unding o be mo e easily and e icien ly alloca ed.
The implemen a ion and e olu ion o ABF in acu e public hospi als o e s aluable
insigh s o policymake s, pa icula ly in shaping he PBRA sys em and he
es ablishmen o HSE HRs. We demons a e below how he implemen a ion o ABF
in hese hospi als has enabled heal hca e p o ide s and planne s o add ess
nume ous o ganisa ional challenges ha a e also likely o a ise wi h he
in oduc ion o PBRA.
P oposed HSE Heal h Regions and PBRA o mula | 23
Regional decision-making
The policy es ablishing ABF iden i ied key p io i ies and le els o decision-making
o esou ce alloca ion a he Hospi al G oup le el. Acco ding o he i s ABF
implemen a ion plan:
‘Hospi al G oups will o m he con ac ing en i y o Ac i i y-Based
Funding’ and Hospi al G oups we e o be ‘gi en he au onomy o
ha ness he bene i s o independence and g ea e con ol a local
le el’. (HSE, 2015)
These g oups we e g an ed au onomy o op imise he bene i s o independen
decision-making a a local le el. This au onomy included adjus men s in he cos
base and s a deploymen o mee local demands. Impo an ly, his au onomy was
also in ended o suppo hospi als acing geog aphical o s uc u al challenges,
which is he app oach also aken in England and Sweden. As Rice e al. (2002)
discussed, his app oach is a c i ical aspec o budge de olu ion wi hin a b oade
‘s a egic esou ce alloca ion’ sys em. These insigh s a e also aluable o he
ansi ion owa ds PBRA and he es ablishmen o HSE HRs.
The mos ecen ABF implemen a ion plan (2021–2023) ou lines ha Hospi al
G oups a e esponsible o he go e nance and managemen o hospi als wi hin
hei g oups, and o p o iding good quali y, imely da a o na ional ABF (HSE,
2021). Hospi al G oups emain ‘ he con ac ing en i ies o ABF, wi h unding
lowing om he HSE o he G oups, a he han indi idual hospi als’; hey
‘ he e o e de e mine how unding is dis ibu ed among hospi als’. I is ou lined
ha esponsibili ies o Hospi al G oups will be subsumed by he newly es ablished
egional bodies, e.g., HSE HRs.
Cu en ly, i appea s ha esponsibili y o ABF will emain p edominan ly a he
hospi al and egional le el, as I eland ansi ions o HSE HRs. The e o e, a e iew
o he ole Hospi al G oups ac ually played wi hin ABF and wide esou ce
alloca ion decision-making as i occu ed in eali y could be aluable in e ms o
ou unde s anding o how imp o emen s can be made.
Communi y and long- e m ca e esou ce alloca ion
As we explo e in mo e de ail in subsec ion 3.2.3, he e ec i eness o ABF is
somewha educed due o he lack o in eg a ion be ween acu e and non-acu e
ca e. Fi s , he misalignmen o egional bounda ies be ween Hospi al G oups and
communi y heal hca e o ganisa ion (CHOs) (and local heal h o ices (LHOs)) likely
hinde s he in eg a ion o hese sec o s. Second, ABF is also impac ed by he
poo e le el o in o ma ion on cos ing and a ailabili y o non-acu e se ices. In ligh
o his, he la es ABF Implemen a ion Plan (HSE, 2021) iden i ied se e al key a eas
o ocus du ing he 2021–2023 pe iod. One such a ea is he commencemen o
he p ocess o cos assessmen s o communi y and home suppo se ices, wi h
24 | Popula ion-based esou ce alloca ion in I eland
he e en ual goal o ans e ing p icing esponsibili y o hese se ices o he
Heal hca e P icing O ice (HPO). This would be ano he signi ican change in
unding mechanisms o I ish heal h and social ca e. Gi en ha in eg a ing acu e
and non-acu e ca e is a c i ical aspec o he p oposed HR es uc u ing, u u e
plans o shi ing p icing esponsibili ies o communi y se ices o he HPO
wa an close examina ion.
T ansi ion adjus men s
The issue o ansi ioning o de-coupling om his o ic budge s was acknowledged
by he HSE since he incep ion o ABF (HSE, 2021). T ansi ion adjus men s emain
a con inuing ea u e o ABF wi hin acu e public hospi als. The shi om ixed block
budge s o ac i i y-based budge s necessi a ed g adual changes, as will PBRA.
Go e nance
A key goal o ABF is o encou age he deli e y o ca e in less complex se ings and
o educe he LOS in hospi als, as paymen s a e no longe linked o longe hospi al
s ays.
ABF, and ex ensions o ABF, aimed o inc ease he a es o same-day su ge ies o
ce ain p ocedu es. No ably, om 1 Janua y 2018, hospi als we e incen i ised o
pe o m lapa oscopic cholecys ec omy (gallbladde emo al) as a day case a he
han as an inpa ien p ocedu e. Essen ially, hospi als would ecei e he same
unding o conduc ing a lapa oscopic cholecys ec omy as a day case as hey would
o an inpa ien p ocedu e (Valen ely e e al., 2023; B ick e al., 2025). Howe e , a
ecen analysis o his ABF incen i e, using a di e ence-in-di e ence s a is ical
app oach ha compa es he use o day case su ge y be o e and a e he unding
change, e ealed no signi ican e ec on he a es o day case p ocedu es
(Valen ely e e al., 2023). The s udy concluded ha ‘ he implemen a ion o he
unding policies did no imp o e hospi al e iciency’ (Valen ely e e al., 2023). The
au ho s discuss ha hei esul s con o m wi h in e na ional e idence ha shows
a bes modes impac s o ABF- ype mechanisms on inc easing he use o mo e
e icien hospi al ca e. Bu hey also discuss ha I ish hospi als may ha e a lowe
capaci y o espond o ABF due o unde lying capaci y cons ain s, high bed
occupancy a es, and long wai ing lis s o day case and elec i e inpa ien ca e.
I is possible ha ABF equi es ime o become embedded and ully in eg a ed in o
hospi als, and esul s will no be e iden sho ly a e i s in oduc ion (e.g., o
lapa oscopic cholecys ec omy). In e na ional e idence sugges s ha he bene i s
o ABF may ake se e al yea s o ma e ialise (Gaughan e al., 2019). This esea ch
also e ealed signi ican a ia ions in how hospi als espond o ABF in hei
decision-making p ocesses. Such a ia ions we e obse ed wi h bo h small and
la ge incen i es, and ac oss di e en clinical se ings. These pa e ns migh
indica e issues in he go e nance o ABF, and he capaci y o a sophis ica ed

P oposed HSE Heal h Regions and PBRA o mula | 25
unding mechanism o become embedded in p ac ice by clinicians, clinical
decisionmake s and hospi al managemen . Fu he mo e, ecen esea ch
published by he Depa men o Heal h has shown subs an ial dispa i ies in
hospi al key pe o mance indica o s (KPIs) associa ed wi h ABF in acu e public
hospi als (Clancy e al., 2023). Collec i ely, hese indings unde sco e he
impo ance o obus go e nance in esou ce alloca ion mechanisms, and wi hin
he p oposed PBRA. E ec i e go e nance ensu es no only ha he sys ems
unc ion as in ended bu also ha p o ide s ailing o mee equi emen s ecei e
adequa e incen i es and suppo s uc u es o compliance.
3.2.2 Case s udy 2: Va ia ion in esou ce alloca ion in u gen and
eme gency ca e sys ems in I eland
This case s udy highligh s ha in I eland, wi hin a ela i ely small and homogenous
sec o o he heal hca e sys em – u gen and eme gency ca e – la ge di e ences
cu en ly exis in how inancing and esou ce alloca ion decisions a e made. Unlike
inpa ien and day pa ien ca e, ABF has no ye been inco po a ed wi hin
eme gency depa men o ou pa ien ca e. The objec i e o a esea ch s udy
unde aken by Thomas e al. (2019) a T ini y College Dublin was o examine he
unding mechanisms wi hin he u gen and eme gency ca e sec o in I eland,
ocusing on he dynamics o heal hca e unding used and he egional dispa i ies
ha exis . As discussed by he au ho s, in e na ional esea ch consis en ly inds a
highe isk o poo heal h ou comes om eme gency condi ions in u al a eas
compa ed o u ban a eas. This is due o u al a eas consis ing o olde and mo e
socioeconomically disad an aged popula ions, longe a el imes o hospi als and
ca e clinics, and lowe su i al a es (Smi h e al., 2008; Alanazy e al., 2019).
In hei key analyses, Thomas e al. (2019) examined o al unding pe capi a wi hin
he h ee a eas o u gen and eme gency ca e (ambulance se ices, eme gency
depa men s and gene al p ac i ione (GP) ca e) ac oss coun ies in I eland. They
ound he lowes unding in Wicklow (€47) and highes in Lou h (€208). The
analyses also showed ha o ambulance se ices, many u al coun ies, including
Donegal, Cla e, Ke y, Roscommon and Lei im, ha e well-sou ced ambulance
se ices. Howe e , he pa e n is inconsis en , wi h some u al coun ies like Sligo
no being well se ed (Thomas e al., 2019). This inconsis ency is also appa en in
GP ca e, whe e some u al coun ies a e ela i ely well- inanced (Donegal and
Mayo) while o he s a e no (Ca an and Monaghan). In e es ingly, in u al coun ies
whe e public eme gency depa men unding is low, GP unding is ela i ely high
and ice e sa. This la e inding may poin o di e ences in how heal hca e
sys ems di e ge in hei ope a ion as well.
Thomas e al. (2019) also ound ha p i a e eme gency ca e se ices a e
concen a ed in Dublin and he sou h o he coun y (namely Co k) while public
eme gency ca e se ices a e concen a ed in Dublin no h-eas , he midlands, and
he sou h-eas o he coun y. The au ho s ound no link be ween p e-hospi al (GP,
26 | Popula ion-based esou ce alloca ion in I eland
p ac ice nu se and ambulance se ices) unding and dep i a ion (Thomas e al.,
2019). This is in di ec con as o nume ous in e na ional s udies which ound
signi ican ly poo e ou comes in mo e dep i ed a eas (Rigby e al., 2017; McCann
e al., 2018), indica ing inadequa e p e-hospi al unding o dep i ed a eas.
In conclusion, he au ho s ound ha ac oss u ali y and dep i a ion, which a e key
pa ame e s wi hin he p oposed PBRA o mula, u gen and eme gency heal hca e
unding is agmen ed and inconsis en . This lack o uni o mi y in he u gen and
eme gency ca e sys em in I eland may be due o he sys em cu en ly being based
p edominan ly on his o ic pa e ns o expendi u e, wi h limi ed adjus men o
case mix. Li le o no acknowledgmen o cu en ine iciencies, in e ms o unding
ac oss coun ies and egions, will only se e o ad ance inequali ies, no ably in u al
a eas. The indings om his s udy also poin o he need o PBRA o make
sys ema ic decisions o unding based upon popula ion needs. They also sugges
ha egional inequali ies exis , which may ake ime o dissipa e unde PBRA.
3.2.3 Case s udy 3: Social ca e supply and hospi al leng h o s ay
An impo an aspec o he heal hca e sys em changes ecommended in
Sláin eca e is he need o ans e ca e ou o hospi al in o mo e app op ia e
se ings. The es uc u ing en isaged unde HRs and PBRA pa ly aims o help his
ecommenda ion be ealised. Resea ch om he Economic and Social Resea ch
Ins i u e (ESRI) ound ha imp o ing non-acu e ca e supply can help educe use o
less app op ia e hospi al ca e, using he example o he impac o access o public
home suppo on he use o hospi al se ices among olde people (65+). This s udy
was one o he i s o iden i y how heal h and social ca e se ices can o en ac as
a subs i u e o each o he in I eland (Walsh e al., 2020). In he con ex o
Sláin eca e, and he goal o placing ca e in he leas complex se ing and as close
o home as possible, indings om his s udy highligh ha di e ing esou ces
om hospi als in o o he pa s o he sys em has bene i s o he e icien and
equi able alloca ion o heal hca e esou ces.
This s udy used in o ma ion on o e 300,000 inpa ien hospi alisa ions be ween
2012 and 2015 among hose aged 65+ om he Hospi al In-Pa ien Enqui y (HIPE)
da ase . Using his in o ma ion on pa ien s’ home add ess (coun y and pos code in
Dublin), he au ho s we e able o ma ch home suppo (o home ca e) supply in
pa ien s’ local a ea, a a poin in ime, o hei hospi alisa ion da a.
As highligh ed in Sec ion 1.2, he e exis s la ge a ia ion in heal h and social ca e
supply ac oss I eland, including home suppo . An upda ed analysis by Walsh e al.
(2020) ound simila o home suppo ; hey showed ha some indi iduals will
ha e lowe access o home suppo , ce e is pa ibus, han o he s, based solely upon
hei coun y add ess. This is in pa a esul o no mechanism being in place o
ma ch home suppo supply wi h need. The au ho s exploi ed his a ia ion in
home suppo supply ac oss coun ies, o e ime, o examine he impac o an
P oposed HSE Heal h Regions and PBRA o mula | 27
inc ease in home suppo supply on he inpa ien LOS o olde pa ien s (aged 65+).
Fu he mo e, as he Model 3 and Model 4 hospi als included in he analyses ha e
ca chmen a eas ha d aw pa ien s om nume ous coun ies, he au ho s we e
able o compa e pa ien s wi hin he same hospi al a he same poin in ime, who
had simila p o iles excep ha hey came om di e en coun ies, and o ha
eason had di e en home suppo supply a ailable o hem. The esul s show
home suppo supply has li le e ec on a e age LOS. Howe e , using a no el
uncondi ional quan ile eg ession echnique ha subdi ides LOS in o sho and
long ca ego ies, Figu e 3.1 shows ha inpa ien s om a eas wi h a highe pe
capi a a ailabili y o home suppo se ices ended o ha e sho e hospi al s ays
on a e age. Concen a ing on longe LOS pa ien s who a e likely delayed ans e s
o ca e, he pape inds a 10 pe cen inc ease in home suppo a ailabili y
co ela es wi h a 1.2 o 2.1 pe cen dec ease in hospi al s ay du a ion. La ge
e ec s we e ound among s oke and hip ac u e pa ien s, who may po en ially
u ilise home suppo se ices mo e han he a e age pa ien . La ge e ec s we e
also ound in one egion ha in es ed hea ily in home suppo du ing he pe iod
s udied (2012–2015).
FIGURE 3.1 THE IMPACT OF HOME SUPPORT SUPPLY ON INPATIENT LENGTH OF STAY
Sou ce: Walsh e al. (2020).
The esul s o Walsh e al. (2020) demons a e he signi ican impac ha non-
acu e ca e supply can ha e on he usage o acu e ca e se ices. I also highligh s
how inequali ies in access o ca e can lead indi iduals o use less app op ia e
se ices, such as hospi al o long- e m esiden ial ca e (LTRC). The s udy poin s ou
a key ine iciency: hospi als a e penalised o longe LOS, despi e no being
esponsible o decisions on home suppo supply. This disconnec ion in esou ce
alloca ion decisions wi hin he heal hca e sys em unde mines he po en ial
e iciency gains o measu es like ABF wi hin hospi als. A c ucial policy akeaway
28 | Popula ion-based esou ce alloca ion in I eland
om his esea ch is he po en ial bene i s o join planning and managemen o
heal h and social ca e ac i i ies wi hin a egion, as p oposed by PBRA. Such
in eg a ion may enable mo e e icien hospi al discha ge iming while ensu ing
pa ien s ecei e he mos app op ia e ca e. Addi ionally, esul s may poin o he
lack o bene i s om ABF obse ed by Valen ely e e al. (2023) being in luenced by
ac o s ou side a hospi al’s con ol. This s udy unde sco es he impo ance o
ensu ing ha he p oposed PBRA mechanism e ec i ely in eg a es acu e and non-
acu e ca e.
3.2.4 Case s udy 4: Men al illness and heal hca e u ilisa ion
Incidence o men al illness is inc easing in I eland as well as many o he coun ies,
leading o an inc ease in bo h gene al heal hca e u ilisa ion and use o mo e
specialis men al heal hca e se ices (Figue oa, e al., 2020). Fu he mo e, while
u ilisa ion and expendi u e by hose wi h men al illness may be high (Figue oa e
al., 2020), access o, and use o , heal hca e se ices can also di e ac oss
sociodemog aphic g oups and heal hca e co e age (F ank e al., 2014). Heal h
co e age and b oade s uc u al ba ie s o en lead o lowe up ake o men al
heal hca e. Ba ie s such as dis ance o se ices and lack o anspo a ion can
de e hose in u al a eas. Mo eo e , wai ing lis s and he inancial cos o
ea men , pa icula ly o hose in lowe socioeconomic g oups, can lead o lowe
men al heal hca e u ilisa ion.
While o en o e looked in PBRA mechanisms, men al illness and poo e men al
heal h ou comes lead o signi ican heal hca e u ilisa ion (Himelhoch e al., 2004;
Salone e al., 2014; Salone e al., 2017; González-Suñe e al., 2021). Howe e , no
PBRA o mula examined in Chap e 2 explici ly includes men al heal h as a
cha ac e is ic o help de e mine esou ce alloca ion decisions mo e gene ally.
Sepa a e men al heal h budge s, hough, a e now common in PBRA o mulae,
including in England (NHS England, 2023).
The 2024 HSE budge alloca ed almos €1.3 billion o men al heal hca e se ices,
5
wi h he majo i y o his budge spen on specialised inpa ien and communi y-
based men al heal hca e se ices. O’Malley (2023) ou lined ha his expendi u e
on men al heal hca e se ices will be included in he p oposed PBRA o mula. This
is in line wi h PBRA sys ems ac oss he Na ional Heal h Se ice (NHS) and o he
compa a o coun ies. Howe e , ea men o men al heal h issues will in a iably
include expendi u e on gene al acu e public hospi al ca e and p ima y ca e.
The e o e, as he p e alence o men al ill heal h con inues o inc ease, u u e
i e a ions o PBRA o mulae may begin examining he app op ia eness o including
men al heal h a es explici ly when ying o accoun o he addi ional heal hca e
5
See h ps://www.go .ie/en/p ess- elease/ae213-minis e - o -men al-heal h-and-olde -people-launches-hse-digi al-
my-men al-heal h-plan/.
P oposed HSE Heal h Regions and PBRA o mula | 35
3.4 PROPOSED POPULATION-BASED RESOURCE ALLOCATION
FORMULA
The p e ious sec ion ou lined he HR s uc u e h ough which he PBRA in I eland
will occu . In his sec ion, we ou line he key pa ame e s wi hin he p oposed
o mula and o e some discussion and ecommenda ions on how u u e i e a ions
o he o mula could be imp o ed upon.
The p oposed PBRA o mula is:
𝐴𝑑𝑗𝑃𝑜𝑝𝐻𝑅 = 𝑃𝑟𝑜𝑗𝑃𝑜𝑝𝐻𝑅 𝑥 𝐴𝑔𝑒_𝑆𝑒𝑥𝐼𝑛𝑑𝑒𝑥𝐻𝑅 𝑥 𝐷𝑒𝑝𝐼𝑛𝑑𝑒𝑥𝐻𝑅 𝑥 𝑅𝑢𝑟𝐼𝑛𝑑𝑒𝑥𝐻𝑅
whe e he adjus ed popula ion o each HR (𝐴𝑑𝑗𝑃𝑜𝑝𝐻𝑅) accoun s o he
(p ojec ed) popula ion o each HR (𝑃𝑟𝑜𝑗𝑃𝑜𝑝𝐻𝑅), he age and sex composi ion o
each HR (𝐴𝑔𝑒_𝑆𝑒𝑥𝐼𝑛𝑑𝑒𝑥𝐻𝑅), he le el o dep i a ion in each HR (𝐷𝑒𝑝𝐼𝑛𝑑𝑒𝑥𝐻𝑅),
and he u ali y o emo eness o each HR (𝑅𝑢𝑟𝐼𝑛𝑑𝑒𝑥𝐻𝑅).
In he analyses ha ollows, we lis HRs by le e : HR A = Dublin & No h Eas ; HR
B = Dublin & Midlands; HR C = Dublin and Sou h Eas ; HR D = Sou h Wes ; HR E =
Mid Wes ; and HR F = Wes & No h Wes . The p oposed PBRA o mula, de ailed
by he Depa men o Heal h in O’Malley e al. (2023), d aws on a ange o e idence
om p io academic s udies (Johns on e al., 2021) and a epo by he Depa men
o Heal h (McCa hy e al., 2022). Gene ally, he pa ame e s inco po a ed in o he
PBRA mechanism closely align wi h pa ame e s included in PBRA o mulae in
Aus alia, England, New Zealand and Sco land. We examine hese pa ame e s in
g ea e de ail below, pa icula ly how hey a e sequen ially in eg a ed in o he
o mula. We also examine he impac o he p oposed PBRA o mula on HSE
budge s, ollowing he me hodology o O’Malley e al. (2023). Thei app oach
in ol es compa ing he 2021 budge s alloca ed ac oss HRs wi h he hypo he ical
budge s ha would esul unde he p oposed PBRA. In hei analyses, O’Malley e
al. (2023) examine he impac he PBRA o mula would ha e on acu e public
hospi als, p ima y ca e, social inclusion, pallia i e ca e, men al heal h and olde
peoples’ se ices. Fo he sake o b e i y, ou examples will p ima ily ocus on
acu e public hospi al ca e.
3.4.1 Popula ion
In line wi h PBRA o mulae used in e na ionally, he popula ion o each HR
(𝑃𝑟𝑜𝑗𝑃𝑜𝑝𝐻𝑅) is he s a ing poin in he esou ce alloca ion decision wi hin he
I ish p oposed PBRA o mula. Popula ion will ha e he la ges impac on he
dis ibu ion o esou ces using his o mula, as Figu e 3.5 shows la ge a ia ion in
popula ion ac oss each HR. O e all, HR A (Dublin & No h Eas ) has he la ges
popula ion, wi h HR E (Mid Wes ) ha ing he smalles popula ion.

36 | Popula ion-based esou ce alloca ion in I eland
FIGURE 3.5 PERCENTAGE OF POPULATION BY HSE HEALTH REGION
Sou ce: O’Malley e al. (2023).
Figu e 3.6 illus a es he acu e public hospi al unding alloca ion once HR
popula ion is adjus ed o . In gene al, as would be expec ed, he inclusion o
popula ion does esul in changes in unding alloca ions ac oss HRs. Howe e , he
changes seen o acu e ca e a e ela i ely small ( wo pe cen age poin s o less).
FIGURE 3.6 ACUTE PUBLIC HOSPITAL FUNDING ALLOCATION, POPULATION ADJUSTED
Sou ce: O’Malley e al. (2023)
22.7%
20.8%
18.9%
14.5%
8.2%
14.9%
0%
5%
10%
15%
20%
25%
HR A
(Dublin & No h
Eas )
HR B
(Dublin &
Midlands)
HR C
(Dublin and Sou h
Eas )
HR D
(Sou h Wes )
HR E
(Mid Wes )
HR F
(Wes & No h
Wes )
24%
22%
17%
13%
7%
17%
23.0%
20.9%
18.9%
14.4%
8.0%
14.8%
0%
5%
10%
15%
20%
25%
HR A HR B HR C HR D HR E HR F
Ac ual Popula ion Adjus ed
P oposed HSE Heal h Regions and PBRA o mula | 37
No weigh ing is used in he adjus men o he popula ion s uc u e o HRs o
acu e ca e o o he se ices examined in O’Malley e al. (2023). Fo olde peoples’
se ices, he popula ion aged 65+ wi hin each HR is used in lieu o he wide
popula ion, as hese se ices a e a ge ed o his age g oup.
The adjus men based on HR popula ion size is elian on eadily a ailable da a
p o ided by he CSO om he na ional census. O e a sho e - e m ho izon ( wo
o i e yea s), i would be expec ed ha he sha es o popula ion wi hin each HR
would no change o a la ge ex en . Howe e , he size o he I ish popula ion has
been inc easing in ecen yea s, la gely due o inc eases in ne mig a ion among
he wo king age popula ion and imp o emen s in li e expec ancy a olde ages
(Walsh e al., 2021). The e o e, elying on popula ion p ojec ions p o ided by he
Cen al S a is ics O ice (CSO), o using he COSMO model (which models e ili y,
mig a ion and li e expec ancy) loca ed a he ESRI (Walsh e al., 2021; Be gin e al.,
2024), will p o ide accu a e medium- e m popula ion p ojec ions. This will allow
heal hca e policymake s o exploi a key bene i o PBRA mechanisms: mul i-yea
budge s. This would be o conside able impo ance, and ollows calls by he I ish
Fiscal Ad iso y Council (Casey e al., 2021) and o he s o de ine sho - o medium-
e m budge s o emo e some o he unde budge ing and o e spends ha a e
common wi hin he heal h budge .
3.4.2 Age and sex index
The second pa ame e , 𝐴𝑔𝑒_𝑆𝑒𝑥𝐼𝑛𝑑𝑒𝑥𝐻𝑅, included in he o mula is he age and
sex p o iles o each HR. This e lec s he impac age and sex ha e on heal hca e
u ilisa ion and cos s. The PBRA o mula uses heal hca e cos s pe capi a o each
age g oup ( i e-yea age bands) and o bo h males and emales. These age–sex
heal hca e cos p o iles a e based in pa on p e ious ESRI esea ch using he
Hippoc a es model (Keegan e al., 2020; Walsh e al., 2021) and esea ch on
pallia i e ca e (May e al., 2019). These pe capi a cos p o iles a e subsequen ly
compa ed o he na ional a e age pe capi a cos , o es ima e ela i e age–sex
p o iles.
Figu e 3.7, using he age g oups examined in O’Malley e al. (2023), shows li le
a ia ion in he age composi ion o he six HR popula ions. HRs A and B ha e he
smalles pe cen age o people aged 70+, which may educe he le el o esou ces
o ca e o olde people equi ed in hese HRs compa ed o o he egions.
38 | Popula ion-based esou ce alloca ion in I eland
FIGURE 3.7 PERCENTAGE OF POPULATION IN EACH AGE GROUP BY HSE HEALTH REGION
Sou ce: Au ho s’ calcula ions.
Figu e 3.8 illus a es he acu e public hospi al unding alloca ion once he age and
sex cos p o iles o acu e public hospi al ca e in I eland a e adjus ed o . In he case
o acu e public hospi al unding, hese adjus men s ha e a simila e ec on unding
alloca ions as he popula ion adjus men .
FIGURE 3.8 ACUTE PUBLIC HOSPITAL FUNDING ALLOCATION, AGE AND SEX ADJUSTED
Sou ce: Au ho s’ calcula ions.
No addi ional weigh ing is applied o he age–sex p o iles wi hin he p oposed
o mula.
28% 28% 27% 27% 28% 28%
64% 65% 63% 63% 63% 62%
8% 7% 10% 10% 10% 10%
0%
20%
40%
60%
80%
100%
HR A HR B HR C HR D HR E HR F
0-19 20-69 70+
24%
22%
17%
13%
7%
17%
22.0%
19.8% 19.6%
14.7%
8.2%
15.6%
0%
5%
10%
15%
20%
25%
HR A HR B HR C HR D HR E HR F
Ac ual Popula ion Adjus ed Age Sex Adjus ed
P oposed HSE Heal h Regions and PBRA o mula | 39
Simila o popula ion da a, he e exis s g anula in o ma ion on HR popula ions by
age and sex, and changes o he demog aphic p o ile can be modelled wi hin CSO
and ESRI popula ion p ojec ions. This ea u e once mo e poin s o he abili y o
heal hca e policymake s o o mula e mul iannual budge s using his PBRA
app oach.
3.4.3 Dep i a ion
A ea-le el dep i a ion is a key ac o in he p oposed o mula, and he hi d
pa ame e included in he o mula. The de e mina ion o wha dep i a ion
measu e o include when calcula ing he PBRA mechanism o I eland is, in pa ,
based upon a ailable da a. O’Malley e al. (2023) use he Pobal HP (Hasse and
P a schke) Dep i a ion Index, based upon he Small A ea Popula ion S a is ics
(SAPS) om Census 2016 and 2022. The Pobal HP Dep i a ion Index uses da a om
he na ional censuses o assess a ious socioeconomic indica o s a a egional
le el, and i one o he mos commonly used dep i a ion indices in public policy
esea ch in I eland (Whelan e al., 2023).
The Pobal HP Dep i a ion Index has h ee dimensions o ad an age:
• demog aphic p o ile o each small a ea popula ion (e.g., pe cen age o
households wi h child en aged unde 15 yea s and headed by a single
pa en );
• social class p o ile ( he pe cen age o he popula ion wi h a hi d le el
educa ion); and
• labou ma ke pa icipa ion (e.g., unemploymen a e).
O en, he HP Index sco e is pa i ioned in o decile o quin ile a iables ha
appo ion SAPS and hei popula ions o speci ic quin iles (deciles), based upon
whe e hey a e anked on he dep i a ion index. This allows o pa icula ocus on
he mos dep i ed popula ions – hose seen as being e y o ex emely
disad an aged.
The HP Dep i a ion Index is also included in many su eys including he HIS and
has been used p e iously o examine heal h ac oss g oups (Walsh e al., 2020;
Walsh e al., 2022). Using Wa es 1–5 o he HIS, Figu e 3.9 iden i ies he pe cen age
o adul s in each HR li ing in he mos dep i ed quin ile (mos dep i ed 20% o he
na ional popula ion). We ind ha HRs A and F a e he mos dep i ed HRs, wi h
23.1 pe cen and 24.2 pe cen espec i ely li ing in he mos dep i ed quin ile.
HR D is he leas dep i ed HR. These di e ences in dep i a ion show he
impo ance o accoun ing o dep i a ion o socioeconomic inequali ies wi hin he
PBRA.
40 | Popula ion-based esou ce alloca ion in I eland
FIGURE 3.9 DEPRIVATION BY HSE HEALTH REGION
Sou ce: Au ho s’ calcula ions o Heal hy I eland Su ey Wa es 1–5.
Wi hin he p oposed PBRA o mula, a dep i a ion ela i e sco e is es ima ed, in
which SAPS is di ided in o eigh ca ego ies, om ex emely a luen o ex emely
disad an aged. This measu e is also included in HIS o es ima e dep i a ion o each
esponden . The p oposed o mula used de ined dep i a ion weigh s.
• A weigh ing o 1 is applied o indi iduals who a e ca ego ised as no being
disad an aged.
• A weigh ing o 2 is applied o indi iduals who a e ca ego ised as
disad an aged.
• A weigh ing o 3 is applied o indi iduals who a e ca ego ised as e y
disad an aged.
• A weigh ing ac o o 4 is applied o indi iduals who a e ca ego ised as
ex emely disad an aged.
The dep i a ion index included is hen compa ed o he na ional a e age and
no malised as app op ia e.
Figu e 3.10 illus a es he acu e public hospi al unding alloca ion once he
dep i a ion weigh ing ou lined abo e is adjus ed o . In he case o acu e public
hospi al unding, hese adjus men s ha e a simila e ec on unding alloca ions as
he popula ion adjus men .
23.1% 22.1% 22.4%
17.5%
22.4%
24.2%
0%
5%
10%
15%
20%
25%
HR A HR B HR C HR D HR E HR F

P oposed HSE Heal h Regions and PBRA o mula | 41
FIGURE 3.10 ACUTE PUBLIC HOSPITAL FUNDING ALLOCATION, DEPRIVATION ADJUSTED
Sou ce: Au ho s’ calcula ions.
Howe e , as discussed by Penno e al. (2013), a numbe o di e en dep i a ion
and socioeconomic measu es, and weigh ings, a e used ac oss PBRA mechanisms
in e na ionally.
In he pas in I eland, di e en dep i a ion indices and weigh ings we e used o
esou ce alloca ion decisions and ecommenda ions in heal h. In 2006, he HSE
in oduced a simple esou ce alloca ion o mula o y o alloca e esou ces mo e
e icien ly and equi ably o adul communi y men al heal h eams (Vega e al.,
2010). This app oach es ima ed dep i a ion a he local (elec o al di ision le el)
and used he Small A ea Heal h Resea ch Uni Dep i a ion Index de eloped by D
Alan Kelly a T ini y College Dublin in he 1990s.
8
I applied highe weigh s o he
mos dep i ed a eas. Simila ly, dep i a ion was used by he HSE in hei o mula o
de e mine he loca ion o new P ima y Ca e Cen es, which also placed impo ance
on he dep i a ion o local a eas.
9
Ou side o heal hca e, one o he mos impo an uses o dep i a ion ela es o
educa ion and he DEIS (Deli e ing Equali y o Oppo uni y in Schools) scheme
(Depa men o Educa ion, 2022). The Depa men o Educa ion speci ically a ge s
esou ces o DEIS schools, which ca e o s uden s in a eas o high dep i a ion,
aiming o mi iga e he educa ional challenges and disad an ages associa ed wi h
8
See h ps://www. cd.ie/media/ cd/medicine/public-heal h-p ima y-ca e/pd s/sah u- epo -1997.pd .
9
The HSE s a ed ha whe e loca ions had equal sco es, hei ankings we e hen based on he dep i a ion index sco e.
See h ps://www.audi .go .ie/en/ ind- epo /publica ions/2019/2018-annual- epo -chap e -15-de elopmen -o -
p ima y-ca e-cen es.pd .
24%
22%
17%
13%
7%
17%
21.7% 20.2% 19.3%
14.1%
8.4%
16.3%
0%
5%
10%
15%
20%
25%
HR A HR B HR C HR D HR E HR F
Ac ual Popula ion Adjus ed Age Sex Adjus ed Dep i a ion Adjus ed
42 | Popula ion-based esou ce alloca ion in I eland
socioeconomic backg ound. The DEIS o mula also uses he HP Dep i a ion Index
bu applies di e en weigh s o hose chosen in O’Malley e al. (2023).
The DEIS o mula uses de ined dep i a ion weigh s applied o indi iduals based
upon hei loca ion o esidence.
• A weigh ing o 0 is applied o indi iduals li ing in loca ions ha a e
ca ego ised as no being disad an aged (ex emely a luen , e y a luen ,
a luen and ma ginally abo e a e age).
• A weigh ing o 0.5 is applied o indi iduals li ing in loca ions ha a e
ca ego ised as being ma ginally below a e age.
• A weigh ing o 1 is applied o indi iduals li ing in loca ions ha a e
ca ego ised as disad an aged.
• A weigh ing o 2 is applied o indi iduals li ing in loca ions ha a e
ca ego ised as e y disad an aged and ex emely disad an aged.
Figu e 3.11 illus a es he acu e public hospi al unding alloca ion using he
weigh ing applied in O’Malley e al. (2023), and applying he DEIS weigh ing o he
acu e public hospi al unding ac oss HRs.
FIGURE 3.11 ACUTE PUBLIC HOSPITAL FUNDING ALLOCATION, DEPRIVATION ADJUSTED USING DEIS
FORMULA
Sou ce: Au ho s’ calcula ions.
In p esen ing his exe cise in Figu e 3.11, he in en ion is no o pu o wa d he
DEIS weigh ing as mo e app op ia e han o he s. Bu i does show ha u he
examina ion o app op ia e weigh ing is equi ed as he changes in unding di e
ac oss weigh ings. The DEIS app oach o inclusion o dep i a ion has been used
now o a numbe o yea s, and one o he impo an elemen s o he DEIS
21.7% 20.2% 19.3%
14.1%
8.4%
16.3%
20.8% 20.5%
18.5%
12.9%
9.0%
18.2%
0%
5%
10%
15%
20%
25%
HR A HR B HR C HR D HR E HR F
Dep i a ion Adjus ed
(O'Malley e al., 2023)
Dep i a ion Adjus ed
(DEIS)
P oposed HSE Heal h Regions and PBRA o mula | 43
p og amme is ha e alua ion was buil in o he p og amme om i s incep ion
(Smy h e al., 2015).
The e is ela i e s abili y in dep i a ion wi hin an a ea o e ime. All CSO censuses
now cap u e dep i a ion a egula ( i e-yea ) in e als. Once mo e, he da a on
dep i a ions poin o he abili y o heal hca e policymake s o o mula e
mul iannual budge s using his PBRA app oach.
3.4.4 Ru ali y index
Finally, a u ali y index is applied o he o mula. The model includes a iables
based upon he pe cen age o he popula ion wi hin each HR ha li es in a highly
u al/ emo e a ea, using in o ma ion om Census 2016. This measu e is gi en a
weigh ing o wo.
10
Once mo e, he u ali y index is compa ed o he na ional
a e age and no malised as app op ia e. The deg ee o u ali y o an a ea will
emain ela i ely cons an o e ime, he e o e no impeding medium- e m
budge ing; howe e u ali y de ini ions may change o e he longe e m.
3.4.5 Impac o popula ion-based esou ce alloca ion o mula on acu e
and p ima y ca e budge s
Combining all o he pa ame e s abo e, O’Malley e al. (2023) compa e 2021
budge s alloca ed ac oss HRs o he coun e ac ual budge ha would occu unde
he p oposed PBRA. The au ho s compa e budge alloca ions o a numbe o
di e en sec o s, including acu e hospi als and p ima y ca e. We show he impac
he adjus men s ha e on bo h he acu e and p ima y unding alloca ions in Figu e
3.12. O e all, o bo h acu e hospi als and p ima y ca e, he ac ual budge s
p o ided in 2021 di e li le om he coun e ac ual budge ha would occu
unde he p oposed PBRA. Some no able excep ions o his a e seen. In HR A, he
budge o acu e hospi als would be six pe cen age poin s lowe unde he
p oposed PBRA scena io, while a educ ion o h ee pe cen age poin s would occu
in HR B. In con as , a h ee pe cen age poin s inc ease would occu in HRs E and
F.
In e es ingly, in hose HRs whe e PBRA would educe (inc ease) acu e heal hca e
budge s, he p oposed o mula would also inc ease ( educe) he HR’s p ima y ca e
budge . The e o e, i is possible ha some o he di e ences be ween he ac ual
and PBRA budge s o acu e ca e e lec he ela i e impo ance o acu e hospi als
in some HRs. This may be u he unde pinned by he ac ha he ela i e
10
As also shown in O’Malley e al. (2023), applying a u ali y index has only a small e ec on esou ce alloca ion o
acu e public hospi al and p ima y ca e. The e o e, we do no p o ide g aphical ep esen a ion o i s edis ibu i e
e ec in his sec ion. Howe e , based upon e idence om o he coun ies, accoun ing o emo eness is impo an
when alloca ing esou ces o communi y-based ca e and long- e m ca e, whe e heal hca e wo ke s such as home
ca e s and communi y nu ses may be equi ed o spend signi ican ime a elling o pa ien s.
44 | Popula ion-based esou ce alloca ion in I eland
impo ance o he acu e budge s is la ges in HRs A and B, which a e loca ed in pa
in Dublin and he Dublin commu e bel .
FIGURE 3.12 PERCENTAGE OF ACUTE HOSPITAL AND PRIMARY CARE HEALTHCARE EXPENDITURE BY ACTUAL
AND PBRA SCENARIOS ACROSS HSE HEALTH REGIONS, 2021
Sou ce: O’Malley e al. (2023).
3.5 OTHER POPULATION-BASED RESOURCE ALLOCATION FORMULA
CONSIDERATIONS
I is clea ha he PBRA o mula ou lined in he p e ious sec ion ep esen s a
signi ican s ep o wa d o I ish heal hca e and will ha e a conside able impac on
heal hca e unding, and heal h and social ca e p o ision in I eland. Fu he mo e,
he PBRA o mula empla e is well conside ed and many o he pa ame e s
adop ed wi hin he o mula ma ch hose in coun ies wi h mo e sophis ica ed and
embedded PBRA. Howe e , some changes may be equi ed p io o he
in oduc ion o PBRA o , mo e ealis ically, in u u e i e a ions o he o mula, o
imp o e i s e ec i eness. Below we iden i y o he o mula pa ame e s o ea u es
ha policymake s in I eland may need o conside . Whe e app op ia e, we p o ide
op ions and lessons om o he coun ies, as examined in Chap e 2.
3.5.1 Heal h
The heal h and well-being o a popula ion, and he demand o heal h and social
ca e, a e closely ela ed o demog aphic ac o s such as age, sex and dep i a ion,
al eady accoun ed o wi hin he PBRA o mula. Fo example, he age and sex cos
-6%
3%
-3%
1% 1% 0% 1% 0% 3%
-3%
3%
-1%
-10%
-5%
0%
5%
10%
15%
20%
25%
Acu e
Hospi al
P ima y
Ca e
Acu e
Hospi al
P ima y
Ca e
Acu e
Hospi al
P ima y
Ca e
Acu e
Hospi al
P ima y
Ca e
Acu e
Hospi al
P ima y
Ca e
Acu e
Hospi al
P ima y
Ca e
HR A HR B HR C HR D HR E HR F
2021 Ac ual PBRA Di
P oposed HSE Heal h Regions and PBRA o mula | 51
FIGURE 3.16 MEDICAL CARD COVERGE, PHI STATUS AND GP AND INPATIENT CARE DEMAND
Sou ce: Heal hy I eland Su ey, Wa es 1–5.
No es: N: GP isi s=25,669; inpa ien days=22,055. Resul s p esen ed as addi ional demand (a e age ma ginal e ec s) om
a linea eg ession. Reg essions con ol o age, age squa ed, sex and dep i a ion quin ile.
Pa ame e s such as he medical ca d a e no ea u es o he PBRA o mula ound
in o he coun ies, which may be a eason why hey ha e no been included wi hin
he p oposed PBRA o mula. Howe e , he uniqueness o he I ish heal hca e
sys em, and he clea e idence ha medical ca ds a e associa ed wi h highe
demand o heal hca e, sugges s ha policymake s should examine he inclusion
o medical ca d co e age when de e mining esou ce alloca ions. As discussed in
subsec ion 3.5.4, in o de o some expendi u e o be included wi hin he PBRA,
accoun ing o medical ca ds wi hin HRs may also be equi ed. I is ecommended
ha , as pa o e alua ions o PBRA, u he e alua ions o he po en ial o
accoun ing o medical ca d holde s wi hin u u e i e a ions o he PBRA o mula
a e made.
3.5.3 Weigh ing ac o s
Weigh ing ac o s a e commonly used in PBRA o mulae o accoun o addi ional
unds equi ed o mee heal hca e objec i es. They a e o en coun y-speci ic and
selec ed based on empi ical e idence (Dide ichsen 2004). The mos common
weigh ing ac o is cos , which can be inco po a ed as a u ali y, socioeconomic
s a us/dep i a ion, unme need, o demog aphic weigh ing. The mos common
cos weigh s a e weigh s based upon age and sex indices, which ake accoun o
he di e ing heal hca e needs ac oss di e en age g oups, and be ween males and
emales, o en a ying by sec o and in o med by empi ical e idence. Gene ally, as
olde age g oups ha e a g ea e need o heal hca e, models gi e g ea e weigh
o a eas wi h olde popula ions (NHS Sco land, 2020; Sundquis e al., 2003).

52 | Popula ion-based esou ce alloca ion models o I eland
Simila ly, u ali y cos weigh ing is included ac oss all coun ies s udied (wi h he
excep ion o Sweden) o accoun o addi ional cos s associa ed wi h p o iding
ca e in u al a eas. In Sco land, a u ali y cos weigh accoun s o una oidable
cos s associa ed wi h deli e ing ca e in u al a eas. I is based on sepa a e
emo eness adjus men s o communi y and hospi al se ices, and de e mined by
a simula ion model o addi ional a el equi emen s (NHS Sco land, 2020). In New
Zealand, he u ali y cos weigh ing is de e mined by: he u ali y p emium and
diseconomies o scale paymen s o small hospi als in emo e o u al loca ions;
paymen s made o p ac ices in u al a eas o assis in GP ec ui men and
e en ion; and p ice p emia paid o u al ma e ni y p o ide s whe e he olume o
bi hs is below he h eshold le el (Minis y o Heal h, 2004). In England, he model
accoun s o highe cos s in u ban and densely popula ed a eas h ough hei
ma ke o ces ac o (MFF). The MFF cos s in England a e based on s a , building
and land cos s, and highe London pay cos s. The s a MFF is calcula ed by an
analysis o he ac ual cos s bo ne by NHS o ganisa ions and examina ion o egional
a ia ions in pay a es in he p i a e sec o .
All models include a weigh ing o ecognise he di e en challenges in educing
dispa i ies be ween popula ion g oups h ough unme need and/o socioeconomic
s a us/dep i a ion. In New Zealand, he model includes addi ional cos weigh ing
o e hnici y. These cos weigh ings a e calcula ed by assessing expec ed agains
ac ual expendi u e, and an adjus men ac o is applied based on he di e ence
(Penno e al., 2013). In Aus alia, he models inco po a e addi ional weigh ing o
he Abo iginal and To es S ai Islande popula ions, wi h a weigh o 2.5 applied
pe indigenous pe son o e lec poo e heal h ou comes wi hin his g oup (New
Sou h Wales Heal h 2005).
In Sweden, unme need is weigh ed using hei Ca e Needs Index (CNI), wi h CNI
weigh s calcula ed o each decile o he popula ion (Sundquis e al., 2003). The
CNI uses a ange o indica o s (discussed in subsec ion 3.6.5), which a e
subsequen ly weigh ed by a su ey o Swedish GPs’ wo kload associa ed wi h each
ac o (Malms öm e al., 1998). Simila ly, in Sco land, he mo bidi y and li e
ci cums ances (MLC) index gi es mo e weigh o a eas wi h highe p ema u e
dea h a es and g ea e socioeconomic dep i a ion, o accoun o he addi ional
heal hca e esou ces equi ed o comba such inequali ies (NHS Sco land, 2020).
I is ecommended ha , when e alua ing he p oposed PBRA o mula o I eland,
u he e alua ions o weigh s applied o age and sex emain based upon heal h
and social ca e cos p o iles. Fu he mo e, as discussed in subsec ion 3.4.3, a e-
examina ion o weigh s applied o dep i a ion is ecommended, wi h a speci ic
examina ion o weigh s used o in o m he DEIS p og amme o educa ion.
P oposed HSE Heal h Regions and PBRA o mula | 53
3.5.4 Top slicing – Se ices excluded
I will no be possible, o app op ia e, o include all heal h and social ca e se ices
wi hin PBRA o mulae. Commonly used in esou ce alloca ion models (McCa hy e
al., 2022), op slicing e e s o he p ac ice o se ing aside a p opo ion o he
o e all budge o speci ic pu poses be o e alloca ing he es acco ding o he
s anda d alloca ion o mula. In gene al, op slicing occu s in p og ammes ha may
equi e specialised concen a ed esponses, o en a a na ional le el. In Sco land,
he go e nmen se s aside, o ‘ op slices’, e enue unding o speci ied na ional
se ice such as he Sco ish ambulance se ice be o e dis ibu ing he emaining
alloca ions o NHS boa ds.
15
In addi ion, capi al expendi u e does no end o be
included wi hin PBRA o mulae ac oss hose coun ies examined in Chap e 2.
Howe e , excessi e op slicing can cause subs an ial issues o conce n. In he case
o HRs and PBRA in I eland, a key ac o unde pinning hese changes ela es o
in eg a ing se ices and pa hways o ca e. Bu exclusion o key heal h and social
ca e se ices can impede he abili y o hese s uc u es o c ea e in eg a ed ca e
pa hways. Case s udy 3 (subsec ion 3.2.3) o example highligh ed he impac he
lack o in eg a ion be ween social ca e and acu e ca e can ha e on he use o acu e
public hospi al ca e, and how his can educe he e ec i eness o unding
mechanisms such as ABF. We e excessi e op slicing o occu , his may indi ec ly
esul in inequi able alloca ions o included se ices.
In hei epo , O’Malley e al. (2023) ecommended ha o e he sho o medium
e m, only acu e public hospi al and communi y expendi u e should be subjec o
he p oposed PBRA o mula. A key issue wi h his ecommenda ion is ha a
subs an ial pe cen age o public heal h and social ca e expendi u e lies ou side o
he p oposed PBRA mechanism. Table 3.1 ou lines he key a eas, as de ailed in
O’Malley e al. (2023), ha a e ini ially p oposed o be included in PBRA. O e all,
unde he p oposed o mula, almos hal o all public heal h and social ca e
expendi u e will emain ou side he PBRA. La ge sec o s such as he acu e public
hospi al sec o (€5.11bn), men al heal h (€0.97bn) and olde peoples’ se ices
(€0.90bn) will be included in he o mula. Mos no ably, he Nu sing Home Suppo
Scheme (NHSS, €0.99bn), disabili y se ices (€1.99bn) and PCRS (€2.80bn)
expendi u e a e also no be included in he p oposed PBRA mechanism.
15
See h ps://www.nss.nhs.sco /media/1063/nsd602-00101.pd .
54 | Popula ion-based esou ce alloca ion models o I eland
TABLE 3.1 PUBLIC HEALTHCARE EXPENDITURE INCLUDED AND NOT INCLUDED IN PROPOSED
PBRA MECHANISM
Included in PBRA (€000s)
No Included in PBRA (€000s)
Hospi al G oup expendi u e
5,110,908
Child en’s Heal h I eland
347,771
P ima y ca e
886,051
Acu e egional and na ional se ices
8,136
Social inclusion
161,149
Na ional Ambulance Se ice
171,204
Pallia i e ca e
87,577
Nu sing Home Suppo Scheme
986,202
Men al heal h di ision
986,833
Disabili y se ices
1,992,614
Olde peoples’ se ices
889,246
P ima y Ca e Reimbu semen Scheme
2,798,048
O he communi y se ices
20,621
O he
1,802,082
To al
8,142,385
To al
8,106,057
Sou ce: O’Malley e al. (2023).
The op slicing o se ices such as Child en’s Heal h I eland (CHI) and he Na ional
Ambulance Se ice is based upon he specialisa ion o hese se ices, and he ac
ha hey o en co e na ional popula ions. Simila op slicing o hese se ices also
occu s in o he coun ies. Howe e , as PBRA mechanisms ma u e wi hin coun ies,
many such se ices o en ge abso bed in o PBRA. Ambulance se ices o ins ance
ha e been included in he NHS England PBRA o mulae in mo e ecen yea s (NHS
England, 2023).
Ea lie , we discussed how he es uc u ing o he HSE will e ol e a ound he
es ablishmen o HSE HRs, wi h a cen alised HSE body emaining. The mos ecen
HSE HR implemen a ion plan p o ides de ails on he esponsibili ies o his cen al
HSE body in he con ex o PBRA, p oposing ha he HSE Cen e:
… will plan, esou ce, and deli e a small c oss-sec ion o se ices,
namely, na ional se ices (e.g. Na ional Ambulance Se ice, Na ional
Sc eening Se ices, Na ional En i onmen al Heal h Se ice, and he
Na ional O ice o Suicide P e en ion) and na ional sha ed se ices
(e.g. PCRS, S a u o y Home Suppo Scheme), which would no be
e icien o a single Heal h Region o deli e .
(Go e nmen o I eland e al., 2023)
The e o e, he se ices op sliced om he PBRA will e ec i ely be commissioned
and deli e ed by he HSE Cen e. Mo e de ail is needed on how he HSE Cen e and
he HRs will coo dina e o allow o de ol ed decision-making o in eg a ed ca e
o occu in p ac ice.
Two o he key sec o s no included in he p oposed o mula a e he PCRS and he
NHSS:
P oposed HSE Heal h Regions and PBRA o mula | 55
I is ecommended ha he Nu sing Home Suppo Scheme (NHSS o
‘Fai Deal’), he P ima y Ca e Reimbu semen Scheme (PCRS), and
Disabili y Se ices no be included in he ini ial applica ion o he PBRA.
(O’Malley e al., 2023)
I appea s ha a key eason why he NHSS and PCRS ha e been excluded om he
i s PBRA o mula ela es o da a issues. The epo is explici ha :
Wi h ega d o CHO expendi u e, NHSS is excluded om he PBRA
model in his p oposal as expendi u e da a does no appea o be
a ailable a he egional le el and he majo i y o nu sing homes in he
scheme a e p i a e, wi h p ices nego ia ed wi h he Na ional
T ea men Pu chase Fund (NTPF). PCRS is excluded o simila easons.
(O’Malley e al., 2023)
The PCRS and NHSS oge he accoun o o e 23 pe cen o o al HSE expendi u e
(Table 3.1). Exclusion o hese se ices esul s in an incomple e unding pic u e o
esou ce alloca ion in I eland. PBRA aims o alloca e esou ces based on popula ion
needs, including socioeconomic ac o s. Wi hou hese sec o s, any PBRA
mechanism will be less in o med by he ac ual esou ce needs o HRs, which may
exace ba e heal h inequali ies. The lack o inclusion o hese se ices may educe
he abili y o PBRA and HRs mo e gene ally o implemen key in eg a ed ca e
pa hways o impo an popula ion g oups.
P ima y Ca e Reimbu semen Scheme
The PCRS expendi u e co e s paymen s made o GPs unde he Gene al Medical
Se ices (GMS) Scheme o p o ide ca e o medical ca d and GP isi ca d holde s.
In addi ion, he PCRS includes expendi u e o pha macis s unde he D ugs
Paymen Scheme (DPS), he Long-Te m Illness (LTI) Scheme, he High Tech D ug
Scheme, o medical ca dholde s, and some publicly unded den al and au al ca e.
Pha maceu icals: The la ges pe cen age o PCRS expendi u e is spen on
pha maceu ical medica ions. The e is a clea cen alised componen o his
expendi u e. In pa icula , many o he decisions on nego ia ions o d ug p ices
a e made cen ally. I may be app op ia e o pha maceu ical expendi u e o
emain ou side he PBRA ini ially.
Gene al p ac ice: The exclusion o he PCRS om PBRA would e ec i ely esul in
GP ca e emaining ou side o he esou ce alloca ion mechanism in I eland. This
would be unique in an in e na ional con ex . Fo example, wi hin he NHS England
PBRA o mulae, GPs a e cen al ac o s and he popula ion and age and sex p o iles
o ICBs is based upon GP lis s wi hin an ICB, and GPs a e ea ed as key p o ide s
o ca e wi hin he sys em.
56 | Popula ion-based esou ce alloca ion models o I eland
The e a e a numbe o limi a ions o excluding GP ca e om he PBRA. GPs o en
ac as a p incipal agen in a pa ien ’s ca e pa hway, and as ga ekeepe s o o he
o ms o ca e; exclusion o GPs would he e o e g ea ly educe he PBRA’s
e ec i eness in e ms o imp o ing he e icien and equi able alloca ion o
heal hca e esou ces in I eland. In addi ion, new p og ammes such as he Ch onic
Disease Managemen P og amme and he As hma Cycle o Ca e o unde 8s we e
designed in pa o educe demand o acu e public hospi al ca e and imp o e he
ca e pa hways o ch onic disease pa ien s. Including GP expendi u e wi hin he
PBRA mechanism is impo an in o de o he bene i s o hese p og ammes o be
mo e e ec i ely inco po a ed wi hin PBRA.
I is ecommended ha e o s o include PCRS expendi u e on GP ca e and public
den al ca e wi hin he PBRA o mula a e made om he ou se o he es uc u ing
p ocess, using he in o ma ion ha is a ailable. In o de o include PCRS wi hin he
PBRA, we i s acknowledge ha he e a e da a limi a ions on expendi u es a he
egional le el. Poo da a and heal h in o ma ion sys ems ha e consis en ly
impeded e icien alloca ion o heal hca e in I eland (Walsh e al., 2021). Howe e ,
i is he au ho s’ unde s anding ha su icien in o ma ion is cu en ly collec ed o
colla ed by he PCRS, which can be used o de elop expendi u e da a a he HR
le el. Cu en ly, he PCRS cap u es qui e comp ehensi e da a on paymen s o GPs.
I should be possible o use hese da a o g oup ac i i y and expendi u e o he HR
using in o ma ion on he add ess o GPs, as well as in o ma ion on GMS pa ien s’
add esses. As highligh ed in hei online sys em,
16
he PCRS collec s and p o ides
high-le el da a on he numbe o con ac s wi h GPs, and he numbe o medical
ca d and GP isi ca d holde s by age and sex wi hin each LHO (which a e nes ed
wi hin HRs). While no as de ailed as he ABF in o ma ion a ailable in hospi als,
hese da a a e signi ican ly mo e de ailed han in o ma ion a ailable on mos
communi y ca e and men al heal h se ices (B ick e al., 2020; Walsh e al., 2021).
As acknowledged by he Depa men o Heal h (O’Malley e al., 2023) and he HSE
(HSE, 2021), inancing o GPs al eady inco po a es weigh ed capi a ion when
de e mining ees and allowances o GPs (age and sex a e accoun ed o ); his
should educe some ic ions when inco po a ing he PCRS GP expendi u e a he
HR le el. While including mo e de ailed in o ma ion (especially on non-capi a ion
paymen s) may be a la ge unde aking, coo dina ion wi h he PCRS, he CSO and
o he s akeholde s should be unde aken o e alua e how much in o ma ion can
be ga ne ed om he PCRS.
Den al ca e: The case made o including GP ca e can also be applied o den al ca e.
While no as in eg al o in eg a ed ca e pa hways as GP ca e, den al ca e is an
impo an heal hca e se ice. Examina ion o he in o ma ion a ailable on den al
16
See h ps://www.sspc s.ie/po al/annual- epo ing/.

P oposed HSE Heal h Regions and PBRA o mula | 57
p ac ice and GMS pa ien s should be unde aken o assess he iabili y o using his
in o ma ion.
Nu sing Home Suppo Scheme
Including se ices o olde people (e.g., home suppo , day cen es, e c.) wi hin
he p oposed PBRA, while excluding he NHSS, is likely o impac he e ec i eness
o in eg a ing hese se ices, pa icula ly in he con ex o any new S a u o y Home
Suppo Scheme. We acknowledge once mo e ha da a limi a ions may exis ,
which could inhibi he inclusion o NHSS expendi u e in he PBRA o mula.
Howe e , we ecommend a ho ough examina ion o he da a a ailable on he
NHSS o es ima e HR-le el expendi u e on he NHSS. The da a a e collec ed by he
HSE, and pa icula ly by he Na ional T ea men Pu chase Fund (NTPF), which plays
a cen al ole in he NHSS. Iden i ica ion o such da a may help wi h he po en ial
inclusion o he NHSS in o he PBRA mechanism.
The NTPF plays a key ole in de e mining expendi u e on he NHSS. While hey do
no nego ia e NHSS bed paymen s o public long- e m esiden ial ca e (LTRC)
homes, as hese a e de e mined by he HSE, hey do nego ia e NHSS bed paymen s
o p i a e ( olun a y and o -p o i ) LTRC homes. In hei 2021 e iew o he NHSS
p icing sys em, he NTPF ou lined ha hey nego ia e paymen s made o p i a e
LTRC homes based on ou c i e ia:
• cos s incu ed by he LTRC home and e idence o alue o money;
• p ices p e iously cha ged by he LTRC home;
• he local ma ke p ice o NHSS paymen s; and
• ‘[b]udge a y cons ain s and he obliga ion on he S a e o use a ailable
esou ces in he mos bene icial, e ec i e and e icien manne o imp o e,
p omo e and p o ec he heal h and wel a e o he public’ (NTPF, 2021).
Wi hin he NHSS p icing mechanism, he NTPF uses a coun y-speci ic benchma k,
known as he ‘local ma ke p ice’, as one o i s ou p ima y c i e ia o se ing
paymen s o LTRC homes. This me hod ypically leads o minimal a ia ion in
paymen s wi hin a coun y o p i a e LTRC homes. Howe e , he e is no iceable
a ia ion ac oss di e en coun ies. This benchma king app oach is also employed
in de e mining paymen a es o new LTRC homes en e ing in o NHSS ag eemen s
(NTPF 2021).
The au ho s belie e ha he e a e su icien da a cu en ly a ailable – collec ed by
he NTPF (and he HSE o public LTRC homes) – o enable he inclusion o he NHSS
wi hin he PBRA. Da a a e cu en ly a ailable on he age and sex b eakdown o
NHSS esiden s ac oss LHOs, as is he NHSS p ice paid o ca e deli e ed wi hin
LTRC homes. Ine i able, he e will be da a limi a ions, such as hose a ising om
some LTRC homes ha ing esiden ca chmen a eas ou side o hei HR, and he
ac ha nego ia ions be ween he NTPF and LTRC home p o ide s may lead o
58 | Popula ion-based esou ce alloca ion models o I eland
luc ua ions in he amoun paid o p i a e LTRC homes o e ime. Howe e , a
ho ough examina ion o hese da a should p o ide a eliable ounda ion o
in eg a ing NHSS expendi u e in o he PBRA mechanism.
3.5.5 C oss-bounda y lows
The HRs a e de ined geog aphic egions; none heless, i is possible ha some
pa ien s (o LTRC esiden s) li ing wi hin one HR may use se ices p o ided wi hin
ano he HR, especially acu e public hospi als. This a ec s he accu acy o
popula ion, age, and sex adjus men s used in he PBRA o mula. These ‘c oss-
bounda y lows’ o pa ien s, howe e , a e common in all coun ies examined in
Chap e 2. Some PBRA o mulae explici ly add ess c oss-bounda y lows in hei
PBRA o mulae. Fo example, NHS England accoun s o indi iduals egis e ed wi h
a GP p ac ice in one ICB a ea bu esiding in ano he (NHS England, 2023). This
me hod acknowledges pa ien mo emen ac oss ICB bounda ies, hus ensu ing
ha esou ce alloca ion e lec s ac ual heal hca e se ice use, no jus he
egis e ed loca ion o pa ien s. This app oach is c ucial o accu a ely dis ibu ing
esou ces and planning heal hca e se ices, as i accoun s o he dynamic na u e
o pa ien lows ac oss egions.
Figu e 3.17, based on O’Malley e al. (2023), shows ha a signi ican pe cen age o
acu e public hospi alisa ions occu o pa ien s wi h home add esses ou side o
hei HR, a ac o ha may a ec he PBRA. No ably, he highes pe cen age o
c oss-bo de lows is seen in HRs ha include pa s o Dublin.
FIGURE 3.17 PERCENTAGE OF HOSPITAL DISCHARGES FROM PATIENTS OUTSIDE A HSE HEALTH REGION
Sou ce: O’Malley e al., (2023).
The issue o c oss-bounda y lows is likely o impac he PBRA un il su icien heal h
in o ma ion sys ems a e inco po a ed in o he heal hca e sys em. De eloping
12.9% 14.9%
43.9%
6.4% 4.9% 5.6%
0%
10%
20%
30%
40%
50%
HR A HR B HR C HR D HR E HR F
P oposed HSE Heal h Regions and PBRA o mula | 59
in eg a ed heal h in o ma ion sys ems ha acili a e da a sha ing be ween HRs,
and wi h specialised se ice p o ide s (e.g., Child en’s Heal h I eland), would
enable mo e accu a e acking o pa ien lows and esou ce u ilisa ion. Howe e ,
o e he longe e m, be e da a and heal h in o ma ion sys ems will be equi ed
o educe he impac o c oss-bounda y lows, and simila app oaches ha e been
aken by NHS England.
3.5.6 T ansi ions
As highligh ed in Figu e 3.12, implemen ing PBRA would esul in some HRs
ecei ing mo e o less unding, o di e en se ices, han is cu en ly he case.
Implemen ing PBRA quickly would lead o sha p shocks o HRs and se ices ha
would he eby ecei e unding cu s. Fo his eason, ansi ioning om he cu en
unding s uc u es o PBRA needs o ake ime. The e a e in e na ional examples
on how bes o inco po a e ansi ions. In mo ing om CCG o ICB s uc u es in
NHS England, o example, a con e gence p ocess was c ea ed whe eby ICBs a e
o be g adually mo ed om hei ini ial unding le els o a ge alloca ions
de e mined by he upda ed o mula. This ensu es ha sudden inancial impac s
can be a oided and con inui y o heal hca e se ices o pa ien s and popula ions
is achie ed (NHS England, 2023). I is clea om he abo e ha a ansi ion pe iod,
and app op ia e ansi ion adjus men s, would be needed o allow o PBRA o
become accep ed. T ansi ion adjus men s emain a pa o ABF wi hin acu e public
hospi als. Re iewing how hese ansi ion adjus men s wo k in p ac ice would be
aluable.
3.5.7 Go e nance and o e sigh
Go e nance and o e sigh – o he PBRA and he ansi ion o HRs – will be i al o
he success o each. This is especially so conside ing i is likely ha a numbe o
i e a ions o he PBRA o mulae will be equi ed p io o i being embedded wi hin
he heal hca e sys em, and o he ue bene i s o acc ue. The Depa men o
Heal h ecommends a pe manen ad iso y g oup be es ablished (O’Malley e al.,
2023). This ollows s anda d p ac ice in o he coun ies. An impo an elemen o
he NHS England o mulae is he le el o o e sigh in ol ed. In gene al, he
esou ce alloca ion p ocess is o e seen by he Ad iso y Commi ee on Resou ce
Alloca ion (ACRA). A simila s uc u e in used in Sco land. The ACRA e iews he
o mula and decisions, using e idence om academic li e a u e and in o ma ion
on he la es da a and heal hca e ends. ACRA comp ises independen expe s,
including om academia, and ad ises he sec e a y o s a e o heal h and social
ca e and he chie execu i e o NHS England. Many o he discussions and
ecommenda ions in his epo also poin o he impo ance o anspa ency in
ela ion o how decisions a e made. Inpu om a b oad ad iso y g oup would be
bene icial.
The PBRA could also lea n om o he alloca ion mechanisms in I eland. Fo
ins ance, wi hin educa ion, he DEIS p og amme has p og amme e alua ion buil
60 | Popula ion-based esou ce alloca ion models o I eland
in o i om i s incep ion (Smy h e al., 2015). A numbe o e alua ion s udies o
DEIS ha e been conduc ed by he Educa ional Resea ch Cen e, he Inspec o a e
o he Depa men o Educa ion and Skills and he ESRI (Smy h e al., 2015). These
e alua ions ha e highligh ed changes in bo h he s uc u e and p ocedu es o
schools in ol ed in he DEIS p og amme, as well as in s uden ou comes (Smy h e
al., 2015; Ka anagh e al., 2017). Speci ically, in e ms o school p ocesses, DEIS
schools ha e imp o ed hei planning o eaching and lea ning and ha e se
clea e academic achie emen objec i es.
Conclusions | 67
The de elopmen o a unique pa ien iden i ie , based upon pe sonal public se ice
numbe s and he Heal h In o ma ion Bill, will comp ise key de elopmen s o
de e mining accu a e popula ion and age in o ma ion o he PBRA. These ype o
da a a e used o good e ec in o he coun ies. In Sco land, o example,
popula ion sha es ac oss NHS boa ds a e based on he Communi y Heal h Index
(CHI) egis e ed popula ions, which a e inco po a ed in o popula ion p ojec ions.
19
4.3 CONCLUSION
The in oduc ion o a PBRA model in I eland has he abili y o g ea ly imp o e he
e icien and equi able alloca ion o heal h and social ca e esou ces. PBRA and
de ol ed decision-making a e also key aspec s o Sláin eca e. In combina ion wi h
he es ablishmen o HSE HRs, PBRA can become a ulc um owa ds he u he
de elopmen o a uni e sal heal hca e sys em and new models o inno a i e and
in eg a i e ca e. The i s PBRA o mula p oposed is o be welcomed and ollows
closely o mulae implemen ed by in e na ional pee s.
Howe e , imp o emen s o PBRA will be equi ed and PBRA i sel will be an
i e a i e p ocess ha may equi e ime o become embedded wi hin decision-
making (McCa hy e al., 2022; O’Malley e al., 2023). This is in ecogni ion o he
udimen a y alloca ion sys em ha cu en ly exis s, and he heal h in o ma ion
sys ems and da a challenges aced. Howe e , in es men o imp o e da a sys ems
is being unde aken, and as I eland mo es owa ds he inclusion o unique pa ien
iden i ie s and ca e summa y eco ds as p oposed in he Heal h In o ma ion Bill,
PBRA will in ime ha e he capabili ies o in eg a e mo e g anula in o ma ion in
he alloca ion p ocess.
In his epo , in addi ion o he in o ma ion challenges highligh ed, we iden i y
ha he le el o op slicing p oposed in O’Malley e al. (2023) may hinde he PBRA
e ec i eness, especially in e ms o in eg a ion o ca e. Exclusion o expendi u e
on he NHSS and publicly unded GPs ca e in pa icula will educe he abili y o
PBRA o pe o m o he le el o sys ems in o he coun ies. The in eg a ion o key
p og ammes including he PCRS, disabili y se ices and he NHSS should be
p io i ised by policymake s. Wi hou b oadening p og amme inclusion, local
decision-make s will s uggle o implemen in eg a ed ca e app oaches and
implemen he goals o Sláin eca e o p o iding ca e in he leas complex se ing,
as close o home as possible.
In coun ies wi h longe es ablished esou ce alloca ion mechanisms, he app oach
has mo ed om equali y o esou ce alloca ion o ou come-based ocus and
accoun abili y (Buck e al., 2013). Fu u e i e a ions o PBRA may also inco po a e
di e en app oaches as he ocus o commissioning and esou ce alloca ion shi s
19
See h ps://publicheal hsco land.sco /publica ions/ esou ce-alloca ion- o mula-n ac/ esou ce-alloca ion- o mula-
n ac- o -nhssco land- esul s- o - inancial-yea -2024- o-2025/.

68 | Popula ion-based esou ce alloca ion models o I eland
o ou comes, while decision-making and accoun abili y a e inc easingly de ol ed
o local a eas. This p ocess again will be hea ily dependen upon mo e
sophis ica ed heal h in o ma ion sys ems. This epo , alongside p e ious esea ch
(Johns on e al., 2021; McCa hy e al., 2022), has iden i ied impo an PBRA
app oaches in o he coun ies, which can be used as guides o he u u e
imp o emen o PBRA in I eland.
In conclusion, o e ecen decades he heal hca e sys em in I eland can be
cha ac e ised by he cons an changes o o ganisa ional s uc u es made o
p oposed. Many o hese changes we e inc emen al in na u e, and o en adequa e
ime was no p o ided o ensu e s uc u al changes became embedded wi hin he
sys em. Howe e , all o hese changes ailed o implemen a sys ema ic esou ce
alloca ion mechanism. The inclusion o PBRA wi hin he cu en p oposed
es uc u ing p ocess, he e o e, is welcome. While de eloping PBRA o mulae is
clea ly impo an , he mos di icul ac o is secu ing s akeholde ag eemen s and
embedding PBRA mechanisms ac oss he heal hca e sys em. I is i al ha he
in oduc ion o PBRA is no ea ed simply as an impo an key pe o mance
indica o (KPI), bu a he ha PBRA and HSE HRs ep esen he i s s age in a
mul i-yea p ocess o in eg a ion, coo dina ion and anspa ency, and de olu ion
o impo an decisions o local decision-make s.
Re e ences | 69
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