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Key Trends 2018 presents evidence from across the health sector of the progress made and the challenges that still exist in providing efficient and high-quality healthcare in Ireland. This research provides the background and context for the Department of Health’s work in creating legislation, policy and strategies to address these critical issues. This work is ongoing in the form of Sláintecare, which will work to systematically address these significant challenges to the health care system in the coming decade. Improving provisions for mental health, reducing pressure on health resources, limiting spending increases in the health system, supporting the uptake of generic medicines, and reducing hospital waiting lists are key targets for the coming years.

1.        We are living longer
Over the past decade we have added, on average, 3 months per year to our life expectancy, which is currently standing at 83.6 years for women and 79.9 years for men. (Table 1.6)

2.        The life expectancy gap between men and women has narrowed from 5.6 years to 3.7 years
Life expectancy at birth for women in Ireland was 3.7 years longer than for men in 2016; this has improved from a 5.6 year difference in 1996. (Table 1.6)

3.        Irish men are living longer than their European counterparts

Male life expectancy in Ireland has been above the EU average over the past decade. The life expectancy at birth for men in Ireland has been consistently greater than that of the EU average by over a year (Figure 1.6 and Figure 1.7). Female life expectancy in Ireland matches the EU average. 

4.        Increase in life expectancy is due to significant reductions in major causes of death such as circulatory system diseases and cancer
This decrease is particularly strong for mortality rates from stroke (-39%), breast cancer (-16%), suicide (-26%) and pneumonia (-39%) (Table 2.4). The overall mortality rate has reduced by 14.9% since 2008.

5.        We think we are healthier than our European neighbours
In 2016, 83% of Irish men and women rated their health as good or very good. This is the highest in the EU and compares with an average of 70% and 64% for males and females respectively across the EU. (Figure 2.3)

6.        We are getting better at curing cancer
There have been improvements seen in survival rates from breast, cervical, colon and rectal cancer in the last 15 years (Figure 2.11). However, with the exception of rectal cancer, 5-year net survival rates are lower in Ireland than the average for OECD countries where data is available. 

7.        We are seeing a reduction in deaths from suicide
There has been a 26% reduction in the mortality rate from suicide since 2008. After a rise in the male suicide rate from 2008 to 2012, the three-year moving average has decreased and the latest figures (2015) have fallen below the EU average for the first time since 2010. (Table 2.4, Figure 2.8)

8.        Men are more inclined to binge drink than women
Over half of Irish men binge drink on a typical day of drinking, compared to just under 20% of women in 2018. A gender gap is present across all age groups, but the highest rates of binge drinking among the 15-24 age group. (Figure 2.14)

9.        The average length of hospital stay is 5.6 days
From 2008 to 2014 the average length of stay decreased by 10.6%. It has since increased by 3.7%, with the average length of stay currently at 5.6 days. (Table 3.1a)

10.        The number of patients waiting for an Inpatient or Day Case procedure has fallen by 24%
The total number of patients waiting over 9 months for an inpatient or day case procedure has fallen by 5,300 or 24% since October 2017 to 15,523 as of Oct 2018. (Figure 3.2)

11.        11am to 2pm on a Monday is the busiest time for Irish emergency departments 
The highest attendances to hospital emergency departments occur between 9am and 5pm on weekdays, with Monday mornings between 11am and 1pm seeing the highest attendance volumes across the week. (Figure 3.5)

12.        Less than 2% of the population donate blood
Both the number of blood donations and the percentage of blood donors in the Irish population have declined in the past 5 years. The percentage of blood donors in the population in 2017 was 1.7%. (Figure 4.6)

Ends

Notes for Editors

This is the eleventh edition of this easy-to-use reference guide to significant trends in health and health care over the past decade, including population and health status, as well as trends in service provision. This year includes a number of new additions, including a new chapter on health service efficiency as well as data on HPV vaccination, blood donations and results from the National Patient Experience Survey. Each section has a brief introduction summarising key statistics.

Key trends include:

·        The number of live births has been falling year-on-year since 2009 and in 2017 the number of registered births was 62,053. Despite reductions in the numbers of births in recent years, the fertility rate in Ireland is the 3^rd highest in the EU, behind France and Sweden.

·        Ireland is now beginning to catch up with other European countries in terms of population ageing. The population of those aged 65 years and over has increased by 35% since 2009 and has been increasing at a faster rate than that of our EU neighbours. The numbers of people in this age group is expected to almost double in the next 20 years, with the greatest proportional increase in the 85+ age group. 

·        Over the past decade, Ireland has achieved an improvement in life expectancy. Life expectancy in Ireland has increased by almost two and a half years since 2006, with male life expectancy consistently higher than the EU average throughout the last decade.  

·        Much of this increase in life expectancy is due to significant reductions in major causes of death such as circulatory system diseases and cancer. Since 2008 there has been a reduction in mortality rates for most major causes. The overall mortality rate has reduced by 14.9% since 2008. 

·        In comparison to other EU countries, Ireland continues to have the highest levels of self-perceived health of any EU country. Those in higher income brackets tend to report better health than those in lower income brackets. 

·        There have been improvements seen in survival rates from breast, cervical, colon and rectal cancer in the last 15 years. With the exception of rectal cancer, 5-year net survival rates are lower in Ireland than the average for OECD countries where data is available. 

·        While there has been a reduction in the mortality rate from respiratory diseases of almost 12.6% since 2008 the rate in Ireland is 37.4% higher than the EU28 average.

·        There has been a 26% reduction in the mortality rate from suicide since 2008. After a rise in the male suicide rate from 2008 to 2012, the three-year moving average has decreased and the latest figures (2015) have fallen below the EU average for the first time since 2010.

·        Total hospital discharges continue to rise with 63% of this activity now carried out on a day case basis (including dialysis). 

·        While there are fewer public inpatient beds than a decade ago, there has been a 25% increase in day beds and a reduction in the average length of stay. The increase in day beds has allowed for a 39% increase in the number of day case patients over the last decade.

·        There are 1,796 inpatient beds in private acute hospitals in Ireland. 

·        From 2007 to 2016 the average length of stay in public acute hospitals decreased by 
7.4%. Between 2015 and 2016 there was a decrease of 1.4%. 

·        The number of adults waiting over 9 months for elective procedures has seen a decrease over the period October 2017 to October 2018. For children waiting 6 months or longer the number waiting for elective procedures remained relatively stable throughout the year.

·        The total number of people on outpatient waiting lists increased between October 2017 and October 2018. The number of people waiting longer than 52 weeks also increased during the year.

·        The 30-day moving average of the number of admitted patients on trolleys at 2pm in emergency departments saw a spike during the first 5 months of 2018. It has since fallen and in October, was similar to figures for 2017 and 2016. 

·        Between 2016 and 2017 there was a decrease (6.1%) in the number of medical cards to 1.58 million. Numbers of GP only visit cards in 2017 increased to just over 486,000, though it should be noted that this is largely due to the introduction of GP visit cards to all children under six in 2015. 

·        There were 116,496 wholetime equivalents employed in September 2018; this represents a 1.9% increase since December 2016. 

·        Total public health expenditure has risen from €14.9 billion in 2009 to an estimated €16.8 billion in 2018. Estimates for 2018 indicate a 6.3% increase in expenditure from 2016.

·        Only 4.8% of tonsillectomies are performed as day case surgeries in Ireland, compared to an OECD average of almost 30%.

Further key trends are presented by chapter below:

Section 1 – Population and Life Expectancy

The latest population estimate for Ireland in 2018 has shown that the population has grown by an estimated 2% since the 2016 Census.

·        The population estimate for 2018 is 4,857,000, an increase of 2% on Census 2016 (Table 1.1). 

·        The population has grown by 7.1% since 2009. The largest change was seen in the over 65 age group which increased by 35% between 2008 and 2017 (Table 1.2). 

·        The west and north-west of Ireland have the highest old age dependency ratios (Figure 1.1a). 

·        The total population in Ireland has increased more rapidly than the EU average in the last decade. The population aged 65 and over has increased at a greater rate than the population as a whole, and at a greater rate than the EU average for those aged 65 and over (Figure 1.2).

·        The numbers of births in 2016 have shown a 2.8% decrease on the previous year, with 62,053 births being registered in the year. The number of live births has fallen year on year since 2009 (Table 1.3).

·        The Total Fertility Rate has decreased in recent years and now stands at 1.80. However, Ireland has the 3^rd highest rate of fertility amongst EU countries behind France and Sweden. The EU average fertility rate in 2016 was 1.60 (Table 1.3 and Figure 1.4).

·        In 2017, counties Cork, Kerry, Roscommon, Dublin, Kilkenny and Donegal had the lowest fertility rates (Figure 1.2).

·        The number of people in older age groups is beginning to increase significantly. The numbers of people over the age of 65 years is projected to almost double to around 1.2 million by 2038. The greatest proportional increase will be in the 85+ age group (Table 1.4 and Figure 1.5).

·        Life expectancy at birth for women in Ireland was 3.7 years longer than for men in 2016; this has improved from a 5.6 year difference in 1996 (Table 1.6).

·        Female life expectancy in Ireland has matched the EU average and male life expectancy in Ireland has been above the EU average over the past decade. The life expectancy at birth for men in Ireland has been consistently greater than that of the EU average by over a year (Figure 1.6 and Figure 1.7). 

·        In addition to longer life expectancy, women at age 65 are likely to experience a higher proportion of healthy life years than men, indicating that men live shorter lives with more health problems (Figure 1.8). 

Chapter 2 – Health of the Population 
Please note that any references below to 2017 mortality data should be considered provisional as 2017 data in this report are based on year of registration, and not year of occurrence. 
·        In 2016, 82.7% of males and 82.8% of females rated their health as being good or very good. This is the highest in the EU and compares with an average of 69.6% and 64.4% for males and females respectively across the EU. With those in higher income brackets tending to report better health than those in lower income brackets (Table 2.1, Figure 2.1 and 2.2).

·        49.9% of males and 50.1% of females aged 65 and over reported suffering from a chronic illness or health problem in 2016. In people over the age of 75, 41.7% and 43.9% of males and females respectively reported some or severe limitation in usual activities due to health problems (Table 2.2 and Table 2.3).

·        Over the 10 year period 2008-2017, age-standardised death rates for all causes fell by 14.9% (Table 2.4). 

·        Among those aged 65 years and over diseases of the circulatory system accounted for 31.4% of all deaths registered in 2017. This compares with 19.5% of deaths of those aged less than 65 years (Figure 2.5a and Figure 2.5b).

·        Deaths from respiratory diseases (including cancer of the trachea, bronchus and lung) accounted for 21.2% of all deaths to those aged 65 and over and 12.0% of all deaths of those aged under 65 (Figure 2.5a and Figure 2.5b).

·        There has been an 11.3% decline in the age-standardised death rate for cancer in the last decade. Cancer of the female breast death rate has decreased by 15.9% since 2008 (Table 2.4).

·        Death rates from suicide are down 26% since 2008 and have decreased by 11.2% between 2016 and 2017 (data for 2017 are provisional). Males have consistently had a higher suicide rate than females, in both Ireland and the EU. For the first time since 2008, the latest figures show that Ireland’s three-year moving average for male suicide deaths have fallen below the EU average (Table 2.4, Figure 2.8).

·        The 5-year age-standardised death rates from lung cancer (2013-2017) are highest in counties Dublin. Carlow, Louth and Westmeath (Figure 2.6).

·        Ireland’s age-standardised death rate in 2015 was below the EU average. The death rate from respiratory diseases (including cancer of the trachea, bronchus and lung) was 37.4% above the EU average (Table 2.5).

·        The age-standardised death rates for cancer (excl. trachea, bronchus and lung), circulatory system diseases, ischaemic heart disease and respiratory system diseases (incl. cancer of the trachea, bronchus and lung) have all decreased since 2000 (Figure 2.7).

·        Ireland has had a lower infant mortality rate than the EU average over the last decade; however the gap has narrowed in recent years (Figure 2.10). 

·        There have been improvements in survival rates from breast, cervical and colon and rectal cancer in the last 15 years. However, with the exception of rectal cancer, 5-year net survival rates are lower in Ireland than the average for OECD countries where data is available (Figure 2.11). 

·        Sports participation among 16-19 year olds declined between 2015 to 2017, however the 20-24 year old age group has seen a slight increase in sports participation over the same period (Figure 2.12). 

·        Cigarette consumption has declined over the past decade, while alcohol consumption has also decreased but at a slower rate.  The official figures do not include purchases made outside the State or illegal imports into the State which may exaggerate the recent years’ decline.  Cigarette consumption excludes ‘roll-your-own’ cigarettes (Figure 2.13).

·        Over half of Irish men binge drink on a typical day of drinking, compared to just under 20% of women in 2018. A gender gap is present across all age groups, and the highest rates of binge drinking are among the 15-24 age group (Figure 2.14). 

·        Almost 10% of smokers report having bad or very bad oral health across all age groups, except for 15-24 year olds, where 5% report bad or very bad oral health (Figure 2.15).

Chapter 3 – Hospital Care 
·        Inpatient discharges from publicly funded acute hospitals have increased by 6.9% since 2008 (Table 3.1a). 

·        From 2008 to 2014 the average length of stay decreased by 10.6%. It has since increased by 3.7%, with the average length of stay currently at 5.6 days (Table 3.1a).

·        The number of beds for day cases has risen to 2,170 in 2017, an increase of 24.9% since 2008 (Table 3.1a).

·        The number of day cases has risen to 1,072,902 in 2017, an increase of 39.2% compared to 2008.  The number of day cases per total discharges has increased 11.2% in the period 2008-2017 (Table 3.1a). 

·        The majority of bed days used in public acute hospitals are used by the over 65 age group. Figure 3.1 shows that the proportion of bed days used increases with age. 

·        Private acute discharges increased by 1.7% between 2016 and 2017. Day cases account for 74.6% of total discharges in private acute hospitals, compared to 62.9% in public acutes (Table 3.1a and Table 3.1b). 

·        There has been a decrease of almost 5,000 people in the number of adults waiting 9 months or longer for an elective procedure during the period October 2017 to October 2018. The number of children waiting 8 months or longer has remained stable throughout the year (Note: refers to those classified as active) (Figure 3.2).

·        The total number of people on outpatient waiting lists has increased to over 500,000 in October 2018. (Note: refers to those classified as active) (Figure 3.3).

·        The 30-day moving average of the number of admitted patients on trolleys at 2pm in emergency departments saw a spike in the first four months of 2018 but has since fallen and the figures are currently similar to this time last year (Figure 3.4). 

·        11am to 2pm on a Monday is the busiest time for Irish emergency departments (Figure 3.5)

·        311 transplants were carried out in Ireland in 2017, with kidney transplants being the most common. This includes 5 pancreas transplants, the first pancreas transplants carried out in Ireland since 2014 (Figure 3.7).

·        The number of admissions to psychiatric hospitals and units has decreased by 19.3% over the period 2008 to 2017. The admission rate per 100,000 population has fallen by 25.5% over the same period (Table 3.2, Figure 3.9). 

·        84% of people felt they were always treated with respect and dignity in Irish hospitals, according to the 2018 National Patient Experience Survey. Women, particularly younger women, are more likely to rate their hospital stay as fair to poor than men (Figure 3.10 and Figure 3.11). 

Chapter 4 – Primary Care and Community Services 
·        33% of the population had a medical card at the end of 2017. This compares with 30.1% in 2008 (Table 4.1).

·        Numbers of GP only visit cards in 2016 increased significantly to just under 487,000, though it should be noted that this is largely due to the introduction of GP visit cards to all children under 6 in 2015 (Table 4.1).

·        The number of people registered for the Drugs Payments Scheme has decreased by 22.5% between 2008 and 2017 (Table 4.1).

·        The numbers of people on the Long-Term Illness Scheme has increased by 118.7%, or over 140,000 people, since 2008 (Table 4.1).

·        In 2017, Donegal, Galway and counties in the South-East had the highest percentage of population with medical cards (Figure 4.2). NOTE: data in the map are presented by Local Health Office areas. 

·        The average cost per item dispensed under the General Medical Services (GMS) scheme decreased by over 4% from 2016 to 2017 (Figure 4.3). 

·        Almost 80% of people have visited a GP in the past year, according to the latest Healthy Ireland survey. In the younger age groups, more women than men had attended a GP in the past year, but this gap narrows for those over the age of 45 (Figure 4.4). 

·        The percentage of the population covered by private health insurance has risen slightly between 2013 and 2017, from 41.4% to 42.8% (Figure 4.5). This increase can be seen across most age groups and is particularly large among those aged 80 and over (+5% since 2013) (Figure 4.5).

·        The number of beds available in long-term care units covered by the nursing homes support scheme has increased by 6.9% over the period 2014 to 2017.  The proportion of patients aged 75+ in long term care has decreased slightly over this period, with nearly half of all patients in long term stay units in 2017 aged 85 or over (Table 4.2).

·        Both the number of blood donations and the percentage of blood donors in the Irish population have declined in the past 5 years. The percentage of blood donors in the population in 2017 was 1.7% (Figure 4.6). 

·        The immunisation uptake rates of children aged 24 months in 2016 was 95% for most immunisations, with the exception of the MMR, Meningococcal and Pneumococcal Conjugate vaccines (Table 4.3). 

·        HPV vaccine uptake rates among secondary school girls fell to 51% in 2017, down from a high of 88% in 2014. 

·        The number of people registered with the National Physical and Sensory Disability Database was 20,676 in 2016, with half of these having a physical disability only (Table 4.4).

·        The number of persons under 18 with an intellectual disability availing of day services has increased by 9.3% over the period 2008-2017. There has been a fall of 8.5% in full time residents availing of these services, compared to an increase of 19.2% availing of the services as day attendees only (Table 4.5).

·        The number of cases in treatment for problem drug use (including alcohol) has increased by 15.4% during the period 2008-2017. The number of cases in treatment for problem drug use (excluding alcohol) has increased by 42.7% over the same period. There has been a decrease of 6.3% in new entries for drug and alcohol treatment between 2016 and 2017 (Table 4.6 and Figure 4.7). 


Chapter 5 – Health Service Employment 

·        Over the period 2009 to 2013 total numbers employed in the public health services saw a gradual decline, however in recent years this trend has been reversed. There were 116,496 whole time equivalents employed in September 2018; this represents a 1.9% increase from December 2017 (Table 5.1, Figure 5.1).

·        All grade categories have shown an increase since 2017. Nurses make up the largest grade category in the public health service, with 31.9% of total staff employed (Table 5.1, Figure 5.2).

·        The number of hospital consultants employed by the public health service increased by 32.8% in the period 2009-2017. They also increased by 3.2% between December 2017 and September 2018 (Table 5.2, Figure 5.3).

·        The number of non-consultant hospital doctors increased by 34.2% in the period 2008-2017. They also increased by 3.3% between December 2017 and September 2018 (Table 5.2, Figure 5.3).

·        There were 2.94 practicing doctors per 1,000 population in Ireland in 2016. This is below the OECD28 average of 3.39 (Figure 5.5).


Chapter 6 – Health Service Expenditure 
·        Total public expenditure on health has increased by 12.8% since 2009, with an increase of 6.3% between 2017 and 2018 (data for 2018 are estimates) (Table 6.1, Figure 6.1).

·        HSE non-capital total allocation has increased by 24% in the period 2011-2017, with an increase of 5.9% in the period 2016-2017.  Acute hospitals accounted for 34.1% of HSE gross non-capital expenditure in 2017 (Table 6.2, Figure 6.2).

·        Public capital expenditure on health increased 9.9% between 2016 and 2017 and decreased by 22.2% since 2008 (Table 6.3).

·        According to the System of Health accounts (SHA) methodology, Ireland’s total (public and private) health expenditure was estimated to be €20.3 billion in 2016. The largest financing scheme in Ireland is Government financing schemes and compulsory contributory health care financing schemes, accounting for 72% of all finance in health care expenditure.  Curative and rehabilitative care accounted for 55% of total current health care expenditure, and hospitals accounted for 36% of total current health care expenditure (Table 6.4, Table 6.5 and Table 6.6).

·        Total health expenditure in Ireland per capita in real terms (adjusted for inflation) has shown an overall increase over the period 2007-2017 (Figure 6.3).

·        In terms of health expenditure per capita, Ireland ranks as the 7^th highest spend amongst selected OECD countries. Using modified gross national income or (GNI*) for Ireland as a comparator with GDP from other countries (as recommended by the Economic Statistics Review Group), Ireland’s total current health expenditure as a percentage of GDP/GNI* ranks 3^rd behind the United States and Switzerland. This position changes to 8^th when looking at public expenditure only (Table 6.7, Figure 6.4).

Chapter 7 – Efficiency Indicators 

·        In-patient discharges per bed have increased from 50 to 60 discharges per bed between 2008 and 2017, showing increased utilisation of in-patient beds. There was a steady year-on-year increase from 2008 to 2015, peaking at 61.4, but the past two years have seen a slight decrease (Figure 7.1) 

·        Ambulatory Care Sensitive Conditions are conditions which could be more appropriately treated in a primary care setting or prevented with early primary care interventions, thus reducing strain on hospital inpatient resources. The four conditions presented in Figure 7.2 have been identified by the OECD as being particularly relevant in the European context as conditions which would benefit from improved primary care alternatives to hospital admission. Over the past 7 years, there has been an increase in the number of emergency bed days used in treating these conditions, but because the total bed days used by all conditions has increased, there has been a slight decrease in the percentage of total bed days used by these conditions. 

·        Figure 7.3 looks at three high-volume surgical procedures that can safely be performed as day cases and compares Ireland’s rate of day case surgeries with the OECD average. Day case surgeries allow patients to spend less time in hospital and reduce strain on hospital resources. 94% of cataract surgeries in Ireland are performed as day cases, above the European average of 84%. However only 4.8% of Irish tonsillectomies are day cases compared to almost 30% across the OECD, showing that significant improvements can be made in this area. 

·        An ‘Out-of-Hours’ fee is payable for non-routine consultations when a GMS cardholder is seen by their GP or another GP acting on their behalf outside of normal working hours (Mon-Fri, 9am-5pm. The number of out of hours contacts with GPs has increased by over 90,000 between 2012 to 2017, allowing for increased access to primary care (Figure 7.5). 

·        Ireland’s rate of C-Sections per 1,000 live births is higher than the EU28 average and is also increasing at a faster rate (Figure 7.6). 

The use of pharmaceutical generics can increase cost-effectiveness and efficiency in health care provision and spending. Percent share of generics has more than doubled in Ireland since 2008, while the OECD average has increased by 36.6% in the same period. However, Ireland is still significantly below other OECD countries for use of generics (Figures 7.7 and