Understanding the legacies of shocks on health system performance: Exploring Ireland's management of recent crises and its implications for policy.

This paper contrasts the Irish experience of the 2008 economic crisis and the Covid-19 pandemic, and the health system responses to these shocks, from the perspective of health system leaders working across both time periods. Based on semi-structured interviews with seven senior national and international officials, the research presented here forms the qualitative component of RESTORE, a five-year research project examining health system resilience and reform, funded through the Health Research Board's Research Leader Award in Ireland. Findings indicate that the financial crisis deeply impacted the Irish health system in relation to infrastructure and capacity, service delivery and workforce. Due to these legacy issues, Ireland's health system was in a relatively weak position when faced with the Covid-19 pandemic but the system proved adaptive and innovative during this time. Furthermore, the pandemic proved to be a catalyst for positive change, providing opportunities for long-term reform, alongside an immediate response to the crisis. This was facilitated by increased funding, a devolution in decision-making structures and a political commitment to the health system. Exploring lessons from the Irish response to these crises provides a case study for developing appropriate policy responses around financing and resource allocation, fostering support for healthcare among political leaders and policy makers, and preparing for future shocks. Furthermore, examining these experiences facilitates understanding around the impact of each crisis on the health system, exploring options for addressing legacy issues and considering practical steps to improve health system performance.

How International Health System Austerity Responses to the 2008 Financial Crisis Impacted Health System and Workforce Resilience - A Realist Review.

BACKGROUND: The Great Recession, following the 2008 financial crisis, led many governments to adopt programmes of austerity. This had a lasting impact on health system functionality, resources, staff (numbers, motivation and morale) and patient outcomes. This study aimed to understand how health system resilience was impacted and how this affects readiness for subsequent shocks. METHODS: A realist review identified legacies associated with austerity (proximal outcomes) and how these impact the distal outcome of health system resilience. EMBASE, CINAHL, MEDLINE, EconLit and Web of Science were searched (2007-May 2021), resulting in 1081 articles. Further theory-driven searches resulted in an additional 60 studies. Descriptive, inductive, deductive and retroductive realist analysis (utilising excel and Nvivo) aided the development of context-mechanism-outcome configurations (CMOCs), alongside stakeholder engagement to confirm or refute emerging results. Causal pathways, and the interplay between context and mechanisms that led to proximal and distal outcomes, were revealed. The refined CMOCs and policy recommendations focused primarily on workforce resilience. RESULTS: Five CMOCs demonstrated how austerity-driven policy decisions can impact health systems when driven by the priorities of external agents. This created a real or perceived shift away from the values and interests of health professionals, a distrust in decision-making processes and resistance to change. Their values were at odds with the realities of implementing such policy decisions within sustained restrictive working conditions (rationing of staff, consumables, treatment options). A diminished view of the profession and an inability to provide high-quality, equitable, and needs-led care, alongside stagnant or degraded working conditions, led to moral distress. This can forge legacies that may adversely impact resilience when faced with future shocks. CONCLUSION: This review reveals the importance of transparent, open communication, in addition to co-produced policies in order to avoid scenarios that can be detrimental to workforce and health system resilience.

Metrics and indicators used to assess health system resilience in response to shocks to health systems in high income countries-A systematic review.

Health system resilience has never been more important than with the COVID-19 pandemic. There is need to identify feasible measures of resilience, potential strategies to build resilience and weaknesses of health systems experiencing shocks. The purpose of this systematic review is to examine how the resilience of health systems has been measured across various health system shocks. Following PRISMA guidelines, with double screening at each stage, the review identified 3175 studies of which 68 studies were finally included for analysis. Almost half (46%) were focused on COVID-19, followed by the economic crises, disasters and previous pandemics. Over 80% of studies included quantitative metrics. The most common WHO health system functions studied were resources and service delivery. In relation to the shock cycle, most studies reported metrics related to the management stage (79%) with the fewest addressing recovery and learning (22%). Common metrics related to staff headcount, staff wellbeing, bed number and type, impact on utilisation and quality, public and private health spending, access and coverage, and information systems. Limited progress has been made with developing standardised qualitative metrics particularly around governance. Quantitative metrics need to be analysed in relation to change and the impact of the shock. The review notes problems with measuring preparedness and the fact that few studies have really assessed the legacy or enduring impact of shocks.

Implications for health system reform, workforce recovery and rebuilding in the context of the Great Recession and COVID-19: a case study of workforce trends in Ireland 2008-2021.

BACKGROUND: Workforce is a fundamental health systems building block, with unprecedented measures taken to meet extra demand and facilitate surge capacity during the COVID-19 pandemic, following a prolonged period of austerity. This case study examines trends in Ireland's publicly funded health service workforce, from the global financial crisis, through the Recovery period and into the COVID-19 pandemic, to understand resource allocation across community and acute settings. Specifically, this paper aims to uncover whether skill-mix and staff capacity are aligned with policy intent and the broader reform agenda to achieve universal access to integrated healthcare, in part, by shifting free care into primary and community settings. METHODS: Secondary analysis of anonymised aggregated national human resources data was conducted over a period of almost 14 years, from December 31st 2008 to August 31st 2021. Comparative analysis was conducted, by professional cadre, across three keys periods: 'Recession period' December 31st 2008-December 31st 2014; 'Recovery period' December 31st 2014-December 31st 2019; and the 'COVID-19 period' December 31st 2019-August 31st 2021. RESULTS: During the Recession period there was an overall decrease of 8.1% (n = 9333) between December 31st 2008 and December 31st 2014, while the Recovery period saw the overall staff levels rebound and increase by 15.2% (n = 16,789) between December 31st 2014 and December 31st 2019. These figures continued to grow, at an accelerated rate during the most recent COVID-19 period, increasing by a further 8.9% (n = 10,716) in under 2 years. However, a notable shift occurred in 2013, when the number of staff in acute services surpassed those employed in community services (n = 50,038 and 49,857, respectively). This gap accelerated during the Recovery and COVID-19 phase. By August 2021, there were 13,645 more whole-time equivalents in acute settings compared to community, a complete reverse of the 2008 situation. This was consistent across all cadres. Workforce absence trends indicate short-term spikes resulting from shocks while COVID-19 redeployment disproportionately impacted negatively on primary care and community services. CONCLUSIONS: This paper clearly demonstrates the prioritisation of staff recruitment within acute services-increasing needed capacity, without the same commitment to support government policy to shift care into primary and community settings. Concerted action including the permanent redistribution of personnel is required to ensure progressive and sustainable responses are learned from recent shocks.

Building health system resilience through policy development in response to COVID-19 in Ireland: From shock to reform.

Health systems worldwide are experiencing profound shocks resulting from the COVID-19 pandemic, with increased attention to health system resilience and researching ways to endure shocks. Pre-COVID-19, Ireland had begun a ten-year programme of reform, Sláintecare, aiming to deliver universal, timely access to integrated care. This study examines whether and how the Irish government's pandemic response contributed to health system reform and increased resilience including delivering universal healthcare. Documentary analysis identified and critiqued relevant government, health system and budgetary documents, published March 2020 - May 2021. Thirteen national policy documents were found, showing increased policy rhetoric and intent to implement reform, demonstrated by increased policy alignment with and budgetary allocation to Sláintecare, alongside implementation of key innovations. Ireland's health system response to COVID-19 offers a unique opportunity to advance understanding of government efforts to reform amidst a global pandemic. It indicated policy intent and funding to manage the Irish COVID-19 crisis, but to also build health system resilience through implementing Sláintecare. This case study has international significance, enabling policy development with potential for long-term health system transformation.

Intensive home care packages for people with dementia: a realist evaluation protocol.

BACKGROUND: Dementia presents a significant challenge to health systems and to the person and family affected. Home care is increasingly seen as a key service in addressing this challenge in a person-centred and cost-effective way. Intensive Home Care Packages (IHCPs) were introduced in Ireland to provide personalised and high levels of support for people with dementia to remain at home or be discharged home from hospital, and to build on the work of the HSE & Genio Dementia Programme. This realist evaluation is concerned with real world questions of feasibility and effectiveness; specifically understanding in what ways IHCPs work, how optimum outcomes are achieved, for whom and in what contexts do IHCPs work best. METHODS: A mixed-method, multi-stakeholder study was designed within a realist evaluation conceptual framework. The process evaluation includes semi-structured interviews with health service staff at all levels, social network analysis and secondary database analysis; the outcomes evaluation includes quantitative measures and qualitative data collected through in-depth interviews with people with dementia and family carers; and the cost evaluation includes analysis of data from the Resource Utilisation in Dementia (RUD). The four stage cycle of realist evaluation is adopted, with iterative rounds of theory formulation, data collection and theory testing throughout. DISCUSSION: This realist evaluation of a complex intervention involves a variety of data and perspectives in order to provide confidence in moving from hypothetical constructs about how IHCPs might work to explanations of potential or observable causal mechanisms. In spite of being a key form of service delivery in most healthcare systems, the ways in which home care works to produce the desired outcomes seems to be poorly understood. While there is much descriptive and comparative work, there is a lack of understanding regarding which patient groups might benefit most from home care, or the influence of different service or cultural contexts on outcomes from home care. As well as addressing the core research objectives, this study aims to make a contribution to the underlying theory of home care in ways that can progress our understanding of how outcomes are produced for home care recipients.

Day Service Provision for People with Intellectual Disabilities: A Case Study Mapping 15-Year Trends in Ireland.

BACKGROUND: Day services for people with intellectual disabilities are experiencing a global paradigm shift towards innovative person-centred models of care. This study maps changing trends in day service utilization to highlight how policy, emergent patterns and demographic trends influence service delivery. METHODS: National intellectual disability data (1998-2013) were analysed using WINPEPI software and mapped using QGIS Geographic Information System. RESULTS: Statistically significant changes indicated fewer people availing of day services as a proportion of the general population; more males; fewer people aged <35; a doubling in person-centred plans; and an emerging urban/rural divide. Day services did not change substantially and often did not reflect demand. CONCLUSIONS: Emergent trends can inform future direction of disability services. Government funds should support individualized models, more adaptive to changing trends. National databases need flexibility to respond to policy and user demands. Future research should focus on day service utilization of younger people and the impact of rurality on service availability, utilization, quality and migration.

Intervention trial of previous nonattender invitation for breast screening.

BreastCheck, the National Breast Screening Programme in the Republic of Ireland, invites women aged between 50 and 64 years biennially. A pilot intervention trial of invitation for screening of women not attending the previous appointment [previous nonattender (PNA)] was carried out that aimed at maximizing the efficiency of resources in terms of radiographer workload and scheduled appointment slots. The trial was conducted during screening round 5 at two of the regional units. The intervention arm implemented an alternative process for inviting PNA women, in which they were sent a letter inviting them to phone their screening unit to make an appointment at a convenient date/time. The control arm continued usual practice - that is, all PNA women were sent a single invitation letter with a scheduled appointment slot at a predetermined date/time. In the intervention arm, fewer PNAs took up their appointments (15.5%) compared with the control arm (18.3%; P<0.001). Uptake among PNAs fell in both arms between screening rounds 4 and 5 (intervention arm: 22.0% OSR 4, 15.5% OSR 5; control arm: 21.4% OSR 4, 18.3% OSR 5). There was a significant increase in mobile unit screening days saved because of the intervention and a significant improvement in the percentage of women reinvited for screening within 27 months in the intervention arm (85.5%). PNA recall and cancer detection rates were significantly higher compared with the general screened population. This trial showed an improvement in the efficiency of resource use. However, there was a higher cancer detection rate in PNA women. This trial provides important evidence for invitation policy for screening.

Intermittent attendance at breast cancer screening.

BACKGROUND: To determine why women skip rounds and factors influencing return of previous non attenders (PNAs) to breast screening. DESIGN AND METHODS: Retrospective, quantitative, structured questionnaire posted to 2500 women. First PNAs did not attend their first screening appointment in 2007/2008 but then attended in 2010; First Controls first attended in 2010 without missed previous appointments. Women who attended screening in 2006 or earlier then skipped a round but returned in 2010 were Subsequent PNAs; Subsequent Controls attended all appointments. RESULTS: More First Controls than First PNAs had family history of cancer (72.7% vs 63.2%; P=0.003); breast cancer (31.3% vs 24.8%; P=0.04). More PNAs lived rurally; more First PNAs had 3rd level education (33.2% vs 23.6%; P=0.002) and fewer had private insurance than First Controls (57.7% vs 64.8%; P=0.04). Excellent/good health was reported in First PNAs and First Controls (82.9% vs 83.2%), but fewer Subsequent PNAs than Subsequent Controls (72.7% vs 84.9%; P=0.000). Common considerations at time of missed appointment were had mammogram elsewhere (33% First PNA) and postponed to next round (16% First PNA, 18.8% Subsequent PNA). Considerations when returning to screening were similar for First PNAs and Subsequent PNAs: I am older (35.4%, 29.6%), I made sure I remembered (29%, 23.6%), could reschedule (17.6%, 20.6%), illness of more concern (16.5%, 19%). More First PNAs stated my family/friends advised (22.3% vs 15.2%) or my GP (12.6% vs 4.6%) advised me to attend, heard good things about BreastCheck (28.8% vs 13.6%). CONCLUSIONS: Intermittent attenders do not fit socio-demographic patterns of non-attenders; GP recommendation and word of mouth were important in women's return to screening. Fear and anxiety seem to act as a screening facilitator rather than an inhibitor. Significance for public healthAll breast cancer screening programmes strive to achieve and maintain a high level of attendance, as this is essential to reduce breast cancer mortality, together with cancer detection. While non-attendance has been widely studied, little is known about intermittent attenders. It is unclear why a woman chooses not to attend her breast screening appointment but then decides to respond positively to screening invitation two or more years later. The literature identifies many reasons why some women choose not to attend; but this study distinguishes those who then change their mind and return to screening. This study explores a sub-set of non-attenders which have, to date, been largely ignored, or grouped with people who never attend. This study will inform those struggling with non-attendance in their population based health programmes and will help to tackle the problem of non-attendance, which has adverse affects both economically and epidemiologically.