the organisation which bears the resultant cost. Consequently, preventive care is emphasised;
medicines, X rays and tests are not ordered unnecessarily; and, although studies show that
patients in those plans have as many, or more, visits to the doctor as under traditional
models, they typically have less hospitalisation . This has been found to be the principal
reason for the savings which are estimated at 10-40 per cent on traditional models"
(CHF,101).
There has been a large increase in employment in the Irish health service in recent
decades. The White Paper estimates that there are currently over 75,000 employees in the
service. This compares with 43,000 in 1975, 58,400 in 1990, and 65,800 in 1996. Nurses in
1996 were the largest single category of employees in the health service, accounting for 41
per cent of all staff. The Irish ratio of nurses to hospital beds for example, in 1987 was 1.2.
This compared with 0.5 in Belgium, 0.45 in Germany, 0.55 in France, 0.47 in Spain, 0.91 in
New Zealand and 0.69 in Britain. (OECD,1990, Table 46). The number of nurses in Ireland
increased by a further 9 per cent between 1987 and 1996 while the number of beds remained
constant.
OECD studies indicate that the Irish healthcare system is heavily based on
hospitalisation. The estimate for 1983 is that Ireland spent 73.4% of its public health care
expenditure on institutional services compared to an OECD average of 54.4% and 59.7 per
cent in the United Kingdom (OECD, 1990, 33). In 1982 the hospitalisation rate in Ireland
was 17.6 per cent compared to 12.7 per cent in the United Kingdom (OECD, 1985, 15).
Britain's share of its population over 65 years is 40 per cent higher than the share in Ireland.
Since 15.5 per cent of the population of Britain is over 65 years compared to 11.0 per cent in
Ireland (OECD, 1990, 88) one would expect hospitalisation rates in Ireland to be significantly
lower than in Britain rather than 38 per cent higher as in 1982. The cost of health services by
age is illustrated as a U-shaped curve with higher health expenditures by the young and the
old than by the 16 to 44 age group. For example United Kingdom data for the three years to
1998/1999 indicate that expenditure on the hospital and community health services was
lowest in the 5 to 15 age group. Expenditures per head on the over 85, 75 to 85 and 65 to 75
age groups were, respectively, 7.4, 4.7, and 1.4 times the expenditures on the age group 16
to 44. The problem of a relatively young population and a relatively high cost health service
is shared by Ireland and the United States whereas Sweden, Norway, Denmark, Germany and
the United Kingdom have a relatively large number of older people in their populations
(Jonsson, OECD, 1990).
O'Hagan (1984) found that the cost per hospital bednight increased from 3.386 to
6.929 times GDP per head in Ireland between 1966 and 1979. The cost ratio increase of