Diabetic care is a substantial driver of overall health care utilisation and costs. In Europe and North America, the proportion of health care expenditure on diabetes in 2010 ranges from 6 to 14 per cent (1). In the Republic of Ireland, the incremental cost of additional health service use is estimated to be €89 million annually (2). Health care utilisation and health care costs among those with diabetes are strongly related to diabetic complications; in the UK, 80 per cent of diabetic health care costs are due to complications (3, 4). In addition to direct health care costs, diabetes significantly impacts on mortality rates, quality of life and labour market productivity (5, 6).
It is currently difficult to make direct comparisons between the prevalence of diabetes in Northern Ireland (NI) and Republic of Ireland (ROI). In Northern Ireland (NI), based on register data, 5.6% of the population aged 18 and over have diabetes (7). While in ROI a similar register does not exist, it has been estimated that 5.2 per cent of those aged 18 and over have diabetes (8). However, given the strong relationship between diabetes prevalence, age and gender comparing these two figures is problematic. A previous study, based on prescribing databases in the two jurisdictions found clinically equivalent prevalence rates of diabetes in NI and ROI across all age groups (9).
NI and ROI have operate different health care systems. In both, the GP is the primary point of contact between the health service and people with diabetes. However, there are differences in the way that GP services are delivered in NI and ROI. In NI practices provide publicly funded care, free at the point of use, to a defined list of patients on a universal basis. The Quality Outcomes Framework (QOF) system, in place from 2004, provides financial incentives for GPs to maintain disease registers and meet quality indicators. The QOF system resulted in three simultaneous changes: better data collection by GPs, public information on the quality of care, and pay for performance (10). For diabetes, GPs receive additional payment for having higher proportions of patients with biomarkers such as blood pressure, lipids and blood sugar in specified ranges as well as records of screening/examinations (11). However, beyond the upper thresholds of each QOF indicator, GPs receive no additional financial reward to improve care (12). In the UK QOF has been shown to be associated with improvements in both process and outcomes of diabetes care (13).
In ROI, GPs have a mix of publicly funded and private fee paying patients. The mixed nature of GP care in ROI means that GPs who see additional private patients can generate more revenue (14). In contrast in NI, private patients as a potential revenue stream do not exist. In ROI, at the time the data for this study were collected (2011), there was no specific financial support for GPs providing primary care to patients with diabetes. While several diabetes initiatives were in place in Ireland, diabetic care was frequently unstructured and record keeping by many GPs was poor (15, 16). However, structured reviews and record keeping are only one component of quality primary care. Access and quality of interaction in GP consultations, continuity of care, and access to practice nurses are important components of care quality (17-19). The supply of GPs has been shown internationally to be associated with improved outcomes, such as reduced mortality (20). In this context it is notable that there are fewer GPs in NI per capita than in ROI; the average GP list size was 1,620 in NI in 2014 (21) and 1,175 in ROI (1,335 based on Whole Time Equivalent, WTE), based on total number (head count) of GPs for 2014 and population numbers (22). While we do not have WTE values for GPs in NI, even if all GPs were working on a full time basis in NI, there would still be more supply in ROI. Differences in the supply of GPs may result in shorter consultation durations (23, 24) and longer waiting times for non-emergency consultations in NI, as in the rest of the UK (25, 26). Practice nurses play an increasingly important role in the provision of primary care (27). As with GPs there are more practice nurses per capita in ROI. In ROI there are 0.26 practice nurses per 1,000, this compares with an average of 0.2 in NI (22, 28, 29).
Cost has been shown to be an important factor in the demand for GP care (30). While GP care is free at the point of use for patients in Northern Ireland, a substantial minority (31.5%) of people in ROI with diabetes are not covered by the medical card or GP visit card schemes and will have to pay for their GP care (31). For those who have to pay out of pocket for a GP consultation, the cost of a consultation is in the region of €50, which may represent a significant deterrent to attending (32, 33). While the cost of attending the GP may be a deterrent for some people it may, by reducing demand, reduce capacity constraints that permit easier access for others (14).
The approach to outpatient diabetes care varies widely across public hospitals in ROI in terms of the discharging of uncomplicated cases back to primary care (34). There is also substantial variation in waiting lists across hospitals for outpatient care. All patients have access to free public outpatient diabetes care but non-medical card holders (those who have to pay to access GP care) usually have to pay for diabetes services provided by their GP (34). This can result in a reluctance by some patients to be discharged to their GP (34). There is no costs to patients for attending outpatient clinics in NI. Outpatient waiting lists are not available for diabetes care.
In this study, we examine, for patients aged 50 and over with diabetes, differences between NI and ROI in the prevalence of diabetes and the number and type of health care contacts (GP, Outpatient, A&E Visits and Hospital Nights). Older people are the main population of interest for examining health care utilisation by people with diabetes given this is where the disease is most prevalent – in the UK, 83 per cent of people with diabetes (type I and type II) are over the age of 50 (35, 36). One previous study, using different data sources, has previously compared the age adjusted prevalence of diabetes between the two jurisdictions. Differences in entitlement to care (including sub-groups differentiated by income level) and utilization of care between the two parts of Ireland have been explored previously for the overall population (33, 37, 38). As far at the authors are aware a needs adjusted comparison of health care utilisation by people with diabetes is not available.