Speech by the Minister on launch of ESRI Report Activity in Acute Public Hospitals: 1990-1999

I am delighted to be launching this report which summarises ten years of data from the Hospital In-Patient Enquiry from 1990 until 1999. Above all else, the report shows the value and importance of well-developed, comprehensive and well-utilised health information systems.

Very often, data and information are dismissed with a phrase such as “you can prove anything with statistics” or are considered at best a kind of necessary administrative evil. The truth, of course, is that without accurate information we can have no objective evidence-based view of what we are doing or how well we are doing. And, perhaps most importantly, we are not in a position to plan effectively.

An examination of many, if not all, of the major improvements in health over the past two or three centuries demonstrates that they were largely based on the collection and application of health information. One can point to the control of infectious diseases through improved hygiene both within hospitals and in the wider environment. Likewise, more recently, data on health determinants, including lifestyle factors, such as smoking, provide the basis for effective measures for the improvement of population health.

Information also provides the basis for the evaluation and planning of health services. This is very explicitly recognised in the recent National Health Strategy: Quality and Fairness, A Health System for You. In the Strategy, information is highlighted as one of the six critical frameworks for change required for the successful implementation of the Strategy. The Strategy also sets out the establishment of a Health Information and Quality Authority to serve as the engine for change. A National Health Information Strategy is currently in the final stages of preparation and will clearly set out the information functions of this new agency.

In many respects, the Hospital In-Patient Enquiry provides an example of health information at its best. It is a system which has been progressively developed over the years and has become an indispensable source of information on acute hospital activity particularly during the past decade.

As most of you will know, HIPE collects a range of information on each patient stay in public acute hospitals in Ireland. It covers inpatients and day cases and includes clinical, administrative and demographic data.

From 1990, the Economic and Social Research Institute has been contracted to manage and develop the HIPE system, and since then, the number of hospitals included in the system has risen from 45 to 60 and the coverage of patient stays increased from just over 50% in 1990 to 95% in 1999. Over that period, data on close to 5 ½ million hospital discharges have been collected.

Considerable effort has been put into training the dedicated staff that input and code the data and without whom the system could never have achieved its current quality. Much work has also been done in streamlining the system through computerisation.

Setting out data over a ten year period as this Report does allows us to get a feel for some of the major changes in acute hospital activity over the period. Perhaps the most striking change is the huge rise in day case activity. There has been an almost 7-fold increase in the annual number of day cases recorded in HIPE since 1990. But given the increased coverage of HIPE over the period, a more accurate reflection of the change is that by 1999 about a third of all hospital discharges were day cases compared with just 13% in 1990.

Indeed, since 1999, there has been an acceleration of this trend. Nearly 40% of hospital treatment is now carried out on a day case basis, and this figure rises to 50% for the major acute hospitals.

There has also been a very marked decrease in the average length of stay of inpatients of some 9% over the period covered by this report. Strikingly, this decrease has been accompanied by a very significant increase in the proportion of patients on whom a procedure was performed (52% in 1990, 75% in 1999) and also in the average number of procedures per patient (1.3 in 1990, 1.6 in 1999). Taken together these trends show an acute hospital sector applying the benefits of advanced methods to expand day treatment, carry out more procedures and reduce the length of stay for inpatients.

While these figures show a hospital system that is highly efficient in the intensive use of capacity, there is an acknowledgement by Government that more acute beds and back up support in “step down” and community nursing units should be provided to ensure that patients get ready access to appropriate facilities.

In fact, HIPE data provided the principal data source for the recent in-depth analysis of bed capacity and the requirements for hospital beds now and into the future. Current usage taken together with age-based and other projections, allowed us to arrive at an objective estimate of an additional 3,000 beds required for the sector by 2011 of which 700 will be provided this year.

To return to the report, other interesting findings relate to the distribution of patients between types of hospitals and to the flows of patients between regions. While there may be a generally held view of large-scale movement to Dublin for treatment, the Report shows that this view may be exaggerated and concludes that most movement is between adjacent health boards. Not surprisingly, analysis by month of admission demonstrates the increased pressures which affect acute hospitals during the winter months. The 77% to 23% split between public and private patients is also confirmed in the figures presented.

A key feature of acute hospital usage is the extent to which the older age groups are the principal users. The figures for 1999 indicate that those aged 65 and over accounted for almost half of all the bed days used. While life expectancy continues to improve and while older people can be confidently expected to remain healthier for longer as we move into the 21st century, the implications of an ageing population for the provision of acute services is considerable.

This leads me to say a few words about the fundamental importance and value of a system like HIPE. I have already mentioned its use in the review of bed capacity. HIPE is also a central pillar of casemix-based funding. When matched with specialty costs, hospital activity data is used to measure and compare hospital outputs.

Funding can be directly and objectively related to hospital workloads, and positive incentives are created for improved efficiency and value for money. In addition, information on casemix is shared between hospitals participating in the national programme. This provides hospitals with comparative performance information and is an invaluable management tool. Casemix has also had a very beneficial effect on the timeliness and comprehensiveness of returns to the HIPE system.

The importance of casemix as a model for evidence-based funding is explicitly recognised in the Health Strategy. Proposals for its further development and extension provide a strong indication of my commitment to performance measurement and its application in the area of transparent, evidence-based allocation of funds.

The use of HIPE as an information source for budgeting serves to emphasise the close reinforcing connection between the use of data and its quality. And HIPE is increasingly used and useful.

Performance indicators such as day case rates and readmission rates can be derived from hospital activity data, and increasingly have an important role to play in service evaluation and service planning. Issues of access and equity can be, and are, examined and monitored with reference to HIPE data.

Targeted strategies such as the Cancer and Cardiovascular strategies need to be informed by analysis of hospital activity. Furthermore, the contents of HIPE are not static. The system has recently been extended to cover all maternity hospitals, and ongoing consideration is given to including additional information for improved monitoring in areas such as inequalities and social inclusion.

Indeed, acute hospital activity data provides an essential information source for public health and epidemiology. The National Cancer Registry, for example, utilises hospital data to ensure the comprehensiveness of its notifications. Likewise, HIPE provides important insight into national and regional rates of hospitalisation for events such as heart attack, motor vehicle and other accidents and for specific diagnosis categories. It is for this reason that hospital activity is currently an essential component of the Public Health Information System which brings together public health data from a number of national sources and is widely used for the assessment of population health at national and regional levels.

For the future, I am committed to the further development and use of high quality information as a basis for all health decisions. Information must be relevant and accessible to all those who require it, in the most useful formats, and using the potential of ICT to the full in its collection and dissemination.

Hospital data is an example of an area where information is well developed as evidenced by the Report being launched today. To some extent, this is due to the resource intensity of hospital services but also to the fact that information is more readily captured where it is concentrated in a limited number of single locations.

An urgent requirement now is to bring other information systems to a similar level of development particularly in the area of Primary Care. This poses a major challenge, but also promises major benefits. The overwhelming majority of contacts with the health services are at primary care level (an estimated 16 million GP visits per year). Good information would provide an unparalleled resource in public health terms but also in the coordination of service delivery.

A Primary Care Strategy was launched in conjunction with the Health Strategy. Its proposals for a team-based approach will depend critically on the effective development and use of information. Progress toward the implementation of unique patient identifiers is considered essential if we are to realise the benefits of shared-care arrangements and maximise the potential of health information.

I understand that the HIPE system which collects information on both public and private patients attending public hospitals has also taken some steps towards including private hospitals within the system. This is a welcome development. Information on private health care at all levels is crucial in facilitating shared care, as mentioned above, and in obtaining a complete picture of health in Ireland.

The development of comparable health information across the whole island of Ireland is also seen as increasingly important given the many common all-Ireland health issues and problems. The Institute of Public Health has made a good start to this process and is well placed to carry this work forward. It should also be noted that the new EU Public Health Programme places improved information at the centre of its agenda in order to measure health differences and evaluate performance between countries.

The Health Strategy states that, “Information plays a central role in supporting strategic goals and in underpinning the principles of the Health Strategy. It must not be seen merely as an add-on”. The implementation of the National Health Information Strategy will be critical in ensuring that information remains central and is appropriately resourced and developed. Acute hospital activity will quite obviously continue to be an essential part of that framework.

It only remains for me to congratulate Professor Wiley and the dedicated staff of the HIPE Unit for the production of this valuable report, and I look forward to the continued successful development and application of hospital activity data for the benefit of all.