2008 Cohort

Dr Sara Burke

How three policies aimed at increasing for-profit hospital care became an accepted method of reform in Ireland between 2000 and 2005 – ‘How many ditches do you die on?’

Institution: TCD, 2008 cohort
Supervisors: Prof. Steve Thomas (TCD), Prof. Ruairi Brugha (RCSI)

Abstract:
This research set out to explore why three specific policies aimed at increasing private, for-profit hospital care became an accepted method of reform in Ireland between 2000 and 2005. It seeks to explain these three policy-making processes in order to understand more about how policy choices get made and what influenced these specific policy processes. I carried out this research using three policies as case studies:

1. The changes to the Finance Act in 2000 and 200 I which gave tax reliefs to build private for-profit hospitals.
2. The National Treatment Purchase Fund (NTPF), which was established in 2002.
3. The plan to co-locate private hospitals on the grounds of public hospitals, 2005.

I utilised qualitative methods of documentary analysis and in-depth interviews to explain and explore my research questions. Documents were gathered from many sources, including using Freedom of Information requests to gain access to previously unseen documents. Semi-structured, in-depth, elite interviews were carried out with 21 people involved in the three policy-making processes. Large amounts of data were gathered through these methods. The interviews were transcribed and coded in NVivo. All the data were then analysed using a conceptual framework that I developed for this research drawing on leading authors in this field.

The strongest finding to emerge from this research is the personalised and political nature of the three policy-making processes under scrutiny. While each policy process was different and resultedin different outcomes, the absence of the use of evidence – including the very limited use oflearning from other countries – was an associated key finding in this research. Where evidence was used, it was used to justify a political decision that had already been made. There was also a lack of good – or in some instances any – information that would help guide the policy-making processes.

The role and impact of a few powerful people – politicians, consultants and/or private hospital owners – on the three policy-making processes is another one of the most robust results from this research. In particular, the role and influence of the political party the Progressive Democrats (PDs)

and two senior politicians in these policy-making processes emerge as a central finding. This shows how particular personalities and politicians can have a powerful influence on the processes of making health policy, even when they are not the Minister for Health. This research also found how the broader political arena had more impact on these health policies than health system influences and demonstrates the impact Irish political institutions, in particular coalition governments, can have on policy choices. ]t also clearly shows the role of power in policy-making processes and how people in political and economically powerful positions wielded most influence in these three case studies.

Where it was possible to show lobbying took place, such as the changes to the Finance Act, that lobbying was very effective and led to policy change. It is harder to quantify the extent of the lobbying that took place in the other two policies. However, the research finds that private hospital owners and consultants benefited significantly from the two policies that were implemented and in some instances politicians represented the private sector interests in the policy making processes.

There was a strong degree of consensus among proponents of the three policies that the private sector could more easily solve the ills of public policy and that this was preferential to reforming the public sector. The failure of previous attempts to reform the public hospital system, and the

health system overall, was a common theme amongst the interview findings. Closely associated with this from proponents of the policies was a firm belief that the private sector was a more efficient and effective provider of care. There was no evidence to support this viewpoint.

The three policies set out to increase access to public patients to either hospital beds or hospital treatment. While each policy was proposed on the basis that it would lead to an increased provision of private for-profit care, they were all promoted on the basis that they were in the interest of public patients. The continued long waits for public patients and the negligible increase in beds for public patients demonstrate that, apart from the public patients who received care under the NTPF, these policies did not benefit public patients. Instead, the policies benefited private patients and those who owned and worked in private hospitals, such as consultants. This research quantifies the amount of public money that was diverted to private for-profit hospital care under two out of the three policies that were implemented. This added up to €830 million.

The level of disagreement among the interviewees as to the causes of the problems is evident from the findings . This is apparent across the three cases. Implicit in these findings were ideological differences which influenced the differing assessments of the problems by different interviewees.

Another strong finding that emerges from the research is the failure to reform or invest in the public system, ie not building up public hospital bed capacity, not addressing the long waits in the public system for public patients, not getting rid of the perverse incentives that maintained the public private-mix. This inaction created a space from which these private initiatives could emerge and gain political and public approval.

Furthermore, the failure to take responsibility for private healthcare is contradictory to the Department of Health’s simultaneous tolerance and promotion of a public-private mix of hospital care, even within the public hospital system. Each case raises questions about the capacity of the Department to develop and implement health policies. Another finding, evident in all three policies but most obvious in the case of the NTPF was how formal policy-making processes were undermined and ultimately overruled by informal processes. The research proposes a revised conceptual framework and a ‘macro-dynamic’ version ofKingdon’s multiple streams (Kingdon, 1995).

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Dr Olga McDaid

The chronic ills of multimorbidity : a cross-sectional examination of the prevalence, patterns and factors associated with multimorbidity in the Irish population aged 50 years and over and its corresponding impact on health and social care utilisation

Institution:  TCD, 2008 cohort
Supervisors:  Prof. Charles Normand (TCD)

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Dr Laura Currie

Public Policy and Health Behaviour Change: An investigation of tobacco control policy

Institution: RCSI, 2008 cohort
Supervisors: Prof. Hannah McGee (RCSI), Prof. Frank Doyle (RCSI), Prof. Richard Layte (TCD)

Abstract:
This thesis documents four interrelated studies, which seek to understand the impact tobacco control policies have had on patterns of smoking in Ireland.

Study 1 critically compares four tobacco use surveys in Ireland: SLAN, OTC, EURO, and FAST, and examines trends in smoking prevalence and social inequalities in smoking between 1990 and 2011. Study 2 re-contacts young adult respondents to SLAN 2007 (age 20-39 years, n = 1039; 83% response rate) to complete structured telephone interviews three years later. This study examines factors associated with continuity and change in smoking, and cessation related outcomes (quit intentions, quit attempts and nicotine dependence). Study 3 uses the same young adult follow-up data to examine responses to a recent large tax increase and estimates factors associated with compensatory behaviour. Lastly, Study 4 employed IrelandSS – an adapted version of the SimSmoke simulation model, to examine the effect of past policies and the potential effect of stronger policies on smoking prevalence and smoking-attributable deaths.

Triangulation of data suggests a significant downward trend in overall smoking prevalence among adults (18+ years) between 1990 and 2011; however, rates among the young and most socioeconomically disadvantaged are high (over 32%) and have not declined significantly. Social inequalities in smoking prevalence, initiation and cessation are increasing in both relative and absolute terms. The social differential in smoking prevalence is largely driven by widening inequalities in smoking among women and a widening differential in quit ratios between the highest and lowest socioeconomic groups.

Longitudinal analysis of young adults suggests overall prevalence declined from 33.3% to 32.2% between 2007 and 2009, with one in five making some transition in smoking behaviour; 5.8% (n=60) increased through initiation (n=32, 3.1%), relapse (n=28, 2.7%) or escalation from occasional to daily smoking (n=19,1.8%), while 8.7% (n=90) decreased reducing from daily to occasional smoking (n=22, 2.1%) or quitting altogether (n=68, 6.6%). Older age, lower education and lower perceived behavioural control were associated with higher odds of nicotine dependence at follow-up. Risky drinking predicted an upward smoking trajectory, while higher education predicted a downward trajectory. Smokers with higher perceived control and social norms favourable to smoking cessation were more likely to intend to quit. A past attempt and higher perceived control increased the odds of a current quit attempt. Young adult smokers of hand-rolled tobacco (HRT) (n=57,17%) and low- or untaxed tobacco (n=48, 15.3%) were more likely to be of lower socioeconomic position and significantly more likely to be men. Younger smokers with lower socioeconomic status were more likely to report responding to the tax increase.

Ireland’s simulations suggest that tobacco control policies implemented between 1998 and 2010 contributed to a 22% relative reduction in smoking prevalence by 2010. Stronger policies could reduce prevalence by 13.1% in the first year and 27.7% by 2040 relative to the status quo scenario, with greater reductions among young adults, and could avert 24,768 smoking-attributable deaths between 2011 and 2040.

This thesis concludes that tobacco control policies implemented in Ireland have contributed significantly to overall reductions in smoking prevalence; however, there is further scope for improvement. A number of implications for future research and policy are documented.

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Dr Jacqueline O’Reilly

The performance of diagnosis-related groups in Ireland & Europe, 2005-2008

Institution: TCD, 2008 cohort

Supervisors: Prof. Charles Normand (TCD)

Dr Niamh O’Rourke

Factors influencing Breast Cancer Referral Patterns in Ireland

Institution: RCSI, 2008 cohort

Supervisors: Prof. Anne Hickey (RCSI), Prof. John Browne (UCC), Prof. Ronan Conroy (RCSI)

Abstract:       

A policy of centralisation of symptomatic breast services was implemented in Ireland in 2009. This included centralising surgical services in eight Symptomatic Breast Disease (SBD) units and introduction of evidence-based GP referral guidelines for suspected cancer.

The aim of this PhD is to investigate the factors influencing GP referrals to SBD units in Ireland.

Four individual studies were conducted in a mixed-methods design. Study 1 analysed breast cancer referral and detection rates. Studies 2 and 3 comprised in-depth interviews with 9 cancer centres (hospitals) and 28 randomly-selected GPs to explore factors influencing GP referral. The impact of centralisation on referral patterns was analysed in Study 4, using the national cancer database.

Referrals to breast units in Ireland increased by almost 60% in five years, without a corresponding increase in breast cancers detected. Reasons for referral included mastalgia (15%) and family history (9%). Clinical and non-clinical factors were identified as influencing referrals, such as;

• GP factors, including fear of missing a cancer and risk aversion
• Resources, including ease of access to breast clinics and high quality of the service
• Social influences, such as patient anxiety, media and patient expectations

A significant increase was identified in analysis of national data of the proportion of patients having their diagnosis and surgery at designated cancer centres rather than non-cancer centres, indicating a high level of policy implementation. Cox proportional-hazards regression showed prompt access for GP referrals.

This is the first study to examine the effects of centralisation of breast cancer services in Ireland. The results provide useful evidence on the impact and effectiveness of this policy initiative and show early indicators of success.

GP referrals are influenced by GP, health service, social and clinical factors, which can be both social and contextual in nature. GP beliefs about consequences coupled with social influences are challenging barriers to address and will require multifaceted interventions to overcome.

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Dr Celine Larkin

Self-cutting and prospective repetition of self-harm: Studies of emergency department presentations in Ireland

Institution: UCC, 2008 cohort
Supervisors: Prof. Ella Arensman (UCC), Dr. Zelda Di Blassi (UCC)

Abstract:        
Self-harm places an individual at increased risk of future self-harm and suicide, and indicates distress and maladaptive coping. Those who present to hospital with self-cutting form a significant minority of self-harm patients who are at increased risk of prospective repetition of self-harm and suicide compared with those presenting with intentional overdose. In addition to increased risk, there is emerging evidence of demographic, psychological, clinical, and social differences between those presenting with self-cutting and those presenting with overdose.

The aim of the current doctoral work was to examine in detail the association between presenting with self-cutting and risk of prospective repetition. The objectives were: to identify evidence-based risk factors for repetition of self-harm among those presenting to emergency departments with self-harm; to compare demographic and presentation characteristics and prospective repetition across presentations of self-cutting only, self-cutting plus intentional overdose, and intentional overdose only; to compare prospective repetition and other characteristics within self-cutting presentations based on the type of treatment received; to compare self-cutting and intentional overdose patients on psychological risk and protective factors for repetition; and to examine the lived experience of engaging in repeated overdose and self-cutting.

The current doctoral work used a mixed-methods approach and is comprised of one systematic review and four empirical studies. The empirical studies were two registry-based prospective studies of Irish hospital presentations of self-harm, one prospective structured interview study, and one qualitative study using Interpretative Phenomenological Analysis.

The systematic review identified several consistent and emerging risk factors for repetition of self-harm, compared to which self-cutting had a medium-sized effect. The registry studies demonstrated that the involvement of self-cutting, particularly less medically severe selfcutting, confers an increased risk of 1-month and 12-month repetition among Irish index selfharm presentations. The structured psychological study detected higher hopelessness and lower non-reactivity to inner experience among those presenting with self-cutting, and higher depression among those who repeated self-harm. Repeaters had lower baseline levels of protective psychological factors than non-repeaters and continued to have higher depression and hopelessness at follow-up. Finally, the qualitative study indicated that self-harm is a purposeful action taken in response to an overwhelming situation and is evaluated afterwards in terms of personal and social effects. Chosen method of self-harm seemed to be influenced by the desired outcome of the self-harm act, capability, accessibility and previous experience.

Despite limitations in terms of recruitment rates, the work presented in this thesis is innovative in examining the issue of the association between self-cutting and repetition from multiple perspectives. No one factor can reliably predict all repetition but self-cutting represents one consistent and easily detected risk factor for repetition. Those who present with self-cutting exhibit significant differences on demographic, clinical, and psychological variables compared with those presenting with intentional overdose, and seem to exhibit a more vulnerable profile. However, those who present with self-cutting do not form a discrete or homogenous group, and self-harm methods and levels of suicidal intent are liable to fluctuate over time.

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Dr Sara McAleese

The “humanisation”of medicine? : the feminisation of medicine: a qualitative study of the career experiences of female doctors and implications for human resources management in Ireland

Institution: RCSI, 2008 cohort
Supervisors: Prof. Ruairi Brugha (RCSI), Dr. Niamh Humphries (RCSI), Prof. Stephen Thomas (TCD)

Abstract:        
The féminisation of medicine is an international phenomenon referring to increasing numbers of females undertaking medical education and entering the medical workforce. This phenomenon has been a hallmark of the medical profession in Ireland since the 1990s. Associated with this phenomenon are several trends that may have implications for human resources management of the medical workforce. These trends are: distinct variation in the distribution of female doctors across the medical specialties, under-representation of female doctors in senior medical roles, and a greater likelihood of less-than-full-time working among female doctors compared to males. Suggested implications of the féminisation of medicine for human resources management are: the development of shortage and surplus specialties in terms of applicants, a decline in interest in hospital-based specialties, and an overall decrease in available WTE. However, the implications of this phenomenon for the medical workforce in Ireland are unclear.

This PhD study provides an in-depth exploration of the féminisation of medicine and identifies the possible implications of this phenomenon for human resources management in Ireland. A qualitative methodological approach was employed for this PhD study as it facilitated exploration of the phenomenon and generation of in-depth knowledge to understand the associated trends. A two-phase semi-structured interview study was carried out: Phase One described and analysed the trends associated with the féminisation of medicine from the experiences of female doctors working in Ireland. Phase Two reported and analysed the perspectives of key national stakeholders in areas related to human resources management to ascertain the consequences of the féminisation of medicine for the medical workforce in Ireland and describe possible policy responses.

Key findings are (i) the ‘plannable’ characteristics (i.e. working hours, and location and duration of training) of specialties are crucial influencing factors on specialty choice for female doctors, (ii) the existence of a gender bias against female doctors in the form of a glass ceiling, and (iii) human resources management as a discipline is in its infancy in Ireland, which has largely ignored not only the féminisation of medicine, but wider challenges facing the medical workforce. These findings support the existence of Acker’s theory of gendered organisations with respect to the medical profession in Ireland, which asserts that organisations have developed with a male worker at the core.

The key findings of this PhD study suggest that human resources management in Ireland must address organisational structures in the medical profession to reduce a gender bias against female doctors inherent in their foundation. However, human resources management must first address underlying medical workforce challenges, such as the working conditions of doctors, before it can prioritise issues arising due to the féminisation of medicine.

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Dr Gemma Smith

Communicable Disease Screening for Asylum Seekers and Refugees in Ireland

Institution:  RCSI, 2008 cohort

Supervisors:  Prof. Samuel McConkey (RCSI), Prof. Ruairi Brugha (RCSI), Prof. Richard Coker (LSHTM)

Abstract:       

Numerous countries employ migrant communicable disease screening programmes and initial health assessments (IHAs). Although the evidence base under-pinning screening policies has been criticised, relatively little is known about the extent to which screening policies, guidelines and programmes are implemented and practice is evidence-informed.

A case study design was employed to examine the development of communicable disease screening guidelines for asylum seekers and refugees in Ireland and the enacting of the guidelines and programme in practice. A national mapping study of screening service provision was undertaken, alongside a document review. Three sets of in-depth interviews were conducted with key informants involved in the guideline development, the related broader policy context, either current or past screening service provision or the provision of services relating to HIV/AIDS, TB or depression, for example referral services.

Screening service coverage was decentralised and fragmented nationally, and concerns were raised regarding access and continuity of care. Where screening services existed the national guidelines were broadly implemented, but there was variation in implementation and barriers were particularly identified to Mantoux testing and polio screening.

Adaptation of the screening service and guidelines was evident, with some screening health care providers (sHCPs) adopting a more holistic perspective. The findings demonstrated the importance of the adaptable elements of the intervention in understanding the enacting of the guidelines, programme and services, for example, the provision of screening through a dedicated screening service or mainstream General Practitioners (GPs).

Conceptual and theoretical insights were gained from the critical use of a conceptual framework, based on an adapted version of the Consolidated Framework for Implementation Research (CFIR) and the Normalisation Process Theory (NPT). The use of the adapted CFIR highlighted the multiple interacting barriers to implementation and normalisation. These included the characteristics of the intervention, the multiple stakeholders involved and the process, including the development of the guidelines. Contextual factors were also influential, for example, the lack of national level responsibility for the screening programme and the historic decentralised establishment of the screening service. The use of the NPT in the conceptual framework particularly highlighted the dynamic and social nature of implementation, including the individual and collective responses to implementation.

The findings illustrate the value of a more bottom-up perspective in order to understand the enacting of the screening guidelines and programme, and provide support for an alternative view to a simple top-down conceptualisation of an implementation gap. Through the use of the conceptual framework these findings could have broader applicability to understanding and getting knowledge into action in other contexts.

Screening service provision needs to be evidence-informed, rather than determined by the implementation barriers identified in this thesis. Ensuring evidence informs guideline and programme development, and is subsequently enacted in practice, is necessary in order to provide equitable, high quality and sustainable health services, including screening, which contribute towards public health. This is also essential if the services are to meet the needs of vulnerable populations, including asylum seekers and refugees.