In Northern Ireland (NI), based on registry data, 5.6% of the population aged 18 and over are registered with diabetes (1). While in the Republic of Ireland (ROI) a similar register does not exist, it has been estimated that 5.2 per cent of those aged 18 and over have diabetes (2). Diabetic care is a substantial driver of overall health care utilisation and costs. In Europe and North America, the proportion of healthcare expenditure on diabetes in 2010 ranges from 6 to 14 per cent (3). An earlier study estimated the cost of Type II diabetes in ROI to be 6.4 per cent of the total healthcare budget (4). In addition to direct healthcare costs, diabetes significantly impacts on mortality rates, quality of life and labour market productivity (5, 6).
Healthcare utilisation and healthcare costs among those with diabetes are strongly related to diabetic complications; in the UK, 80 per cent of diabetic healthcare costs are due to complications (7, 8). The direct healthcare cost of complications in the UK include: cardiovascular diseases related to diabetes (36% of the overall healthcare cost) and foot ulcers and amputations (13%) (7). Predicative factors for the development of complications include duration of diabetes and glycaemic control (9, 10).
The risk of diabetic complications can be reduced by self-management of the disease as well as appropriate management by healthcare practitioners. In the 2016 Scottish Diabetes Survey, 45 per cent of patients had a HbA1c of more than 58 mmol/mol (7.5% DCCT), suggesting substantial scope for improved glycaemic control and management of diabetic care. A combination of diet, exercise and medication are typically advised for people with diabetes to achieve good glycaemic control. In addition to accessibility to quality health care, social, cultural and economic factors play an important role in an individual’s capacity to manage their diabetes (11). Factors that have been shown to be associated with poor glycaemic control include younger age, number of years of education, longer duration of diabetes, insulin treatment and poor self-management behaviours (12, 13).
The GP is the primary point of contact between the health service and people with diabetes. There are substantial 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 (14). For diabetes, GPs are paid on the basis of 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 (15). However, beyond the upper thresholds of each QOF indicator, GPs had no financial incentives to improve care (16). 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 work longer hours can earn more revenue from private patients which may incentivize them to provide easier access through, for example, extended working hours. In contrast in NI, the revenue that a GP practice earns is largely determined by the list size. In ROI, prior to the Cycle of Care programme, established in 2015, there was no specific financial support for GPs providing primary care to patients with diabetes. Diabetic care was unstructured and record keeping by many GPs was poor (17). 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 (11, 18, 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 WTE), based on total number (head count) of GPs for 2014 and population numbers (22). While we do not have working time equivalent (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 (34). The higher cost of inpatient services and longer waiting times in ROI (in 2014) may also increase the proportion of services delivered though primary care (35, 36).
A number of demand side factors, other that need, are also likely to influence differences in the utilisation of GP services under the two systems including cost, geographic accessibility and time cost (37). NI has a population density of just under twice that of ROI, which may lead to differences in transport times to GPs in the two jurisdictions. However, while significant differences in the transportation times and cost for urban and rural patients have been shown in ROI; these have not been shown to translate into differences in utilisation (38). Employment status may also be related to the utilisation of GP care, both as a covariate of need and also by increasing the opportunity cost of attending the GP; however, there is little variation (36% vs 35%) in the employment rates of the over 50 s age group between the two jurisdictions (39, 40).
In this study, we examine, for patients aged 50 and over with diabetes, differences between NI and ROI in the number and type of health care contacts and clinical outcomes.