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THE JOURNAL OF

CROSS
BORDER
STUDIES
IN IRELAND
No. 3

with information about the


CENTRE FOR CROSS BORDER STUDIES
(including 2007 annual report)

Spring 2008 - Year 9

7/10
JOURNAL OF CROSS BORDER STUDIES IN IRELAND No.3

THE JOURNAL OF CROSS


BORDER STUDIES IN IRELAND

Cover photo: from The Forest by Paul Seawright,


first exhibited at Hasselblad Gallery/Museum of Fine Art,
Gothenburg, Sweden, 2001 courtesy of the artist.

The Centre for Cross Border Studies receives


financial support from the EU Programme
for Peace and Reconciliation

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JOURNAL OF CROSS BORDER STUDIES IN IRELAND No.3

SURVEYING THE SICKBEDS: INITIAL STEPS


TOWARDS MODELLING ALL-ISLAND
HOSPITAL ACCESSIBILITY
Ronan Foley, Martin Charlton and Patricia Clarke

Ronan Foley Martin Charlton Patricia Clarke

There has been increasing interest in recent years by both civil servants and
academics in both Irish jurisdictions in modelling economic and social
structures across the whole island, with health services one of the key
areas explored1. There has been some limited cross-border movement in the
utilisation of health care, and a recently published preliminary study by
Jamison and Butler (2007)2 examined the existing configuration of acute
hospital services, identifying considerable potential for cross-border
collaboration in these services, particularly in the border region.

Hospital rationalisation remains Report7 in the Republic. However all


somewhat further advanced in Northern these reports contain practically nothing
Ireland than in the South, which may with a cross-border dimension. Recent
present some issues around reciprocal developments in cancer services with
service provision.3 However, strategic patients from Donegal going to Belfast
reorganisation plans in the health sector for radiotherapy show that it is
have been drawn up since 2000 in both possible to begin to envisage the future
jurisdictions, as represented by the pattern of acute hospital services on a
Hayes Report in the North4, and the cross-border basis. This initiative is the
Hanly Report5, the Developing Better first indication that the Irish Government
Services Report6 and the Teamwork is prepared systematically to access

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JOURNAL OF CROSS BORDER STUDIES IN IRELAND No.3

services in the North which benefit Ireland of the National Health Service
citizens of the Republic8. model created one structure, while a
notional national public hospital system,
This article, based on work the National but one characterised by a more
Centre for GeoComputation at NUI complex public-private mix with a
Maynooth is doing for the Centre for stronger role for private health
Cross Border Studies, is a development insurance, emerged in the South.
of Jamison and Butlers work in that it
takes a geographical or spatial approach Similarly, the organisation of hospitals in
to measuring accessibility to acute both jurisdictions differed. In the North,
hospitals and examines how the current they were organised under a Trust
configurations in both jurisdictions can model with multiple sites within each
be expressed in terms of an accessibility Trust area. For the purposes of this
score. It also investigates quantitatively article we have based our assumptions
another of these authors themes, on a Trust model with nine acute
namely the relative accessibility of hospitals and a simple bed count with
hospitals both North and South as no differentiation by specialism. In the
expressed by beds per patient. South, the 40 hospitals providing acute
care are a mix of voluntary hospitals and
The role of spatial planning Health Board/Health Service Executive
funded units. Within both jurisdictions
Jamison and Butler note the role of there is a range of hospital sizes,
history in explaining the current expressed in both the number of
distribution of hospitals North and specialisms and the total bed count,
South. For a health geographer this is a although the latter was the sole
crucial aspect in modelling health care measure which was used in the model
provision.9 The distribution of the for this study.
current hospital network in Ireland
reflects the previous organisation of There has been a concerted effort in
hospital services, developed from the both jurisdictions in recent years to look
18th century onwards and reflected in seriously at the organisation of hospital
the pre-partition model, which covered services. In addition to the reports listed
the whole island. In this model the above, the 2005 Appleby Review11 is
general hospital provision was broadly crucial because it looked at the
based on two elements: voluntary performance and efficiency of the wider
hospitals, mostly located in the cities, health and social services in Northern
and the general county hospitals, Ireland and identified particular
typically associated with local weaknesses and inefficiencies. All these
authorities.10 The pattern of provision reports are informed by the twin aims of
after partition initially maintained these providing both a more equitable and a
structures. In the latter half of the 20th more efficient health service. In this
century, the introduction in Northern paper it is the spatial element whose

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JOURNAL OF CROSS BORDER STUDIES IN IRELAND No.3

exploration could help in improving that as density of population and the impact
service which concerns us. Clearly of distance have rarely been factored
geographical tensions always exist in into strategic planning.12
any decision on where to locate health
services. These will reflect tensions Yet the fact is that all policy requires
between urban and rural areas, better evidence bases. The existence of
between densely and lightly populated data sets which can be spatially
areas, and between local, regional and referenced and fed into analytical tools
national imperatives. Few decisions such as Geographical Information
made around either additions to, or cuts Systems (GIS) means that there is now
in, service provision escape the considerable potential for a spatially
contentious question of exactly where informed modelling approach which can
these adjustments should take place. provide valuable evidence bases for
Both Jamison and Butler and Murphy making decisions about locating hospital
and Killen12 stress the importance of services. This article begins in a small
spatially-informed decision-making way to identify how those spatial data
when choosing the location of new sets can be put together to help inform
hospitals (both regional and such planning. Perhaps the primary
service-specific). value of a GIS based approach is its
ability to collate large volumes of
One area where policy is arguably information and to produce not one
lacking is evidence bases with spatial answer but several answers to inform a
dimensions. It is possible to access number of different planning scenarios.
information on an annual basis on the
nature and level of hospital service The aim of the work the National
provision in terms of bed counts, Centre for GeoComputation is currently
occupancy rates, specialisms and day doing for CCBS is to start using a spatial
patient activity. These statistics are approach to examine specific aspects of
associated with individual hospitals but accessibility associated with existing and
can also be aggregated up to regional potential future hospital provision on an
or national level. It is also possible to get island basis. It is by definition a pilot
information on utilisation of services study and the aim is relatively broad for
though spatially-tagged data, although this reason. The specific objectives of
this is better in the North due to the the study are: to use GIS to model
existence of UK postcodes and the very spatial accessibility to acute hospitals in
limited spatial coding contained in the both Northern Ireland and the Republic
Souths Hospital Inpatient Enquiry of Ireland; to model for two different
System. Both these data sets have been time periods to see how changes in bed
studied and analysed but rarely have provision and local populations have an
their locational and spatial aspects been impact on accessibility; to provide a
put together in a holistic way. spatial measure of supply equity in the
Additionally, geographical aspects such form of beds per patient; and to explore

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JOURNAL OF CROSS BORDER STUDIES IN IRELAND No.3

how changes, even over a very short two quite different health care systems,
time period, impact spatially on North and South. Need is also a
improvements or reductions in bed complex term with a number of
supply. different definitions relating to
expressed need in the form of patients
The arrival of GIS and digital and unexpressed need within the wider
spatial data population13. Finally, equity can be
expressed in a number of ways,
Modelling accessibility is a subject that depending on whether one uses a
has engaged the minds of medical and vertical or horizontal definition,14 or even
health geographers from an early stage. whether one takes a measure based on
One of the original core texts in the population or catchment area15.
subject was by Joseph and Phillips13,
which explicitly studied the twin terms The work of Khan and Bhardwaj16 is
accessibility and utilisation. While the particularly useful in developing a fuller
two themes can be and often are understanding of what they refer to as
discussed separately, it is important to spatial and aspatial aspects of
acknowledge the utilisation dimension accessibility. The aspatial aspects they
up front, although this study will focus refer to include a wide and complex set
primarily on accessibility. Clearly any of variables including income,
study of access to and utilisation of education, social class, insurance and
health care needs to be aware also of other social and economic factors which
core concepts such as need, equity, affect how people access and utilise
supply and demand it is important to health care. They identify these as being
recognise that all these elements play a separate but linked elements to the
role in a full exploration of accessibility. more purely spatial aspects of location,
distance, time and supply which provide
We have incorporated some of these the other part of the equation. Together
elements into our spatial modelling, these provide a completely integrated
though others would require additional model, but it is the spatial side of the
data and research. For example supply is equation that this article will focus on,
expressed through the number of while understanding that a fuller
hospitals but also the relative size of development incorporating the aspatial
those hospitals and the level of services would be needed to develop the work
provided. Demand is often measured in the future.
through utilisation, but there are issues
here in terms of how fully demand The traditional approach used by
identifies need in a setting of waiting medical and health geographers has
lists and staffing shortages, and where been to focus on a number of core
the structure of the system itself informs datasets and use these in the modelling
utilisation rates. This is a particular issue of accessibility. Some of these
in a study like this one, which looks at approaches were used before the

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JOURNAL OF CROSS BORDER STUDIES IN IRELAND No.3

widespread use of GIS and digital spatial effective accessibility score by area,
data.17 The arrival of the latter has, weighted by population, and which also
however, allowed for more efficient and incorporated a locally relevant
effective modelling using a number of remoteness factor. Other studies have
new spatial analytical techniques. The used the power of the GIS to produce
location and distribution of health care more robust forms of spatial modelling
facilities form the first layer of by including consideration of distance
information. While much of this work along road networks and travel time.23, 24
has focussed on secondary and tertiary Other researchers25, 26 have used
care, other services associated with additional spatial modelling techniques
primary care, community care and even to measure the effect of clustering of
voluntary services have also been services and its impact on access.
modelled in this way.1,19
Within the Republic of Ireland, the first
The second core element is a layer that work that looked at the geography of
incorporates demographic data and the hospitals and the ways in which
distribution of different populations. geography could be used to model
These function as proxies for demand proposed changes was carried out in
and need and can be broken down into 197917. This looked at the impacts of
sub-populations depending on the the 1968 Fitzgerald Report and
services being modelled8. The final layer modelled a proposed re-organisation of
of information needed is on the hospitals into a set of regional networks,
transportation network used to model a proposal surprisingly similar to
the spatial linkages between patients or proposals in 2007. More directly
potential patients and services. This was relevant were a number of recent
traditionally modelled as Euclidian or studies which were informed by policy
straight-line distance, which often decisions and aimed at modelling the
enabled planners to quickly see buffers implications of those decisions. Teljeur et
or catchments zones around hospitals al27 carried out the first GIS-informed
and to visualise quickly those areas or study of the potential impact of the
groups which fell outside those zones.2 Hanly report by producing tabulated
outputs by health board area for the
With the advent of GIS, the ability to effect of Hanly on travel times for two
overlay and merge these three different specific acute interventions, heart
layers within a single automated attacks and road traffic accidents.
information system provided an Essentially they modelled a pre and post
important new evidence base for health Hanly model for these interventions and
care planning21. Brabyn and Skelly22 took concluded that access to services for
these core elements and combined them them had deteriorated. Kalogirou and
in a vector (linear) GIS to model access Foley28 also modelled the impact of
to public hospitals by travel time across Hanly more widely in terms of general
New Zealand. They identified an hospital provision. They identified three

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different models: one current, one


based on a partial roll-out of Hanly and
one based on a full roll-out. Two further
recent studies have focused on the
optimal location of a new national
childrens hospital29, 12. What has been
useful in all these studies is the
development of GIS-based models to
provide the beginnings of an evidence
base which informs policy by identifying
the importance of geography in the
decision-making process. The current
work begins to extend the above
analysis by applying it on an all-island
basis. While there are clearly structural
and system-based complications in
modelling two hospital networks
simultaneously, we hope that the spatial
outcomes from the modelling will
interest policy makers in the role of
geography on both sides of the border. Figure 1

Data and method


(potential need and demand), the
With governments in both Irish configuration of hospitals North and
jurisdictions engaged in the South (potential supply) and the
restructuring of health services, the transport network (accessibility based on
Centre for Cross Border Studies travel time).
approached the National Centre for
GeoComputation to critically explore the Based on the literature on spatial
potential for developing a GIS-based accessibility, three core datasets
spatial model of access to hospitals on were identified as being essential.
an all-island basis. The initial pilot study These were:
has a single research aim: to develop a a) demographic data at electoral division
robust model of spatial accessibility (ED) and output area (OA) levels (drawn
which would be realistic enough to from the Northern Ireland Statistical
satisfy health care planners while also Research Agency and the Central
being technically sound enough to Statistics Office in the South);
satisfy GIS modellers. It was driven by b) point datasets for individual hospitals
the three core geographical with associated data on size, status and
considerations mentioned previously: the levels of provision (data was gathered
distribution of potential patients directly from the Department of Health,

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Social Services and Public Safety in of the hospitals with small area
Northern Ireland and the Irish population counts to produce an
Department of Health and Children); effective cost-distance surface which
c) data related to the road networks in provided us with an accessibility score.
both countries (commercially purchased The final technical stage was to remodel
NAVTEQ data). the accessibility scores with the border
both included and excluded in order to
A number of issues arose in relation to examine its spatial effect on hospital
spatial scale, compatibilities of activity in both jurisdictions.
classifications and the timing of data
collection, but a robust initial model was
still produced30, 31. This will be more fully
detailed in a final report later in 2008.

Given that the aims were to produce a


working accessibility score as well as to
define nominal catchments, the model
started by assuming nominal non-
overlapping catchments for each
hospital. Once these catchments were
defined and mapped, it was possible to
use the background demographic data
to compute the number of residents in
each catchment. Given that we also
knew how many beds were available in
all the hospitals, we could compute the
ratio of beds per head of population in
Northern Ireland and Republic of
Ireland. We were then able to compute
the expected number of beds if local
supply followed the national rate, and
calculate the ratio of the actual number Figure 2
of beds relative to the expected number
of beds this gave us the local bed rate Some initial results
as a location quotient. This approach
will be more fully described in the final The initial modelling focused on the
project report. years 2001-2002 as this was the best fit
in terms of demographic data North and
The second piece of modelling was South. There was an estimated
more complex: it was carried out within combined island population of 5.59
the GIS to combine the road network, million in this period. The total number
travel speeds and the specific locations of beds modelled into the system at this

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time was 14,129, and taking the two 14,129 in 2001-02) kept up almost
jurisdictional datasets together an all- exactly with a 6.2% increase in the
island rate of 0.00257 beds per person islands population.
was calculated. Multiplying each
modelled catchments population by this It was also interesting to look at change
rate would yield the expected number in a more disaggregated way by
of beds in a particular area, which could examining modelled bed rate provision
be compared with the actual number. at regional and local levels. As noted in
Not unexpectedly, the initial map the methodology section, for each
(Figure 1) identified a strong clustering hospital catchment a form of location
of high accessibility around urban quotient was calculated which
centres. Obviously this was affected by compared actual local provision to the
the location of most hospitals in high expected provision if all-island averages
density population areas. Equally it was were applied. When the two time
not surprising that there were low levels periods were compared (Figure 2), it
of accessibility in much of the western was possible to tease out more fully
seaboard and in upland areas of changes at a local level. A number of
Northern Ireland. These common sense areas showed a reduction in their
conclusions indicated that the modelling location quotients, most definitively in
was working satisfactorily. Galway but also in the Midlands, along
the south coast, in Donegal and in
The second phase of the modelling south Down. Much of Northern Ireland
looked at the period 2005-2006 using saw slight increases in the their location
updated hospital, road and quotients as did parts of central and
demographic data. There were strong mid-Leinster, and perhaps surprisingly
caveats on the demographic data due to even some more remote parts of
the lack of up-to-date small area data Mayo and west Cork. Policy makers
for Northern Ireland, and as a result this could find this data, even with the
data was modelled from district level caveats mentioned, useful in a number
estimates. The accessibility modelling of ways. Spatial approaches such as this
identified for 2005-2006 provided identify more exactly where change is
results very similar to the earlier 2001- taking place. However it should be
2002 period. It was difficult to get a noted that a reduction in the location
strong sense of change from the spatial quotient for an area like Galway, while it
accessibility maps as the two periods might suggest a diminution of service
were only five years apart and the provision, could also indicate an over-
increases in bed provision were matched supply in the first period which was
by increases in population across both brought back in line with the national
jurisdictions. However it was interesting average in the second period.
and encouraging for policy makers
that the provision of beds in this period The most interesting part of the
(15,008 in 2005-06 as opposed to modelling was when the impact of the

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border was modelled as two scenarios, while 52% of the population in border
one with and one without the border. areas were disadvantaged by the
This allowed the impact of a non- presence of the border by less than five
border scenario to be modelled and minutes, a full 26% of the residents
compared with provision in the present were disadvantaged by fifteen minutes
separate systems. This identified the or more. Put bluntly, for someone
location of areas close to the border suffering a heart attack or a serious road
which were disadvantaged in terms of traffic accident, this border factor
accessibility, as well as the extent, could make the difference between life
expressed in excess travel time zones, of and death32. As Figure 3 demonstrates,
that disadvantage (Figure 3). This was the GIS was able not only to calculate
done by using the GIS to calculate a these inequities but also to identify
time disadvantage grid. This grid was exactly where these zones were. Thus,
then classified into time bands, and for example, people living in north
vectorised and intersected with the Donegal in the Inishowen peninsula and
population data to obtain the in south Donegal near Lough Derg could
proportions of accessibility and travel to hospitals in Northern Ireland
inaccessibility in each band. faster in an emergency. Likewise people
living in west Tyrone would get faster
The most significant finding was that access to emergency care in the

Figure 3

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Republic of Ireland. Other areas where Additionally a predictive version of the


travel to hospital distances would be model for 2011 or even 2015, which
decreased by allowing cross-border included planned hospital capacity
access include north-west Cavan along changes, would also be relatively easy to
the N87, in the Cooley Peninsula and do once the respective datasets in the
along the Northern Ireland border with two jurisdictions are in place. Such
Monaghan in areas such as Aughnacloy, modelling could also feature a set of
Roslea, Keady and Crossmaglen. This scenarios based on minimal, partial and
exercise thus identified another very full achievement of those plans. A third,
useful policy function for a spatial quantitative approach would be to
modelling approach in a cross-border model individual services according to
context. accessibility, perhaps also weighted by
utilisation data. Finally, detailed
Conclusions qualitative research would be required
to put flesh on the bones of such spatial
A developed version of this model modelling by using new data on
would incorporate analysis of population utilisation, patterns of referral, links with
data at small area level along with primary care, and local evidence on both
health service data by specialism public feeling and patterns of ad hoc
(utilisation rates, staffing numbers, use. The role of private insurance and
hospital throughput etc), but this was private hospital care would also have to
beyond the scope of this initial research. be factored into such a study.
In addition, a number of caveats exist in
relation to accurate bed counts (most Communities on both sides of the
are averaged across the year) and the border are reluctant to embrace
extent to which certain hospitals might government policy of centralising
be slotted in or out of the model. hospital services, believing that the
However the primary aim of the majority of time critical emergencies can
research was to identify the potential of be treated locally. An illuminating study
GIS for scenario modelling involving by Nicoll et. al. (2007)33, a leading UK
both a spatial and a numerical analysis researcher, concluded that for every
of the impact of the border. Tracking the extra 10 kilometres you travel when you
spatial impact of future policy are seriously ill, your risk of dying rises
developments using this method should by one per cent. There is good evidence
be very feasible. It should have particular for some groups of emergency patients,
applications in the south-west of for example major trauma patients with
Northern Ireland, where a new hospital multiple injuries, that travelling longer
is being planned for Enniskillen, and in distances to specialist care centres
the north-east of the Republic where improves outcomes. Anecdotally these
a new regional hospital has been groups of people are already bypassing
proposed, both serving border local care and being taken directly to
region populations. the nearest appropriate care irrespective

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on which side of the border it is Martin Charlton is the Deputy


delivered. However Nicoll suggests that Director of the National Centre for
for patients in anaphylactic shock, GeoComputation at NUI Maynooth
choking, drowning, or having acute
asthma attacks who need urgent care, Patricia Clarke is the Research
having to travel increased distances for Manager of the Centre for Cross
care that could be delivered locally is Border Studies, Armagh
detrimental. Applying this principle to
the border region, optimal patient care
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34. The cross-border GP Out-Of-Hours


service is being piloted to improve
access by allowing people living in
the border region to access their
nearest out-of-hours service
irrespective of which side of the
border they live.

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