Spending Review 2022 Review of the Long Term Illness Scheme

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Spending Review 2022

Review of the Long Term Illness Scheme

NIAMH O’REILLY AND ROBERT SCOTT

HEALTH VOTE

DEPARTMENT OF PUBLIC EXPENDITURE AND REFORM

SEPTEMBER, 2022

This paper has been prepared by IGEES staff

in the Department of Public Expenditure and

Reform. The views presented in this paper do

not represent the official views of the

Department or Minister for Public

Expenditure and Reform.

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This paper has been prepared by IGEES staff in

the Department of Public Expenditure & Reform.

The views presented in this paper do not

represent the official views of the Department or

the Minister for Public Expenditure and Reform.

Executive Summary – Review of the Long Term Illness Scheme

Context:

 The Long Term Illness Scheme is a non-means tested, 16 condition specific community pharmacy

scheme operated by the Primary Care Reimbursement Service (PCRS) of the HSE with a cost of €292m

in 2021. Through the scheme eligible participants receive prescription medication, medical products,

and medical and surgical appliances associated with their qualifying condition free of charge.

 The scheme is operated alongside a suite of community pharmacy schemes that assist individuals

with their drug costs overseen by PCRS, including the General Medical Services Scheme (also known

as the Medical Card scheme) and the Drugs Payment Scheme.

 This paper analyses the LTI scheme to assess the drivers of this growth, considers scheme policy

issues and discusses recommendations on potential next steps arising from the analysis.

Expenditure Trajectory and Drivers:

 Expenditure associated with the Long Term Illness Scheme has increased by 175% since 2013, from

€106m to €292m in 2021. Over this period, the number of claimants increased by 175% (from a total

of 71,000 to 195,000 claimants).

 A majority of the expenditure in 2021 relates to the conditions of diabetes (78%) and epilepsy (8%),

with these two conditions accounting for a similar proportion of total claimants.

 It is evident that the key expenditure driver for the scheme in recent years has been the increase in

the number of claimants for the conditions of diabetes and epilepsy (89% of the overall claimant

increase).

 In addition, the average cost per item has been trending upward consistently since 2017, growing by

on average 2% per year. As there are various pharmaceutical pricing agreements and legislative

mechanisms in place to stabilise drug costs this may indicate that more effective but more expensive

products may be being used.

Key Policy Considerations:

 The Department of Health have committed to review the LTI scheme as part of a wider Sláintecare

commitment to review the overall eligibility framework which will consider the policy trajectory of

the scheme as a whole, however, this paper has found the following core policy challenges worth

considering within any future analysis:

o Core eligibility criteria for the scheme is limited to 16 conditions and the provision of eligibility

for a scheme on the basis of specific conditions presents challenges regarding equity and

fairness.

o Schemes like the LTI appear to be relatively uncommon internationally based on the available

evidence, with only 6 other EU countries offering specific pharmaceutical cost supports using a

specified condition list.

o The non-means tested nature of the scheme and the absence of co-payment is unusual among

community pharmacy schemes in Ireland.

o The wider context under which the LTI scheme was created has substantially changed, with

much broader financial supports now available to individuals in relation to pharmaceutical

expenditure provided via the Drugs Payment Scheme (which effectively caps pharmaceutical

expenditure at €80 per month) and General Medical Services schemes (where an individual only

pays prescription charges up to a maximum of €15 per month).

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Contents 
Introduction & Context ...................................................................................................................... 4 
Methodology and Limitations ............................................................................................................. 4 
Contextualising the LTI within the Community Drugs Space ............................................................... 5 
Analysis of Long Term Illness Scheme Activity and Expenditure ...................................................... 8 
Expenditure Context ............................................................................................................................ 8 
1 LTI Scheme Expenditure Driver Analysis ........................................................................................ 8 
1.1 Number of Persons on Scheme .................................................................................................. 8 
1.2 Expenditure and Scheme Claimants by Condition .................................................................... 10 
1.3 Disease Prevalence of LTI Conditions ...................................................................................... 10 
2 Data Constraints .......................................................................................................................... 15 
Policy Discussion .............................................................................................................................. 16 
1 Introduction................................................................................................................................. 16 
2.1 LTI Creation Rationale and Current Community Pharmacy Policy ........................................... 16 
2.2 European Context ..................................................................................................................... 17 
Conclusion and Recommendations ................................................................................................. 19 
1 Conclusion ................................................................................................................................... 19 
2  Recommendations and Policy Considerations....................................................................... 19 
Appendix 1: ....................................................................................................................................... 22 
Appendix 2: ....................................................................................................................................... 22 
 
   

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1. Introduction & Context

The Long Term Illness (LTI) Scheme is a non-means tested, condition specific, prescription charge

exempt primary care scheme overseen by the Primary Care Reimbursement Service (PCRS) within the

HSE. The scheme commenced in 1970 through the Health Act (1970) and was last amended in 1975.

To qualify, a patient must have one (or more) of the following sixteen eligible conditions:

1. Intellectual disability

2. Mental illness (for individuals under 16 only)

3. Diabetes insipidus

4. Diabetes mellitus (Diabetes Type 1 and 2)

5. Haemophilia

6. Cerebral palsy

7. Phenylketonuria (PKU)

8. Epilepsy

9. Cystic fibrosis

10. Multiple sclerosis (MS)

11. Spina bifida

12. Muscular dystrophies

13. Hydrocephalus

14. Parkinsonism

15. Acute leukaemia

16. Conditions arising from use of Thalidomide

Through the LTI, patients receive all approved

medications and appliances

associated with the listed

condition(s) free of charge without having to pay prescription charges. The scheme is limited only to

products related to the listed illness(es)

This paper outlines a high level analysis of trends in expenditure, uptake, and outputs (such as volume

of items prescribed) of the LTI scheme and its relationship to the wider community drugs scheme

landscape. This paper reviews the policy context and considerations for the scheme in the context of

the proposed policy reform ongoing in the health sector.

Methodology and Limitations

Trend analysis is the methodological underpinning of this spending review, with an aim to establishing

expenditure trends across the scheme, particularly expenditure trends in relation to scheme

expenditure growth. In addition, this paper seeks to analyse the policy context in which the scheme

was created and its intended aims in relation to the current policy landscape of community drugs

schemes, with a view to assessing the extent to which its original aims are being achieved. One of the

The HSE maintains core lists for each LTI of approved products, products not on the core list may be provided

on receipt of an application from a community pharmacist.

The term 'medical appliance' covers all products used in healthcare for the diagnosis, prevention, monitoring

or treatment of an illness or handicap and which achieves its principal intended action by physical means.

http://www.hpra.ie/homepage/medical-devices/regulatory-information

Due to this limitation, the cost of the LTI scheme is a portion of the overall cost associated with providing

healthcare to individuals with the relevant conditions, not the total amount.

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core limitations to this methodology is the limitation imposed by what data is available for analysis.

This is not a comprehensive policy review of the scheme assessing all factors, as only certain data in

relation to the scheme is collected and published.

Due to the non-means tested nature of the scheme, financial data on claimants is not collected. This

has limited the scope of this analysis to the expenditure trends of the scheme overall without the

possibility to analyse the impact of the scheme on participants in relation to the schemes original aim

of increasing access to and affordability of LTI treatment

Additionally, as this scheme is directed towards covering the cost of pharmaceutical, medical and

surgical products, data on patient clinical outcomes from the interventions they access through the

scheme is not assessed as it does not relate to the overall purpose of the scheme.

Due in part to the scheme being fully centralised into PCRS relatively recently (2019)

there is limited

data available on the interaction of the scheme with other community drugs schemes such as the

Drugs Payment and General Medical Services schemes. Notably, while simultaneous eligibility is

possible across schemes, data on the number of claimants who possess simultaneous eligibility is not

currently published. This limits the ability to analyse the necessity and utility of the scheme as unique

entity as it is not possible to assess the true levels of multi-eligibility and the proportion of LTI

claimants whose needs could currently be met through other schemes. Additionally, it limits the ability

to assess income of LTI claimants as it removes the ability to use the GMS threshold as a financial

indicator.

Contextualising the LTI within the Community Drugs Space

There are two other community drugs schemes in the Irish healthcare system administered by the

Primary Care Reimbursements Service in the HSE, these are the Drugs Payment Scheme (DPS) and the

General Medical Services (GMS) Scheme, which is often referred to as the medical card scheme. Figure

1 below summarises the three core community pharmacy schemes in relation to their means criteria,

non-means criteria, and applicable co-payments or charges.

Figure 1: Eligibility criteria and associated level of co-payment or charges of community pharmacy schemes

Scheme Title

Means Criteria

Non-Means Criteria

Co-payment/charges

Drugs Payment

None

€80 per month co-

payment

General Medical

Services

Satisfy a means test

(various rates)

Limited specific

categories

Prescription charges of

€1/€1.50 per item up to

€10/€15 per month

Long Term Illness

None

Have one of 16 listed

conditions

None

Source: https://www2.hse.ie/services/schemes-allowances/

https://www.oireachtas.ie/en/debates/debate/dail/1969-04-16/51/

HSE Pharmacy Circular 019/2019

Through the drugs payment scheme, individuals or families are refunded all pharmaceutical costs above €80

in a calendar month i.e. drug costs are capped at a maximum of €80 per month.

Specific entitlement categories for medical cards consist of those with EU (European Union) entitlement,

children under 18 years of age who have been diagnosed with cancer within the last 5 years, people affected

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Drugs Payment Scheme:

The Drugs Payment Scheme is a community drugs scheme whereby an individual or family pay a

maximum of €80 in a calendar month for approved prescribed drugs and medicines, and certain

appliances. The scheme is universal and open to anyone ordinarily resident in Ireland. The scheme

was introduced in 1999 and has undergone several monthly financial threshold changes since

introduction. At its highest, the drugs payment scheme payment threshold was €144 a month (2017).

The threshold was most recently changed in March 2022 to €80 a month

General Medical Services Scheme:

The General Medical Services Scheme is a community drugs scheme whereby if an individual and any

dependents meet eligibility criteria, they can get certain health services free of charge. The scheme

was introduced in 1953 and amended multiple times since, most recently in November 2020 to reduce

prescription charges and increase the weekly income threshold at which persons over 70 can qualify

for a medical card. Services available through the scheme include GP care, dental care, acute care, and

prescription medication. Eligibility is determined by means testing whilst recipients of a medical card

are required to pay prescription charges of up to €1.50 per item capped at €15 per month for

prescription medication.

High Tech Drugs Arrangement:

There is a third programme known as the High Tech Arrangement which is overseen by PCRS and

administered at community pharmacy level. For the purposes of this paper it is not considered a

distinct community pharmacy scheme, rather, it is considered a patient-specific pharmaceutical care

and treatment programme

. The High Tech Drugs Arrangement oversees the supply and dispensing of

High Tech medicines through local pharmacies. Such medicines are generally only prescribed or

initiated in hospital, for example, anti-rejection medication for transplant patients. The medicines are

supplied through pharmacies with a patient care fee payable. There are some high tech medications

provided through this arrangement for LTI conditions, however, any expenditure incurred falls under

the high tech drugs arrangement in this instance. It should be noted that the High Tech Drugs

Arrangement is not an income support focused community pharmacy scheme like LTI, GMS and DPS,

and therefore it is not included in certain comparison pieces within this paper due to this difference

in eligibility, purpose and outputs. Additionally, it should be noted that High Tech eligibility arises out

of the individual’s primary eligibility, i.e. through GMS, DPS, or LTI.

Figure 2 below shows the total expenditure across schemes from 2013 to 2021 as well as the overall

change in scheme expenditure over this time period.

by the drug Thalidomide, women who have had a symphysiotomy, people who live in direct provision

accommodation, children in foster care, and women who were resident in certain institutions.

https://www2.hse.ie/services/schemes-allowances/drugs-payment-scheme/card/

https://www.thepsi.ie/Libraries/Folder_Pharmacy_Practice_Guidance/PPGF_03_1_High_Tech_Scheme.sflb.as

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Figure 2: PCRS community pharmacy scheme expenditure 2013 - 2021

€m

2013

2014

2015

2016

2017

2018

2019

2020

2021

Change in

Expenditure

GMS

€1118

€971

€1047

€882

€855

€858

€833

€874

€894

-€224

-20%

High-

Tech

€424

€468

€544

€578

€616

€609

€756

€802

€846

€422

99%

LTI

€106

€130

€189

€204

€215

€237

€258

€279

€292

€186

175%

DPS

€88

€66

€67

€66

€62

€67

€76

€83

€95

€7

Source: December Management Data Reports 2013 - 2014 and 2016 – 2021, PCRS Annual Report 2015, Internal PCRS Data

Previous Reviews of the Long Term Illness Scheme

The LTI scheme was featured as part of a 2017 review by the Department of Public Expenditure and

Reform

. This review found that expenditure growth was primarily driven by growth in volume due

to an increase in the number of claimants and the number of items per claimant. The review also

found that the central component of spend on LTI was on Diabetes Mellitus, accounting for 76% of

the total spend 2016. This review recognised the contribution of the 2016 IPHA Agreement to

alleviating some of the expenditure pressure on the scheme, but recommended that “further reform

should be undertaken to contain expenditure on LTI”. The review had two recommendations

regarding the LTI:

1. It may be more cost effective and efficient to deal with diabetes separately due to its

significant proportion of demand within the scheme.

2. A separate scheme for diabetes may provide opportunities to utilise better tendering of

diabetes medicines and medicinal products, or, the ability to implement managed agreements

similar to the Hep C programme.

The Department of Health has committed to conducting a full review of the scheme as part of a wider

review of the overall current eligibility framework within the Sláintecare reform programme, with the

date of completion to be confirmed.

Connors, J., Future Sustainability of Pharmaceutical Expenditure, Department of Public Expenditure and

Reform, 2017 available here

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2. Analysis of Long Term Illness Scheme Activity and Expenditure

Expenditure Context

In recent years the expenditure associated with the LTI Scheme has grown substantially, rising from

€96m in 2013

, to €292m in 2021

as shown in the Figure 3 below. There are a number of different

variables which can impact scheme spend, examined in detail in this section.

Figure 3: LTI scheme budget allocation and expenditure outturn from 2013 to 2021

Source: PCRS Annual Reports and internal PCRS data for 2021 where annual report not yet published

2.1 LTI Scheme Expenditure Driver Analysis

The main factors influencing LTI expenditure are examined below:

1. Number of people

2. Disease specific treatment costs

3. Disease prevalence

4. Pharmaceutical product usage and price

2.1.1 Number of Persons on Scheme

Individuals who qualify for the LTI scheme may simultaneously qualify for other PCRS schemes such

as the medical card or drugs payment scheme, but in this case LTI products may be treated separately

i.e. prescriptions dispensed through the medical card incur a prescription charge whereas LTI

prescriptions do not. The below table reflect claimants for schemes on a per scheme basis, and where

schemes are not mutually exclusive a claimant may be counted individually in two schemes in the

same year. Data is not currently available on the number of claimants who possess simultaneous

Statistical Analysis of Claims and Payments, 2013

Internal PCRS Data, 2021

116

182

220

221

257

266

297

106

130

189

204

215

237

258

279

292

2013 2014 2015 2016 2017 2018 2019 2020 2021

€ MILLIONS

Budget Outturn

Key message:

 Expenditure on LTI has almost tripled over 8 years.

 Various policy initiatives and agreements are in place to stabilise drug costs, however average

annual item cost has grown steadily since 2017.

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eligibility across schemes, however, initial estimates by PCRS indicate that of the LTI cardholders for

whom a PPS number is recorded (approximately 80% of all cardholders), 50% also hold medical card

eligibility

. Due to the demand-led nature of the LTI scheme and other community drugs schemes,

the number of claimants fluctuate year to year, as shown below:

Figure 4: Claimant numbers since 2013

DPS

% Change

GMS

% Change

LTI

% Change

2013

308,357

1,974,806

71,926

2014

278,227

-10%

1,963,459

-1%

111,940

56%

2015

269,930

-3%

2,230,734

14%

138,415

24%

2016

270,525

2,239,832

153,446

11%

2017

265,891

-2%

2,188,767

-2%

166,818

2018

285,599

2,178,786

177,481

2019

273,594

-4%

2,195,211

185,903

2020

280,703

2,247,031

190,829

2021

2,079,818

-7%

195,064

Change from 2013 - 2021

-9%

+5%

+171%

Source: PCRS Annual Reports 2013 – 2020, PCRS Online Database with author’s calculations and PCRS Internal Data 2021

Note: Total DPS claimant numbers for 2021 are not currently available.

LTI claimant numbers have grown more consistently than other schemes, potentially as eligibility is

not means-tested, and therefore the scheme does not lose claimants due to changes in economic

status. Additionally, unlike DPS and GMS, the scheme has not been subject to policy changes in

overarching eligibility criteria, with this unchanged since 1975. However it should be noted that up to

2013 medical card recipients were required to use their medical card eligibility for LTI products

While participants may be an overall driver of scheme expenditure across a demand led scheme like

the LTI, a more in depth analysis is conducted below to establish what aspects of scheme participation

in particular are leading to increased expenditure.

Point in time draft estimate provided by PCRS on 27

July 2022.

HSE Pharmacy Circular 025/2013

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2.1.2 Expenditure and Scheme Claimants by Condition

Figure 5: Claimants and expenditure by condition 2013 - 2021

Note: 2014 to 2018 condition breakdown inferred from December PCRS Performance Reports. 2013 inferred from January

2014 data provided by PCRS.

Source: PCRS Annual Reports 2013 – 2020 and Internal PCRS data for 2021.

Participation in the scheme has almost tripled since 2013 starting at 71,000 in 2013 and increasing to

195,000 in 2021, meanwhile expenditure has also approximately tripled, starting at €106m in 2013

and increasing to €292m in 2021.

It should be noted that internal HSE policy may have impacted growth rates in both expenditure and

claimants between 2013 and 2015, though without data on the level of claimant overlap across years

this cannot be stated definitively. Prior to December 2013 the HSE has a policy whereby persons with

an LTI illness who had a medical card would claim LTI medications on their medical card. This may have

led to LTI eligible medical card claimants not applying for LTI cards or having their LTI related

expenditure counted within GMS, details of this are included in Appendix 1.

2.1.3 Disease Prevalence of LTI Conditions

A majority of LTI claimants across years are categorised within two of the sixteen conditions, diabetes

mellitus and epilepsy. These conditions account for 89.1% of all claimant growth, and approximately

90% of total claimants across all years of this analysis (range of 89.1 – 90.1%)

. With this observable

concentration of growth across just two conditions, the most efficient way to analyse conditions as a

driver is to analyse the change in disease prevalence rates for these conditions over the time period

of the analysis.

In the below tables trends in diabetes and epilepsy prevalence within the scheme (LTI inferred) are

presented with broader national prevalence estimates (OECD IDF data for diabetes and research data

for epilepsy) to examine if growth within the scheme is being driven by an increase in disease

prevalence. It should be noted that this is not a definitive estimate of disease prevalence but rather a

comparison between uptake rates and estimated true national prevalence (i.e. rates cannot be

directly compared). It should also be noted that estimates are based on adults as that is the age cohort

the OECD uses in estimates for diabetes prevalence and in epilepsy research. The EU average disease

Author’s calculations

50,000

100,000

150,000

200,000

250,000

Claimants

Diabetes Epilepsy Other

50.00

100.00

150.00

200.00

250.00

300.00

350.00

Millions

Expenditure

Diabetes Epilepsy Other

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prevalence is provided to indicate how Irish prevalence rates compare to the broader EU region to

establish if Ireland has a disproportionately high or low number of diabetes and epilepsy patients.

Figure 6: LTI recipients with diabetes as % of population and diabetes disease prevalence estimates

Year

LTI Recipients as % of

Total Population

OECD IDF Estimated Prevalence

of Diabetes in Ireland

EU Estimated

Prevalence of Diabetes

2013

1.33%

5 – 6.5%

6.8 – 8.5%

2021

2.94%

3.6 – 4.5%

7 – 9%

Change

+1.61%

-1.5 – 2%

+0.2 – 0.5%

Note: LTI inferred prevalence estimates based on adult population as recorded by the CSO in line with OECD estimates.

Source: Author’s calculation, OECD and International Diabetes Federation Reports.

The number of LTI claimants as a proportion of the population (CSO population estimates)

has

increased from 1.33% in 2013 to 2.94% in 2021. Available OECD data on diabetes prevalence in Ireland

over this time period estimated prevalence among adults at 5 – 6.5% in 2013

, and 3.6 – 4.5% in 2021



, which is in line with other indicative datasets (Healthy Ireland

, TILDA

)



While diabetes makes up the majority of claimants and expenditure within the LTI scheme, this does

not appear to be indicative of an unusually fast growing prevalence of diabetes within the state, as

prevalence according to indicative OECD data is not consistently trending upwards. This trend within

the scheme also does not appear to indicate a disproportionately large diabetes cohort, as the

prevalence of diabetes within Ireland is consistently below the EU average.

Therefore, change in prevalence of diabetes cannot be isolated as a definitive core driver in the high

amount of expenditure growth in the scheme, though uptake among patients of this condition may

be a growth factor outside of general prevalence.

Figure 7: LTI recipients with epilepsy as % of population and epilepsy disease prevalence estimates

Year

LTI Inferred

Research Estimated

EU Average

2021

0.44%

0.7%

Note: Research estimated epilepsy prevalence in Ireland based on 2010 research paper as this is the most recent national

estimate available. LTI inferred prevalence estimate based on adult population as recorded by the CSO in line with research

estimate.

Epilepsy is the second largest of the sixteen LTI conditions by expenditure and total claimant for all

years analysed in this review. The number of LTI claimants as a proportion of the population is an

estimated 0.44% in 2021. However, this does not align with research data available on estimated

https://www.cso.ie/en/statistics/population/archive/

International Diabetes Federation Diabetes Atlas – 6

Edition, 2013



It should be noted that the methodology used to calculate national prevalence of diabetes in Ireland was

different in 2013, the fall here may be indicative of more reliable data rather than reduced prevalence.

OECD, "Diabetes care", in Health at a Glance 2021: OECD Indicators, OECD Publishing, Paris, 2021

https://doi.org/10.1787/807d14aa-en.

Healthy Ireland Survey Summary Report, 2021

High-risk categories for COVID-19 and their distribution by county in Republic of Ireland-evidence from the

TILDA study



TILDA estimated prevalence rates are higher than general population prevalence rates, however they align

with OECD estimated prevalence rates for the specified age cohorts.

Epilepsy priorities in Europe: A report of the ILAE-IBE Epilepsy Advocacy Europe Task Force

https://onlinelibrary.wiley.com/doi/full/10.1111/epi.13201

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epilepsy prevalence in Ireland, which estimated prevalence at 1%

, and is below the EU average of

0.7%. It should be noted that there is little data available on national epilepsy prevalence change over

time both in Ireland and the EU, which is why the above table does not analyse change in prevalence

over time.

While epilepsy prevalence as inferred from LTI participation is growing, data on prevalence change

over time from the United States Centre for Disease Control from 2017

suggests that growth in the

US population with epilepsy is likely linked to growth in the general US population, rather than a

notable prevalence increase over time. Further research is required to definitively assess epilepsy

prevalence trends in Ireland.

Like diabetes, uptake of the LTI among patients of epilepsy may be an expenditure driver and growth

factor within the scheme outside of any possible increase in general disease prevalence, though it is

not possible to assess epilepsy prevalence over time and therefore whether this is a driver of increased

uptake of the scheme.

2.1.4 Condition Cost (per Patient)

Figure 8: LTI yearly cost per patient by condition

Year

Diabetes

Epilepsy

Parkinsonism

Multiple

Sclerosis

Intellectual

Disability

Other

Average

2013

€1,831

€988

€3,287

€1,429

€1,345

€2,520

€1,900

2014

€1,543

€904

€2,703

€1,298

€1,316

€2,057

€1,637

2015

€1,579

€1,048

€2,485

€1,318

€1,243

€2,217

€1,648

2016

€1,574

€1,094

€2,319

€1,481

€1,184

€2,261

€1,652

2017

€1,545

€1,023

€2,246

€1,460

€1,135

€2,354

€1,627

2018

€1,590

€1,091

€2,197

€1,504

€1,192

€2,441

€1,669

2019

€1,646

€1,130

€2,118

€1,512

€1,208

€2,507

€1,687

2020

€1,719

€1,202

€2,061

€1,489

€1,416

€2,586

€1,746

2021

€1,759

€1,216

€1,918

€1,402

€1,335

€2,356

€1,664

Note: For illustrative purposes the five conditions with the largest patient cohorts are listed, with the remaining eleven

categorised under “other”.

Note: The above table reflects yearly cost within the LTI scheme only, where medications for LTI conditions are High Tech,

the cost of those medications is counted as part of the High Tech Arrangement expenditure.

Source: PCRS Performance Reports.

Individual cost per condition refers to the average cost of the provision of items provided through the

LTI scheme for one patient with one specified illness for one year. For example, in 2013 the average

annual cost of providing LTI items to one person with epilepsy was approximately €988. The purpose

of providing a condition specific per patient cost estimate is to display year on year cost growth within

specific condition categories.

Removing claimant volume as a driver in this way displays the ongoing reduction in cost per condition

that occurred across all conditions up to 2014 in relation to a combination of policy changes including

the reduction and removal of mark-up rates, and the first off patent pricing reductions, and the

Linehan, C., Kerr, M.P., Walsh, P.N., Brady, G., Kelleher, C., Delanty, N., Dawson, F. and Glynn, M., Examining

the prevalence of epilepsy and delivery of epilepsy care in Ireland. Epilepsia, 51: 845-852. 2010

https://doi.org/10.1111/j.1528-1167.2009.02417.x

https://www.cdc.gov/media/releases/2017/p0810-epilepsy-prevalence.html

13 | P a g e

introduction of internal reference pricing, and another smaller decrease following the introduction of

periodic realignments in relation to external reference pricing in 2016. More detail on internal

reference pricing and periodic realignments is provided in Appendix 2.

With the exception of Parkinsonism, average annual cost has increased consistently across conditions

following the 2014 low point, with most of these conditions costing within €100 of their 2013 average

in one or more years by 2021, in particular epilepsy has exceeded its 2013 average every year since

2015 and has overall increased by 34% over the time period. This significant increase may merit further

research as other pharmaceutical cost drivers such as volume of items used and patent status of

medications (further outlined below) do not show similar growth.

2.1.5 Condition Cost per Unit

Figure 9: LTI average cost per item 2013 - 2021

Source: Internal PCRS data.

The average cost per item on the LTI scheme has fluctuated during this time period, declining on an

ongoing basis up to 2013 due to a combination of various policy changes including the reduction and

removal of mark-up rates, and the first off patent pricing reductions, and continuing to decline after

2013 in line with the introduction of internal reference pricing

, reaching its lowest point over the

time period in 2017. Nonetheless, average item costs have steadily increased since 2017.

In each year where average item cost per condition

was available, the least expensive average item

cost was for conditions arising from the use of Thalidomide (€3.41 in 2021), and the most expensive

was for Phenylketonuria (PKU) (€231.21 in 2021). Despite this reduction in average item cost between

2013 and 2017, the scheme continued to rise in overall expenditure. Reductions in item cost were not

significant enough to negate the impact of growth in other areas within the scheme, namely demand

factors like increased uptake of the scheme over this time period.

Health (Pricing and Supply of Medical Goods) Act, 2013

Average item cost refers to the average cost of one item for the treatment of a specified illness.

€33.15

€29.64

€28.03

€27.32

€26.72

€27.16

€27.75

€28.44

€28.64

2013 2014 2015 2016 2017 2018 2019 2020 2021

14 | P a g e

Figure 10: LTI average number of items prescribed per condition 2016 to 2021

Year

Diabetes

Epilepsy

Parkinsonism

Multiple

Sclerosis

Intellectual

Disability

Other

Average

2016

5.64

2.59

3.56

3.8

3.18

3.37

5.14

2017

5.59

2.58

3.55

3.75

3.29

3.33

5.1

2018

5.62

2.61

3.55

3.71

3.49

3.29

5.12

2019

5.61

2.6

3.51

3.69

4.7

3.08

5.12

2020

5.62

2.61

3.54

3.69

3.73

3.06

5.13

2021

5.59

2.54

3.52

3.49

3.36

2.71

5.08

Source: Internal PCRS data.

Average number of items prescribed reflects the average number of items per prescription for LTI

claimants across illness categories, displaying the varying levels of usage across illnesses within the

scheme. The average number of items prescribed has remained relatively consistent within conditions

over the time period, especially among patients of diabetes and epilepsy, where the average item

number did not change by more than 0.07 items over this period. Where change has occurred, it was

most often a decline, with only intellectual disability showing growth in this area. This indicates that

prescribing practices in relation to item volume have remained consistent over time and are likely not

contributing to the significant expenditure growth seen within the scheme.

Figure 11: LTI scheme top 20 products prescribed by expenditure and prescribing frequency 2020

Source: PCRS database and Irish Patent Office SPC database.

Analysing the top 20 products by highest expenditure (43% of all expenditure) and prescribing

frequency (47% of all products prescribed) indicates that patented products may be

disproportionately impacting expenditure, as they make up 55% of the top 20 highest expenditure

products, but only 15% of the top 20 most commonly prescribed products.

Pharmaceutical patents in the European Union apply for a duration of 20 years from date of filing

with possibility of extension through a supplementary protection certificate (SPC)

of up to 5 years

Convention on the Grant of European Patents (European Patent Convention) 1973 Article 63 (1)

Regulation (EC) No 469/2009 of the European Parliament and of the Council of 6 May 2009 concerning the

supplementary protection certificate for medicinal products

The total allowable duration of a product receiving intellectual property protection using a combination of

patent and SPC cannot exceed 15 years from the date of market authorisation of a product by the EMA.

Top 20 Products by Expenditure

On patent Off patent

Top 20 Products by Prescribing Frequency

On patent Off Patent

15 | P a g e

As the current LTI condition list is 47 years old, some medications used to treat LTI conditions are off-

patent generic or biosimilar, including the most prescribed medication in 2021, Metformin.

The top 20 medicines by expenditure in 2020 are shown in the table below along with their associated

condition, proportion of scheme expenditure, proportion of scheme usage, and patent or SPC

expiration month where relevant

Figure 12: LTI top 20 products prescribed by expenditure and patent status

Name

Condition

% of

Exp

Exp €m

Estimated Patent

Expiry

% of

Scheme by

Frequency

Insulin Aspart

Fast-Acting

Diabetes Mellitus

4.71%

€10.0m

Expired

2.12%

Semaglutide

Diabetes Mellitus

4.14%

€8.8m

March 2026

0.81%

Metformin

and Sitagliptin

Diabetes Mellitus

3.39%

€7.2m

July 2022

1.99%

Insulin

Glargine

Diabetes Mellitus

3.21%

€6.8m

Expired

1.20%

Liraglutide

Diabetes Mellitus

3.15%

€6.7m

November 2028

0.49%

Levetiracetam

Epilepsy

2.98%

€6.3m

Expired

1.44%

Empagliflozin

Diabetes Mellitus

2.17%

€4.6m

March 2025

1.18%

Insulin

Degludec

Diabetes Mellitus

2.10%

€4.5m

July 2024

0.60%

Lamotrigine

Epilepsy

2.07%

€4.4m

Expired

1.40%

Dapagliflozin

Diabetes Mellitus

1.98%

€4.2m

May 2023

1.05%

Dulaglutide

Diabetes Mellitus

1.84%

€3.9m

June 2024

0.39%

Linagliptin

Diabetes Mellitus

1.80%

€3.8m

August 2023

1.08%

Apixaban

Diabetes Mellitus

1.71%

€3.6m

May 2026

0.60%

Sitagliptin

Diabetes Mellitus

1.61%

€3.4m

April 2023

0.97%

Insulin

Detemir

Diabetes Mellitus

1.44%

€3.1m

Expired

0.47%

Atorvastatin

Diabetes Mellitus

1.26%

€2.7m

Expired

6.95%

Lacosamide

Epilepsy

1.13%

€2.3m

Expired

0.25%

Rivaroxaban

Diabetes Mellitus

1.05%

€2.2m

April 2024

0.36%

Metformin

Diabetes Mellitus

0.99%

€2.1m

Expired

9.07%

Canagliflozin

Diabetes Mellitus

0.95%

€2.0m

November 2028

0.42%

Total

43.68%

€92.8

12 Active

Patents/SPCs

32.84%

Source: PCRS database and Irish Patent Office SPC database.

The proportion of the top 20 medications that are on patent has remained relatively consistent at 50-

60% over the last four years. This would rule out the possibility of the above being indicative of an

upcoming patent cliff.

2.2 Data Constraints

Detailed condition data including claimants and spend by condition was not available for the years

prior to 2014, while detailed pharmaceutical data including average item cost by condition and

https://www.ipoi.gov.ie/en/ip-search-tools/patents-search/spc-database-snapshot/

16 | P a g e

average number of items was not available for years prior to 2015, or for some datasets, including

most frequently prescribed items, in 2017.

While all community pharmacy schemes are overseen and administered by PCRS, data on the level of

scheme overlap within PCRS was not available. This is despite application of all schemes requiring

PPSN details and the database that is used by pharmacists having a PPSN eligibility check function

It should be noted a point in time estimate was provided by PCRS which accounts for 80% of LTI

claimants, however overlap cannot currently be comprehensively assessed for all claimants. This

estimate showed that 50% of included claimants had medical card eligibility in addition to their LTI

eligibility.

3. Policy Discussion

3.1 Introduction

There are two core policy aspects of the LTI to be considered:

1. Creation rationale and eligibility criteria in comparison with current community pharmacy

policy

2. Comparison with wider European policy

3. 2.1 LTI Creation Rationale and Current Community Pharmacy Policy

The LTI scheme was created in 1970, a time where the only community pharmacy scheme operating

at that time was the medical card scheme (created in 1953). From creation the medical card was

means tested, with a maximum income threshold per family at that time of IR£600/year,

approximately €20,000/year adjusted for inflation

The Minister for Health at the time of the establishment of the LTI scheme explained the rationale for

the scheme as “[f]or such [LTI] conditions only rare households could afford the expense of the drugs

and medicines required and it is right that an exception [to a government policy position that

medicines should not be provided free for all] should be made here so that all income groups will

benefit from this provision.

”

In addition to the economic benefits provided to individuals availing of the scheme, there is evidence

that the health interventions provided by the scheme can reduce complications associated with

certain LTI conditions. For example, effective management and clinical treatment of diabetes,

including use of medication and monitoring blood sugar using appliances available through the LTI,

https://www.hse.ie/eng/staff/pcrs/contractor-handbooks/pcrs-handbook-for-pharmacists.pdf

Author’s calculation

https://www.oireachtas.ie/en/debates/debate/dail/1969-04-16/51/

Key message:

 The LTI scheme was created at a time where little support was available for pharmaceutical costs.

This is no longer the case.

 Schemes like the LTI are uncommon across the EU, with specific list based cost reductions or

exemptions only available in six other EU countries, while broader cost reduction or exemption

measures exist in ten other EU countries.

17 | P a g e

have been linked to prevention or delay of diabetic retinopathy, a diabetes complication which is

known to cause blindness

While the rationale for scheme creation was that very few individuals or families could afford the cost

of such medications or interventions due to their expense, due to a changing landscape in the

community drugs space there is now significant state support in this area. Notably, pharmaceutical

expenditure is effectively capped for all individuals or families at €80 per month through the Drugs

Payment Scheme. Where individuals or families may not be able to afford medicines due to low

income they may qualify for a medical card.

The policy direction has also changed since the establishment of the scheme, with the ongoing

Sláintecare reform programme emphasising a shift towards universality within healthcare provision

with an ultimate goal of delivering universal healthcare. As part of the Sláintecare reform programme,

the broader eligibility framework including the LTI scheme is to be reviewed, with Department of

Health commencing work on this review shortly.

Eligibility to a community pharmacy scheme based on condition is relatively unique and out of step

with the relatively means-centric eligibility criteria of the other schemes. On one hand limiting the

scope of the scheme to just sixteen conditions when the WHO define over 100 across 4 categories

as long-term/chronic could be seen as arbitrary. On the other hand, eligibility without reference to

means can be seen as inequitable as an LTI claimant with a comparatively high income level could

receive all medications free of charge whereas another claimant with a relatively average income may

be required to contribute €80 per month.

3.2.2 European Context

The comparative analysis of specific health policies and systems is a challenging task given the

significantly different nature of systems (including mix of public and private care, overall model of

health system, and population size served). The purpose of this section is to analyse the extent to

which there are comparable schemes to the LTI in other countries. However, the findings presented

here should be seen with the caveat of the complexity of assessing different health systems.

According to self-reported data provided to the WHO by countries in 2018

, there are six countries

within the EU which totally or partially exempt patients from other applicable pharmaceutical costs

and charges using a defined list of conditions, and a further ten EU countries with various degrees of

reduction or exemption from co-payments or charges on the basis of broad categories such as “chronic

illness” “terminal illnesses” and “severe illness”. Due to time constraints, limitations of data reported

to the WHO, and language barriers, it is not within the scope of this analysis to assess the totality of

each reimbursement policy for medications across the EU.

 Cyprus, France, Greece, Portugal and Slovenia provide total exemptions to co-payments for a

specific, certain, or defined list of conditions.

 Finland provides a higher reimbursement rate for treatments related to a specific list of thirty-

four conditions (but not an outright total exemption of co-payment or charges), and a lower

https://www2.hse.ie/conditions/diabetic-retinopathy/#reduce-your-risk-of-diabetic-retinopathy

https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases

https://www.euro.who.int/__data/assets/pdf_file/0011/376625/pharmaceutical-reimbursement-eng.pdf

18 | P a g e

co-payment rate for medicines for a further twelve conditions. Greece also provides a reduced

co-payment for a further shorter list of diseases.

 Bulgaria, Estonia, Hungary, Latvia, Lithuania, Luxembourg, Poland, Romania, Spain and

Sweden provide partial or full exemptions to co-payment or caps on co-payment for a less

specific cohort of diseases, medications, or indications.

Where lists were provided to the WHO or otherwise publicly available in English, overlap in conditions

covered was evident, notably in terms of the most common conditions on the LTI, diabetes and

epilepsy. Available data indicates diabetes treatment coverage in Greece, Slovenia, Portugal, and

France, and epilepsy coverage in France and Greece. These conditions may be covered in all list

schemes, however, due to research limitations, it is not within the scope of this analysis to assess the

totality of each condition list.

Based on available evidence, the closest direct comparison system appears to be that of France, where

a specific scheme, the Affections de Longue Dureé (in English, Long Term Diseases) Scheme operates

and provides coverage for pharmaceutical costs as well as medical and surgical appliance costs for

patients with a set list of long term conditions

. Unlike the Irish LTI Scheme, the French scheme

includes clinical management of conditions including specific treatment directives provided to

healthcare providers such as GPs, and this is cost free to the recipient without requirement for the

standard co-payment. This type of care is provided to an extent in Ireland through the Chronic Disease

Management (CDM) Programme provided to medical card recipients, however, this is separate to the

LTI scheme, and only covers four conditions

. Another core difference between the ALD and LTI is

that the condition list for the ALD is reviewed and updated more regularly than the Irish LTI list, and

was last updated in 2011

Non-Pharmaceutical Measures

There are a number of other healthcare schemes or programmes specifically for long term or chronic

illness across the EU that focus on standardising treatment pathways for individuals with long term

illnesses rather than subsidising or reimbursing costs associated with such illnesses

Overall, LTI style schemes appear to be relatively uncommon in the EU. Where condition list based

schemes do exist they may include healthcare supports outside of financial coverage of individual

pharmaceutical costs, or may not provide products completely free of charge. Broader supports for

pharmaceutical costs incurred by persons with long term or chronic illnesses appear to be more

common, with ten EU countries providing some form of non-list based cost reduction, exemption or

higher reimbursement rate for a less defined categorisation of diseases.

Chevreul K, Brunn M, Durand-Zaleski I, et al. France. In: Nolte E, Knai C, editors. Assessing Chronic Disease

Management in European Health Systems: Country reports [Internet]. Copenhagen (Denmark): European

Observatory on Health Systems and Policies; 2015. (Observatory Studies Series, No. 39.) 6. Available from:

https://www.ncbi.nlm.nih.gov/books/NBK458739/#

https://www.hse.ie/eng/about/who/gmscontracts/2019agreement/chronic-disease-management-

programme/

https://www.ameli.fr/assure/droits-demarches/maladie-accident-hospitalisation/affection-longue-duree-

ald/affection-longue-duree-maladie-chronique

19 | P a g e

4. Conclusion and Recommendations

4.1 Conclusion

In conclusion, this paper has reviewed in detail activity and policy matters related to the Long Term

Illness Scheme, outlining the main expenditure drivers and trends in the scheme, and policy challenges

going forward.

A primary finding from the analysis is that expenditure on the scheme has grown at an exceptional

rate, averaging 10% per annum between 2013 and 2021, and almost tripling over the time period.

After assessing various expenditure drivers, claimant volume growth appears to be the most

significant contributor, however use of patent medications may also be disproportionately impacting

expenditure when volume growth is removed as a factor. The use of medications and the viability of

substitution for off-patent medication is a complex area that merits further in-depth analysis,

especially in the area of biologic medicines such as insulin, where internal reference pricing is not

applicable.

Despite various initiatives that should stabilise medicine prices, on an individual level treatment costs

are increasing. This may be indicative of an overall prescribing trend that favours patent medications

or a trend of switches to more clinically effective but more expensive new medications, which results

in this consistently growing per patient costs. This issue also merits further detailed analysis.

While the conditions funded by the scheme may be expensive for the claimant over time without

assistance, the expenditure incurred by the scheme due to its lack of means testing and co-payment

may represent an inequitable and ultimately non-redistributive use of exchequer funding. While the

original scheme rationale was that very few households could afford such expenses, in the current

community drugs space this rationale may no longer hold, as the maximum annual pharmaceutical

cost payable per household is €960, or between €120 and €180 for medical card recipients.

4.2 Recommendations and Policy Considerations

Publish LTI Data for Years Prior to 2014:

Currently, historical data publicly available on the LTI is limited prior to 2014. In order to facilitate a

better understanding of the scheme overall, a data gathering and updating exercise could be

conducted in order to make a wider range of detailed LTI data available over a longer time series. It

would be particularly valuable for any future investigation to have condition specific data (such as

expenditure and claimant number by condition) available prior to 2014. Additionally, it would be

useful to have detailed pharmaceutical data that is publicly available for years prior to 2017. The

provision of this data would allow for any future analysis to assess trends over a more significant time

period accounting for a more varied range of external factors, particularly in the pharmaceutical area,

as prescribing trends within specific LTI conditions could be better assessed.

Collect More Detailed Claimant Data:

More detailed claimant data, particularly in the area of claimant income level, though there may be

legislative challenges or a requirement to amend legislation to facilitate, would be useful for further

analysis of the scheme, as this would provide better insight into the value added by the scheme and

the level of financial hardship experienced by claimants. Alleviating financial hardship associated with

treatment costs was part of the creation rationale for the LTI scheme, so having access to this data

20 | P a g e

would allow for better assessment of the benefits of the scheme in relation to this rationale.

Additionally, in collecting more detailed claimant data it would be useful to make available data on

the amount of claimants with multiple eligibility within PCRS schemes for all claimants, particularly

the overlap between medical card, drugs payment scheme, and long term illness scheme claimants.

Conduct an In-Depth Review of Prescribing Trends Within the LTI Scheme:

Data on average item cost within the LTI shows an upward trend from 2017 despite cost control

measures included in industry pricing agreements and legislative controls such as internal reference

pricing. Additionally, a majority of the medications incurring the most expense within the LTI scheme

are currently on patent. While ensuring best clinical outcomes is a priority, a review should be

conducted in light of this trend to assess the drivers of this increase and potential mechanisms to

reduce it. The increase in the cost per condition for epilepsy merits further research in particular.

Due to the high proportion of diabetes patients in the scheme, it may be worth assessing in particular

methods to control spend on biologic medicines such as insulin, as biologic medicines are not included

in reference pricing legislation.

Ensure the Scope of the Upcoming Department of Health Review is Broad and Considers Wider Equity

Issues

The upcoming Department of Health review of the long term illness scheme should maintain a broad

enough scope to consider potentially integrating the LTI scheme with other community pharmacy

schemes. In any review there would be a wide range of issues to consider in detail including the health

rationale of the scheme, impact of the scheme on relevant cohorts and access, most efficient use of

available resources, and the best measures for managing chronic diseases. Due to the current

community pharmacy space providing a broader range of supports than was available at the time of

introduction of the LTI scheme, it may be possible in the future to integrate the supports offered by

the LTI scheme with other schemes rather than maintaining it as a unique entity. Additionally, it would

bring the community pharmacy space in line with previous policy recommendations that found that

selecting conditions for automatic eligibility for schemes was “neither feasible nor desirable”

While it is not possible to fully cost scenarios related to the scheme, the following provides some

indicative estimates based on prescription charges and the DPS threshold. It should be noted that any

costs would depend on the actual proposal and the proportion of scheme recipients that would be

eligible for other existing drug schemes. If prescription charges were added to the LTI scheme,

effectively aligning it with the conditions of the GMS scheme, cost would reduce as shown in the range

outlined in the table below, reflective of the current rates for medical card prescription charges:

Figure 13: Total cost of LTI if a prescription charge was applied

Rate

Prescription income

Cost after prescription charges

€1 per item €10/month cap

€11,662,899

€280,447,100

€1.50 per item €15/month cap

€17,494,349

€274,615,651

Sources: Author’s calculations, PCRS Internal Data

If co-payment was added to the LTI scheme, either at a reduced (50%) DPS rate or through aligning it

with the full DPS scheme rate, costs would reduce as shown in the table below. Calculations for two

Report of the Expert Panel on Medical Need for Medical Card Eligibility pp.7, 2015

21 | P a g e

specific assumptions are included, an average monthly usage across conditions, and calculation

accounting for specific usage across conditions:

Figure 14: Total cost of LTI if co-payments were applied to all claimants

Rate

Cost after co-payment average

Cost after co-payment disease specific usage

€40

€198,483,280

€198,479,280

€80

€104,848,560

€105,886,480

Sources: Author’s calculations, PCRS Internal Data

Consider How Resources Could Be Best Targeted at Chronic or Long Term Illnesses

The Department of Health should consider how available resources can be best use to support

individuals with chronic conditions, and in doing so, explore the criteria used to define a chronic

condition in this scheme and the utility of condition specific criteria. If the department were to move

away from condition specific criteria, resources could more efficiently be utilised in supporting all

patients with the over 100 illnesses the WHO defines as long term or chronic, rather than just the

sixteen on the LTI list.

Ireland recently introduced the Chronic Disease Management Programme (CDM) at GP level which

may be more in line with European approaches to supporting long term illness patients. Integrating

the LTI with other community pharmacy schemes could potentially resolve issues of inequity that have

been raised about the LTI scheme by removing the condition specific criteria and free up resources to

use on disease management. This would bring Ireland more in line with our counterparts in Europe in

shifting the focus away from specific limited income supports and towards standardising care models

across the healthcare system. Consideration should be given to how the state deals with long term or

chronic illnesses as a whole and the most efficient and beneficial ways to ensure support for patients

across all aspects of their treatment and care. In particular, diabetes treatment and supports should

be assessed due to the large proportion of diabetes patients on the LTI and their particular care needs.

22 | P a g e

Appendix 1:

Prior to 2009 there was a 50% mark-up on the LTI scheme, this was reduced to 20% in 2009 (S.I. No.

246/2009) and eliminated in 2013 (S.I. No. 279/2013). However, in the period prior to 2013 the LTI

was a more expensive way of delivering care to people who held both LTI and GMS cards and the

HSE directed pharmacies to only claim under the GMS scheme in compliance with the HSE

requirement under Health Act 2004 to use its resources in the most efficient manner possible. With

the elimination of mark-up and contemporaneous introduction of prescription charges on GMS the

position had to be reviewed. The Department of Health communicated to the HSE its view that the

HSE could no longer stand over this position and the HSE accepted this direction and issued the

referenced circular (025/2013).

Appendix 2:

Reference Pricing

The Health (Pricing and Supply of Medical Goods) Act 2013 provides for the introduction by the

Health Service Executive (HSE) of a system of reference pricing, which involves the setting of a

common reimbursement price, or reference price, for a group of medicines which are deemed

interchangeable by the HPRA. The HPRA has no role in reimbursement or in setting prices of

medicines. This is the responsibility of the HSE

Periodic Realignments

External Reference Pricing, where prices of a pharmaceutical in one or several countries is used as a

benchmark price for the purpose of setting an agreed price, is utilised in Ireland using a group of

fourteen other countries. The price of pharmaceuticals across this group is regularly assessed, with

prices then reduced as appropriate. The agreement 2016 IPHA agreement also included, for the first

time, an annual price realignment, also known as periodic realignments, to ensure that the prices of

medicines in Ireland reduce in line with price changes across the reference countries.

http://www.hpra.ie/homepage/medicines/regulatory-information/generic-and-interchangeable-medicines

23 | P a g e

Quality Assurance process

To ensure accuracy and methodological rigour, the author engaged in the

following quality assurance process.

☑ Internal/Departmental

☑ Line management

☑ Spending Review Steering group

☑ Other divisions/sections

☑ External

☑ Other Government Department

24 | P a g e

Tithe an Rialtas. Sráid Mhuirfean Uacht,

Baile Átha Cliath 2, D02 R583, Éire

Government Buildings, Upper Merrion Street,

Dublin 2, D02 R583, Ireland

T:+353 1 676 7571

@IRLDeptPer