Cliff Taylor: Children’s hospital cost overrun a symptom of deeper ailment

There are symptoms – and then there is the underlying disease. This week we have seen the nurses extending their strike action, a big protest by family GPs and the controversy over the cost of the national children’s hospital.

These issues will – in time – disappear. But the underlying disease is a health system which is swallowing money without delivering the necessary improvements.

This is most serious in terms of ongoing day-to-day spending. The nurses are wrong to link their pay issues with the hospital overrun – one is a massive one-off, the other an ongoing bill, recurring year after year.

But the massive overrun on the children’s hospital investment is another flashing red light.

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In the management jargon, an emerging overrun of several hundred million euro should have been escalated immediately

Here again, the link between money in at one end and an output to improve the health system at the other is broken. When the new chairman of the Health Service Executive, Ciarán Devane, said this week that health spending needs to be diverted or it could eventually threaten the solvency of the State, then it is probably time to listen.

Something else has also been clear this week. The key relationships between the senior officials in the Department of Health, the HSE and other government departments are dysfunctional.

How else do you explain Department of Public Expenditure and Reform officials complaining in November that no one told them about the overrun in the run up to the budget, with health officials replying that they had been seeking a meeting since September? Could someone not have picked up the phone?

Spending code

The public spending code – the official guideline on dealing with such issues – has clear instructions on the need to report and monitor overruns and seek sanction when spending is going to be above expectations. But nothing was done ahead of the October budget.

In the management jargon, an emerging overrun of several hundred million euro should have been “escalated” immediately.

To you and me, this means the people in charge should have been told – the Ministers for health, finance and public spending and the Taoiseach. Minister for Health Simon Harris says he wanted to get to the bottom of the problem and get an exact figure before bringing it to the rest of the Government.

Given the scale of what was at stake, this simply doesn’t wash. It is like saying you won’t sound the alarm about the approaching tsunami before you know precisely how high the wave is going to be.

The political blame game will take its course here and will damage the minister and the Government. But will anything change? Health spending is soaring, but this does not seem to be reflected in the kind of improvements in services that you would hope for. The Sláintecare programme,a major reform of health spending, is now being rolled out, albeit less ambitiously than its original incarnation. But can it be delivered in the context where people who are planning the health service and those arranging it appear to be barely talking to each other?

The regular overruns in health seem to have broken any trust between the health system and those looking after the State’s cash. In response, we have seen the classic Irish answer of putting in new structures, rather than ensuring those already there are working properly.

So we had a board and two committees overseeing the children’s hospital, a special executive put in to drive Sláintecare (in addition to the HSE and department bosses) and now a new HSE board and chairman. Will this drive efficiency and progress or just lead to a more complex game of finger-pointing when things go wrong?

At the management level something simply isn't working. Fires are breaking out all over the place

Health spending was cut sharply during the crisis and there is no doubt that some of what is happening is the legacy of that period. The cutbacks left holes and problems – nurses, GPs, doctors all say that more money is needed.

And in some areas it surely is. But the problem is that the rapid build-up in funding in the last few years does not appear to be yielding the appropriate results. There are pockets of improvement and progress, but it is not consistent.

Hidden deep in some analysis by the Department of Public Expenditure and Reform is data which suggests that we are not getting the appropriate return on money spent in terms of national life expectancy and dealing with diseases such as cancer and heart disease. The comparisons with other countries are underlined when the figures are adjusted for our younger population.

Spending study

A separate paper from the same department looks at the 17 per cent rise in spending on acute hospitals between 2014 and 2017. It then compares this with output in areas such as outpatient or day-case discharges – where there were generally small increases – and on waiting lists, which just went higher during the period, by 59 per cent for day cases and 46 per cent for inpatient cases.

It concluded: “There appears to be no link between the growth in spending and output levels.”

Now the HSE and the Department of Health would not share this analysis. They would point to progress in some key areas, major increases in staffing levels and a plan to redirect spending to the community, thus freeing more hospital time to deal with and develop excellence in treating acute and serious cases.

But at the management level something simply isn’t working. Fires are breaking out all over the place.

The nurses are now engaging in a high-stakes game by pushing the Government to concede something which would bust its annual budget by leading to a flood of pay claims.

Something will be sorted on the nurses’ dispute, sooner or later. The children’s hospital will be built. And health spending will head ever upwards. But can we be confident our money is being well spent?

When the people involved are hardly talking to each other, there is only one answer.