It has been another year dogged by controversy in healthcare. Health Correspondent Eithne Donnellanlooks back on a tough 12 months for health and previews the difficult year ahead as the HSE's spending cuts deepen
LAST JANUARY, a leaked memo drawn up by the HSE outlining plans to cut a range of services in the northeast in 2008 in a bid to ensure "breakeven" by year's end came as a great shock to many.
Cutbacks in the health service were nothing new but talk of proposed cuts in hospital services just weeks into a new financial year were unheard of.
The memo, headed "Breakeven Plan - Identified Actions January 22nd 2008", included plans to close beds, reduce the number of days on which outpatient clinics would be held and reduce orthopaedic elective surgery at Our Lady's Hospital, Navan, by 25 per cent.
While the HSE at the time suggested there was nothing really to fear as the plan was a mere proposal, we now know that in fact much of it was put into action. As it happened, the orthopaedic unit in Navan was actually shut down in November because there was no money to keep it going.
But what a difference a year makes. This year the HSE is being clear before even the new year begins that cuts across the board will be the order of the day in 2009.
The effect of a range of cost- containment measures which achieved savings of €280 million this year will have to be continued next year while the HSE has indicated savings of up to an additional €650 million may have to be made before 2009 is out. It says some of this will be required to cover the cost of extra medical cards which families will qualify for as a result of the economic downturn.
As the head of the HSE, Prof Brendan Drumm, put it: "Ideally we would be able to meet every need. The reality is that funding is finite and we have to make choices."
Next year, he conceded, the HSE would "have to do more with what we have".
There are concerns in some quarters that the HSE will not implement the recommendations of a number of reports into adverse patient events if, under financial pressure, it tries to cut too many corners.
During 2008, yet again the cases of a number of new individuals whose cancer had been misdiagnosed were highlighted and the reports into the misdiagnosis of Rebecca O'Malley, an anonymous 51-year-old Tipperary woman, nine breast cancer patients in Portlaoise and nine lung cancer patients in the northeast were all published.
Even the Minister for Health, Mary Harney, has recently written to the HSE saying the executive's progress "in implementing the specific recommendations of investigations into a number of very serious incidents is a matter of enormous concern".
So what hope is there that anything will change in 2009?
Rebecca O'Malley, whose breast cancer diagnosis was delayed by 14 months, is not too confident. She said her confidence in the HSE to implement recommendations regarding patient safety dwindled during 2008, particularly after it dismissed news of the misdiagnosis of Ann Moriarty's cancer at Ennis hospital as a one-off, only for it then to emerge there was at least one other case, that of Edel Kelly.
She said the implementation of the recommendations wasn't just about money. "It's about attitude. I'm not sensing a commitment or enthusiasm to change," she said.
Prof Drumm has, however, insisted he wants to continuously drive change in the interests of patient safety and this is why the HSE plans to continue to reorganise cancer services in 2009 and to restructure the way AE and other acute hospital services are delivered, particularly at smaller hospitals.
But he has said he can never say there will not be other cases of cancer misdiagnosis. Experts say even with the new system of just eight designated cancer centres, a small number of errors can be expected every year.
Also next year Ms Harney has told the HSE she wants patients referred for colonoscopies, which are crucial tests for bowel cancer, to be seen within a month. At present, some patients wait up to eight months which has the potential to result in a delayed diagnosis. But whether this target can be achieved remains to be seen.
In addition, it will become clearer as 2009 rolls on whether Ms Harney's controversial plan for private co-located hospitals on public hospital sites will actually materialise. While planning has been granted for a number of them, there are concerns in some quarters that banks may not lend the capital for them in the current economic climate, where more people are likely to let private health insurance policies lapse, either because they have lost their jobs or as a result of the cost of the policies themselves having increased.
Fine Gael's health spokesman, Dr James Reilly, said 2008 in the health service would be remembered for "the terrible scandals" that were again uncovered in cancer care and for "the most mean-spirited" budget in half a century in which the automatic entitlement for over-70s to medical cards was withdrawn and a decision to introduce a cervical cancer vaccination programme was reversed on the basis of cost.However, a national cervical cancer screening programme was finally introduced in September.
For 2009, Dr Reilly said he did not think anything would change unless a new health minister was appointed. "It's difficult to see her [Ms Harney] still there this time next year," he said.
There has been speculation about whether Ms Harney might step down next year, following the winding-up of the PDs, if Taoiseach Brian Cowen were to decide on a Cabinet reshuffle.
Stephen McMahon of the Irish Patients Association said while 2008 was a year when a new pharmacy Act and new medical practitioners Act came into force and a new audit suggested hospital hygiene was improving, the decision to strike 20,000 over-70s off the list of medical card holders would not be forgotten. He also said lessons had to be learned by the HSE from its attempts in 2008 to cut payments to pharmacists without agreement.
The decision was ultimately overturned by the High Court and the €100 million the HSE had banked on making from the cuts then had to be found elsewhere. "The State should be careful not to include savings for procurement until it has achieved them," he said.
The Supreme Court's decision to strike down risk equalisation was also disappointing, he said, and has ultimately resulted in plans to put an extra levy on all those covered by health insurance next year. Hibernian Health, which is passing the levy of €160 per adult and €53 per child onto subscribers, said it would challenge this in the courts next year.
Hospital consultants may also be going to court next year if Ms Harney continues to insist €68 million due to them after they finally signed up to new consultant contracts earlier this year will not be paid. She said the money would only be paid once changed work practices including longer working days and weekend work were obvious on the ground.
Mr McMahon said of 2009: "There's going to be a need for real teamwork as opposed to partnership to overcome the challenges to ensure patients are not put at risk by the multi- million euro cuts."
It goes without saying of course that thousands of patients were, despite a range of service cuts, successfully treated in Irish hospitals in 2008 and they will be again in 2009 but the financial challenges the system will face next year will be worse than has been seen in decades.
Just how bad the cuts and their impact will actually be, only time will tell.