Patient care will be first casualty of additional cuts


ANALYSIS:It is still manifestly unclear who is in charge of what in the Irish health service, writes Sara Burke 

SOMETIMES IT'S hard not to think that the Health Service Executive is its own worst enemy. The day it published its detailed service plan for 2009, earlier this month, it quietly let slip that an additional €400 million in savings needed to be made. This was on top of €500 million savings already built into the plan. Can it still achieve it commitments without affecting patient care?

The service plan is the most important document the HSE publishes each year. It is the contract between the HSE and the Government. It details how much and what kind of patient care will be provided by the public health system in the year ahead, within the allocated budget.

The HSE has been allocated €14.7 billion for 2009, up 1.1 per cent on this year. This is a small increment, which in effect is a cut due to our growing, aging population, increased demand for services, and the high cost of medical inflation.

The service plan promises to provide the same amount of services next year as it did this year, with some developments, despite a constricted budget and fewer staff. It was an ambitious proposition by any standards.

The 2009 plan is a huge improvement on previous efforts. It details targets, costs and timeframes for delivering the plan. It earmarks new money to areas such as cancer care, long-term public beds for older people, new therapy posts for children with disabilities, additional staff in primary care.

The plan continues the HSE policy, being championed by chief executive Brendan Drumm, of providing most health and social care through primary and community services. Under the plan in 2009, there will be fewer inpatients, shorter hospital stays, increased hospital daycare and out-patient visits, more services provided locally.

The plan also sets out quite specifically how it intends to save more than €500 million so that the whole plan could be delivered. Value for money initiatives and efficiencies are included. The value for money savings are to be made in areas such as procurement and cuts in advertising, consultancy, administration, transport and travel costs. The efficiencies include reducing money spent on overtime pay and agency staff.

The HSE envisages there will be 3,000 fewer staff on the payroll this time next year. This staff decline includes the budget redundancy announcement, and a 3 per cent cut in HSE management and administration.

Just like the detail of the services promised for next year, the savings set out were brave and possibly deliverable without hurting the quality and availability of patient care.

But what about the impact of another €400 million savings - and why was this not factored into the plan?

According to the HSE press release that accompanied the publication of the plan on December 16th, the plan was submitted and completed in October, before the extent of the challenging economic climate for 2009 was known. While increased numbers of medical cards and demand for services were factored in, the HSE's head of finance, Liam Woods, said: "We may now be faced with revising this [the service plan] . . . we will do everything we can to ensure we protect delivery of services but many of the developments we had included may be challenged."

Why on earth did the Minister for Health Mary Harney and the HSE management not manage this bombshell better? Why not have a Dáil debate on it and a press conference to explain the changed economic forecasting and the need for a supplementary plan to deal with the recessionary times we are in?

Both the service plan and the Minister's letter of approval of it to the chair of the HSE board, Liam Downey, provide some answers. In the letter, Harney is bluntly directing the HSE to manage its finances better, to live within its budget and provide the health and social care services as detailed in the service plan.

The HSE is legally obliged to do so - and maybe as her last hurrah the Minister will make sure it does.

The HSE, on the other hand, has a section titled "risks" early in the plan. Here it very explicitly lists areas over which it has no control, which may result in the HSE being unable to provide all the services promised within budget. Included here is doubt that €100 million can be saved by the U-turn on over-70s medical cards (as promised by the Taoiseach and the Minister), uncertainty as to the final cost of the consultants' contract, and the decline in income that public hospitals may get from private care in the year ahead (due to commitments in the consultants' contract of actually having an 80/20 public/private mix, and decline in health insurance coverage).

What is happening now is a stand-off between the HSE and the Minister.

The absence of leadership and management in the communication and detail on where an additional €400 million can be saved demonstrates the continued confusion between the Minister, her department and the HSE. It is still manifestly unclear who is in charge of what in the Irish health service. The 2004 Health Act failed to clarify this fundamental issue. And while it may have been possible to fudge on it in times of abundance, the policy and political confusion and contradictions in Irish health policy are raising their ugly heads once again in times of less.

The Minister has directed the HSE to provide a contingency plan by January on how it can make more savings (ie cuts) so that it can live within budget in the changed economic circumstances. This perhaps will provide detail on where this additional €400 million will be found.

No matter what this says, two things are for sure. Firstly, a visit to a public hospital ward, emergency department or local health centre shows there is no fat to be cut in frontline health services. Secondly, the Minister cannot expect the HSE to provide all of its commitments in the plan for 2009 and save €900 million without hurting the quantity and quality of patient care.

Sara Burke is a journalist and health policy analyst

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