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Back to reality for cash-strapped HSE
[ by Niall Hunter, Editor www.irishhealth.com]
Two days after Dr James Reilly promised better things to come for the health service through a major HSE restructuring, it was back to reality.
So let's for a minute forget much of the political flim flam and window dressing of recent days - new HSE directorates, no HSE eventually, who told who what, who phoned who, who does and doesn't get on with whom, and do ordinary people really care? etc.
A letter from HSE National Director for Integrated Services Laverne McGuinness ordered further savings (for 'savings' read 'cuts') in an attempt to deal with a €280 million deficit, as we were reminded quite forcefully that the health service is essentially broke.
This sad fact is not simply going to go away just because the HSE is getting new directorates and will be abolished by 2014, or because we're all so very worried that James and Roisin won't be exchanging Christmas or Valentine cards.
Whatever replaces the HSE will undoubtedly still have to operate in financial crisis mode, unless Dr Reilly performs a major 'loaves and fishes' act with health funding in the meantime. Perhaps the thinking is that by simply abolishing the HSE you will abolish the annual health service deficit-cutbacks cycle. If only.
No grandiose reform plans can escape from the fact that, thanks to the Troika, by the end of 2013 around €3 billion will have been lopped off the health budget over the previous four years.
Even if things go reasonably well over the next few years, and James Reilly's new model universal health system emerges in 2016, and that's a big 'if', it will be setting out on a very shaky financial base after years of cuts. The health service, it should be remembered, took years to recover from the cuts of the mid and late 1980s.
No amount of wishful thinking can deny the fact that you cannot provide a decent level of health services, while meeting increasing demands, having divested the service of so much of its budget.
It should be remembered that a wide range of savings and efficiency measures have already be made. A wide range of direct service cuts have also been made in terms of closed hospital beds and theatres and curtailed public nursing home and other home care facilities.
Perhaps the health service could do some more paring back, but at this stage it is debatable whether changing rosters, or cutting overtime and agency staff would generate the savings required to out the HSE into the black.
In any case, most of the overtime and agency staff spend does not simply materialise on some manager's whim. It is surely there to cover service gaps caused by staff shortages and increasing demands for care.
Yes, you can argue to a certain extent that poor health service and workforce planning has led to an over-reliance on overtime, agency staffing and other less than ideal employment practices.
But the reason the HSE spends millions of euros each year on junior doctor overtime is because we do not have enough consultants, and many consultants in the system do not work flexibly enough, although many undoubtedly do.
Also, far too much unnecessary work is carried out in hospitals in any case that could be done more cheaply and efficiently in the community. However, with no major resourcing to kickstart it on the horizon, that switch from hospital to primary care is some way off.
These structural issues are certainly not going to be sorted out overnight in time to bring down the HSE's deficit.
No, what will happen from major cuts to overtime and agency staff is that services will suffer, despite Ms McGuinness stressing that hospitals should, in spite of this, maintain patient safety and quality of care.
So we can expect further rounds of bed and theatre closures and cuts in activity that may, come the winter time, lead to increases in treatment waiting lists and trolley waits, thereby negating much of the limited progress that has been made recently in these areas.
In any case, cutting healthcare activity is simply waiting for chickens to come home to roost, as patients at some stage will have to be treated, for however long this treatment might be postponed.
A key 'learning' from the HSE's latest and greatest financial crisis is that health is not a business ruled by a profit and loss account, although judging from recent statements from politicians and managers you would be forgiven for thinking that that providing a complex entity like healthcare is no different to selling mobile phones.
Even if for a moment you were to believe that the HSE was strictly a business, and its service plan for 2012 was it 'business plan' for the year, such a plan would have been a financial suicide note for any self-respecting firm.
The HSE service plan for 2012 can be filed under 'fiction', based as it was on expectations of income those in charge surely must have known were never going to materialise in the short-term, and on hospital and community service activity level projections that were way off the mark.
One example of the cack-handedness that passes for financial planning in the health service nowadays is the issue of State reimbursement of the cost of expensive drugs for seriously ill patients.
The Department of Health recently announced that the cost of some of these drugs would now be covered by the State. The HSE, however has stated quite clearly that its service plan for 2012 did not provide for funding for this measure.
The HSE is also awaiting Government measures to provide it with badly-needed income from overall drug cost savings, additional revenue from private patients in public hospitals, and compensation for the cost overrun on the recent 'grace period' retirement scheme.
Such measures would make considerable inroads into the HSE deficit, but if there was any doubt as to how quickly these measures would be implemented, why were they banked on so heavily in the service plan?
Much of the blame for this funding mess lies with the Health Minister, who, after all, approved the service plan, and whose Department is now effectively in direct charge of the HSE.
The HSE may protest that hospital activity levels, with emergency and planned admissions rising all the time, are 'unsustainable'. It may protest that medical card numbers are going through the roof, but these increases in activity levels have largely taken place to meet the health and social needs of an ageing population living through a crippling economic depression.
Calls to cut activity levels and to make savings in certain areas are essentially calls to stop providing care to large numbers of people.
If these health needs cannot be met from current resources, and what resources are available are not spent properly, then we really should query whether our whole public health service as it stands is sustainable even in the shorter term.
You get to read some fairly scary stats from the HSE's performance report, which gives you some insight into the level of challenge facing our health service.
The May report shows that while some inroads have been made into treatment waiting lists, around 108,000 patients have been waiting over a year for an outpatient appointment.
Even if you completely verified these numbers and half this amount were still genuinely on these lists, would the system be able to cope if all of these patients were offered an appointment within the next month?
The current financial crisis is not helped by major differences between Government and health managers over how to deal with it, and even the side issue of tensions between Coalition ministers doesn't help 'the optics' either, although much of the latter seems related more to egos than policy.
The resignation of Cathal Magee as HSE CEO is symptomatic of the current political and planning mess. While an able replacement will it is hoped be found, it is a pity that Dr Reilly will no longer have the services of a very able manager as he tries to progress his reforms and the financial crisis inevitably gets worse in the short-to-medium term.
If Dr Reilly does not get a grip on the HSE's finances and show that he has real plans to reform things for the better, then his public relations difficulties of recent weeks will seem like mere blips.
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