The outgoing Chief Executive of Dublin's Tallaght Hospital has warned that unless hospital savings measures are planned properly, they can be detrimental to patient care.
With the HSE now now telling hospitals to make additional savings measures to slash their budgets for the remainder of the year, and further cuts expected in 2014, Eilish Hardiman told irishhealth.com that hospitals needed to be able to plan properly in order to achieve savings.
"The more 'knee-jerk' measures are hardest to deliver", she said.
Tallaght Hospital,which has been beset by both patient safety and financial controversies in recent years, has managed to make €30 million in savings since 2011, which Ms Hardiman says, have not impacted on patient care.
The hospital, after many years of running up large deficits, was planning to break even on its 2013 budget at the end of the year, she said.
Ms Hardiman stressed that the HSE and Department of Health must address the fact that hospitals will not be getting any of the targeted income this year from new private patient charges, as these have been put on hold until 2014, and measures needed to be taken to address this.
Ms Hardiman, in an interview with irishhealth.com, said there had been significant improvements made in the hospital's governance structures and financial management systems over the past two years. This followed a number of patient safety controversies and budgetary problems.
She defended the hospital's policy of putting patients on trolleys onto wards during demand surges, in order to take pressure off Tallaght's emergency department.
"This is a safer policy because it has been proven irrefutably that that overcrowded EDs are not safe places because you cannot physically monitor the patients, as there are too many."
In the summer of 2011, HIQA ordered Tallaght so cease placing ED trolley patients on corridors, with the safety body highlighting serious patient safety issues with this practice. Coroner inquests at the time had linked the deaths of two patients to their being placed on corridors, and a subsequent HIQA probe report was highly critical of safety standards.
The hospital has since changed its ED escalation policy to one where patients are now placed on wards to avoid ED overcrowding. In recent months, on certain days Tallaght has one of the highest numbers of trolley patient on wards during demand surges compared to other hospitals.
Ms Hardiman will leave Tallaght Hospital next month to take up the post of CEO of the Children's Hospital Group, charged with developing the new national paediatric hospital on the St James's site. She has been with Tallaght since the autumn of 2011.
Since she took up her appointment, Ms Hardiman has been implementing an action plan to ease the hospital's serious financial problems. However, it took some time for the hospital to get its finances on track, even after it started extensive savings measures in 2011.
At one stage in 2012, the hospital had to ask the Department of Health and the HSE for assistance as it had simply run out of cash to pay wages and bills.
"We ran out of money - we weren't going to have enough to pay staff, vendors etc so we needed a cash injection. We entered into an agreement whereby the Department and HSE wanted us to break even - because we were adding a million euro a month to our deficit."
With financial management measures already having begun in late 2011, an overall sustainability plan for the hospital was eventually agreed in late 2012, with a commitment to reach financial breakeven on the hospital's day to day spending by the end of 2013.
As a result of a number of measures taken since 2011, Tallaght will have made €30 million in savings by the end of this year. "We needed two years to achieve break-even as we felt felt it would be unsafe for patients to deliver anything in a shorter timeframe."
The deficit is being cleared mainly by savings measures but also by increasing hospital income.
The Department of Health also agreed, as part of the budget plan, to clear €39 million of a €58 million 'legacy deficit' the hospital had built up through budget overruns migrating from one financial year to another over a number of years.
"Because they were satisfied we were achieving our trajectory and putting in financial controls, there was an acknowledgement that this was a legacy issue - we are now left with a legacy deficit of around €18 million, which is more palatable."
Eilish Hardiman believes the savings measures the hospital has implemented to date have not impacted on patient care.
"We have reduced the number of delayed discharge patients whose acute care had ended but were awaiting alternative care - this equated to two full wards of patients. We have managed to keep delayed discharge numbers down by finding alternative accommodation for these patients."
"We have been able to close a 31 bed ward and reduce our staffing complement in terms of of agency and temporary staff. We have also reduced our length of stay. The average length of stay was cut by a day last year and we are aiming for a further day this year."
Ms Hardiman says the opening of an acute medical assessment unit has helped cut length of stay.
"Before this unit opened, 50% of medical patients presenting at the hospital would be admitted-this is now down to 40%."
"Closing beds has not impacted on waiting lists. We achieved our targets last year. It is a little more difficult trying to do it this year but in general most of our specialties are compliant with waiting list targets despite them having been put back to eight months from nine. It's about using the beds a little bit better, faster than quicker than before."
"We have cut out all agency because of the excessive costs, with fees on top of pay costs. This was mainly among clerical and nursing staff. Where temporary staff contracts expired we did not renew them. We also cut back on overtime."
"Curbing staff costs has been tough, but I must acknowledge that staff have been tolerant of most of the changes that had to be brought in."
On the relatively high number of trolley patients Tallaght has on wards on certain days, Ms Hardiman says managing bed demands for patients presenting at the ED and requiring admission is a fine balancing act.
"All it takes to tip the balance in the wrong direction is is for a huge number of admissions to come in during the night, or not many patients being discharged over a weekend."
"Our ED is physically small and we are planning to extend it. From a patient safety perspective it is not safe to crowd an ED."
"While we don't want any patients on trolleys and it's our objective to achieve that, it has been proven to be safer to have some of these on the wards than having them in overcrowded conditions in the ED."
"As much as possible our focus is on getting a quick patient turnaround; or seeing can we get their diagnostics/investigations done as outpatients or day cases, so we don't have to use inpatient beds. We try to 'ring-fence' beds to particular specialties, thereby preventing doctors having to look for beds all over the hospital-what's known as the 'safari ward round'."
"When trolleys are placed on wards, these tend to be the younger patients or people going for overnight or day surgery. We have criteria to keep this practice as safe as possible."
With hospital finances already cut to the bone, does she think it feasible or the HSE to be looking for further savings from hospitals for the remainder of the year?
"There are always ways of making savings but at this stage savings cannot be quick ones; you need to plan to achieve some of these savings in order not to impact on services. We don't want to be doing that."
"The more 'knee-jerk' measures are hardest to deliver. We have a plan up to our year end and we understand that there will be further cost containment savings in 2014, so we are planning next year's budget now with the HSE. The earlier you can start on planning savings the better, as opposed to trying to, for example, save a million within a month - it is not feasible to do that."
Tallaght Hospital has had major problems in recent years with safety and financial issues, most of which were felt to be due to deficits in governance and administrative structures at hospital. Elish Hardiman says these have now been rectified.
"It is gratifying now to serve a board that has developed to the level it is now at. It is constantly probing how things are run and seeking assurances on the maintenance of quality and safety."
However, despite things improving in the south-west Dublin hospital, it has had the disappointment of losing out on a number of key national specialties.
Firstly, it lost out on becoming a designated major cancer centre. Ms Hardiman, however, points out that while this may be the case, Tallaght still has a significant volume of cancer patients.
Tallaght also bid to become the site for the new national children's hospital but lost out to St James's.
While its paediatric unit (formerly Harcourt Street Hospital) will be closing when the new children's hospital opens, Ms Hardiman feels Tallaght would be well-placed to become of the designated satellite paediatric centres for Dublin to work in tandem with the new hospital.
She accepts that it is unlikely that the previous plan to move the Coombe Hospital to the Tallaght site will now be acted upon, given that a new maternity unit is likely to be located on the site of the St James's children's hospital.
On leaving Tallaght, Eilish Hardiman is quick to pay tribute to hospital staff, who, she feels, have taken an unfair 'bashing' following the controversies of recent years.
"Overall, they can be proud of the service they deliver, especially given these straitened economic times."