HSE Reform

eolas reviews reform in the HSE as it faces budget cuts and a €208 million deficit.

The Health Service Executive’s budget has decreased from €14.6 billion in 2009 to €14.1 billion in 2010 and €12.35 billion in 2011. Using the whole time equivalent (WTE) measure, the number of Health Service staff were reduced by 4,179 from 109,843 in March 2010 to 105,664 in March 2011. This includes 1,626 WTE staff leaving under the voluntary exit packages in 2010, 960 secondments from the Community Welfare Service to the Department of Social Protection and other reductions due to normal retirements.

A potential overrun of €400 million by the end of the year prompted the HSE to implement a complete recruitment ban at the end of July, including posts such as social workers, therapists and senior doctors which were previously exempt under the Croke Park Agreement.

Conversely, due to the complete moratorium, frontline services have been using agency staff to plug the gaps. However, a new contract for agency staff is in place, with a target cost reduction of €33 million this year.

The executive recorded a deficit of €208 million in the first six months of 2011, with agency staff, hospital overspending and community care services cited as the main culprits. Taoiseach Enda Kenny criticised hospital managers for generating €120 million of the total overspend in July, saying: “It’s either incompetence, it’s either mismanagement, or it is expenditure on agencies.”

The HSE’s gross budget for 2011 had been €13.45 billion until the EU-IMF bailout saw it reduced by €960 million to €12.35 billion. For that reason, Health Minister James Reilly has said that costs need to be reduced and productivity improved if services are to be protected.

The general consensus is that services will experience cuts or temporary closures. However, the body is keen to emphasise the continued importance of small hospitals, announcing on 1 July that two-thirds of existing cases will still be seen in local hospitals but that acute and major surgery would mostly be dealt with in larger centres where there are teams of specialists. A framework for the development of small hospitals is to be developed in the wake of the 14 July Health Information and Quality Authority report which identified “serious concerns for patient safety” in Ennis and Mallow hospitals. (The HSE later identified 10 more hospitals that were of potential concern).

The closure of Roscommon Hospital’s 24-hour emergency department has highlighted how health reform is fraught with political and local anger at cuts to services. Two Fine Gael councillors resigned in July when it was announced that an 8am to 8pm urgent care centre to be run by GPs would be established despite Fine Gael’s election pledge to retain the emergency department.

HSE Chief Executive Cathal Magee told the Oireachtas Health Committee on 7 July that demand for services “continues to grow year on year” and is exceeding its capacity. He told the committee that during 2010 there were 369,000 more hospital admissions, 4,535 more emergency admissions and 5,614 more people showing up at hospital when compared to 2009.

Magee said that during the past year there has been a “renewed focus” on reducing the length of hospital stays, increasing day surgeries, putting in place additional ward rounds by consultants, increasing the number of senior clinical decision makers and ensuring patients are discharged by 11am. The National Service Plan cited that the HSE would provide the same level of service as 2010 while making savings of €683 million in 2011 and reducing staff.

However, figures presented to the new HSE board at the end of July are reported to show:

• increased waits for elective procedures in both adults and children;

• increased emergency department presentations and admissions;

• under 50 per cent of those needing a hospital bed getting it within the six hours of arrival at an emergency department;

• increased use of out of hours GP services;

• more inpatients and day cases than expected; and

• increased numbers of delayed discharges.

Implementing reform

The Health Minister had appointed a new interim HSE board in May consisting of senior officials in the department (including Secretary General Michael Scanlan) in a bid to streamline management. He had asked the former board to resign thus making the Health Service more accountable to his office.

The Programme for Government devotes seven pages to health reform and while the Universal Health Insurance Bill has not yet been brought to the Dáil, other reforms have progressed.

Under universal primary care, GPs will work in primary care teams and a new GP contract, which would incentivise GPs to care for patients with chronic illnesses thereby reducing demand on the hospital system, is currently being consulted on. In addition, compulsory GP registration will be introduced. Galway GP Andrew Murphy previously told eolas that this is a “simple and very important thing to do.”

The Special Delivery Unit “to assist the Minister in reducing waiting lists and introducing a major upgrade in the IT capabilities of the health system” has begun its work with Dr Martin Connor – former advisor to the Department of Health, Social Services and Public Safety in Northern Ireland – appointed as head on 7 June. The unit will initially focus on tackling trolley waiting times and the surge in emergency department admissions in the winter months.

The following measures, stipulated by the Croke Park Agreement are currently underway:

• Laboratory modernisation:

overseeing the rostering of 3,000 medical laboratory staff who now can be called in to work between 8am and 8pm from Monday to Friday. A new payment structure for out-of-hours emergency work is expected to deliver €5 million in savings in 2011;

• Radiology services: extend the working day and ensure radiology diagnostics are aligned to meet the requirements of the acute medicine programme;

• Redeployment: including the relocation of services from St Mary’s Orthopaedic Hospital to South Infirmary Victoria University Hospital;

• Community nursing units:

development of an integrated model of care services for elderly across hospital and community services in HSE South and West;

• Child care services: implementation of recommendations in the PA Consulting and Ryan reports; and maintain linkages between child palliative care teams;

• Disability services: move from residential to community care;

• Dental services: implementation of the Independent Strategic Review of the Delivery and Management of HSE Dental Services;

• Multi-disciplinary working:

development of primary care teams (530 to be in operation by the end of 2011);

• Better risk, safety and quality management: implementation of acute medicine, emergency medicine, critical care, elective surgery, epilepsy, dermatology and rheumatology clinical care programmes; and

• Centralisation: of medical card services, Fair Deal and re-alignment of processing staff into the shared services structure. Funding for the Fair Deal scheme has now run out and no new applicants will be able to enter the scheme this year unless existing applicants die.

Ambulance services have been flagged up by the HSE as no achievements have been made on the implementation of modern te
chnologies such as advanced medical priority dispatch system; effective rostering systems; elimination of restrictive work practices; or re- organisation of on-call working.

The introduction of a clinical audit; improvements in response time; and the centralisation of business support functions have been identified by the department as ‘achievements’ in ambulance services.

In May 2011, a letter from the Department of Health and the HSE to the Croke Park Agreement Implementation Body highlighted the main reform achievements. On the modernization of laboratory services, an agreement was secured on revised terms for working outside normal working hours in early 2011. The health sector was the first to offer voluntary exit schemes for its staff, as stated earlier, it added.

The implementation body welcomed the way that: the HSE “has been progressing an extensive nationwide re-configuration of services and reallocation of resources with consequent redeployment of staff, aimed at prioritising front line service posts and supporting new services for the elderly and children.”