Major changes urged in service planning

Senior health managers believe major changes should be made in the Service Plan and Service Level Agreements processes and that the shortcomings and limitations of the current system should be made clear to the public and politicians, writes Maureen Browne.

Senior health managers believe major changes should be made in the Service Plan and Service Level Agreements processes and that the shortcomings and limitations of the current system should be made clear to the public and politicians.

Maureen Browne
Maureen Browne

They say that the current HSE Service Plan is, to a large extent, an exercise in smoke and mirrors, and it should be updated every four months so that it will stand as a living document.

They also believe it is imperative that Service Level Agreements cover both the acute hospitals and the community services in each area, as both are co-dependent in the provision of services.  They would also like to see the legal standing of the Service Plan and Service Level Agreements clarified.

Managers also argue that the way the system currently works – with annual funding based on the previous year’s outturn – makes it difficult to introduce new and more efficient systems of working. They say that proper planning cannot be kaleidoscoped into 12 months and a longer term view and multi annual budgeting are required, to facilitate changes from one system to another. “At present, it seems to be based on being asked to deliver the same level of services as the previous year with less money and vacant ‘mission critical’ posts,” said one manager.

There is a very strong view among managers that neither the public nor politicians are aware of how the current processes work, which allows the political system to literally wash its hands of problems, on the basis that managers have agreements in place, the money to implement them and should get on with it, when the reality is that six months into the year, a number of major agencies may not have signed any service level agreements.

Managers in acute hospitals point out that their ability to deliver services is often directly related to the provision of community services, over which they have neither control nor influence.

The current HSE Service Plan is, to a large extent, an exercise in smoke and mirrors and should be updated every four months so that it will stand as a living document

“Our Emergency Department, admission beds and outpatients could be backed up with people, who might never have needed to come to hospital if they had local community services in place, while at the same time we could have a couple of hundred delayed discharges, who cannot go home or to residential care because there are no services available,” said one hospital manager.

“For example, we may not be able to take in electives because the beds may be occupied by older people who can’t go home because the community services say they have no money for safety equipment they might need, or care in the home which they require.  The community side obviously has a Service Level Agreement in place to provide these services, but especially towards the end of the year they can just say they have no money and there is nothing we can do about it.  Similarly, there can be huge problems in discharging patients into nursing homes because of lack of Fair Deal resources. Our elective waiting list increases and we are pilloried for it, but it’s outside our control.  Then there are the GPs, with no agreements on the number and type of patients whom they will treat.”

The other side of the coin is that their colleagues in the community are forced to spend money on services for which they may not have budgeted and which would not be required, if patients could get to hospital for outpatient or inpatient services which they require.

“In addition to the ever increasing demands on our services, they can be over-run by patients, whose health has deteriorated because they can’t get treatment and need more and higher levels of support, or those who need to be in long term residential care, but can’t get in.

“We also have to manage within our budgets. I would be all in favour of the acute hospitals and the community co-operating on Service Level Agreements, where we would each know each other’s responsibilities and obligations, work more closely together instead of in the current silos and, very importantly, be in a better position to manage public expectations.  We need greater engagement, particularly around the new HSE Clinical Programmes.

“Does this mean anything?” “Ah, no sir” was the reply “It means nothing – smoke away”

“While each HSE region has a plan in place, I think we really need to break this down to a unified hospital/community plan, perhaps at least for each of the new Integrated Service Areas.”

There is also general agreement among managers that the HSE Service Plan should be updated regularly to take into account changes in activity and resources throughout the year.  “The HSE has a massive amount of on-going information from IMRs, management overviews and HealthStat.  While these stats which detail budgets, activity and staff numbers mightn’t always agree and be based on different parameters, it should be possible to pull out stats to update the Service Plan regularly, so that it reflects what is actually being done. At present, it is very rarely amended and so it can end up as just an aspiration,” said one manager.

“I appreciate that the Service Plan is probably unique in the public services. I don’t think there are any comparable agreements in other areas, where money seems to be just handed out without any formal agreements on how it will be used.

“But, I would also have concerns now that the Service Plan is signed off by the Minister (obviously having been approved by the Department of Finance) with the HSE Board, but with the exception of the Chair, all members of the HSE Board are now either employees of the HSE or the Department of Health.  This situation which raises serious governance issues looks set to continue.”

Contrary to popular belief, the HSE Service Plan does not appear to be a legal document, a according to the Health Act 2004.  A week after they were asked on its legal status, neither the HSE nor the Department had clarified this.  “I think it is a bit like the pre smoking ban story about three guys in a train carriage which had a big “No Smoking” sign.  Two of the men were smoking and the third asked the Inspector “Does this mean anything” “Ah, no sir” was the reply “It means nothing – smoke away,” said one manager ruefully.

Neither do the Service Level Agreements appear to be legal documents, although it is generally considered that they are formal agreements and of course they carry penalties for agencies which breach them. It also makes things very difficult when half way through the years (and in some cases later) some agencies still have not signed service level agreements with the HSE, following what managers describe as months of wrangling, threatening, promises and broken promises. While it is difficult to begin detailed negotiations until the HSE Service Plan is signed, generally in January of each year, it is considered that negotiations between the HSE and the agencies it funds should be started in the autumn of the previous year when the broad parameters will be obvious and not, as is frequently the case, beginning in March of the funding year.

About three years ago a large group of Section 38 and Section 39 providers coalesced to fight what they saw as an attempt by the HSE to insert a provision in the first part of SLAs, which would allow the HSE to replace agency CEOs, who did not, in the words of one manager, “play ball” with the HSE on the delivery of service planning.  This was subsequently abandoned by the HSE.