Health service can spend €115 million more this year

The National Service Plan for 2015 (NSP 2015) indicates that the health services can spend €115 million or 1% more this year than it did in 2014, Mr. Stephen Mulvany, Chief Finance Officer, HSE told a meeting of HMI Regional Forum in Dublin.  Maureen Browne reports.

Stephen Mulvany
Mr. Stephen Mulvany

The National Service Plan for 2015 (NSP 2015) indicates that the health services can spend €115 million or 1% more this year than it did in 2014, Mr. Stephen Mulvany, Chief Finance Officer, HSE told meetings of HMI Regional Forum in Dublin. The service plan is based on projected year end 2014 figures and the final 2014 figures indicate that €77m or 0.7% more can be spent this year compared to last year.

He said the HSE had received a budget increase of about €625 million in 2015. But there had been a final core deficit of €549 million in 2014 (covered by a supplementary allocation at the end of the year which, unusually, was in effect carried through to 2015).

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Services both in community and in hospitals have actually got to reduce their costs in real terms in 2015 in order to operate within their budgets.

“However, the normal pay and other cost pressures will eat up all of that €77m and more, so in reality many of our services both in community and in hospitals have actually got to reduce their costs in real terms in 2015 in order to operate within their budgets.

“Managing pay related costs in a much more pro-active way is core part of this. The HSE will be giving greater decision making authority around staffing matters to local managers in 2015 on the basis of ‘earned autonomy’. Living within budget is the primary requirement in 2015 rather than operating within any arbitrarily set staff ceiling. Those services which stay within budget will have much more flexibility around their staffing decisions for both replacement and new posts. The level of agency and overtime costs currently present in acute hospital and other services is neither funded nor sustainable. Most but not all of this can be converted to directly employed services. However there is also a need for a little more than 10% of current agency hours to be removed and not replaced on the basis that there have been significant unfunded increases in directly employed staff, particularly in hospital services, over the last 18 months or so which should allow this to be accommodated safely. The work being done by this 10% of agency staff may well need to continue however it needs to be done by other existing staff or where necessary it needs to displace other work.

Living within budget is the primary requirement in 2015 rather than operating within any arbitrarily set staff ceiling.

“Where the health services wants to get to is annual funded workforce plans covering most of our services which set out the level, skill mix and source of staff hours needed to safely run the service. Achieving this medium term goal will require a balance between:

  • Changing skill mix to ensure scarce health professionals are operating on average near the limits of their scope of professional practice
  • Flexing staffing levels and mix up and downwards dynamically to respond to workload and complexity
  • Shifting resources between services based on a transparent assessment of relative staffing
  • Some targeted additional investment to address key residual staffing shortages.
  • Setting realistic and sustainable staff ceilings (resource limits) coupled with staff floors (safety limits).

“Our budget for 2015 is more realistic than in previous years but it has not been possible to secure the full amount required. We need an exceptional level of focus in order to manage services safely within the available funding. There is a strong requirement on us to perform well financially in 2015. Unless we can demonstrate strong financial control this year, it will be very hard to persuade our funders to convert that into recurring additional funding for the future. As the economy improves we want to position health so that it can benefit from the sustained additional investment in health that the population needs. Unless we can reduce unit costs safely, improve productivity and demonstrate clearly why health services cost what they do we will not secure the level of additional investment required.”

Mr. Mulvany said that there is good evidence of the need for this sustained additional investment. For example, for 20 years, Ireland’s health spending as a proportion of GDP was below the average of OECD countries. It then exceeded it for a year or two before falling back again in 2012. Comparisons with other countries were made more difficult by the fact that Irish health spending figures included social care, which was not necessarily so in other OECD countries.

Unless we can reduce unit costs safely, improve productivity and demonstrate clearly why health services cost what they do we will not secure the level of additional investment required.

Speaking on “Supporting Service Delivery Into The Future,” he said he saw his remit as including supporting professional development for all finance staff in the publicly funded health and social care services. This included staff reporting to him as part of the Finance Division of HSE Corporate as well as the finance staff who were working in services and who reported to community or hospital based service managers.

In terms of the future, he said the WHO had looked at global health and aging around the world. In Ireland by the year 2050 there would be fewer people under the age of five than those over 65. There would also be a huge rise in the number of people aged over the age of 85 which would provide a significant additional demand on service provision. “There used to be a big bulge around the 45 – 55 age group. In 20 years time there will be a second big bulge in the 65 – 86 age group and how we manage dementia care will be one of the biggest issues for the financing of health and social care.”

Worldwide, the number of those aged over 65 would increase by 188 per cent between 2010 and 2050, the number aged over 85 would increase by 351 per cent and those aged over 100 would go up by 1004 per cent.

Mr. Mulvany said that in future the burden would shift to chronic non communicable diseases in high income countries (and Ireland is in that league). This meant that there would have to be a change in how and where we provided care.

“The big four challenges we are facing are cancer, mobility impairment, diabetes and hypertension.”

He said that between 2007 and 2014 total WTE staff numbers in the health services dropped by 13.48 per cent. The largest reduction was in general support staff, which was down over 30 percent (although this might not represent the real picture as services had been supplemented by external provision). Health and social care professionals had decreased by 13.8 per cent, management/administration was down by over 18 per cent, nursing staff by 12.41 per cent and other patient and client care staff had decreased by over 8 per cent. Medical and dental staff were up by 8.51 per cent.

Over the previous eight years (2008-2015), government net funding to the HSE was down by about €1.6 billion or 12% from €13.78 billion to €12.1 billion, while activity had increased significantly.

Between 2003 and 2013 there was an increase of 9 per cent in the number of babies born. In 2013 there were 615,211 discharges from hospital, 3.3 million bed days used, an increase of 11 per cent on 2004. Between 2004 and 2014. ED attendances were up 0.8 per cent, the number of people with medical cards was up 60 per cent, and there were also 125,000 GP visit cards. The number of people admitted to mental health services was down 17 per cent, people receiving treatment for problem drug use were up 54 per cent and the numbers attending intellectual disability days services was up 10 per cent.

Absenteeism rates in the health sector were down from 5.45 per cent in 2009 to 4.27 per cent in the most recent 2014 figures which were lower than the Q1 2014 figures for the NHS.

There had also been significant innovations through the Clinical Care Programmes. The medical average length of stay had been reduced by 21 per cent since 2005, thrombolysis rates in stroke care was one of the highest in the world, 99 per cent of babies received audiology screening within four weeks of birth, 82 per cent of   ST-Segment Elevation Myocardial Infarction (STEMI) patients received Primary Percutaneous Coronary Intervention and there were 10,000 new patients triaged and treated from the orthopaedic and rheumatology waiting lists.