The uneasy relationship which has developed between the HSE and some voluntary service providers – including some of the powerful public voluntary hospitals is posing serious challenges for senior health managers in both sectors, writes Maureen Browne.
The growing mistrust and suspicion is particularly unwelcome as acute hospitals move to solidify the new Hospital Groups and is not helped by the Government’s delay in legally underpinning these fledgling Groups.
Historically there has been little love lost between both sides, dating back to the more innocent days in the 1960s when the Department of Health began to put money into the voluntary hospitals by picking up their then modest deficits at the end of each year and then moving on to paying for public patients treated in the hospitals.
Even when things moved on to the stage when the Department announced a bloc budget for each hospital at the start of the year for what was basically a notional level of services, there was ongoing concern on the Department side that they might not be getting value for money and on the voluntaries’ side that they were being exploited by being expected to provide the majority of services without proper resourcing and blamed when the quantum felt short.
Some of the hospitals are furious at what they see as unwarranted HSE interference in the running of their services and governance, believing that the HSE would be better employed looking after the governance and services of its own hospitals.
These misgivings were exacerbated in the 1970s and 1980s when some of the old voluntaries transferred their services to new sites. The Department felt that since they were funding the new hospitals, the old sites should have been sold and the money ploughed into the new hospitals, but the voluntaries were not always willing to do this, arguing that they should retain control of at least some of the money to be used to fund health services of their choosing, with some stating that they were obliged to do so under their charters.
The kernel of the distrust between both sides was a reluctance on the part of the funders to provide money without control, while the voluntary hospitals were impatient at what they saw as too much bureaucracy and red tape often for the introduction of new services. Added to this was the tendency of the Department/HSE and the voluntary hospitals to be suspicious of the other’s governance arrangements.
At the beginning of the new millennium, the acute voluntary hospitals in Dublin wielded considerable power when they banded together – and frequently spoke in unison – under the banner of the Dublin Academic Teaching Hospitals (DATHs). However, this grouping fragmented in the face of the recession when it was obvious that no matter how loudly anybody shouted there was just no more money to be found.
If it was thought that a more cordial relationships or at least an accommodation had been achieved, this was rapidly dissipated last year when the row over the pay of some voluntary managers was played out before the Oireachtas, with the HSE finding itself bitterly criticised for not knowing that the salaries being paid to some voluntary managers exceeded HSE caps, while some voluntary managers believed they were being publicly pilloried for arrangements which they believed were in line with the HSE pay policy or justified by additional work being carried out.
The fallout from this debacle was bitter with resignations, accusations and counter accusations.
The HSE for its part considers it still does not have proper control over the voluntary hospitals’ budgets believing that some are operating in a culture of asking for forgiveness rather than permission when they go into the red.
Then the HSE was outraged when it emerged that St. Vincent’s University Hospital in Dublin had put the public hospital up as collateral to raise money for a private hospital, it queried whether certain consultants working in the public hospitals were allowed under their contracts to work in the private hospitals and hinted at one stage that special administration might have to be considered for St. Vincent’s. St. Vincents argued cogently that consultants’ contracts allowed post holders to work, inter alia, in co-located private hospitals on public hospital grounds, and that St. Vincent’s was covered by this.
More recently St. Vincent’s expressed concern at the lack of communication over the planned transfer of the National Maternity Hospital in Holles Street, Dublin to the St. Vincent’s campus.
There is still uncertainty rife between the HSE and many of the voluntary hospitals. Some of the hospitals are furious at what they see as unwarranted HSE interference in the running of their services and governance, believing that the HSE would be better employed looking after the governance and services of its own hospitals.
They were and are concerns about the current Service Level Agreements and Compliance Statements, which they say effectively gives them no rights but can be used selectively by the HSE to interfere unwarrantedly in their service with very little excuse. They also say that HSE hospitals are not held to the same level of accountability.
They see it as completely unfair that while their budgets may be announced at the beginning of the year or even earlier, there can be long delays in their getting their money, that HSE hospitals are bailed out if they overspend but voluntaries have no such luxury.
The HSE for its part considers it still does not have proper control over the voluntary hospitals’ budgets believing that some are operating in a culture of asking for forgiveness rather than permission when they go into the red, leaving the HSE to pick up the tab and face the consequences, financially and politically.
The HSE can point out that if voluntary hospitals overspend, the money has to be found either at the expense of other services which may also be in dire financial need or from an additional supplementary allocation from the Department of Health, on which it is becoming increasingly difficult to rely. As the HSE is the accountable body where the health budget is concerned it believes that any monies over and above those allocated should only be spent with its prior approval.
The acute voluntary hospitals have now come together again with the recent formation of the Voluntary Hospitals Forum, which was established to represent the acute hospitals. The respected and experienced, Dr. Ruth Barrington (former Health Research Board CEO and former Asst. Secretary, Department of Health) told the Forum’s Conference that the initial signs that the future hospital trusts would be independent were not encouraging and evidence suggested that what was proposed would destroy that very autonomy and governance and the quality of patient care that was associated with the voluntary sector. She also said: “It suggests to me that what is proposed is not so much a divestment of HSE/Department of Health responsibility for the hospitals in public ownership as – and I choose my words carefully – an effective nationalisation of hospitals that are independently owned and/or governed in the proposed trusts.”
However, she said she did not think it was in the state’s power to ‘devolve’ autonomy from voluntary hospitals to the new hospital groups.
Mr. John Morgan, who was Chair of Mater Misericordiae University Hospital for 13 years to the end of last year told the same Forum that in practice the relationship between the voluntary hospitals and the State found its expression in, and was confined to, the Annual Service Contract.” Not only have the terms and conditions of these contracts been drawn totally in favour of the State side, as a precondition of receipt of funding, but no certainty of even indicated funding is provided and the timing of its receipt is invariably both unknown and late. Most do not know how much funding will be received until certainly the last month of the year if not in the last working day of a year,” he said.
It is to be hoped that the developing Hospital Groups, which are bringing statutory and voluntary hospitals together will be able to facilitate a move to a greater understanding and a more collegiate working arrangement between the voluntary hospitals and the HSE and the Department of Health.