SAME OLD, SAME OLD!

It seemed like a good idea at the time. Appoint a committee of Oireachtas members and ask them, within a defined time period, to come up with a cross party approach to reforming our health services over the coming ten years. That could only happen successfully by adopting a ‘new politics’ approach, writes Denis Doherty.

Denis Doherty
Denis Doherty

The omens are not promising. The expected publication date has passed and the kites that have been flown suggest that the fiasco that was the Oireachtas consideration of how water should be paid for could be repeated here.

Que sera, sera, as healthcare managers we can only hope that a workable, enduring solution will prevail over the pursuit of irreconcilable political ideologies. Healthcare in Ireland has suffered from that for far too long.

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There are important changes required that ought to underpin whatever overall approach is adopted. We should first ask how much are we prepared to spend on our health services? We know that there is not a direct correlation between what is spent on healthcare and the return on that social investment. If there was, the healthcare system in the USA would be the best in the world but we know it’s not.

Professional and transparent cost based approaches to funding service provision have not been developed and the separation of purchasing/commissioning from direct service delivery have not been introduced.

Investment ought to be based on need rather than on demand and need ought to be evidence based. The public health specialty could play a valuable role in that regard but has not been permitted to do so. When the HSE was set up, an opportunity to move the then maturing public health specialty to a higher level was spurned. The resulting weakness in our system has resulted in many important decisions on new investment being made in response to media generated controversies rather than on sound evidence. Any new system ought to recognise the importance of an evidence-based approach to decisions when choices have to be made between competing interests.

Try describing the Irish healthcare delivery system to anyone not familiar with it and note how quickly eyes glaze over as you describe the hotchpotch that it is. There is the HSE that operates public hospitals and funds voluntary hospitals, public voluntary hospitals, Section 38 providers who deliver services on behalf of the HSE, Section 39 providers who provide services similar to those provided by the HSE. Oh, and then there also private hospitals! Public hospitals, voluntary hospitals and public voluntary hospitals are organised in groups, like Trusts in the NHS except they do not have Deeds of Trust or Trustees. That’s not all, but you have lost everyone at this stage.

How the amount of funds allocated to third party providers is calculated is almost as mysterious and as ancient as the third secret of Fatima. Up to 2004, the calculation was largely based on a formula that took last year’s out turn, deducted non-recurring costs and added an amount for new developments. The current approach is considered to be just as opaque. There is a widely held perception and some evidence that HSE directly funded services are better resourced than third party provided services are. A process that resembles prescription more than negotiation is nigh impossible to judge.

Professional and transparent cost based approaches to funding service provision have not been developed and the separation of purchasing/commissioning from direct service delivery have not been introduced. Those issues need to be addressed.

Now is hardly the time to embark on radical changes on either ideological or funding grounds. There is ample scope for significant improvements to be made using a much less disruptive approach.

Shortly before the swinging cuts in healthcare funding were introduced, a standards and regulatory entity, HIQA, was established under the Health Act 2007 and conducts its work independently of the other parts of the system. Providers, statutory and non statutory, often struggle to meet the standards expected of them on budgets and staffing levels that are inadequate and in facilities that are unfit for purpose. The reports of the regulator sometimes gives rise to public criticism of providers who lack the resources to improve their standards to the level they accept is necessary.

In a well functioning system, service provision rates would be based on the cost of meeting HIQA standards of accommodation and service delivery. That would involve meeting the cost of systems, adequate staffing levels, staff training and development and, in the case of commercial private providers, a reasonable return on their investment. In areas where there is, say, an undersupply of nursing home beds an approach to fee levels based on ‘the going rate in the area’ will only guarantee that undersupply will prevail. Capital investments will only be made where a return on investment is possible.

The current clamor for the State to acquire hospitals owned by religious communities and the separation of public and private hospital care provision is unlikely to improve either access or standards. A much more potentially beneficial approach would be one based on evidence based and assessed need, delivery systems based on considerations of economy of scale, relative cost and ease of access for users. Why not use the best of the facilities in the public, voluntary and private systems on the basis of optimum user benefit, value for money considerations and compliance with HIQA standards.

Healthcare systems that, like ours, have evolved over decades don’t lend themselves to sudden changes of direction. Having regard to all the predictions of possible shocks to our economy and to our way of life over the coming decade now is hardly the time to embark on radical changes on either ideological or funding grounds. There is ample scope for significant improvements to be made using a much less disruptive approach.