Two and a half weeks ago, amidst the media frenzy of George Lee’s resignation, the HSE Service Plan was published. The HSE Service Plan is the HSE’s most important publication of the year, as it is the contract between the HSE and the government which details the type and volume of service the HSE will provide in the year ahead within the budget it is allocated by government.
It is the fifth HSE Service Plan and, significantly, the last one with Brendan Drumm at helm. In short, it details a €1bn budget cut, fewer staff and fewer hospital beds. Delivering all its promises in such a constrained environment will be difficult, if not impossible.
The Service Plan details how the HSE will, more or less, provide the same amount of services this year as last with €1bn less. The budget for 2010 is €14bn, with approximately €4bn going to hospitals and the rest going to everything else. Last year the HSE made €900m in efficiencies and it plans to continue them again this year and make an additional €100m in ‘efficiencies’. Notably in 2009, the HSE lived within its budget for first time ever.
However, many of these so called ‘efficiencies’ are really just cuts; there are about 3,000 fewer staff than 18 months ago. Also, there has been a staff moratorium in place, the termination of any short terms contracts and a big push to curtail agency staff. Closing beds or services can be seen as a cut and there are significantly fewer hospital beds in the system. The plan outlines the closure of another 1,100 beds.
Other areas where these efficiencies are being made are in relation to lower wages resulting from public sector pay cut, as well as renegotiated deals with GPs, pharmacists and drug companies which were long over due. Cuts will also come from reductions in admininistration costs and reducing travel, and practices such as using hotels for meetings.
Such ‘efficiencies’ alongside the greater demand that is evident in HSE’s own stats mean that the year ahead is going to be very challenging for the the HSE. The greater demand is evident in the fact that last year more services were provided across the board than planned and that there are currently 4 per cent more medical card holders than a year ago. Now medical card provision is at the highest level since the 1980's.
Yet this year, except with very few exceptions (cancer care and older people), no extra services will be provided. Yet we have an ageing, growing population and are in the middle of the a baby boom. For example the percentage of the population aged 0-4 is up 2.8 per cent, while over 65s are also up 2.8 per cent. We know that when you are at both ends of the life cycle is when you have greatest needs for the health system, especially older people in need for chronic illness services. There is a new focus on chronic diseases in this service plan.
There has been a lot of messing around with HSE structures, but last year primary and community services were merged with hospitals and new Integrated services established. A ‘Quality and Clinical Care Directorate’ was also set up, headed up by Barry White.
The rationale for integrated services is the need for continued patient care across services whether at home or in hospital – part of this is to meet the need of chronic diseases in the community. The quality and clinical care directorate is starting with the most common chronic diseases; chronic obstructive pulmonary disease, asthma, stroke, diabetes and heart failure. This new way of managing diseases is also in line with Drumm’s drive to move care from hospitals to the community.
However, this increased dependence on community services is not reflected in the budget as the budget is down all-round except for older people and medical card allocation – even primary care and mental health budgets are down despite the current political emphasis on them. The plan commits to 400 Primary Care Teams in place by the year end (I am going to look in detail at the primary care teams next week).
There is extra money allocated for child protection and 200 extra social workers which even Brendan Drumm has admitted its a real area of neglect. For example, 83 per cent of children in care are without a social worker – although 100 per cent are meant to have one and 15 per cent are without a care plan. In total there are 5,700 children in care in Ireland.
The service plan also reveals that in 2009, over 150 children were admitted to adult mental health units, despite official policy being that no child should be in adult units. So there are still huge areas of neglect, and one wonders if there is sufficient budget to adequately address them. In relation to hospitals its all about more ‘reconfiguration’ and reform, reducing inpatient care and very minor day case increases.
The hospital budget is down €500m. The plan is dependent on 33,000 fewer emergency admissions. There are 54,000 fewer inpatient admissions planned for 2010 compared to those actually admitted in 2009, a massive 10 per cent decrease in actual cases which is huge and contrary to the spin put out in the press briefings for the HSE NSP which said it was 5.6 per cent.
This figure is got from comparing the target not the actual number of cases provided. An 10,569 additional day cases in 2010 to those actually provided in 2009 (678,741 to 689,310) which in fact is a 1.5 per cent increase. The HSE New Service Plan says it is 6.5 per cent but that’s comparing the 2009 and 2010 targets not 2010 target with the actual no of cases provided in 2009.
The plan details the occupancy rates at 90 per cent, yet we know that anything over 85 per cent occupancy is dangerous. It also reveals that colocation going ahead in 4 hospitals ‘subject to satisfactory banking arrangements’. In the hospital section, there is a focus on the quality and safety of services – which is a good thing, as we need it – but it is at the expense of equity and access. It tells us that 75 per cent of inpatient discharges are public and its meant to be 80 per cent, where as interestingly, 81 per cent of day cases are actually public. Is this to do with more private patients buying a quicker appointment outside of the public hospital system?
But most significantly this plan is dependent on two premises.
The first of these is that union and HSE management cooperation increases, yet right now there are very serious industrial relations issues in the health sector, with unions saying they will with draw cooperation and the HSE saying this plan is contingent on increased cooperation.
The second is that we have comprehensive primary and community services. These quite simply do not exist.
The year ahead is interesting in health, there’ll be a change in the ranks in the health system in 2010. A new HSE CEO, a new HSE board, a new cancer chief, a new minister perhaps…. and a pretty impossible service plan.