Uncertainty and confusion on way forward

One month into the new year, senior health managers are plunged into uncertainty over slashed budgets, funding February’s exit package and the challenges of continuing to provide safe, sustainable services following the departure of thousands of staff, writes Maureen Browne.

One month into the new year, senior health managers are plunged into uncertainty over slashed budgets, funding February’s exit package and the challenges of continuing to provide safe, sustainable services following the departure of thousands of staff.

These difficulties are compounded by confusion over whether the Minister, the HSE, the Department of Health, the Department of Children or an amalgam of all four is now running the health services.  Many managers just don’t know who they are working for, or who is their boss is and they said that it is impossible to satisfy the Minister, the Department and the HSE.

A number of managers believe that the time has come for tough political decisions. They say we cannot afford the network of hospitals, which we have and which reflect the needs of the middle years of the last century.

Many managers just don’t know who they are working for, or who is their boss is and they said that it is impossible to satisfy the Minister, the Department and the HSE

“Then, there are the new Sectoral Directorates and the new Trusts coming down the road. It is obvious that they will involve dismantling the current structures but we have no information, no clarity, yet we are the people who will have to work the new arrangements.

“In governance terms, the last vestige of independence – the independent Chairman – is gone from the HSE which is now governed by public officials. While, they are excellent people, running the health services directly from a government department is not a recipe for innovation or creativity.

“Now the Minister is planning to re-organise the HSE into seven Sectoral Departments. Did nobody tell him that silos just do not work? What has happened to the Holy Grail of integration and why are we again splitting hospitals and community services? We have sick patients, services need to be delivered in the community, in disabilities, in mental health and in hospitals and we don’t want to be fighting for each other’s budgets. There is also considerable concern that there is no mention of where elderly, disabilities or social inclusion services will sit within these directorates. Will they be in the Social Care Directorate? Will there be money for training, housing, and advocacy? Will the new Director General of the HSE be a primus inter pares (first among equals) rather than a Chief Executive and will a DG have the authority required in the current challenging times.

A number of managers believe that the time has come for tough political decisions. They say we cannot afford the network of hospitals, which we have and which reflect the needs of the middle years of the last century

“Then again it looks as if there will be some “tapping on the shoulder” in the new appointments. How does this fit in with accountability and transparency

“The Minister says he wants to move to a Trust structure, but look at the new management arrangements in the West and Mid West. These groups do not have a Board of Directors, so where will the CEOs report?”

Managers point out that they still haven’t got their budgets for the year, which effectively means they will have lost one sixth of the year before they can come to grips with the financial situation. They say they have been told that acute hospitals’ budgets will be cut by about four per cent, but with the VAT increases and with some hospitals carrying over deficits, it could be up to 11 per cent in some cases, which will inevitably result in decreased activity at a time of increased demand. On top of that, 555 long stay nursing home beds are to be closed and Fair Deal is being drip fed, both of which will mean an increase in delayed discharges and increased elective waiting lists.”

We are a time of incredible crisis, where we are potentially going to run out of money and have major problems of safety and service delivery and don’t know where to go for advice and help

The overall HSE budget for 2012 is €13.3 million – a massive reduction of €750 million on last year and further cuts are expected over the next three years.

The HSE says acute hospitals can raise €140 million through increased charges for private patients, but with more and more people cancelling their health insurance and challenges likely to the Ministerial directive to designate all beds in public hospitals as private for the purpose of charging private patients, this is very unlikely to be achieved.

“What we are facing is “mission impossible,” said one senior hospital manager. “There is an increasing demand for services, acute hospital and nursing home beds are being shut down, we are losing vital staff and the HSE is down our throats morning, noon and night about Emergency Department waits and elective waiting lists. The two messages are just not connecting.

“We have a rudderless ship, and I just don’t see the leadership or the vision which we need… We are a time of incredible crisis, where we are potentially going to run out of money and have major problems of safety and service delivery and don’t know where to go for advice and help.

“The SDU handed out additional money for two months to cover the winter on the basis that the third month’s funding came from the hospitals. This results in extra costs in the first month of 2012. The result of this is that the hospitals and the Minister were not seen to be in trouble, but this is all changing now.”

For all sectors, the elephant in the room is the early retirement package. It looks as if managers are powerless to prevent anybody who wishes to leave from taking the package, but there is no guidance as to what they are meant to do if they lose vital front line staff

Managers in the community sector are also finding it very difficult to see how they will continue to sustain services in the face of the cuts which they now see as inevitable. They point out that they are looking after very vulnerable people and cuts could mean the removal of a vital safety net.  They say that the disabilities sector is going to be particularly badly hit. For example voluntary organisations providing services to people with intellectual disability have already had a cumulative ten per cent cut in funding over the period 2008 – 2011.

“We are now seeing the closure of good quality community residential units for older people and the transfer of nursing staff to acute hospitals, where they will lose their specialist experience in the care of the elderly and it will be a challenge to them to adapt to the different skill sets required in the acute sector. It is difficult to see how this will work,” said a community manger.

For all sectors, the elephant in the room is the early retirement package. It looks as if managers are powerless to prevent anybody who wishes to leave from taking the package, but there is no guidance as to what they are meant to do if they lose vital front line staff. There was some idea about a right of appeal if they wanted to keep particular staff but that seems to have gone out the door now.

“The health service should not be viewed like salami, where you can cut off a slice whenever you feel hungry, because the result will be that in time, the salami will be used up and we will not have the ability to replace it.”

“It is not clear what we are to do if, say, the nurses managing particular wards all decide to go, or we lose our theatre nurses and can’t replace them.  The HSE plans to slash agency costs in half this year. We also don’t know if we can re-employ consultants who leave as locums or how hospitals are to manage risk when they cannot close their doors. Staff will just fill out forms and pass the risks on to management. The mantra seems to be – keep the show on the road until you’re caught, then you’re on your own. We don’t know who is in charge and even if we did, that’s going to change with the new Sectoral Directorates,” an angry manager said.

“The health service should not be viewed like salami, where you can cut off a slice whenever you feel hungry, because the result will be that in time, the salami will be used up and we will not have the ability to replace it.”

Latest figures show that a total of 3,300 staff are expected to leave the health services at the end of next month. This will put a massive financial burden on the health services this year, as they will have to find the money to pay those who are leaving lump sums equivalent to one and a half times their yearly salary plus a pension of half their annual salary.

Essentially this will mean that in 2012, health agencies will have to pay out a sum equivalent to twice their annual salary to all those who leave and then have to try and find other people to do their jobs.  Some voluntary agencies have a “pension pot,” funded from staff superannuation contributions.  However, because so many staff have been leaving in recent years, outgoings are now far exceeding incomes to these funds. It is expected that both the HSE and individual voluntary agencies will therefore have to top slice their annual budgets to finance these payouts and while there may be rolling savings from people who left in previous years, the books are just not balancing in this regard.

Managers believe that agencies should be given a target for early retirements, allowed to implement it as they see fit and protect frontline services.

“All the low lying fruit is gone, suppliers have been cut as far as possible and we cannot make people redundant. We are really struggling to deliver services.  We are also concerned over our cash flow for the first time ever, said another hospital manager.

“If we could put our own redundancy scheme together and target those who could safely leave and keep the money for re-investment, that would be different. After paying out staff there is very little left to run hospitals. I believe some hospitals are doing stuff that is not sustainable. The only solution now is to take out a hospital or a significant component of a hospital to make savings. The time has come for some tough decisions.”

One manager spoke for a number of her colleagues when she said: “We simply cannot afford the network of hospitals, which we have and which reflect the needs of the middle years of the last century. The 1968 Fitzgerald Report is as relevant today as it was then, but at best only half hearted efforts have been made to implement its recommendations or the recommendations of the Hanly Report. Our political masters have ignored the need to rationalise the acute hospitals and have deflected attention from their failure by attributing blame to management for what is in reality major structural fallout that can only be remedied by the political system.

“The Minister should now take the courageous step of recognising the financial reality and put in a place a structure that will provide us with a more modest health service but which will recognise the current and forecast economic reality and is likely to be sustainable in that context.