The Department for Health was termed Angola by Brian Cowen, due to the many adminstrative and political explosions, attacks and land mines that damaged ministers who headed it. What could Leo Varadkar, who was appointed Minister for Health in July, do to make the Republic’s hospital health care system more peaceful and productive?
There are four key things missing which leave the system chaotic and driven by crisis.
The public money given to Irish hospitals is not linked strongly to the amount of work done. If a care team does twice as much clinical care work it does not get twice as much funding. If it does half the work the team’s income is not cut in half. Doing more work – for example more emergency diagnosis and treatment of pneumonia, more treatment for people with HIV, more hip replacements or more screening colonoscopies – does not lead in a predictable way to more income for a more productive unit. So there is little or no financial incentive to do more – in fact there is a disincentive.
On the other hand if a unit or department is to get more public resources, more money and staff then the most effective way has been to have a crisis, or a vocal, disaffected patient advocacy group or political champion – for example, a very long waiting list for specialist care; adverse publicity about a bad outcome; a public scandal about a death; or long waiting lists for procedures or activities.
A failure to deliver good care has been presented as a justification for a greater amount of public resources. The holders of the public purse in the Republic until now have rewarded dysfunction. By providing care that is delayed, inaccessible, slow, poor and undesirable, a healthcare unit is most likely to receive more public funds.
Four steps needed
What can we do? Four steps are needed. We should measure the work activity of each care team; account for how much money each team is costing; calculate efficiency by comparing work done to money spent; and then, most importantly, use this knowledge to grow efficient teams and to change or disband the wasteful, less productive care teams.
1 MEASURE WORK We need detailed, fair measures of how much useful work each healthcare team does. Currently there is a standardised national system for measuring inpatient work in Irish hospitals which quantifies the complexity of a patient's problems.
But it is incomplete, sometimes slow and underused as a management tool. The accuracy is variable and, most problematically, it does not include outpatient services.
For example, an inpatient with cellulitis needing intravenous antibiotics is scored as work, but the same patient treated by outpatient assessment and home administration of the same intravenous antibiotic is not counted at all.
The above problems can be fixed. We could make the system complete and accurate. We could extend it to outpatient activity. This has worked well elsewhere.
2 ACCOUNT FOR SPENDING OF EACH CARE TEAM Currently within each hospital there is very little detailed breakdown of spending by care team. Most hospitals do not have accurate cost centres for care teams. The money goes into one big pot. The metaphor of funds disappearing into a black hole is apt when there is no clear link between money spent and work done.
We can change this in the following way. First we should group all of the publicly funded staff into multidisciplinary clinical care teams, each of which provides specific services – for example the sexual health service for the people of Monaghan and Louth.
Every doctor, nurse, secretary, cleaner, therapist and other staff member should be part of a care team that has defined aims and a mission. They need leadership, team-building and teaching together. Let us make each team a cost centre so every salary payment, every pharmacy purchase and box of consumables is accounted to a specific care team.
3MEASURE EFFICIENCY AND SHOW VALUE FOR MONEY Combining the above measures of work and spending we can determine the cost per unit of work for each care team.
From my crude observations there exists a three- to four-fold variation in the productivity of units in Ireland.
Fixing this would cost us to buy the smart management systems; but could lead to 10-20 per cent more efficiency, freeing substantial funds annually to pay for other things.
4 USE PRODUCTIVITY, COST AND EFFICIENCY DATA TO MAKE CHANGES Some care teams are very efficient, perhaps dangerously overworked and under-resourced, and need more resources. These exemplar teams should grow, get more staff, space and be examples for others. The leaders of these teams may have potential for promotion, to become clinical directors and national managers.
Other teams are costly and unproductive. We have to confront and address this. They need to be fixed, changed or disbanded and their staff moved to other teams. They need investigation, to understand what factors led to their costly wastefulness. Some kind of “special measures” interventions may be needed. They may need a change of leadership, new managers. In other cases, some re-education or mentoring, or temporary decision support may be needed.
We need a national specialist group to help fix underperforming care teams. However – and this is a key point – we should avoid allocating more funds and resources to these failing teams. In the past in Ireland inefficiency, failure and crisis led to allocation of additional resources. I recommend the opposite, to identify and fund care teams that are efficient and productive.
There is hope. In 2013 the department published a policy paper on hospital financing that identified several of the issues above and proposes some solutions. In 2012 the running costs of acute hospitals in Ireland was a staggering €4.2 billion, representing an annual cost to each person in the State of €1,000. So we each have a big stake in this. Many of us are unhappy that we spend billions annually without contractual accountability, a direct link to quantity of work and financial transparency.
Samuel McConkey is head of the department of international health and tropical medicine at the Royal College of Surgeons in Ireland