What does the future hold for the health service after Minister for Health Mary Harney unveiled her plan for 2011?
IN A health budget briefing that was understandably overshadowed by economic decisions of greater national importance, Minister for Health Mary Harney outlined further cuts to the health service for 2011.
On a positive note, she heeded concerns from mental health advocates to protect their sectors from across-the- board cuts; mental health budgets will see a 1.8 per cent slice from this year’s funding.
Elsewhere, the news was not good. In a sign that savings now trump strategy, the primary care sector has been hit yet again at a time when the clear policy of the past five years has been to shift care from hospitals to the community.
In addition, there will be some 120,000 additional medical cards next year: this is good news for those struggling to pay medical bills, but the recipients will find they are accessing care from a sector that will have no choice but to significantly downgrade the level of service it provides next year.
It’s simply not possible to cut €48 million from general practice and other primary care services without affecting patient care.
Practice nurses are likely to see their hours cut and will be unable to see as many patients. Changes to capitation payments, which no longer factor in the distance patients live from the surgery they attend, will probably result in the closure of satellite surgeries that will no longer be viable. As a result, some people may be forced to seek primary care elsewhere.
The current payment for looking after older people in nursing homes is generous, allowing doctors the time to look after the residents’ health in a proactive manner. But an abrupt 50 per cent cut in rates will likely see a return to an inferior “fire-brigade” and reactive type of care for this vulnerable sector.
Specialist clinics such as those for people with asthma, diabetes and heart disease may also be curtailed; in many cases they are provided without direct State reimbursement and will suffer as practices are forced to cut services back to a bare contractual minimum.
As for plans that patients would be discharged more quickly from hospitals to the care of their GPs, HSE chiefs will now have to think again.
Dental health is another loser in the budget. Having undergone savage cuts that left spending at 2008 levels, this year some 1.6 million people with medical cards are left with nothing but a limited emergency service.
Dental benefit under PRSI is already restricted to a check-up-only service, leaving the patient to pick up the tab for any treatment. The new universal service charge offers no additional benefits for dental health.
Although the disability sector is promised an additional €10 million next year, changes outside the health budget threaten the wellbeing of people with a broad range of disabilities.
Already unable to access grants for necessary alterations to their homes, their ability to pay for the aids and appliances they need for everyday living has been reduced by the cut in social welfare payments.
Proposals to create a tiered system of disability benefit could also turn out to be the thin end of a new wedge of inequity.
Harney was careful on Budget Day not to repeat her well-worn mantra of the past few years that the cuts being announced would have no impact on patients.
Instead. she chose her words carefully. She said that in cutting the HSE’s budget by 6.2 per cent next year – that’s the percentage cut by the time its recently announced supplementary estimate for 2010 has been taken into account – she had sought “to minimise the impact on services to patients or those that use the health service”.
But all the indications in the figures she has presented so far are that reducing the HSE’s budget to €13.4 billion in 2011 will have a significant impact on patients.
While she has stressed home help hours will not be cut as they were this year and that there will be funding for an additional 120,000 medical cards in 2011, it’s already clear hospitals will take a substantial hit.
In a letter to the chairman of the HSE board, Dr Frank Dolphin, just over a week ago, which has been seen by this newspaper, she stressed that at a minimum €150 million of the total budget cut would have to be absorbed by the acute hospital sector.
Her intention here is that hospitals will treat more of their patients on a day case basis, more acute hospital beds will close, the length of stay of those patients who are admitted will be reduced, while fewer agency staff will be employed and at lower rates.
Overtime bills will also be cut by getting staff to work longer hours for basic rates of pay under the Croke Park agreement, and the departure of hundreds of staff under the HSE’s early retirement and voluntary redundancy schemes will contribute to savings.
Harney stressed in her letter that hospital budgets next year should reflect their performance, pointing to very significant variations between hospitals in terms of length of stay for patients treated for the same conditions.
She noted “the greater scope which hospitals with below average performance have to make savings which do not require reductions in total patient treatments”.
But these public hospitals are likely to have to deal with greater numbers of patients at a time when their budgets are shrinking, which could result in more patients spending longer on trolleys and longer waiting lists for a whole range of tests and procedures.
That’s because in the current climate, many people are letting their costly private health insurance policies lapse and more are likely to do so following the budgetary decision to increase the price for insurers of private beds in public hospitals by 21 per cent.
This could result in insurers adding as much as 6 per cent to the cost of policies in the coming year.
Meanwhile, the budget of the National Treatment Purchase Fund (NTPF), which arranges treatment in private hospitals for those public patients waiting more than three months on a public hospital waiting list, has been cut by €5 million.
While it will seek to pass the cut on to the private hospitals, it’s likely now that any hopes people had of the NTPF making major inroads into very lengthy outpatient waiting lists will now be scuppered.
While Harney has stressed the need to reduce spending on disability and mental health by no more than 1.8 per cent, her letter to the HSE points out a cut of this percentile could equate to about €40 million, which is not insignificant.
However, she argued this will be saved by reducing the cost of providing services rather than reducing the services themselves.
An extra €1 million has been provided for suicide prevention in 2011 which is welcome but is just a drop in the ocean to address a growing problem, with more lives now being lost to suicide than road traffic accidents.
On a positive note though, the HSE will welcome the fact that €200 million of the savings they are required to make next year have already been achieved before the new year even begins.
In the week leading up to the budget, a new agreement was reached with the Irish Pharmaceutical Healthcare Association (IPHA), which represents multinational drug firms in Ireland, to reduce the price of drugs by €200 million next year.
A previous deal with the IPHA earlier this year saw a further €100 million shaved off the drugs bill. If this kind of money can be saved on drugs without a big song and dance, the question must be asked, why have drug companies been allowed rip off taxpayers for so long?
Talk in the four-year national recovery plan of introducing co-payments for home care packages and some other services were not included in the budget.
The proposal has been long fingered for now, pending the drafting of eligibility legislation for health services. Harney says this will be submitted to Cabinet shortly.
It’s doubtful though if it will get through the Oireachtas under her watch at this stage.
BAD NEWS
A minimum of €150 million will have to be absorbed by acute hospital sector
€48 million will be cut from GP and other primary care services
50% cut in nursing home payments
GOOD NEWS
120,000 additional medical cards
Only 1.8% cut in mental health funding
Additional €10 million for disability sector