The Brennan report recommends radical changes to the organisation of the country's health structures.
It identifies as key problems a fragmentation of responsibility, a lack of cost-consciousness and insufficient evaluation and analysis of current expenditure.
Hospital consultants, health board executives and other service providers in the health sector have "no incentive" to manage costs effectively under existing management control systems, the report found.
Criticising cost over-runs and insufficient auditing procedures in health boards, it calls for management responsibilities to be pooled in a new national health services executive which would report to the Minister for Health and Children. A dramatic change in the consultants' common contract is also sought to ensure medics give value-for-money and are restrained from exceeding caps on private practice work.
All future consultants employed in the health service should be obliged to work exclusively in the public sector, the report adds.
Accountability in the administering of drug dispensation schemes also receives close attention. The report recommends that arrangements for reimbursing pharmacists under the General Medical Services (GMS) scheme, which applies to medical-card users, should be extended to all other drug payment schemes. This means pharmacists will receive a flat-rate fee for dispensing non-GMS drugs when previously they applied their own mark-up.
A total of 136 recommendations are made in the report, which is dated January 31st, 2003 but was not formally published by the Government until yesterday. Its findings represent those of the Commission on Financial Management and Control Systems in the Health Service, a 13-member group chaired by Prof Niamh Brennan, a chartered accountant and professor of management at University College Dublin.
In its introduction, the commission said: "We approached our task with the belief that the primary responsibility of the health system must be to meet the needs of the patient or other person using the service. All the analysis and recommendations that follow are made with the objective of providing a better, most cost-effective, more accountable system where the patient/service user is the number one priority."
On resources, it noted between 1997 and 2002 spending on health had gone up by 125 per cent and employment by more than 25,000. Despite this, however, it said it had heard evidence that 3,000 additional acute hospital beds and 1,000 additional medical consultants were needed to satisfy current demand.
On financial management and control, the report identified a number of key problems including fragmented responsibility, and the fact that "those who make decisions (mainly consultants and other medical practitioners) which commit resources are not accountable" for expenditure and outputs delivered.
In addition, "there is insufficient evaluation of existing expenditure and too much focus on obtaining funding for new developments". The central recommendation in the 184-page document is for a new health service executive, which would assume management responsibility for the delivery of health care in Ireland. It says the health board structure should be retained, although their number and function areas should be reviewed, to safeguard the need for local democratic representation.
The chief executive officers of regional health boards should retain their role as accounting officers, while the CEO of the executive should be accountable for the performance of health board CEOs, it says. Shortcomings in health board finance controls are identified, including unapproved spending of €115 million on capital projects last year.
Citing further examples of unauthorised staffing, failure to impose due charges, delays in the submission of accounts and inadequate record-keeping, the report concludes there is "an inescapable need for fundamental reform" in financial management.
On consultants, the report notes that only 47 such persons have a contract which commits them to work exclusively in the public sector. With the implementation of an EU working time directive, and the accompanied recruitment of a large number of additional consultants, there is "a unique opportunity to recruit a substantial proportion of consultants on a 'public-only' contract.
"This would go a substantial way towards addressing the conflict of interest issue . . . and make sufficient time available to consultants to fully engage in financial management and practice budgeting," the report states.
The existing consultants' contract should be reviewed to ensure they adhere in principle to agreed budgets, the commission adds. Consultants should also agree to core hours of attendance, and to co-operate with more transparent performance monitoring systems.
On pharmacy costs, the commission said it was concerned to learn of "significant" cost variations across the various drug schemes and between health board regions. The operation of drugs payment schemes needed to be "urgently reviewed".
"At present there is no incentive comparable to the GMS to encourage the prescriber (GP, consultant or non-consultant hospital doctor) to prescribe products that may be just as effective but considerably cheaper than high-cost brands."
