Comment: A spending sickness

13 Oct 2004

With the three health reports last year along with this latest information strategy, nobody seems to be able to get at the central problem — where has all the money been going?

You’d have to wonder what is happening in the health sector these days. We know there were a few reports last year about different aspects of the service and that these spawned a number of local interest groups to raise hell about protecting their local hospital facilities. And more recently we saw the publication of a Health Information Strategy, which is really another grand plan to spend a shed load of taxpayers’ money on computers and software across the hospital services in pursuit of an as yet undeclared vision for how things should be done. But the real mystery still remains. That is, with the three reports last year along with this latest information strategy, nobody seems to be able to get at the central problem — where has all the money been going?

Chances are by now they know that throwing money at the health service doesn’t seem to have much of a visible impact on the number of people being ‘accommodated’ in the accident and emergency departments, and that money in the health service seems to act like a gas in a vacuum — it just fills or gets absorbed by every available space. Although the recent announcement of yet more money going to open up hundreds of hospital beds makes you wonder a bit. We know that the ever more sophisticated medical equipment is costly and that the need to reduce the working week of junior doctors to something approaching a civilised arrangement will mean additional money to cover the human resource gaps.

And if you talk to some people they tell you it’s all the fault of the consultants who, they say, are holding the entire system to ransom. Others see it as a symptom of having too many administrators with too much duplication and waste. But what seems to be absent is real empirical evidence that would support or perhaps help to refute some of the arguments, or at least bring some clarity to the issue so that a starting point could be found.

We know that there is a Department of Health and that there is or will be an entity called the Health Services Executive (HSE). There’s also something in gestation called HIQA — the Health Information Quality Agency or Authority. Though it’s not quite clear what role this will have in comparison to that of the new executive or the health department. We know too that the health boards’ days are numbered and that the administrative landscape is set to change fairly soon. So presumably many of the health board staff are at this stage getting extremely anxious about their jobs and their future.

If you take it that the Department of Health is responsible for overall national strategy for the public health system, you would wonder how it managed to produce an information strategy that deals with the operational side of the health service as opposed to the policy side since it doesn’t actually operate the services. You’d wonder also how it managed to come up with a strategy without producing a vision for the health system. In fact, you would probably like to see what kind of a vision it now has for the health service in the wake of the Prospectus, Brennan and Hanly reports. And then you would probably have to question what role, if any, the embryonic HSE played or was allowed to play in the development of the new strategy that it will have to implement.

Another puzzling thing is the amount of tenders out there from the (soon to disappear) health authorities for services to be supplied over the next three to five years. It seems odd legal entities that are about to expire should be embarking on this course when they know they won’t be around to fulfil their side of the contracts. For instance, in recent weeks we have seen tender invitations for such things as managed IT services for the General Medical Services (Payments) Board when it is about to be subsumed into Shared Services.

The North Eastern Health Board is looking for someone to do a community care feasibility study. Meanwhile, Eastern Health Shared Services is looking to contract for computer consumables as well as a primary care information technology system. St James’s Hospital is on the market for a specialty-based clinical record system without, it seems, any reference to the National Patient Information System (NPIS).

Indeed, the NPIS itself has stagnated after a year so that hospitals now face the prospect of expensive interim solutions, which in some cases will mean going backwards for a number of years — completely contrary to the espoused strategy of integrated health service delivery. This contrasts with the €50m going into back-end administration systems this year — where is the focus on the patient? Then we see that the health department itself wants to contract for a consultancy to develop an ICT strategy for primary care when it won’t actually be in this space after 1 January, 2005 — when the HSE will be up and running with the development of an integrated ICT strategy, including primary care, as one of its key priorities.

It is hard for those of us on the outside to understand what’s afoot. Could it possibly be that there is a power play going on and that some of the organisations are trying to retain control of things by putting in place contracts and arrangements that will see themselves involved through the transition period to the calmer waters in the post-change situation?

If, as seems logical, the new HSE were to focus on the delivery of quality health services (the operational side, if you like), you would imagine it would be the main architect of whatever operational strategies are or may be required for it to perform its operational thing effectively. But now it seems it will inherit someone else’s strategy to work with. And that seems strange to say the least because, as far as we know, it has yet to decide what service delivery and supporting administrative strategies will be.

In other words, the HSE’s hands may be already tied before it even gets to the starting blocks. For instance, it will need to review existing policies on the use of expensive administrative systems in terms of their effectiveness and suitability for the new services. They will also have to decide on whether they are going to concentrate on hospitals or patients as the main focus of records — and the information strategy seems already to be focusing on hospital records. It’s hard to get away from the feeling there is a lot of jockeying for position going on while patients suffer and taxpayers pay. Roll on 2005.

By Syl O’Connor