Uphill struggle ahead for Reilly

How has Dr James Reilly fared during his first term as Minister for Health? Sara Burke reviews.

The political season has ended and James Reilly's speech to the MacGill summer school was upbeat, but immense challenges face him now and when the autumn season begins. At the 28 July meeting of the newly formed HSE board, many hard facts were tabled for discussion.

Exactly three months before, the old HSE board members offered their resignations. These had been sought by Minister Reilly, so they went before they were fired.

The new board is made up of the most senior officials in the HSE and the Department of Health; its secretary general, Michael Scanlon; the Chief Medical Officer, Tony Hollohan; the HSE chief Cathal McGee, and other HSE national directors. They have been meeting every two weeks since forming in May. Some of the figures presented to them on 28 July give a very stark insight into where we are now and the challenges ahead.

The HSE annual budget for 2011 is €12.35 billion, so you’d expect half of that spent by the end of June. Figures presented to the board show a €208 million overspend, of which €124 million is hospital budgets. Senior sources say there is no reason to believe that the situation has improved since the end of June.

So over half the overspend comes from hospital budgets. Some hospitals such as Limerick regional have particularly high overspends – between 20-30%. Other hospitals in the west and northwest overspending by about 10% include Mallow, Letterkenny, Roscommon, and Portunicla.

In the North East, Cavan and Drogheda have an overspend of about 10%; in Dublin, Tallaght and Blanchardstown have overspent by about 10%, while Monaghan hospital is the highest overspender at 36%.

The INMO released a statement on the day of the HSE board meeting about cuts to the budget for agency staff in Blanchardstown and Monaghan hospitals by 37%.

The overspend in hospitals and cuts to agency budgets are directly related. Agency budgets are one of the only aspects of hospital spending that can be cut without much notice. The use of agency nurses, doctors and other professionals is a direct result of the blunt instrument that is the HSE moratorium. In the absence of being able to hire new people, frontline services use more expensive agency staff to plug the gaps.

And although there are over 2,500 fewer HSE staff now compared to December 2010, and the HSE is well below its staff ceiling, pay costs have not gone down. There are a few explanations for this:

• those who left in the redundancy programme in December 2010 were mostly lower paid administrative and support staff;
• they are being replaced by much needed but higher paid therapists and consultants;
• while there has been a cut in the rate paid to agencies and a cut in the numbers of agency nurses, agency doctors are up by 33% and healthcare assistants by 17% compared to this time last year.

These budgetary overspends and staffing constraints provide a very real dilemma for the HSE board and the new minister, particularly as other figures presented to the board show increased waits for elective procedures in both adults and children; increased emergency department presentations and admissions; less than 50% of those needing a hospital bed getting it within the six hours of arrival at an A&E; increased use of out-of-hours GP services; more inpatients and day cases than expected; and increased numbers of delayed discharges – back up to 800 in June.

And although it’s become the norm for wards to be closed and services restricted during the summer months as a way of cost saving, people can expect to see more of that. There are plans for extended ‘seasonal closures’ - and inevitably this will result in more people waiting longer, which has more expensive costs both in human and financial terms.

There is also an issue with this in terms of the priorities that Minister Reilly has set himself – “You will not again see 569 people on trolleys in hospitals,” reducing waiting times, improving quality of care; not to mention free GP care by 2016 and the introduction of universal health insurance. As a central pillar in delivering on these priorities, Minister Reilly set up the new Special Delivery Unit (SDU) in the Department of Health, headed up by Dr Martin Connor.

But if the HSE is responsible for reigning in the budget and the SDU is responsible for getting rid of trolleys and long waits, there are inherent contradictions between these roles and it will be interesting to see who wins out. For much of that we will have to wait until Autumn/Winter 2011 to see, but in the meantime what can we tell from Reilly’s first term in office?

If we take the high profile issues that have occupied much of his first four months – the decision to locate the children’s hospital on the Mater site has got the go ahead – something which might not have been expected and shows decisiveness. The suspension of the Fair Deal scheme seemed an unnecessary own goal early on in his tenure; and the management and communication of the closure Roscommon hospital’s A&E was a real blunder. While Minister Reilly can provide real leadership in this area, he needs to do it with greater clarity and consistency while working with the HSE and other health professionals as well as local communities and politicians. Minister Reilly has spoken very publicly about renegotiating GP and consultant contracts and paying them less, yet consultants were excluded for the 15% voluntary pay waiver announced by Minister Howlin on 22 June 2011 for all public servants earning over €150,000 – there needs to be more consistency and better results in areas such as these.

I still don’t understand how Minister Reilly and the government can commit to provide more and better services to more, older, sicker people, free at the point of delivery, with fewer staff and less money particularly when we have no control over our overall finances.

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