Brennan Report - Department of Health and Children

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Report of the Commission on Financial Management and Control Systems in the Health ServiceGiven the importance of the health service in the life of the country and the sums of publicmoney involved, it is imperative that health service organisations and agencies have financialprocesses that are efficient, modern, transparent, geared towards service provision and basedon value for money principles.2.4 POSITIVE ASPECTS OF THE SYSTEMForemost among the strengths of the health service are the very many dedicated andcommitted people working in all areas of the sector. This commitment has ensured that highstandards of care are provided to those in need, despite the difficult circumstances in which stafffrequently operate. The people who work at all levels of our health service are entitled toexpect the system to be organised in a way which best allows them to use their skills andenergy to provide quality care within the resources available. They deserve no less than theopportunity to work in a system which will support them in doing what they wish to do: offerthe highest quality service to the public. This ideal has informed our deliberations throughout.In terms of systems, since the passing of the accountability legislation in 1996, the Departmentof Health and Children has been putting in place a framework of control in the finance andservice planning areas particularly.The key elements of this control framework are:●●●●●●Annual Service Plans linked to approved budgets;First charge on the following year’s budget of any excess above the current year’s budgetdetermination;Accrual based income and expenditure accounting;Accounting standards;Monthly management reports and formal quarterly meetings between Departmentofficials and health board executives; andWeekly monitoring and control of cash disbursement.These controls, some of which do not feature in the public service generally, are largelyunderpinned by legislation.However, we recognise that planning, management and financial accounting within the highlycomplex health service requires to be improved further.2.5 PROBLEMS WITH THE EXISTING STRUCTURESThe two central weaknesses in the system that continually stand out in the work carried outby us and in the various submissions and contributions that we have received are:●●No single institution or person is responsible for the day-to-day management of theservice as an integrated national entity; management and control is too fragmented.The absence of clear accountability for relating clinical and other budgets to outputs.Management of the ServiceThe present structure has 10 health boards (plus the Eastern Regional Health Authority)responsible for the management and delivery of health services in their areas and as many as 5324
Chapter 2 Overview and Issuesother agencies (including six statute-based hospitals) at national level with variousadministrative, service delivery and other regulatory functions (see Appendix 3). No oneorganisation has overall responsibility for day-to-day co-ordination and management of theservice nationally i.e. there is a managerial vacuum at the centre. Under the 1970 Health Act,health boards were given, by the Government, the function of managing the vast bulk of healthservices. The Department of Health and Children holds the health boards and their CEOsaccountable for the delivery of those services. In recent years, other executive agencies havebeen established with the agreement of Government to provide specific services which wereconsidered more appropriate to be placed outside the Department so it could betterconcentrate on its key roles of advising the Minister and Government, policy making, draftinglegislation, international responsibilities etc. In this current configuration, the roles played by theDepartment of Health and Children are not sufficiently defined to address the managerialvacuum at the centre of the health service. Any meaningful reorganisation of the country'shealth system will have to deal with this basic structural and operational weakness.Accountability in the SystemWith an absence of full accountability throughout the system, there is no built-in mechanismthat links clinical decision-making and its financial consequences to those who actually make theclinical decisions. As a result, the service is not providing, as a matter of routine, high-qualityinformation on factors impacting on efficiency and effectiveness including clinical outputs andthe costs involved. Clinicians, service users and those charged with overseeing the service donot currently have sufficient quality information to assess the value obtained from expenditure.At present, those with authority to commit resources and incur expenditure - including clinicalConsultants and General Practitioners - are not designated as budget holders or expenditurecontrollers.This absence of a system of structured accountability has far reaching consequencesfor the way the entire health care system is organised, financed, managed and controlled.2.6 CONSEQUENCES OF THE STRUCTURAL WEAKNESSESThe consequences of the structural weaknesses in the present health system are:●●●Patient costing is not at the centre of the system of financial management and control.The individual medical or clinical practice is not the fundamental unit of accountability inthe system.The collection and interpretation of primary source data about patients is not doneby the professionals who prescribe the services or drugs.Consequence 1: Patient Costing is not at the centre of the systemInformation is not available at the level of the patient on the comparative cost of treating aparticular condition. The absence of data such as, for example, the marginal cost of treating aparticular condition in different types of care settings (e.g. at home, in a day-care unit, in a 5-dayfacility or in the acute bed of a teaching hospital) or in different areas of the country, makes itdifficult to compare costs and value for money between different institutions providing the sameservice. This lack of information also inhibits the capacity to plan for services, based on faircomparisons of costs between different public hospitals or between private and public hospitalseither at home or abroad.A costing system is also needed to accurately determine the full costof treating private patients in public hospitals. From the perspective of service provider andservice user, this costing information gap is an issue.25
Page 1 and 2: Commission onFinancial Managementan
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Page 9 and 10: Executive SummaryWe do not underest
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Chapter 5 Accountability - Hospital
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Chapter 6 Accountability - General
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Chapter 7 Accountability - Employme
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Chapter 8 Audit ReformCHAPTER 8AUDI
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Chapter 8 Audit ReformRecommendatio
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Chapter 8 Audit Reformoutsourcing)
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Chapter 8 Audit Reformaudit reports
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Chapter 8 Audit Reformas relating t
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Chapter 8 Audit Reform●●Penalti
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Chapter 9 External Reporting Proced
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Chapter 10 Information SystemsStrat
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Chapter 10 Information SystemsRecom
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Chapter 11 ImplementationRecommenda
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Chapter 11 Implementationbeing brou
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Appendix 1Appendix 1COMMISSION MEMB
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Appendix 1He has held this position
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Appendix 2SIPTU*South Eastern Healt
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Appendix 3Name of AgencyBord na Rad
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Appendix 3Name of AgencyIrish Blood
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Appendix 3Name of AgencyWomen’s H
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Appendix 4Department of Health and
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Appendix 4collated and assessed by
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Appendix 4The most detailed element
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Appendix 4Ratifying and Submitting
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Appendix 4changes to the Service Pl
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Appendix 4advised of their existenc
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Appendix 4Approvals Required in lin
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Appendix 5Appendix 5DIAGNOSIS RELAT
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Appendix 5Figure: Ax.1 Casemix Adju
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Appendix 6Appendix 6AUDIT OF STRUCT
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Appendix 7(vii)(viii)(ix)participat
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Appendix 8Appendix 8 - Integrated M
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ADDENDUMNumber Recommendation IT Ti
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Number Recommendation IT TimeframeR
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Brennan Report - Department of Health and Children

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