Brennan Report - Department of Health and Children

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Report of the Commission on Financial Management and Control Systems in the Health ServiceConsequence 2: Clinicians are not the fundamental unit of accountability in theserviceThe individual medical or clinical practice is not the fundamental unit of accountability in theIrish health care system. As a consequence, the 600 (circa) admitting clinical Consultants whotreat all the public and some private patients in the general public hospitals in Ireland do nothave budgets negotiated with them within which to manage their clinical activity.The absence ofthis structure creates an anomaly in the operation of financial management and control systemsin the general hospital sector which alone accounts for almost 50% of the total health budget(see Figure 2.5 and Table 2.3). The anomaly is that the chief executive officer of the health board,who is legally accountable for dealing with overruns on budget and for modifying Service Plansaccordingly, has only limited, crude powers for agreeing these budgetary adjustments with theclinicians that have the authority to commit resources. In the absence of agreed mechanismsbetween clinicians and management, any attempts to curtail clinical activity is likely to be metwith an outcry that patients will suffer or die. There is currently no incentive built into thesystem for clinical Consultants to budget for their practices, to manage expenditure to producean agreed output, or to suggest ways of running their units or hospitals more cost effectively.The same weakness exists in relation to contracts for services with General Practitioners – i.e.there is no mechanism for negotiating with over 1,800 General Practitioners an annual budgetto provide an agreed level of service to their patients. At present, the focus of the medical cardscheme is to pay doctors by reference to the number of patients on their panel rather thanthrough a system designed to get the desired clinical output in the most cost effective way. Intotal, the community health services, including the medical card and drugs refund schemes,account for 17% of total health spending (see Figure 2.5 and Table 2.3).Figure 2.5: Health Expenditure 2002 by ProgrammeGeneral SupportProgramme4%Community ProtectionProgramme3%Community HealthServices Programme17%Community WelfareProgramme9%General HospitalProgramme48%PsychiatricProgramme7%Programme forthe Disabled12%26
Chapter 2 Overview and IssuesTable 2.3: Health Expenditure by Programme 2002 4 Source: Revised Estimates for Public Services 2002.Programme Expenditure % of Total Non-Capital¤ Million Programme¤ Million1. General Hospital 3,832 48%2. Community Health Services 1,332 17%Including: GMS GP Service (¤ 738m)Drug Refund Schemes (¤ 344m)3. Community Protection/Welfare 985 12%4. Programme for the Disabled 969 12%5. Psychiatric 570 7%6. General Support 339 4%Total 8,028 5 100%Consequence 3: Primary source data on patientsPrimary source data about patients, their needs and the comparative costs and effectiveness ofdifferent treatment options are not collected and so are not available to the professionals whoprescribe these treatments. For example, data collected from records on "Diagnosis RelatedGroups" and "Casemix" (see Appendix 5) are not systematically reviewed and interpreted by theclinicians from whose practices it is collected. 6 The result is that quality information onclinical work, clinical outputs and their comparative cost, agreed by clinicians, is not available toclinicians and management to evaluate the cost effectiveness of services provided. This is afundamental weakness when trying to determine the real costs of providing services andconducting teaching and research. Such information is basic in the evaluation of performanceand in planning changes in the configuration of primary, secondary or tertiary medical servicesin order to improve services to patients or to control costs. Examples of the problemscreated by the absence of systematic evaluation of resource use were presented to us by theIrish Hospital Consultants Association. They highlighted the bed blockage problem existing inDublin hospitals because patients that are medically fit to be discharged have nowhere to go.They also highlighted the waste of Consultants’ time arising from the cancellation of electiveadmissions to make beds available for Accident and Emergency admissions. Until theunderlying causes of the waste of such expensive resources are tackled, it is not possible todecide whether an extra 3,000 acute hospital beds and 1,000 extra Consultants, as4Because of an accruals adjustment, the totals in this table do not directly accord with the cash allocation from the Exchequer asshown in Table 2.1.5Rounding affects the total.6We understand that the entire national Casemix dataset (both activity and costs), is shared with all hospitals, and their staff (bothclinical and management) who participate in the system. Data for both the hospital itself, and all other hospitals in the programme,can be accessed and viewed locally.27
Page 1 and 2: Commission onFinancial Managementan
Page 3 and 4: TABLE OF CONTENTSEXECUTIVE SUMMARY
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Page 9 and 10: Executive SummaryWe do not underest
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Page 13 and 14: Terms of ReferenceTERMS OF REFERENC
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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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