Brennan Report - Department of Health and Children

Report of the Commission on Financial Management and Control Systems in the Health ServiceAnalysis of the nature of specialist services provided by clinical Consultants through thegeneral hospital programme budget illustrates the role they can play in the process of reform.An estimated ¤ 3.8 billion was spent on general hospital services in 2002 on non-capitalservices. This represents almost 50% of total estimated health expenditure of ¤ 8.0 billion for2002 (see Table 2.3).The Role of the Clinical ConsultantThe clinical Consultant makes clinical decisions independently and free from the direct controlor supervision of hospital management, medical administrators or other Consultant colleagues(see section 5.2 of the Consultants’ common contract in Appendix 7). This concept of clinicalindependence exists for the benefit of the patient who can obtain a personal medical servicefrom the individual Consultant. If the hospital operated in a commercial market, all costs wouldbe assigned to patients to establish a break-even price for services. The clinical Consultantwould be the key cost centre.It is evident from this analysis that that the individual clinical Consultant is fundamental to thestructuring of accountability for the management and control of resources in the generalhospital programme. This reflects two of our core principles from Chapter 2: (i) thataccountability for resources expended should rest with those who have the authority tocommit the expenditure and (ii) that good financial management and control should not be seensolely as a finance function.Recommendation on defining Units of AccountabilityR5.1 We recommend that clinical Consultants and their practices in individual clinical specialties be designated as theprimary unit of accountability in the general hospital programme.The key question is: how can the health services contract with individual clinical Consultants inways that make it possible to negotiate with them, in a systematic way, the resources they needfor their practices without interfering in any way with their clinical independence in thetreatment of their patients?Past attempts to hold clinical Consultants accountable for managing and controlling theresources they use in treating their patients have focused on a variety of initiatives from"Clinicians in Management" to "Diagnostic Related Group" (see Appendix 5) based systems ofinformation and funding. These initiatives are reported to have had limited success in someinstances.Experience has shown that where clinicians have been successfully engaged in management andplanning within the hospital, benefits flow to all concerned. St. James’ Hospital in Dublin is onelocation where a Clinical Directorate system has been successfully instituted.We note that theReview Body on Higher Remuneration suggested that lessons could be learned from locationswhere the Clinicians in Management initiative has been implemented. 1The international literature indicates that clinicians are interested in and wish to have access toinformation on the cost of clinical activity, clinical performance and the outcomes of clinical1Review Body on Higher Remuneration, Report No 38, page 84.64