Brennan Report - Department of Health and Children

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Report of the Commission on Financial Management and Control Systems in the Health Service1. IntroductionIn a modern, democratic society every citizen should have access to a quality public health system.Thepeople who work at all levels of our health service are entitled to expect the system to be organisedin a way which best allows them to use their skills and energy to provide quality care within theresources available.We approached our task with the belief that the primary responsibility of the health system mustbe to meet the needs of the patient or other person using the service. All the analysis andrecommendations that follow are made with the objective of providing a better, more costeffective,more accountable system where the patient/service user is the number one priority.2. Health Service SpendingThe Irish health service employs almost 100,000 people and spends almost ¤ 9 billion annually. It hasgrown substantially in the last five years. Between 1997 and 2002 spending has gone up by 125% andemployment has risen by over 25,000.Demographic changes will increase the demands on the health system. To continue to increase theresources at the rates achieved in recent years is unsustainable; hence much greater effectiveness andefficiency will be required.3. Evidence on Adequacy of ResourcesDespite the substantial increase in health spending, we heard evidence that:● 3,000 additional acute hospital beds and 1,000 additional medical Consultants are needed tosatisfy current demand.● Some of the most expensive acute hospital beds in the health service are usedinappropriately.● Some of the time of Consultants is wasted because they have to cancel admissions,surgery or treatments when their beds are reassigned to patients admitted through Accidentand Emergency departments.● The underutilisation or underprovision of walk-in (ambulatory) day surgery was seriouslycompromising the throughput of patients and productivity.These conflicting perspectives between the need for more money on the one hand and theopportunities for eliminating waste and increasing productivity in the use of existing resources on theother, highlight the complexity of the management challenge in running the Irish health service and theneed to evaluate whether existing resources could satisfy demand by radically restructuring how thoseresources are organised and managed.4. Our ViewIn our view many of the problems are fundamentally structural. They relate to how the system isorganised and managed. We believe that just improving the systems of financial management andcontrol will do little to improve the efficiency and effectiveness of health expenditure unless there isfundamental reform in how the system is organised and managed. For this reason we haverecommended very substantial changes to the way the system is structured and managed.6
Executive SummaryWe do not underestimate the challenges involved in introducing change on the scale we recommend.However, those who work in the health service and whose commitment we acknowledge deserve noless than the opportunity to work in a system which is much better managed and controlled and sowill support them in doing what they wish to do; offer the highest quality service to the public.5. The IssuesThe main problems we have identified in the areas of financial management and control are:●●●●●●●●Management and control of services and resources is too fragmented; there is no one personor agency with managerial accountability for how the overall system performs on a day-to-daybasis.Those who make decisions (mainly Consultants and other medical practitioners) which commitresources are not accountable for that expenditure and the outputs to be delivered.Systems of governance, financial control, risk management and performance management needto be developed further.The capacity of existing systems to provide relevant, timely and reliable information for linkingresources to outputs/outcomes is severely limited.There is insufficient evaluation of existing expenditure and too much focus on obtainingfunding for new developments.The capacity of existing systems to develop cost consciousness and provide incentives tomanage costs is severely constrained by the under-development of systems such as activitybased costing.The usefulness of data for resource management and for strategic planning purposes is limitedbecause the data is not being interpreted by the clinicians treating the patients (Consultants andGPs).Patient cost information is not available. Such data is essential to any review of the system ofallocating funds or in deciding where the most cost effective treatment can be obtained forvarious conditions.6. Proposals For ChangeWe recommend that:The ExecutiveA new Executive should be established outside the Department of Health and Children to assumemanagement responsibility for the delivery of health care in Ireland and for planning and managing theapplication of the resources used by the health service in a comprehensive integrated way.●●●●●●The new Executive should operate under a board, whose Chairman should report to theMinister for Health and Children.A substantial number of existing executive agencies should be subsumed by the new Executive.Staff recruitment should be by open competition.The Chief Executive Officer (CEO) of the Executive should be accountable to the board of theExecutive.The CEO of the Executive should be accountable for the performance of the CEOs of theregional health boards.The CEOs of regional health boards should retain their role as accounting officers.7
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Chapter 4 Service Planning, Budgeti
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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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