Sunday, March 3, 2024

National Service Plan is a hopeful wish-list of good things, and unclear on the rest

The National Service Plan for the Health Service Executive for 2024 is an interesting if inconclusive document.

It sets out the plans of the HSE for the coming year, but one would have to be hopelessly naïve to believe that the policies and actions contained within the document will be implemented in full, and exactly (or even perhaps remotely), like it is set out in the Service Plan.

The figures are enormous. The government has allocated a whopping €23.5 billion for the HSE in this year’s Budget, with €2.8 billion of that coming from the Department of Children, Equality, Disability, Integration and Youth in respect of specialist disability services.

That is probably a good thing in itself. Were that money going directly into health, it’s likely that it would be siphoned off for more immediate needs, and the disability sector would be left once more with their hands hanging.

But in any case, don’t expect the Budget to work out as written. As the Bee Gees might have commented: “It’s only words.”

For example, no figure is given for the ‘funding to support the implementation of the new health regions’ and that’s probably for the best. We could have a social media type argument about the waste of money involved in changing signs and branding and how this doesn’t help a single patient, but, bored with this slagging match, the HSE have decided to tell us that some ‘funding’ will be allocated to that.

And, of course, when they say ‘funding’ they mean our money.

We have learned from RTÉ through bitter experience (in case someone believed that their self-reporting had done it) that money in a semi-state body will always be flittered around without any proper supervision, plan or cost control. People come, people go, either way, money flows.

And we were told when the HSE was formed, and decision-making centralised, that many of the un-needed management layers in the regional health service (the health boards) would be eliminated because the greater corporate structure would have no need of them. So, that didn’t happen. Not a single person in management was let go or done without.

Now, the HSE is going back to a regional system, and you can bet your salary there will be more non-medical staff to facilitate this, because that’s just how we do it in Ireland.

There’s a €918.7 million in once-off funding in there too, so quite possibly that will be used to buy a few new “North West Midlands South Regional Health Authority” signs, branded notebooks, pens etc. so the staff can know where to report.

There is a fund of €834.7 million to ‘fund increased costs and existing services’. Which is understandable. Medical inflation is rising all the time and almost always at a rate higher than regular inflation. Let’s hope that this money is enough, because that is the crux – the HSE is hoping that the extra costs that come this year will be covered by €834.7 million, but if not, they will have to make up the difference out of other funds.

In that way, this National Service Plan is an impossible attempt to make everybody happy. It says all kinds of things, but hidden in the detail is the devil of a conundrum – how do we know this is going to work and end up costing what is projected?

Of course, all projections are just that, and no-one can truly predict the future, but even I can predict that if you remove €250 million in agency pay for medical staff, services are going to run short.

Agency staff are often there to replace regular staff who aren’t available. You could possibly reduce the numbers substantially, but it’s been tried for years and hasn’t been done yet. €250 million – even at agency pay levels – is still a large number of doctors and nurses – at a time when we are already short. If it comes down to keeping the clinic going, or hiring in a few agency workers, most managers will go with the latter option. That’s always going to be the choice.

Unless there’s a coherent plan focusing on how to reduce this emergency workforce, it’s not going to happen in the light of everyday healthcare decision. On the shop floor in healthcare, it’s always ‘heal now, worry about the books later’, and that’s the proper and right decision.

You can’t blame healthcare managers for trying to do their jobs. Unless there is some replacement for agency workers, they are going to continue to be the plug that fills the hole. The costs of agency staff went up by 139 per cent over the period 2015-2022. That reflected the lack of staff needed in the HSE and that hasn’t changed very much.

It’s the Children’s Hospital all over again – if you’ll buy it for a few hundred million euros, surely you’ll be prepared to pay a billion euros? How about two billion euros? It’s frustrating to watch – a price originally agreed but nowhere near the final cost.

We may end up with a children’s hospital in a cycle-only city centre, (as advocated by the Green Party) and while both of those things might be good in their own way, together they are a planning disaster for rural parents.

The National Service Plan even admits that it is, in essence, a fantasy, and that the HSE will almost inevitably have to go back to government for more money later in the year.

Yes, there are positives. There is provision for 2,200 extra staff, but this is well behind the extra numbers added last year which was a more respectable 7,000. That figure of 7,000 looks like a more appropriate figure – given that the report itself mentions the increasing pressures the health service will come under in the coming decade due to changes in demographics.

And, in any case, the HSE admits it will have to go back to government for more funding later in the year to ensure it keeps services going. So this is a ‘plan’ so loaded with mitigations, exceptions and future ‘unknowns’ that we are none the wiser on what it will actually mean for the HSE. Or patients. We have a rough idea – that is supposed to be enough.

And an announcement by Bernard Gloster that he will get rid of some management positions in the central HSE offices – making the change over to more management in the regions ‘numbers-neutral’ is the kind of mathematics that was last attempted in rural Galilee at a large fish supper attended by a reputed 5,000 people around 2,000 years ago.

And its repeat is just as unlikely.

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