The Health Service Executive (HSE) is the single body with statutory responsibility for the management and delivery of health and personal social services in the Republic of Ireland.
Its key role as set out in the Health Act 2004 is to use the resources available to it in the most beneficial, effective and efficient manner to improve, promote and protect the health and welfare of the public.
5.2 CORPORATE SUPPORT FUNCTIONS
The HSE has a budget of €13.46b and a staff of approximately 105,000. As with any multi-billion, multi-site, large organisation, robust core business functions are essential. Financial management, Human Resource management, ICT, Capital, Communications, Planning, Performance Measurement and internal audit are core functions to support the business. In the past, these functions were split over geographical areas and did not have standard operational processes. However, in the past 5 years they have been centralised and standards have been introduced to ensure a consistent quality approach across the country.
The corporate support function in the HSE has helped to drive the change from the pre-HSE structures to those currently in place and supports the management of staffing, financial and capital resources nationally and regionally in order to achieve the most effective and efficient delivery of services.
The Financial Directorate is responsible for supporting and reporting on the delivery of a balanced Vote each year; specifying and monitoring value for money targets; developing an integrated national financial management system; and monitoring financial management controls.
The HR Directorate is responsible for implementing the Employment Control Framework;
implementing the Public Service Agreement; effective workforce planning, including succession management; implementing and centralising recruitment and other key HR services; and complying with legislative responsibilities in regard to medical/clinical education, training and research.
The Commercial & Support Services is comprised of a number of sub-directorates:
The Estates sub-directorate is responsible for: optimising the quality and value of the HSE’s estates; promoting and delivering economic, social and environmental sustainable healthcare developments; ensuring compliance with best practice, design standards and regulatory guidelines; and ensuring that the annual capital allocation is drawn down in a timely and efficient manner and managed and procured in line with HSE regulations.
The ICT sub-directorate is responsible for developing, implementing and supporting national, regional and local business and service initiatives as well as developing and modernising the ICT technical infrastructure as a priority enabler for effective service delivery. Particular priorities include upgrading core hospital systems and ICT infrastructure to support the clinical programmes; Primary Care ICT roll out and integration with acute systems; and national systems for finance, HR, procurement and performance management.
The Procurement sub-directorate is responsible for the sourcing, tendering, contracting and logistics management of goods, services and equipment for the organisation to optimise efficiencies and achieve best value for money.
The Primary Care Reimbursement Service is responsible for driving efficiencies,
standardising business processes and leveraging economies of scale; delivering cost savings including drug price reductions and efficiencies in High Tech drug schemes; and improving Primary Care Reimbursement Services.
The Communications Directorate is responsible for developing and managing the HSE’s internal and public communications initiatives and provides consultancy advice and support to staff across the organisation. It also is responsible for service user involvement and advocacy.
The Planning and Performance Directorate is responsible for producing Corporate and Annual Service Plans, ensuring that finance, workforce and activity are lined up to deliver the type and volume of the activity committed to; collecting, collating and reporting on activity data against the performance indicators agreed with the Department of Health; and supporting the control process to manage action required against variances in performance at a national (PMCC) and operational level (HealthStat).
The WTEs and expenditure associated with the HSE Corporate Functions are outlined in Tables 5.1 and 5.2 below.
Table 5.1: WTEs associated with HSE Corporate Functions.
Table 5.2: Expenditure on HSE Corporate Functions Expenditure by Support Function *
*Excluding Clinical Strategy and Programmes and Quality and Patient Safety.
Service Area WTE
Finance 505 487 515 +37 +10 +28 +5.72% 18.26%
Human Resources 886 845 796 -39 -90 -49 -5.76% 28.22%
Estates 303 279 283 +0 -20 +4 +1.55% 10.03%
ICT 288 283 279 +2 -9 -4 -1.43% 9.89%
Procurement 274 255 261 -1 -13 +7 +2.62% 9.25%
Technical Services 157 178 156 +0 -1 -22 -12.45% 5.53%
Other Corporate
Functions 575 510 530 -3 -45 +20 +3.91% 18.79%
Total 2,986 2,837 2,821 -15 -165 -16 -0.57% 100%
5.3 REFORM OF HSE STRUCTURES
The structure of the health service has evolved significantly since the establishment of the HSE in 2005. Prior to 2005, services were delivered through a complex structure of ten regional Health Boards, the Eastern Regional Health Authority and a number of other different agencies and organisations, each with their own business process and models of service delivery. Following establishment of the HSE, service management transitioned to four administrative areas which oversaw 32 Local Health Offices and 53 acute hospitals (coordinated through 8 Hospital Networks). Service responsibility for hospitals and non-hospital service remained separate at this point.
The operational structure of the HSE changed again in 2009, when a single national Integrated Services Directorate (ISD) was formed. This directorate was given responsibility for the delivery, reconfiguration, performance and financial management of all health and personal social services. Regional Directors of Operations were assigned to each HSE Region and given responsibility and made accountable for regional finance, HR and service delivery, guided by national guidelines, standards and priorities. Care Group Managers were also appointed at national level to be responsible for specifying the type and level of activity required for dedicated services for Older People, Children and Families, Mental Health Services and Disabilities and overseeing agreed standards for service delivery. A Directorate of Quality and Clinical Care was set up to support and embed clinical leadership at corporate level and 49 Clinical Directors were appointed in 2009 within operational services.
In 2010, service delivery was rationalised within the four operational regions under the management of the Regional Directors of Operations. Care is now managed within 17 sub HSE Areas where one person, an Area Manager, has responsibility for all hospital and community services within a defined catchment population. This has moved decision making back to local areas, working within national standards and frameworks.
In 2011 clinical leadership and the involvement of clinicians in planning and delivering care has progressed and is now key to the planned change in models of service provision.
The Programme for Government indicates that the coming years will see an even greater level of reform with the introduction of a Universal Health Insurance system. The Programme also envisages that the HSE will cease to exist as an entity, with its functions returning to the Minister and Department of Health.
The centralisation, standardisation and alignment of HSE corporate functions has resulted in significant benefits. This is evident in the level of cost reductions, the increase in productivity shown by cost avoidance and improved processes which have raised standards.
However, the absence of national/standardised ICT systems is a major block and risk. For instance, the lack of integrated systems across finance, HR and activity places significant limits on the intelligence that can be derived from the data held in the existing stand-alone systems. Specific examples of requirements for the future include:
• A single finance system;
• A national HR system;
• Clinical systems such as the proposed ED clinical system required to support the clinical programmes;
• A single purchase to pay system in order to drive further efficiencies in procurement;
and
• A world-class electronic and social media system to support each clinical and care programme.
In order to achieve maximum benefit, these systems should, where necessary, be integrated with each other.
5.4 KEY EFFICIENCY MEASURES
Since the establishment of the HSE, there has been a focus on the most effective use of resources to ensure the most appropriate level of service. Detail on the trend in HSE staffing is set out in Chapter 6, and expenditure trends are outlined on a programmatic basis in Chapters 8 -17. However, a selection of key HSE led initiatives are outlined below:
Pay: Pay excluding superannuation is projected to reduce by over €250m or 6.24% between 2008 and 2011 based on May expenditure data. The national HR and Procurement functions have also facilitated significant initiatives during 2011 to assist in the management of increasingly challenging variable pay costs.
Numbers: As set out in Chapter 6, the total number of WTEs has reduced by 5,615 since December 2008.
Value for Money Programme: Significant savings have been driven through the HSE Value for Money Programme 2007 – 2010. During this period, a total of €680m cost reductions have been achieved (versus a target of €500m). A further €72m of savings were achieved between January and May of this year with total savings of €200m targeted for the full calendar year.
Cost Avoidance Measures: Significant efficiencies have been achieved by services and managers through the management of non-pay cost growth and the resulting cost avoidance of nearly €1bn. For example, if medical & surgical cost growth had not been managed during 2010, the projected opening cost for 2011 would be nearly €32m or 13% higher and legal costs would be €10m or 24% higher. These economies and efficiencies were challenging not only because of the requirement to maintain VfM from previous years and to continue to manage cost growth, but also, and very significantly, in the context of managing areas of increasing spend and delivering on the broader service reconfiguration and improvement priorities.
These cost reductions were achieved in a challenging environment where costs were being driven up by various factors including pandemic demands which required 1.1 million vaccines to be administered and major increases in the numbers of medical cards and GP cards (9% and 19% respectively).
5.5 HSE EFFECTIVENESS
The HSE has been effective in driving improvements in quality and quantity of services provided while simultaneously delivering in terms of efficiency. It is important therefore, that the reductions outlined in section 5.4 above are considered alongside the detailed service and performance improvements outlined in the monthly Performance Reports, Annual Report 2010 etc. Particular highlights include increased OPD attendances of nearly 5%, an 11% increase in disability assessments, a 12% increase in the number of children in care with an allocated social worker and an 8% reduction in readmission rates for mental health patients.
Table 5.3: Key Activity Trends 2005 - 2010
Key metrics 2005 2006 2007 2008 2009 2010
Patients treated as inpatients 575,476 588,875 612,346 599,910 593,359 588,860 Patients treated as day cases 512,034 558,813 586,369 641,974 669,955 728,269 Attendances at out patients 2,601,95
home help hours 49,578 54,736 55,366 53,971 54,011
Home help hours provided
Considerable improvements in terms of efficiency and effectiveness have accrued since the establishment of the HSE. The structures of the health service have changed significantly in recent years and further, radical change is promised by the Programme for Government.
Key Savings:
• Procurement: The HSE has focused on managing and delivering efficiencies in the price and volume of goods and services procured as part of a multi-year procurement and contracts management programme. Notwithstanding this, it is considered that there should be scope for further savings over the period 2012 to 2014. A target should be set of securing a further reduction of €150m by the end of the three year period (broadly
€50m extra each year).
Key Reforms:
• Shared Services: Many aspects of the HSE corporate functions would lend themselves to shared services within the HSE and across the public/civil service. Consideration needs to be given to which services should be provided at a national level and which should be better provided locally.
• Outsourcing: Options appraisals on outsourcing and contracting services should be part of a wider public/civil service exercise.
• ICT: There is also a clear need to invest in business process reengineering and develop and modernise the ICT technical infrastructure as priority enablers for effective service delivery. For example, the early introduction of a ‘purchase to pay’ system is an essential investment to facilitate better quantification and tracking of volume of use, stock management and wastage.
• Patient Advocacy: Patient advocacy, empowerment and choice are important policy goals within the health service. These goals are reflected in the Programme for Government, including but not confined to the commitment to establish a Patient Safety Authority. However, the Department considers there is scope to rationalise and reduce the amount of funding being provided to support advocacy and support groups.
Accordingly, it is proposed to ask the HSE to establish what level of funding is currently being provided for this purpose across the health services. Alternative patient advocacy arrangements will then be identified including the role in this regard of the proposed Patient Safety Authority and the potential for making greater use of the Citizens Information Bureau.
CHAPTER 6