Managing the unmanageable

Dr Sarah Barry of the Centre for Health Policy Management at TCD outlined to the Inaugural Conference of the National Clinical Programme for Diabetes in Farmleigh, Dublin how the recent economic crisis has impacted on healthcare managers, and by extension, the challenging impact this has had on the optimal provision of chronic care in areas such as diabetes.

She said you cannot reflect on the provision of chronic disease care without taking account of the broader economic context in which patients, clinicians, managers and politicians have been working in recent years.

Her presentation highlighted the pressures under which healthcare managers have operated in attempting to deliver a reasonable level of care against a background of unprecedented budgetary cuts, while at the same time being tasked with planning and delivering on often confusing structural change and a major health reform agenda.

This has imposed obvious pressures on meeting the priority of managing patients with chronic diseases in an integrated, seamless fashion.

The health budget has been cut by almost €3.3 billion since 2009 and there are 12,200 fewer full-time equivalent health staff now than there were in 2007. All this has been happening in the context of planned reforms including universal health insurance, free GP care and reform of the structure of the HSE itself.

The Resilience Project was set up by TCD Centre for Health Policy and Management, to look at: 

• The level to which healthcare funding, particularly funding for services for the vulnerable, was protected during the economic crisis
• The ability of government and providers to manage the system with fewer resources through efficiencies, while not sacrificing priorities, benefits, access or entitlements
• The ability or capacity of government to design and implement desirable and realistic reform when the current organisation, structures and strategies are no longer feasible.

Dr Barry pointed out that statistics show that analysing public spending on health in 18 OECD countries, the greatest percentage fall in recent spending was recorded in Ireland. The TCD research found that in terms of protecting the poor during the period of austerity we fared quite well – pointing to the overall increase in the number of medical cards.

“Nonetheless, as the crisis deepened there was significant cost-shifting from the public purse on to individuals, particularly the old and the sick. We recently reported in the Lancet that in 2013, each person in Ireland paid an average increase in health costs of about €100 since 2008.”

Dr Barry cited under this category increased hospital charges and increased thresholds for drug reimbursement. In terms of adaptive resilience, in the early stages of the crisis, when staffing and budget started to decrease, productivity went up and we were ‘doing more with less’. However, as the crisis continued, it became clear that from around half way through 2012, cuts were having a direct impact on services.

“Day-case and outpatient attendances began to fall, and waiting lists have been rising since 2013. With public bed numbers down by 900 and home help hours down by 18% since 2008, the system is showing the strain.”

Dr Barry  highlighted further research carried out at the Centre for Health Policy and Management on attitudes of health service managers and their experiences. A total of 197 HSE managers were surveyed (41% response rate) and a further seven senior managers were interviewed as part of the research.

Managers were asked to identify which policies they felt were important for government. They said most important was reducing ED waiting times, followed by drug price reductions, living within budget/austerity measures, transferring care from hospital to community and implementing ‘money follows the patient’.

“What is interesting here is that these do not reflect the headline priorities in the Programme for Government, but rather relate to running the health system more effectively in a challenging environment.”

“The question arises as to whether the headline reforms of the Programme for Government are getting the focus they require for implementation. Also pertinent here is how relevant those priorities are from a management perspective,” Dr Barry said.

Asked which policies were important for themselves as managers, they ranked managing change as number one, followed by managing integrated care, transferring care from hospital to community, reducing ED waits and living within austerity measures.

“From this, once again the question arises as to whether headline reforms are of sufficient priority for serious implementation.”

Exploring this question further, the research looked at the priority given by managers to some of the government headline reforms, such as reducing ED waits, setting up hospital groups, free GP care, and universal health insurance (UHI).

It was found, Dr Barry said, that many key reform initiatives are failing to get a proportionate share of managers’ time and practice. 

She said this analysis shows us that health service managers spend much of their time engaged in running the current system and with the immediate rolling out of projects relating to the operation of efficiency, rather than the reform agenda per se. 

“Managers reported that over 25% of their time is taken up with living within budget and managing change. All of this analysis begs the question as to whether the reform programme is being adequately resourced from a health service manager perspective.”

The issue uppermost in mangers’ minds was the challenges in service delivery. There were also challenges identified with the change process, particularly with creating the hospital groups and new HSE divisional directorates, and challenges relating to the culture of the service and its ways of working.

“There are high levels of concern with a lack of leadership in the reform process, large amounts of time going into managing change due to confusion, instability and a lack of participation in the process.”

Dr Barry  said there is a concern among managers that the new HSE divisional structure will further fragment an already fragmented system.

One manager told the TCD researchers that the new directorate system may ultimately suit the managers but may not suit the clients. More layers of bureaucracy, it was felt, could militate against efficiency and hamper effective communication.

Dr Barry also pointed to managers’ concerns about the effect of reduced resources. One respondent referred to a ‘tsunami of cuts’ in 2012.

Other issues identified in the interviews included the lack of succession planning and lack of investment in management capability. One interviewee claimed there was an insufficient number of accountants and IT staff to deliver on ‘money follows the patient’, as a result of the recruitment embargo.

Another key block to change identified was the cultural issues within the system that make change difficult. Dr Barry noted: “Colourfully, although insightfully, this was noted by one respondent, who said ‘I’m the CEO, but I still have no authority to tell any doctor what to do’.”

There was a clear sense that there was no clarity about the plan for progressing through change.

“There is a sense that people are willing to buy into changes but they are very unclear as to what exactly these are and how they will impact on service delivery and therefore there is a lack of ownership of the process.”

There was a sense of confusion and a lack of confidence among managers. ‘How can I be fit for purpose when the pieces that sit on top of me are so mixed up?’ was one comment made. The research also raised issues about the bureaucracy of the HSE and its structures being disempowering. Dr Barry said there is a sense that managers are delivering the service in the face of a deeply challenging level of ‘bureaucracy, intransigence and insecurity’.

It was claimed in the interviews that staff in hospitals feel the level of bureaucracy and centralisation runs counter to people exercising their initiative.

On a more positive note, Dr Barry stressed that the managers interviewed were talented people, actively working with the many challenges, and pointed out that people have been innovative in managing operational challenges, such as waiting lists, and in some cases respondents talked about how real learning was taking place.

In summary, Dr Barry  said the focus of attention of managers in the research was predominantly on the restructuring process, of developing hospital groups and on the implications of the establishment of the divisional directorates. 

“In this context, the expectation is for continued or worsening organisational fragmentation and capacity gaps, although some positive outcomes of the hospital group structures were noted.”

“The challenge of a lack of communication and clarity throughout the change process from various levels of leadership is resulting in a lack of confidence in that very process itself, and therefore a lack of progress on those lines is apparent.”

Dr Barry said possibly key to this situation is also the lack of resources to enable or implement the change process in a time of austerity. This she said begged the question as to how much priority was given to understanding and resourcing the process of change.

“For confidence in the vision behind the change process to grow, people have to become participants and owners of that change.”

Overall, the messages emerging from the research indicate that the nature of the cuts were significant and arbitrary. The system is now doing less with less, and the burden of this shift is being carried by the public. She said there had been a conflict between the drive for reform, the austerity approach and the concern for quality. 

“Also, the ability to continue delivering and improving service through the various reforms is in real jeopardy.” 

Dr Barry stressed that the research showed that the process of reform seems to be undermining its own successful outcome. 

The TCD research results obviously have implications for chronic disease care in diabetes and other areas. 

There are implications for how patients’ transitions across the different levels of care are being managed with all the changes in the new divisional structures, the meeting was told.

Also, if a patient had multimorbidities, are new budgetary practices impacting on how their care is managed? Dr Barry said there was evidence from the research that current flexibilities and relationships within the system are being eroded with the new divisional structures. 

There are questions too, about the functioning of primary care teams, and there was also the question of whether the cuts had impacted on access to care.