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October 31, 2014

Paying the penalty on targets

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Dara Gantly

Dara Gantly questions whether fining hospitals €25,000 a month for missed targets is the fairest and best way to improve the health service.

No-one can complain that they weren’t warned. Back in July 2011, the Minister for Health instructed public hospitals to ensure that they had no patients waiting more than 12 months for inpatient or day-case treatment at the end of the year. Dr James Reilly made some significant changes to the National Treatment Purchase Fund (NTPF) — including removing the bizarre 90 per cent private sector, 10 per cent public sector split in treatment funding — and announced the prospect of sanctions for hospitals that missed their targets. “Where they fail to do so, the NTPF will source the necessary treatments and the hospitals’ budgets will be reduced by a corresponding amount in 2012,” the Minister said at the time.

So we should not be too surprised to learn that University College Hospital Galway (UCHG) and Merlin Park Hospital have been fined for missing the latest targets set for scheduled care. It was reported that while the hospitals were fined €1.2 million, this was suspended on the condition that further targets were met by September 30. For 2012, the aim is to have all patients waiting no longer than nine months for inpatient treatment, whether medical or surgical.

When the first real results emerged at the end of January from the Special Delivery Unit (SDU)/NTPF, everyone knew where the problem existed. By the end of last year, 95 per cent (41) of hospitals met the target to eliminate over-12-month waiters from their active lists. This compares to 28 hospitals at end 2010 that had patients waiting over 12 months for treatment on the active list.

Two hospitals turned out to be more challenging than others: UCHG, with 368 active waiters; and Merlin Park, with four waiting.

Under the new penalty procedures, hospitals can be fined €25,000 a month for missed targets, or may have to pay the full cost of treating the patient in a different centre on top of a penalty.

According to the latest HSE performance report, at the end of February there were 4,454 (inpatients: 1,855; day-case: 2,599) adults waiting longer than nine months for an elective procedure. This represents 8.1 per cent of the adult waiting list for elective procedures and shows a decrease of 224 patients compared to the position at the end of January. However, if just the number of adult inpatients waiting longer than nine months is examined, the rate has increased from 13.3 per cent in January to 14 per cent in February.

The Galway Hospital Group has 961 adult elective patients waiting longer than nine months (323 of these are over-12-month waiters) and 708 day cases >9 months and 276 >12 months. But watch this space: Beaumont has a combined 548 elective and day-case patients waiting longer than nine months and a further 121 waiting longer than 12 months; the Mater 568 >9 months, 91 >12 months; CUH 311 >9 months and 115 >12 months; the Mid-West Hospitals Group 413 >9 months, 96 >12 months; and Letterkenny 198 >9 months and 27 >12 months.

So are financial penalties the only way to go and are more to follow? Former IMO President Prof Seán Tierney doesn’t think so. He has complained that the SDU is too focused on putting forward targets as the only solution to the problems of waiting lists. “There is no point in saying to a hospital, ‘we are going to charge you €25,000 a month for a patient who is waiting longer than a certain amount of time for an operation’, when the reason you can’t do that operation is because there is not sufficient capacity for the demand, or that there aren’t sufficient community beds and community supports to discharge patients more quickly.”

At one level, it would appear the Minister should agree. Speaking in January at an SDU briefing for journalists, Minister Reilly referred to developments in Drogheda, where a holistic approach to delivering improvements in the acute hospital system had, he said, produced some success. “It wasn’t about creating two extra beds; it wasn’t just about long-term residential care beds being opened up, as there were intermediary care beds opened up in Louth and Navan. There were also more home help packages put in place, more home care, more community intervention teams (CITs) established, which allowed for nurses to visit patients in their home to continue their IV antibiotic therapy, having had the first treatment in the emergency department.”

So, yes, fine away if those hospitals have failed to juggle the complexities of lengths of hospital stay, early discharges, opening up step-down facilities, enhanced CIT activity and extra home care packages. But if hospital ‘A’ has no control over many of these services, the exercise is futile and may make matters worse.