Just weeks in office, Minister Reilly said that never again would there be 567 people on a trolley. He set up Special Delivery Unit [SDU] (his swat team or ‘nerve centre’) in the Department of Health to sort out these long waits for public patients for hospital treatment. At the press briefing after the forum on 25 January, Minister Reilly was talking it up, saying that ‘reform does work, and delivers for patients’ that they were ‘improving quality with decreasing resources’, there was a ’cause for cautious optimism’, that ‘this year is a year of reform’ that will ‘deliver Irish people a service they can feel safe in’.

The first target announced is about trolleys – that no one should wait more than nine hours AND significantly 95% should be seen in six hours. That is from time of arrival in an Emergency Department to either leaving the department or getting in to an actual bed.

Given the €750 million cut in budget and decreased staff numbers is this target hour emergency care target realistic? Well the minister and his SDU team think so. They went to great effort showing chart after chart of improvements in numbers of trolleys, comparing recent weeks to this time last year.

Although trolleys are a very crude measurement, there is a considerable improvement since December – there are 1,800 fewer people on trolleys in 16 work days in January 2012 compared to two years ago and 1,300 compared fewer when compared to last year – so that’s progress. There are still 5,000 + people waiting on trolleys. Obviously each one is too many. But fewer than before.

Can the improvement in numbers be explained by the weather or fewer people presenting or is the system getting better?

The numbers presenting are up not down, and the numbers being admitted to hospital beds is slightly up so there is a real improvement although given high numbers still on trolleys there is room for much more.

Can the six hour target be achieved by December 2012? They think so through better systems in Emergency Departments, by monitoring numbers three times a day, the use of newly opened Medical Assessment Units, the better use of hospital beds, more primary care etc…

But there was a difference with the briefing when compared to a previous SDU off-the-record briefing in October - Minsters Reilly was accompanied by Ministers of state Lynch and Shortall,  while HSE head of clinical programmes Barry White was there giving a more coherent, unified, system wide approach.

The other target announced is that ‘no one should wait more than nine months for elective treatment’, given €750 million coming out of health system, 3,000 fewer staff, is it really possible?

Well again, the minister and his swat team seem confident that by December 2012 no one will wait more than nine months for hospital treatment. The minister already set a target of no one waiting more than a year by December just gone. I put it to him these were very unambitious targets, that previous government set targets of maximum wait time of six and three months. Minister Reilly pointed out that difference is previous government never achieved them, this government more or less achieved the 12 month one within 9 months.

I also put it that it might result in increased numbers waiting between three and nine months which with the publicly available material is what we has happened up to October last year but Martin Connor, the SDU special advisor said it was ‘achievable, although ambitious and a stretch to achieve’.

These targets, although unambitious, if achieved are good news for people. Yet we know the longest waits for people is often the wait to see a specialist in the first place (referral from GP to initial appointment with a hospital consultant, which is know as the outpatient waiting list – but despite the promise there was no target set for this.

There are problems with accurate outpatient waiting numbers and times. The SDU are working on this and committed that by the  end of March we will get information on numbers waiting and how long and then they will set a target. Because this is the real bottle neck in the Irish health system, this target will be most important.

Here’s hoping the minister/SDU’s targets are reached… Reason for ‘cautious optimism’ perhaps?

Under legislation, the HSE has 3 weeks to submit a plan to government after the budget, the minister then has 3 weeks to approve it. In the past, this was done with some amendments usually in the form of a letter to the Chair of the HSE board.

It is usual for the HSE to work closely with the Department of Health in developing the plan so that it reflects government policy. And this year, the co-operation was more intense as the HSE is in the process of being abolished and the Department of Health makes up half of the HSE interim board.  The Secretary General of the Dept of Health is now chairman of the HSE Interim board.

Since it was submitted on 22 December and the HSE has been negotiating/amending it with greater ministerial and departmental involvement. So there were no surprises  in it, so why is the minister is rejecting it?

As Sean O’Rourke said on the News at One, it is like ‘Sinn Fein/IRA in the old days’ or as Fergal Bowers said it’s like ‘sending a letter to yourself to complain about yourself’.

In my opinion the Minister’s media outings were a damage limitation exercise. His appearance on the Pat Kenny show was to take the heat out of the badly announced increase in health insurance levy. James Reilly did very well on Pat Kenny Show but it should not have come to that if better managed.

His lunchtime exclusive interview was pure optics, softening up the public to the imminent cuts and an effort to distant the minister from the cuts he will oversee.

The minister made the point that he wanted was the same amount of services for less money. The problem with that is that the HSE has been doing that year on year, since 2007, providing more services with less money and fewer staff, yet we have a growing ageing sicker population.

About €2 billion was taken out of the health system since 2010, and there are 5,000  fewer staff than there were in December 2009.

And there are 3,200 more staff expected to come out of the health system before the February deadline. When the government announced the public sector pay cuts they gave public servants until February 2012 to retire early, without their lump sum being taxed and with their pension at pre cut rates – a significant carrot.

Counter intuitively the fewer who go the more beneficial it is for the HSE in 2012 as they will pay out less in the lump sums and have more staff to provide essential services.

Also in the Fergal Bowers’ interview on the News at One, the minister said after discussion with the minister Howlin, he had negotiated health cuts down from €868 to €650 million. My understanding is that budget 2012 announced €550 cuts to health but €300 million was unaccounted for eg increments, new VAT rate and over runs from 2011 were not included. But there is no new money for the health system, what the minister might have negotiated is that if number who leave in 2012 is lower than 3,200 then the HSE get to keep €97 million allocated for lump sums.

Staffing costs are a majority of the health budget usually 50-60% of the budget and in some cases 90%. New information on staff pay was released in PQ on 24 December showing that 40% of HSE staff earn less than €40k, 75% earn less than €60k therefore 25% earn more than €60k. These same figures also show that 4.26% of HSE staff earn €160-200k!

So choices are being made about what to cut and where in the Service Plan without even considering high pay. And that’s where differences emerge between the minister’s with James Reilly doing a u turn on his pre election promise not to cut consultants pay.

James Reilly was very clear pre election that he wanted to cut consultants pay, then went to IHCA annual conference and said  Croke park was the way to go – yet an opinion piece in the Irish Times on 4 January 2012 by Roisin Shortall on health reform, she stressed the importance of on lowering the cost base of health care,  of more primary care, of providing care at the lowest level of complexity, of managing chronic diseases in the community and crucially of ‘bringing payments for hospital doctors in line with Europe’. This last sentence reads to me as cutting consultants’ pay.

So the minister is sending the plan back to himself for redrafting and we will know the final detail on Jan 13^th and then there is a promise to review in March when the impact of the early retirements are known…

All will be revealed next week. Really it is not a matter of whether to cut but where and how much… Yesterday’s rejection of the plan was mere window dressing and a poor attempt to distance himself for the cuts he has no choice but to oversee.

My hope is to post a weekly audio of my radio slot and or blog the content, so am starting with this weeks.

My main excuse is that I am hoping to complete my PhD by June 2012 and therefore I have to stay focussed on that and I hope by declaring my deadline publicly it will keep me on target.

My weekly blog will be light relief from my PhD! here’s hoping….

Quite simply we don’t know yet and the detail of the legislation will determine that but lets look at its origins –  the EU/IMF Programme for National Recovery where it says ‘all restrictions on appropriately trained GPs who wish to hold General Medical Scheme (GMS) contracts will be abolished’. This sentence on page 33 is contained in the section on professional services which acknowledges that the costs of many professional services have come down but highlights a few specific areas – legal, insurance and GP’s – where costs have not come down. The Competition Authority have also called for such a measure to increase competitiveness in this sector.

Their aim is to drive down the costs of GP care through more open competition between GPs, which in turn should make GPs more accessible. However, the rules of the market do not always apply to health/GP care and particularly in this context where the vast majority of GPs incomes come from their medical card patients, ie the majority of their income does not come from the private free market but from annually guaranteed public money.

We do not know exactly how much of GPs income comes from their medical card patients because GP’s are self employed contractors. There are about 2,600 of them practicing in the country (although no one could give me a definitive number) and 80% of these have GMS patients and were paid about €477 million last year for treating them. They are paid through capitation which works out on average at €240 per person per year but it varies enormously depending on age, distance from GP etc. GP’s also get paid for vaccines, baby checks etc.. but much of what they earn is direct income as it  goes to pay for nurses, premises, equipment. Estimates of average GP incomes are hard to get but average income  is guesstimated at €120,000 a year..

To get ‘free’ GP care, if you are a medical card holder, once you get your card, you get a list of GPs in your area and you can choose which one you want and then you have to get the GP to accept you. You hear about people being unable to get on a GP list as they are closed although both GPs and HSE say today that this is no longer the case except in Kildare.

And there are increased numbers of unemployed and lower incomes, more people are eligible for medical cards so there is a greater demand to get on a GMS list. In June there were 1,680,534 people covered by medical cards – an additional 121,757 since June 2010. When you include GP visit cards, over 39% of population is now covered to go to their GP without paying.

The main obstacle currently in place is for newly qualified GP’s to get a GMS list – either have to apply to the HSE for a list that comes up when someone has retired, which is advertised or join a practice, so it’s a long and insecure route in.. And GMS lists are a majority of most GP’s income so they are crucial.

The press release from the Minister says the HSE ‘can enter into a contract with any suitable qualified GP’ not just those on the list so this might take some of the uncertainty away for newly qualified GPs.

And getting on the ladder of a GP career is particularly a female issue. There is a general feminisation of medical care – currently 40% of GPs are women but 80% of those in training are female .

So is there any chance this move will drive down costs for private patients? This is still unclear. We know from international and national experience that the ‘market’ in health care can lead to over investigation and over referral to hospital care.

Also providers, in this instance GPs, may migrate to richer, more profitable areas as happens now so there’s a real problem in that rural areas and certain urban deprived areas which are under provided. So there is a risk that increased competition or less regulation would make that worse not better.

THis issue could be dealt with in legislation but it never has been up to now. The contract currently in place was agreed in 1989 and health care has changed a lot since then. Minister Reilly has spoken publicly about introducing a new GP contract, about incentivising GPs to treat chronic diseases etc but speaking to an IMO rep he says they have not begun discussions with the minister on this although he is now six months in place.

Finally the programme for government promises free GP care for all by 2016 and the first to get a bite of this will be those on the long term illness scheme – who are due to get free GP care within the first year of government. A spokesman for the government said these plans are on track – although GP’s say they have not heard a word about this. Presumably this requires extra payment to GP’s – interesting to see where this comes from, I will watch with interest…

In reality, this means older people are inappropriately waiting for that bed at home or in a hospital bed. A situation that has been brought to my attention is a woman in her 80′s who fell at home five months ago. She was brought to one of the city’s main Emergency Departments and eventually got a bed, where she took quite a while to recover. But now she has been in hospital for over two months even though she does not clinically need to be there. This woman and her family say she’s getting excellent nursing care in the hospital. The woman has settled in quite well there, her husband and family visit her daily, but she’s on a busy ward, a ward where people are dying or being returned to after serious surgery and it’s just not the appropriate place for her to be.

The family went through the nursing home support scheme application process, were approved, have found a suitable place in a nursing home near her family, have persuaded her to go and now that they’ve got a place and she’s ready to go, she can’t get in… Meanwhile people in the same hospital’s Emergency Department can’t get a bed..

The nursing home support scheme was paused in May when it ran out of money, it was unpaused in June by the Minister and yet it’s grinding to a halt by the end of August. So what’s going on?

The Nursing Home Support Scheme has run out of money less than two years in operation, this was always inevitable with the scheme’s faulty design of a limited budget and yet there is unlimited need. We have a growing, ageing, sicker population, with poor community services, where demand for residential places exceed supply. The bottom line is that it was badly designed and it is just not sufficiently funded

The waiting list of 1,100 older people is made up of two sets of people; those in hospitals beds (offensively known as bed blockers, officially known as delayed discharges) and those in the community. According to the HSE there are 800 delayed discharges, so about 300 others are waiting for their nursing home bed in their own homes. And the HSE said that they are being approved for funding purely on a chronological basis. Basically to get a place at the moment, someone has to move out of one, so those waiting are waiting for others to die.

The 1st September uncoincidently also witnessed unprecedented seasonal highs for the numbers waiting on trolleys in Emergency Departments. According to INO figures, now the official ones, measured at 8am each day, there were 389 waiting on trolleys, an exceptionally high figure for this time of year. The hospitals with the worst situations were

• 48 people on trolleys in Galway
• 21 in Wexford
• 35 Beaumont
• 31 in Vincent’s
• 27 in Beaumont
• 24 in the Mater .

And there is a direct relationship between the waiting list for the Nursing Home Support Scheme, 800 delayed discharges and trolley queues in Emergency Departments.

The scheme as controversially suspended in May when it ran out of money, so what has happened since May to people applying for the nursing home scheme? A new more cumbersome administrative process is in place, operating through 18 offices around the country (why not four or 32 matching the regions or local health offices, I don’t know).  The application process takes much longer before people could reasonable expect to be processed in six weeks, now its double that.

Also the system has been playing catch up, since it was unpaused, 1,750 have been approved for funding and are in now nursing homes.

An additional €15 million has been made available, although €30 million was promised. And the numbers in nursing homes under various schemes has remained static. In May 2011, there were 22,277. On 1 September the figure given was 22,300, not much of an increase given the growing demand of an ageing population and a waiting list of 1,100.

Also, it just does not make sense to have 800 people in hospital beds which cost between five and ten times the amount it costs to keep someone in a nursing home bed when the health budget is under more pressure than ever before. And even though the HSE hospital and community budget has been merged, but there is still a different pot of money for nursing home care – so there is still no incentive in the system for moving someone out of a hospital bed that costs €5000 a week into in a nursing home bed that costs €1000. That’s a real problem and given that the nursing home support scheme is an example money follows the patients, it’s not proving a great example.

Minister Reilly has invested a lot of political capital in this scheme, but he was unavailable for comment on it. In response to questions put in on the extensive waiting list the Department of Health said that “any delays will be resolved in the final quarter in 2011”.

This is a very ambitious statement given the increasing queues to get in to nursing homes, the growing, ageing population, with more people looking for more services.

The new much heralded Special Delivery Unit in the Department of Health under the stewardship of Martin Connor is meant to get up and running next week. The back log of people trying to get into hospital and nursing homes combined with an ever declining HSE budget, less staff and closure of hospital beds, wards and services mean that the Minister’s commitment to rid Emergency Departments of trolleys and reduce waiting lists for elective treatment means James Reilly and his special delivery unit have a very challenging winter ahead…

The new board is made up of the most senior officials in the HSE and the Department of Health, its secretary general, Michael Scanlon, the Chief Medical Officer, Tony Hollohan, the HSE chief Cathal McGee and other HSE national directors. They have been meeting every two weeks since forming in May and  some of the figures presented to them on 28 July give a very stark insight in to where we are now and the challenges ahead.

The HSE annual budget for 2011 is €12.35 billion, so you’d expect half of that spent by end of last month and figures presented to the board show a €208 million over spend of which €124 million is hospital budgets, senior sources say they is no reason to believe that the situation has improved since the end of June.

So over half of the over spend comes from hospital budgets and some hospitals such as Limerick regional have particularly high over spends – between 20-30%. Other hospitals in the west and northwest overspending by about 10% include Mallow, Letterkenny, Roscommon, Portunicla.

In the North East, Cavan and Drogheda have an over spend of about 10%, in Dublin, Tallaght and Blanchardstown have over spent by about 10%, while Monaghan hospital is the highest over spender at 36%.

The INMO released a statement on the day of the HSE board meeting (28 July 2011) about cuts to the budget for agency staff in Blanchardstown and Monaghan hospitals by 37%.

The overspend in hospitals and cuts to agency budgets are directly related. Agency budgets are one of the only aspects of hospital spend that can be cut without much notice.  The use of agency nurses, doctors and other professionals is a direct result of the blunt instrument that is the HSE moratorium. In absence of being able to hire new people, frontline services use more expensive agency staff to plug the gaps.

And although there are over 2,500 fewer HSE staff now compared to December 2010, and the HSE is well below its staff ceiling, pay costs have not gone down, there are a few explanations for this

• those who left in redundancy programme in December 2010 were mostly lower paid administrative and support staff
• they are being replaced by muich needed but higher paid therapists and consultants
• while there has been a cut in rate paid to agencies and a cut in numbers of agency nurses, agency doctors are up by 33% and healthcare assistants by 17% compared to this time last year.

These budgetary overspends and staffing constraints provide a very real dilemma for the HSE board and the new minister, particularly as other figures presented to the board show increased waits for elective procedures in both adults and children, increased emergency department presentations and admissions, under 50% of those needing a hospital bed getting it within the six hours of arrival at an Emergency Department, increased use of out of hours GP services, more inpatients and day cases than expected, increased numbers of delayed discharges – back up to 800 in June.

And although it’s become the norm for wards to be closed and services restricted during summer months as a way of cost saving, people can expect to see more of that. There are plans for extended ‘seasonal closures’, inevitably this will result in more people waiting longer, which has more expensive costs both in human and financial terms.

There is also an issue with this in terms of priorities that minister Reilly set himself – ‘never again seeing 590 trolleys in Emergency Departments’, reducing waiting times, improving quality of care, not to mention free GP care by 2016 and the introduction of universal health insurance. As a central pillar to deliver these, Minister Reilly set up the new Special Delivery Unit (SDU) in the Department of Health, headed up by Dr Martin Connor.

But if the HSE is responsible for reining in the budget and it is and the SDU is responsible for getting rid of trolley and long waits – there are an inherent contradictions between these roles and it will be interesting to see who wins out. For much of that we will have to wait til Autumn/Winter 2011 to see but what can we tell from Reilly’s first term in office ?

If we take the high profile issues that have occupied much of his first four months – the decision to locate the children’s hospital on the Mater site has got the go ahead which might not have been expected and shows decisiveness; the suspension of the Fair Deal scheme seemed an unnecessary own goal early on in his tenure; the management and communication of Roscommon hospital was a real blunder and while Minister Reilly can provide real leadership in this area, he needs to do it with greater clarity and consistency and working with the HSE and other health professionals as well as local communities and politicians; Minister Reilly has spoken very publicly about renegotiating GP and consultants contract and paying them less and yet consultants were excluded for the 15% voluntary pay waiver announced by Minister Howlin on 22 June 2011 for all public servants earning over €150,000 – there needs to be more consistency and better results in areas such as these.

I still don’t understand how Minister Reilly and the government can commit to provide more and better services to more, older, sicker people, free at the point of delivery with fewer staff and less money particularly when we have no control over our overall finances…

It is impossible to get a figure from the HSE as to how many people on its payroll of just under 106,000 staff earn over €200,000, an extraordinary fact in itself. It is some what explained by the fact that there are still 17 different pay roll systems in the HSE but also that many of these 106,000 are not direct staff of the HSE but people who work for voluntary hospitals or large voluntary agencies. Why on earth seven years into its existence the HSE has not managed to merge the pay roll systems remains an unanswered question.

However, it would appear that not very many of the 106,000 workforce earn more than €200,000 from the public purse. Lets start outside of the HSE with the Minister, as a result of various different pay cuts, he now has a salary of €169,000.

Michael Scanlon, the secretary-general in health, as a result of the most recent voluntary cut (on top of the previous pay cuts) is now paid €200,000 exactly, although he will still get his pension at his previous rate – see article linked to earlier. And according to the Department of Health no one else in the department or in any of the agencies directly funded by them is paid over €200,000.

HSE chief Cathal McGee  took up post last year with a €322,000 basic salary, with no bonus, but a car allowance of €13,800. Yesterday, he confirmed he was happy to take the 15% voluntary reduction which leaves him with a salary  of €280,000, signficantly above that of the minister. According to the HSE none of the National Directors earn over €200k ( the highest band starts at €183k).

And again according the the HSE, most consultants don’t earn over €200k FROM THEIR PUBLIC WORK – an important distinction as many earn significantly more than this when their public and private earnings are combined. Pay for consultants on type A contract on which they can only work in the public system ranges €176-196,000, while those on Type B who are allowed to work privately their sarlaries start between €146-158,000 however they  can earn multiples of that from their private work – see below.

Contract

Tracey Cooper, HIQA CEO, earns around  €170-180k. The CEOs of the voluntary hospitals earn less than €200,000 from the public purse according to the pay scales but some receive top up payments from the ‘research fund’ of their hospital.

Jimmy Tolan – the current VHI CEO, is the super high net earner in the health sector – his “total remuneration including pension paid to CEO to December 2010 amounted to a salary of €411,420 and performance related pay of €37,500”. That means he was paid the bones of €450,000 last year. He opted out of a bonus for 2011 (all semi state CEOs were asked to by government). When asked was he taking 15% waiver, I was told he already has taken a 40% pay cut from his original package worth €665,320 including pension and bonuses – he resigned in May but is in post til November. His salary is a multiple of the current minister. Figures published by PER yesterday say the starting salary of the new CEO to be recruited to replace Tolan will be €191k, a fraction of its predecessor’s.

So why is it so hard to know how much hospital consultants earn? 70% of those who work in the public system are allowed to work privately – with a cap of 20-30% of their workload although a minority far exceed that ratio. And while it is hard to get actual figures on their public salaries, it’s impossible to get definitive figures on their private incomes.

HSE figures released for this article say that “27 non academic hospital consultants earn more than €250K”, these are often clinical directors who maybe towards end of career, so they get an additional €50k for the clinical director post and would usually be on quite a high salary scale due to years of service.

The HSE could not give a figure for the numbers of consultants paid more than €200k. Many of the academic posts eg a professor in a university and a consultant could earn over €200k but it might be €180K from HSE and however more from the university.

Incredibly, the consultants earning over €200,000 are not included in the 15% voluntary waiver introduced this week. James Reilly spokesperson said the matter was “still being brought to cabinet table” and “still in discussion as part of Croke Park”. The response from the Dept of Public Expenditure and Reform was similar but different, “The same objectives are being pursued by minister Reilly in relation to hospital consultants through a separate process which is ongoing”.

But there was general consternation that consultants were not included in the waiver as they are the highest earners in the health sector. And rumour abounded that the Minister had been lobbied by consultants to that effect. There was a rare and surprising silence from bodies representing the consultants on this issue.

So can we estimate consultants’ total income – their public and private earnings? No one has those figures except Revenue but in order to get a ballpark figure for Type B contracts who are allowed to practice publicly and privately, one would need to add up their public salary, money paid to them by insurance companies and money paid directly to consultants by people out of pocket for private care. And there is no way of collating that.

When asked how much they paid to conultants, the VHI said it was commerically sensitve and released a statement on this saying that ‘We pay fees to over 2,300 consultant of which the average payout in 2010 was approximately €98,000 per consultant . 70% of consultants were paid less than €100,000 and 6% (138) paid more than  €300,000. But that does not include their public income nor what they get from other insurance incomes plus money paid out of pocket and other earnings eg evidence in legal cases etc..

And earlier in the week news broke that some of these consultants who work privately and publicly are in trouble with the HSE for far exceeding their private workload as agreed in their contract.

The background to this is that a new hospital consultant contract was agreed in 2008 and is in place since 2009. Under this contract for the first time consultants are measured for public and private work. For the last two years, the HSE has been working with consultants carrying out  more than 50% private work to reduce it, to verify the measurement tool and if not reduced the HSE issued a fine to these consultants.

Now, it is the end of the long two year process and this week 17 letters have been issued telling the worst offenders that as of 16 September that “their private practice will be suspended with effect of that date (16 Sept) and we will withdraw the clinical indemnity provided in respect of your private practice”.

And although those numbers exceeding the 20/30% private practice is not widespread, it is extremely significant that the HSE is taking them on in an attempt to level the playing field for public patients. We do not know much about who they are, what type of specialities, where they are except that many are in Limerick and Cork.

The IHCA on behalf of the consultants reject the HSE measurement  of their public and private work, several attempts were made to contact both consultants’ representative bodies (IHCA and the IMO) today and their silence is deafening.

Many people, like the highly thought of geriatrician Des O’Neill, advocacy groups working with older people and I, made this point since the scheme was announced. If you have a limited budget and infinite demand or need then inevitably you are going to run in to trouble and out of money – do the sums – there are approximately 30,000 nursing homes beds with an average cost of €50,000 a year – this adds up to 1.5 billion but the budget is less than €1.01 billion…

But this has not just come out of nowhere, the HSE flagged it in their January and February 2011 HSE PR report. It is unclear from the ministerial briefings released under FOI how much the Minister was aware of this as most of the relevant section is blacked out.

It is not surprising that there is a shortage of money for the scheme, given the declining health budget for this and all other aspects of the health services. When asked for an explanation as to why this is happening now and how it was not foreseen, Minister Reilly and HSE are saying there is a rapid increase in demand for Fair Deal places and the escalating costs of care.

However, no one currently in nursing home care need to worry – nothing will change for them – but for those who are applying it is a problem. The HSE say people should continue to apply, they will be processed but not cleared unless vacancies arise.

The most recent figures show 22,930 people at end of April were covered by Fair Deal – which according to the HSE means its budget is at its ceiling of €1.01 billion. Figures for  March show 900 new applicants, yet only 330 leaving system that means there’s a shortfall of 570. These figures also show a significant increase between December and March with 660 new applicants in December and 900 in March.

As well as the official explanation of increased demand and costs, other factors influencing this funding crisis are the ageing population, our inadequate primary and community care services and according to official sources ‘the scheme is a victim of its own success’. Speaking on 19 May 2011, Minister Reilly said ‘demand outstripped expectation’ however all predictions of population need for residential care would show that as the current system is structured and operates demand will inevitably outstrip supply.

So what happens now? Minister Reilly says he busy banging heads together, that he wants to understand why this situation has occurred but really he has few options and none of them are good. These include: a supplementary budget, although there is no money for a supplementary budget; taking money from elsewhere which is difficult as everywhere is short of money; or else starting a waiting list which in effect is the rationing of residential care for those in need of it.

As the situation stands, people will only get places as existing places are freed up. This will mean more older people will be kept in hospital (often referred to as bed blockers as they don’t need to be there).  This in turn will cause even greater delays in Emergency Departments and even more cancellations of planned surgery and treatment for public patients. This is close to the worst possible news Reilly could get nine weeks into office.

In the long term, this funding crisis highlights the need for a debate about who gets and who pays for what services. Given that the government is committed to universal coverage, its hard to see how this can be delivered in the current environment. Possible solutions lie in better access to home care services, those who can afford to pay more through taxes or co-payments, and or having fewer people in residential care. In Ireland the average length of stay in residential care is four years on average, in the USA it is one year – the best is probably somewhere in between but none of these solutions come quickly or without cost. This is perhaps the first landmine for the new health minister in the department known to be like Angola.