Transcript Report of the Expert Group on Resource Allocation and

Improving Resource Allocation in
the Irish Health Sector –
Some New Insights
Presentation to IPHA Conference on
Enterprise and Health Solutions for
Irish Patients and the Irish Economy
25 November 2010
Frances Ruane, ESRI
Outline of Presentation
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Context: Expert Group Report which sought to
develop resource allocation and financing
systems that support better health and better
health services
Approach of the Expert Group
Characterisation of the Systemic Issues
Today’s system failures
Guiding Principles for the future
Key Recommendations
Better health through better health
services
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Focus on health and wellbeing requires
The right services delivered by the right skills and facilities
in the right places
Fairness, equity and focus on greatest needs
Sustainable and efficient
Joined up and fit for purpose
All of these are stated objectives of Irish health policy
How do we do better at achieving them?
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Perspective: clinical, managerial, economic, administrative
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Achieving these objectives
Sustainability
Achieving these objectives
Stated Policy Objectives
Service Delivery Systems
Financing Methods
Achieving these objectives
Stated Policy Objectives
Service Delivery Systems
Financing Methods
Expert Group Methodology
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Gathered international* evidence on best
practice and sought local submissions
Focus on integrated care: chronic disease
Analysed stated health policy in Ireland
Derived Guiding Principles
Compared current arrangements with Guiding
Principles to identify failures systematically
Systemic Approach: Aim to change how
things work so that individuals are supported
Key Elements
Integrated Care
in System
Public & Private
Involvement
Funding &
Financial
Incentives
Equity &
Fairness
Population
Health Needs
Allocation
Integration is
essential
Public & Private
Involvement
Integrated Care
Integrated
Health Care
System
Funding
& Financial Incentives
Equity
& Fairness
Population Health
Needs Allocation
Current Systemic Failures [1]
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Planning Vacuum
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No integration of capital/current expenditure
No whole system analysis [public/private]
No rational basis for national planning
Focus on fiscal rather than total health cost
Incentives out of line with stated objectives
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Incentives to use hospital care
No rewards for improvements in efficiency/safety
No governance structures / budgeting processes to
locate service delivery in the appropriate setting
Current Systemic Failures [2]
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Financing
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Unregulated GPs [fees/quality] for majority
Access to care overly related to ability to pay
Widespread anomalies in what/who is covered
Continuing issues with consultant contract
Sustainability
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GP contract is totally inappropriate
Pharmacy / GP charges are comparatively high
Prescription rates have risen dramatically
Little use of techniques to improve sustainability
What are the Guiding Principles? [1]
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Money should follow need not history
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Policy and entitlements should be set nationally,
and delivered locally
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We should fund activity not organisations
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We should support integrated, safe, costeffective sustainable care in the best settings –
focus on Chronic Disease requires integrated
system.
Is this the current system?
Primary Care
Acute Hospital
Care
Community and
Continuing
Care
This is what we have!
Primary Care
Acute Hospital
Care
Community
and
Continuing
Care
This is what we also have!
Institutional Care
Care in
Home Settings
This is
what
we need!
What are the Guiding Principles? [2]
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Financial incentives should:
a)
b)
encourage providers to meet priorities and quality
standards set in policy at minimum cost
encourage users to use the appropriate services
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People should pay according to their incomes and
have access according to their needs
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Arrangements should be sustainable.
Resource Allocation Recommendations:
Systems
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Strengthen planning frameworks / processes
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Distribute resources based on real population need
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Deliver locally within national frameworks and
strengthened management – not => health boards!
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Pay providers for what they deliver at (case-mix
adjusted) prices that reflect efficient delivery.
Resource Allocation Recommendations:
Delivery
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Strengthen clinical protocols to manage major
diseases fairly and efficiently
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Develop and strengthen primary/community
services and shift services from hospitals to
community where appropriate
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Guarantee rights to timely care – NTPF approach to
apply to all HSE funding – phase out current NTPF
role on waiting lists.
Financing Recommendations
 Less
pay as you go, more prepaid
 Fairer
and clearer entitlements
 Increase
transparency of flows to providers
 Replace
tax reliefs on medical expenses and private
insurance with more targeted subsidies*
 Lower
and fairer user fees for GP services and
drugs, based on income and health status
Sustainability Recommendations
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Measures to improve information
More fit-for-purpose contracts
More evaluation of drugs and treatments
Improved cost control
Better regulation and performance management
Better capital planning.
Major changes for: DoHC, HSE, Hospital Care,
Primary Care, Community & Continuing Care
Relevance of the Report to Pharma Sector
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Focus on Health and Health care
Focus on moving to new models of care
Focus on Chronic Disease Management – and
making sure that resources support it
Focus on care provision outside institutions
Focus on value for money and efficiency linked to
high standards [clinical protocols]
Focus on sustainability – keeping down unit costs
Specific recommendations
Specific Recommendations [1]
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Evaluation of all high-cost, high-use drugs on
the current GMS/DP lists, based on Irish costs
and international experience of their outcomes
HSE and DoHC engage immediately in the
development of official guidelines and clinical
protocols on the use of new technologies
Develop reference pricing
Review choice of comparator countries used for
setting ex-factory price of pharmaceuticals
Extend tendering for sole supply contracts for
additional pharmaceutical products
Specific Recommendations [2]
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Establish treatment and prescribing protocols that
promote the use of generics
Introduce regulations to mandate that all prescriptions
for public and private patients must contain the
generics name so the drug prescribed
Introduce regulations to mandate all pharmacists to
dispense the lowest cost version of the drug unless the
patient specifically request a particular brand and is
willing to pay the additional cost
Extend information on generics more widely among
doctors, pharmacists and patients
Appendix
What will change for C&C* Care
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Before
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After
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~ Historic budgets
Uneven resources
Weak infrastructure
Weak links to HC*/PC*
Overlap of purchasers
and providers
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Prospective funding
Pop. health budgets
Improved infrastructure
Systemic links to HC/PC
Move to separate
purchasers/providers
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*C&C = Community and Continuing Care; HC = Hospital Care; PC = Primary Care
What will change for the DoHC?
Before
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Fragmented Policy
Framework
Resource usage policy
oriented towards public
health-care system
Lack of multi-annual
capital/current system
planning
Unclear boundary with
HSE in relation to
resource allocation
After
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Integrated Policy
framework
Resource usage policy
covers total health-care
system
Five-year planning
framework to cover all
health-care spend
Clarity with respect to
resource allocation roles
of DoHC and HSE
What will change for the HSE?
Before
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Integration of HSE roles as
purchaser & provider
Separate budgeting for
hospitals / PCCC*
Separate structures for
resource allocation,
management and clinical
leadership
Targeted waiting times
After
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*PCCC = Primary, Continuing and Community Care:
Planned move to
purchaser/provider split
Integrated budgeting for all
sectors
Integrated leadership
across resource allocation,
management and clinical
standards
Guaranteed waiting times
What will change for Hospitals?
Before
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Mostly Block Grant
Inefficiency unknown
Budgets supporting silo
work practices
Large barriers between
hospitals and other care
settings
After
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Prospective funding
Efficiency rewarded
Budgets promoting teambased approach
Resources linking
hospitals and other care
settings
What will change for the Patient?
Before
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Unplanned eligibility
patterns
GP/Drug payments not
related to incomes and
need / charge rates
unregulated
Fragmented care –
people getting services
they do not need and
lacking those they need.
After
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Clear eligibility related to
need
GP/Drug payments
related to income and
need – tiered medical
card for all
Individual care pathways
– crucial for caring for the
ageing population