Tuesday, 27 January 2004

Questions (14)

Liz McManus


136 Ms McManus asked the Minister for Health and Children if he has carried out or received any assessment of the casemix system that he is applying to hospitals, which is penalising patients awaiting treatment and causing further cuts in the budgets of certain hospitals, especially in the greater Dublin area where there are already severe problems; and if he will make a statement on the matter. [2104/04]

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Oral answers (9 contributions) (Question to Minister for Health and Children)

The casemix budget model is an internationally developed system, in use since the 1980s and at present used in most developed countries for health funding. As was stated in the health strategy "... the most developed system for assessing comparative efficiency and for creating incentives for good performance is Casemix." The casemix model is considered to be the only model capable of dealing with the complexities of resource allocation within the hospital services. Every year major improvements to the system are developed with the assistance of all the hospitals involved and in response to their needs and changing clinical practice. A comprehensive review of the national casemix programme has been carried out by the casemix unit of my Department. This review has taken place in an open and inclusive manner and included consultation with all the stakeholders in the process, including hospital managers and clinicians.

The intention of the review was to ensure that the system is fair, accurate and robust enough to incorporate all the strategic developments being proposed in the medium term. A report on the matter is being prepared at present which will make recommendations for the enhancement of the model. This will result in Ireland having one of the most advanced casemix systems in the world, while still being an "Irish" system for Irish patients.

On the matter of casemix penalising patients awaiting treatment, casemix has resulted in more rather than fewer patients being treated year on year. In the period 1999 to 2001, for example, where direct comparison is available, the numbers treated as in-patients and day cases in casemix hospitals rose by 72,829. With regard to some Dublin hospitals losing funding, many of the hospitals that lost some funding under the programme this year gained significant funding in other years. The Adelaide and Meath Hospitals incorporating the National Children's Hospital, Tallaght, for example, lost funding last year but gained this year. The Mater hospital gained funding this year yet lost funding last year.

The rationale for the use of casemix systems as part of the budgetary process is the wish to base funding on measured costs and activity, rather than on less objective systems of resource allocation, and to fund hospitals based on their "mix" of cases. In other words, a hospital should be funded for the patients they treat. The programme is operated in an open and transparent fashion and full details of the clinical and financial information on which casemix budget adjustments are based is provided to all participating hospitals.

Nobody argues with the aim of making hospitals efficient. However, does the Minister accept that the current casemix system does not provide an accurate gauge whereby it can be ensured that more problems are not created for hospitals under pressure, especially in the Dublin area? The result of the Minister's approach in the east coast area has been penal. More than €2 million has been taken away from two key hospitals, St. Vincent's Hospital and St. Columcille's Hospital in Loughlinstown. That must impact on patient care.

Does the Minister acknowledge that it is not a case of inefficiency in these hospitals but that a high number of elderly patients are blocking beds because there are insufficient rehabilitation units? That is a direct result of the Minister's failure to provide such beds. Does he also acknowledge that these hospitals have complied with the appropriate public private balance of 80% and 20%? Other hospitals have disregarded that balance and have catered more for private patients who do not stay in hospital as long as public patients. They are usually not as sick or as old as public patients. The Minister may be rewarding hospitals which care more for private patients than for public patients and which provide for acute cases in accident and emergency departments because they do not have reserve beds.

I know this is technical, but perhaps the Minister would recognise that the result of what he has done is to penalise hospitals which are already under pressure. Approximately 2,400 patients are waiting for care in St. Vincent's Hospital. It is a major hospital which deals with cancer patients and is subject to huge demand from patients in the locality and its catchment area. It is also a tertiary hospital, yet it is taking a hit of more than €1.2 million. That must be absorbed within the hospital and, inevitably, will impact on patient care.

I am glad the Minister is carrying out the review, which I welcome. He must also carry out an equally forensic survey of the impact of this approach. What evidence is there that benefits accrue to patients when hospitals are rewarded? The Minister is rewarding Letterkenny General Hospital, for example, which is great for it. However, that is not of comfort to the thousands of people trying to access services in St. Vincent's Hospital. A young woman I met through my clinic needs a colostomy reversal operation and cannot get into St. Vincent's Hospital because there are no beds. She was told she had to have the operation within a year. It is now the last month of that year and there is no sign that she will receive the necessary treatment. By fining St. Vincent's Hospital, the Minister is ensuring that there is less chance of such patients' needs being met quickly.

As regards the review, I urge the Minister to examine the context in which these hospitals operate and how they ensure that public patients are treated fairly, unlike many other hospitals which are being rewarded under the casemix system.

I reject the attempts to personalise the casemix process as "his approach", that is, the Minister's approach. It has been the approach of successive Governments and is an internationally accepted model. I cannot claim credit for inventing the casemix model.

The Minister should claim responsibility.

Order, please. The time is up and we must move on to the next question.

The Minister should not walk away from it.

I am not. We must be fair in our assessment and in terms of informing the public as to how this happened. I have often been lectured in the House and people have correctly commented about the need to be vigilant in maintaining value for money. This is probably the one model which attempts to achieve a value for money efficiency approach to the organisation of acute hospital activity.

As regards the Deputy's point about length of stay, the hospitals are not penalised for excessive length of stay and are not given credit for quick patient turnover. It is about the cost per case for the same case across hospitals. The costs are higher for the same type of case in some hospitals compared with others. Hospitals can make submissions. Accident and emergency departments place a significant degree of pressure on certain hospitals compared with others. These factors can be taken into account in the casemix model.

There is a need to modernise and enhance the model because there has been a comprehensive review of it. However, we have also examined other models, especially the Australian model, with a view to adapting them to the Irish situation. A report has almost been completed and submitted to the Secretary General of the Department. I have not seen the full report yet but, when I do, it will be sent to the Government for decision.

The argument that we are reducing patients' chances does not stand up. Additional patients are treated year on year in many hospitals under the casemix model. Using comparable figures, there was an increase of 72,000 patients for the years 1999 to 2001. There has been an ongoing increase in patient numbers year on year.

May I ask a further question?

We are well over the time. I must call Question No. 137.