Delivered by Prof Frances Ruane, Chairperson of the Expert Group on Resource Allocation in the Health Sector, Executive Director of the ESRI at the IPHA Annual Meeting 2010.

1. 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

2. Outline of Presentation
 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

3. Better health through better health
services
 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?
 Perspective: clinical, managerial, economic, administrative

4. Achieving these objectives
Sustainability

5. Achieving these objectives
Stated Policy Objectives
Service Delivery Systems Financing Methods

6. Achieving these objectives
Stated Policy Objectives
Service Delivery Systems Financing Methods

7. Expert Group Methodology
 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

8. Integrated Care
Equity &
Fairness
Population
Health Needs
Allocation
Funding &
Financial
Incentives
Public & Private
Involvement
Key Elements
in System

9. Integrated Care
Equity
& Fairness
PopulationHealth
Needs Allocation
Funding
& Financial Incentives
Public & Private
Involvement
Integrated
Health Care
System
Integration is
essential

10. Current Systemic Failures [1]
 Planning Vacuum
 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
 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

11. Current Systemic Failures [2]
 Financing
 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
 GP contract is totally inappropriate
 Pharmacy / GP charges are comparatively high
 Prescription rates have risen dramatically
 Little use of techniques to improve sustainability

12. What are the Guiding Principles? [1]
 Money should follow need not history
 Policy and entitlements should be set nationally,
and delivered locally
 We should fund activity not organisations
 We should support integrated, safe, cost-
effective sustainable care in the best settings –
focus on Chronic Disease requires integrated
system.

13. Primary Care Acute Hospital
Care
Community and
Continuing
Care
Is this the current system?

14. Primary Care
Acute Hospital
Care
Community
and
Continuing
Care
This is what we have!

15. Institutional Care
Care in
Home Settings
This is what we also have!

16. This is
what
we need!

17. What are the Guiding Principles? [2]
 Financial incentives should:
a) encourage providers to meet priorities and quality
standards set in policy at minimum cost
b) encourage users to use the appropriate services
 People should pay according to their incomes
and have access according to their needs
 Arrangements should be sustainable.

18. Resource Allocation Recommendations:
Systems
 Strengthen planning frameworks / processes
 Distribute resources based on real population need
 Deliver locally within national frameworks and
strengthened management – not => health boards!
 Pay providers for what they deliver at (case-mix
adjusted) prices that reflect efficient delivery.

19. Resource Allocation Recommendations:
Delivery
 Strengthen clinical protocols to manage major
diseases fairly and efficiently
 Develop and strengthen primary/community
services and shift services from hospitals to
community where appropriate
 Guarantee rights to timely care – NTPF approach to
apply to all HSE funding – phase out current NTPF
role on waiting lists.

20. 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

21. Sustainability Recommendations
 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

22. Relevance of the Report to Pharma Sector
 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

23. Specific Recommendations [1]
 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

24. Specific Recommendations [2]
 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

26. Appendix

27. What will change for C&C* Care
 Before
 ~ Historic budgets
 Uneven resources
 Weak infrastructure
 Weak links to HC*/PC*
 Overlap of purchasers
and providers
 After
 Prospective funding
 Pop. health budgets
 Improved infrastructure
 Systemic links to HC/PC
 Move to separate
purchasers/providers
*C&C = Community and Continuing Care; HC = Hospital Care; PC = Primary Care

28. What will change for the DoHC?
Before
 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
 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

29. What will change for the HSE?
Before
 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
 Planned move to
purchaser/provider split
 Integrated budgeting for all
sectors
 Integrated leadership
across resource allocation,
management and clinical
standards
 Guaranteed waiting times
*PCCC = Primary, Continuing and Community Care:

30. What will change for Hospitals?
Before
 Mostly Block Grant
 Inefficiency unknown
 Budgets supporting silo
work practices
 Large barriers between
hospitals and other care
settings
After
 Prospective funding
 Efficiency rewarded
 Budgets promoting team-
based approach
 Resources linking
hospitals and other care
settings

31. What will change for the Patient?
Before
 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
 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