Contents Introduction ...... 3 A look into history – Voluntary Care Providers ...... 5 International Precedent and Learning ...... 6 Defining the nature of Volunteerism ...... 12 Distinguishing Characteristics of Voluntary Hospitals ...... 13 National Services Provided by Voluntary Non-Acute Service Providers ...... 17 Developments impacting the future role of Voluntary Healthcare Providers ...... 19 Universal Health Insurance ...... 19 Participation in Hospital Groups ...... 20 Service Level Agreements ...... 21 Emerging Models of Governance ...... 22 Conclusion ...... 25 Scope of Actions ...... 26
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Introduction This paper was commissioned in 2014 by the VHF, whose members believe that it is important for Voluntary organisations to remain a sustainable and dynamic force within Irish healthcare so that they can continue to provide quality care to their service users.
Since the early 18th century Voluntary organisations have played an integral role in the Irish healthcare system, providing care and support to those who need it most in our society. Many were established before the development of a Statutory healthcare system, and were borne out of the evident need to help the sick and the poor.
Today, Voluntary organisations are present in all areas of health and social care including hospitals, maternity, disability, older persons, paediatric, palliative, rehabilitation and community care. These organisations remain as essential today as they were 300 years ago, as the communities in which they serve continue to depend on them for the delivery of vital services.
Throughout the evolution of the Irish healthcare sector, the role of Voluntary organisations has been a topic of interest and debate. This issue has become more pertinent in recent years as the Government undertakes the most ambitious and far reaching reforms of the health sector that have ever been witnessed in the State. The changes within the sector have raised questions about the future of Voluntary organisations and their place within the system.
The move towards not-for-profit Hospital Trusts is one such reform that is evidence of a marked shift in Government policy which, if pursued in a certain fashion, could eliminate diversity of governance structures and participation within the healthcare sector. This move is a cause for concern for many Voluntary stakeholders, particularly as the Government has largely refrained to date from entering direct discussions with the relevant institutions on this important issue.
We feel that the Government should not distance itself from decisions relating to Voluntary participation but that it should engage directly with Voluntary organisations to agree a system-wide approach to facilitating Voluntary participation in the Hospital Group model. In
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response to the current situation, the Voluntary Healthcare Forum has developed this paper.
This paper aims:
To increase awareness of the importance of the Voluntary organisations and a diversity of ownership in the health system To present the case for enhancing the role of Voluntary healthcare organisations To form the basis for engagement and partnership with a wider circle of stakeholders To initiate a structured discussion with funders/policy-makers in relation to securing fair and equitable access and participation for the Voluntary Not-for-Profit sector to and with the DOH and HSE in all matters of mutual concern
We feel it is important to stress that while the establishment of the Hospital Groups and the intended model of governance are the immediate cause for our initiative, it is the totality of the Government’s Reform Programme that is the key driver behind our decision to develop this document and is at the core of our case. Simply put, if enhancing quality, achieving Value for Money and providing equity of access for service users are at the centre of the Government’s Reform Programme, we contend that fixating on a single governance model to deliver on these aims, misses the point entirely.
These outcomes can be achieved and guaranteed in many ways, and not just through a centrally-prescribed governance model. We believe that this includes drawing on valuable learnings and elements from within the Voluntary service providers’ model and applying them to the wider hospital system. This paper includes a set of recommendations which we would encourage stakeholders to consider so that a dialogue on this matter of vital importance can be initiated.
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A look into history – Voluntary Care Providers Voluntary public hospitals have provided the Irish population with essential healthcare services for centuries. From their foundation by philanthropists, doctors, religious orders and active citizens during the 1720s and onwards, they have played a huge role in the progression and improvement of public health in Ireland.
The Irish Voluntary hospital movement can be traced back to the early 18th century with the establishment of a number of institutions by lay philanthropists to alleviate the suffering of the sick and poor. The philanthropists, appalled by the conditions in which the sick were being treated and cared for, began fundraising and developing plans to build and operate hospitals. This development was undertaken mainly in the larger cities, namely Dublin, Cork and Limerick, as the cities had the highest demand for services and greater wealth to leverage for fundraising purposes. Notably, the first Voluntary public hospitals received no funding from the State, but managed to raise funds for capital and running costs through charitable donations, legacies, philanthropic giving, voluntary contributions and public subscriptions.
The lifting of restrictions on the Catholic community in the 19th century saw a number of religious orders establish large healthcare institutions, primarily in Dublin and Cork. For instance, The Sisters of Charity founded St. Vincent’s Hospital in 1834 in Dublin, and The Sisters of Mercy established the Mercy Hospital in Cork in 1857 and the Mater Misericordiae in Dublin in 1861. At around the same time, local authorities began to open hospitals, predominantly in non-urban areas, with the two systems operating in tandem (the Voluntary hospitals providing care in urban areas and the local authority hospitals in more rural areas).
Facilitated by their shared central urban locations, the Voluntary hospitals began to establish early links with the Medical Schools. This prompted their development as teaching hospitals providing clinical education for medical students, another noteworthy difference between the Voluntary and local authority hospitals. In many cases, local authority hospitals did not have these close associations and geographical proximity, and therefore remained non-teaching hospitals.
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This combination of circumstances meant that the Voluntary sector traditionally participated disproportionally, not just in the care of patients, but also in the education of clinicians of all disciplines, the practice of medical research and the translation of that education and research into improved clinical service. To this day, two of the major Irish Medical Schools, Trinity College Dublin and University College Dublin, are largely affiliated with Voluntary hospitals.
International Precedent and Learning
The Irish general hospital system developed in a similar way to other European countries in many respects and fundamental lessons can be drawn from their national healthcare systems in terms of the origins, development and most importantly in this context, the relationship between the Voluntary and Statutory healthcare providers.
In Ireland, close to one third of acute hospitals can be classed as Voluntary Public hospitals in that they are owned and governed by religious congregations or by lay Boards. The remaining hospitals, established more recently, have traditionally been owned, run and funded by the Irish State. This dual development is common to other countries, with philanthropists, doctors and concerned citizens taking the lead in establishing charitable healthcare facilities, followed by State involvement and advancement of public goods such as health and social services at a later date. In fact, many of the most developed and high performing health systems in the world are built on a network of Voluntary independent providers and rely to this day on the diversity of care options that they provide for their success.
Below is a brief account of three other European healthcare systems, and some of the issues that they have encountered during the evolution of the Voluntary/Statutory relationship.
United Kingdom
The history and evolution of health services in the United Kingdom is similar in many respects to that in Ireland, with healthcare initially being established by concerned citizens, philanthropists, charitable organisations, and medics.
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Much like the Irish system, State provision of healthcare in the United Kingdom was gradually introduced through local government and under the English Poor Laws. In the late 19th and early 20th centuries, approximately one third of hospital beds were in Voluntary hospitals, with the remaining healthcare being provided through local government hospitals and Poor Law workhouses and infirmaries. It must be noted however, that the Voluntary hospitals still accounted for the vast majority of medical education, clinical training, research and acute medical care in this period, much like the case in Ireland.
The State took a greater level of control and responsibility for the Voluntary hospitals throughout the wartime emergency and this new relationship was formalised with the introduction of Aneurin Bevan’s 1946 NHS acts, which brought the Voluntary hospitals into public ownership and formed the National Health Service.
It is noteworthy that in the last decade, this heavily centralised system has now moved towards the creation of Foundation Trusts (overtly identified as the model to which Irish hospitals should aspire), which are in line with the UK Government’s commitment to devolution and decentralisation in the public services.
It is also of note that a Deed of Arrangement was put in place as far back as 1971 in Northern Ireland in respect of the ability of the Mater Hospital, Belfast to operate within the NHS in Northern Ireland in a way which would have regard to the "preservation of the character and associations of the hospital".
These Foundation Trusts are characterised by the fact that they:
1. are independent legal entities, 2. have extensive financial freedom (including the ability to borrow and reinvest surpluses), 3. are free from central Government control 4. are overseen by an independent regulator - Monitor It is the responsibility of Monitor to track the performance of the Foundation Trusts. According to Monitor’s analysis of the Foundation Trust section for 2012/20131 there has been a deterioration in Foundation Trusts’ governance risk ratings due to an increase in
1 Performance of the Foundation Trust Sector, year ended 31 March 2013, Monitor ______7 Enhancing Volunteerism www.VoluntaryHealthcareForum.ie
target breaches and in the number of Trusts (19 Trusts) being found in significant breach of their terms of authorisation for both governance and financial concerns. Acute Trusts have been identified as having the poorest governance risk rating profile. In relation to financial performance for the same period, Foundation Trusts delivered a €540 million surplus which was a €31 million improvement in the previous year.
The issue of governance and regulatory compliance within Foundation Trusts was highlighted in the widely publicised case of Stafford Hospital and the subsequent ‘Francis Report’ which was released in February 2013. The Report told a story of the appalling suffering of many patients in Stafford Hospital and describes the leadership of Stafford Hospital as being characterised by an obsession with meeting Government-imposed targets without worrying about the consequences. The Inquiry Chairman, Robert Francis QC, found a culture of secrecy and defensiveness within which many staff did their best in difficult circumstances, while others showed a disturbing lack of compassion towards their patients. There was a pervasive culture where poor practice was tolerated as long as it remained hidden. Instead, the Board focused on balancing the books so they could achieve desired ‘Foundation Trust’ status.
“I have no doubt that the economies imposed by the Trust Board, year after year, had a profound effect on the organisation’s ability to deliver a safe and effective service2”
“The demands for financial control, corporate governance, commissioning and regulatory systems are understandable and in many cases necessary, but it is not the system itself which will ensure that the patient is put first day in and day out. It is the people working in the health service and those charged with developing healthcare policy that need to ensure that is the case.”
France
The French hospital system is characterised by three types of providers:
Public hospitals, which account for 35.3% of hospital establishments and 65% of hospital beds
2 http://www.midstaffspublicinquiry.com/report ______8 Enhancing Volunteerism www.VoluntaryHealthcareForum.ie
For-profit private clinics, which account for 37.2% of hospital establishments and 21.1% of hospital beds Non-profit private hospitals, which account for 27.6% of hospital establishments and 13.9% of hospital beds Private non-profit hospitals, otherwise known as Voluntary public hospitals, which generally have religious or confessional origins or result from charitable and philanthropic endeavours by private individuals, have historically been pioneers in the hospital field3. Today they remain at the cutting edge of French medical practice, illustrated by the fact that many private non-profit hospitals occupy the top rankings across a variety of acute specialties in the annual Le Point Magazine evaluation of French Hospitals.
French Voluntary hospitals are managing to occupy these top rankings in a system where regulatory obstacles, including the differential in social security contributions and the deferral of expenditure, have impeded their progression in recent decades. In France as with most European countries, on average, labour costs account for approximately 70% of all costs in healthcare facilities. This puts the Voluntary providers at a distinct disadvantage considering that:
“According to official estimates from 2007, social security contributions were 27.1% higher on average for all private non-profit hospitals taken together in the employment of medical staff. This means, for example, that to pay a net salary of €1,000, public hospitals have a total labour cost of close to €1,870 (of which €870 goes toward social security contributions altogether), whereas private non-profit hospitals must pay out €2,105, which is €235 more4”
Similarly detrimental to French Voluntary hospitals’ ability to compete on a level playing field is the practice of financing a proportion of last year’s expenditure from the current year’s revenue. The ‘deferral of expenditures’ allows a certain amount of ‘breathing-space’ so that Statutory hospitals are not forced to reduce staff and cut services. This deferral of expenditure is a common occurrence for Statutory hospitals but is forbidden for Voluntary hospitals, putting them at a serious disadvantage in terms of cash-flow options and liquidity.
3 Valentin Petkantchin. “Nonprofit health care hospitals in France”.IEM Economic Note, 2010. 4 Valentin Petkantchin. “Nonprofit health care hospitals in France”.IEM Economic Note,2010 ______9 Enhancing Volunteerism www.VoluntaryHealthcareForum.ie
For French private non-profit/Voluntary hospitals to be ranked so highly in a restrictive regulatory environment such as this, once again shows their resilience and commitment to providing excellent levels of care, much like the Voluntary hospitals in the Irish health system.
In France, private non-profit/Voluntary hospitals provide a true and viable alternative to public hospitals despite being fiscally disadvantaged. They are managed in a way that is more flexible and responsive, unencumbered by the bureaucracy that is sometimes seen in the Statutory system. Notwithstanding the restriction of regulatory burdens that are not imposed on the Statutory hospitals, their ranking in specialty areas is indicative of their proud teaching traditions, focus on quality, and ongoing endeavours to provide an excellent health service to the French public. As a final point, it is noteworthy that the participation of private non-profit/Voluntary hospitals and the promotion of diversity are seen as a social good in France. This sector, often referred to as the ‘Third Way’ (i.e. neither State-owned nor commercial private) is seen as a key component and equal partner in France’s social economy.
The Netherlands
The Dutch system provides wide access to care with minimal waiting lists and is ranked number one in Europe5. Indeed, it is intended that Irish healthcare policy reforms will draw on many aspects of the Dutch model such as risk equalisation and the ‘money follows the patient’ principle in the quest for a universal, single-tier health service, which guarantees access to medical care based on need, not income.
In this context, it is interesting to note that private non-profit/Voluntary hospitals play an enormous role in the Dutch healthcare system. For instance, in excess of 90% of hospitals in the Netherlands are private and non-profit, the rest are public6.
It is also worth noting that the Dutch health system underwent significant reform in 2006 to enable it to function more equitably and efficiently. Before the reforms occurred, the
5 http://www.healthpowerhouse.com/files/ReportQEHCIQ2012.pdf 6André den Exter et al.Health systems in transition: Netherlands. European Observatory on Health Systems and Policies WHO,2004 ______10 Enhancing Volunteerism www.VoluntaryHealthcareForum.ie
Government had imposed greater levels of control and an austere cost reduction plan on the private non-profit hospitals, which had the consequence of increasing waiting lists substantially.
Petkantchin outlines that the reform:
“…together with the responsiveness and flexibility of private non-profit hospitals, helped produce a reduction in waiting lists, which are no longer perceived as a problem by the general public. This reduction was achieved even with total health care spending rising less quickly after the reform, from 2006 to 2008 (+5.3% per year on average), than before it, from 1998 to 2005 (+7.6%)”7
7 Valentin Petkantchin. Non profit health care hospitals in France. IEM Economic Note, 2010 ______11 Enhancing Volunteerism www.VoluntaryHealthcareForum.ie
Defining the nature of Volunteerism Today, Voluntary organisations in Ireland span the full spectrum of health and social care and provide a strong voice for service users and the communities in which they exist. The Voluntary Healthcare Forum acknowledges the importance of all Voluntary and non-profit organisations serving the Irish people and we will discuss their contribution in more detail in Chapter 5.
Voluntarism as a concept has many expressions and multiple definitions. Our focus, however, is on Voluntary healthcare providers such as acute and non-acute hospitals, therefore this paper relates specifically to these types of organisations and their form of Voluntarism. The Voluntary Healthcare Forum has developed a definition of Voluntarism in the context of its own purpose, which is:
“The voluntary participation of independently governed and owned service providers in the provision of care to patients/service users on a non-profit basis and in a manner consistent with core values of their founders, fundamental to which is the holistic care of those people in our community who require our services”
With the diverse ownership and governance structures that exist across the healthcare providers, this definition is intended to aid the distinction between Voluntary organisations and State owned and governed healthcare institutions in the healthcare sector. The Forum fully supports the diverse nature of the healthcare system and recognises that there is a need for Voluntary healthcare providers to work in tandem with Statutory organisations in order to provide best in class service and corporate/clinical governance in a range of areas.
We see diversity in the ownership and governance of participants in healthcare provision as a positive good and are not advocating on behalf of a specific religious denomination or movement. We encourage the active participation of all Voluntary healthcare institutions in the provision of care to the people of Ireland.
In the next section of this paper we will provide an overview of the contribution that Voluntary organisations make to the Irish Healthcare sector. However, we consider it important for stakeholders to first understand how we believe Voluntary organisations
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differ from state-governed healthcare providers. The key distinguishing characteristics of Voluntary hospitals, in our view, are presented below:
Distinguishing Characteristics of Voluntary Hospitals
Voluntary hospitals typically own their land, buildings and infrastructure Unlike Statutory hospitals, Voluntary providers are legally required to comply with all aspects of company law and governance standards, given their legal construct Voluntary hospitals operate as directed by a Board of Trustees/Governors and, since they don’t have shareholders, they have to have alternative means of Board member selection. Voluntary Hospital boards are typically self-sustaining, with members usually selected from community or professional backgrounds and serving without pay Voluntary hospitals are primarily State funded but have a greater degree of independence and autonomy than Statutory providers through their ability to raise and spend private funding from a variety of sources Traditionally, Voluntary hospitals have been distinctly Mission-focused and led by the values of their founders. Voluntary hospitals have always striven to ensure that the care they provide is more than a transaction; from the point of view of both patient and staff Through their Foundations and other mechanisms Voluntary hospitals have a long tradition of campaigning and advocating for healthcare issues Voluntary hospitals typically have distinctively close relationships with their local communities Historical links with the development of our leading medical schools mean that the Voluntary Hospitals have an unmatched record in the research domain in Irish healthcare. Voluntary hospitals tend to have a strong ‘brand identify’; apart from leverage in advocacy issues, this gives them a distinct ability to attract and retain staff in an environment where other incentives are limited
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While we believe that our service users benefit from the distinctive characteristics of Voluntary organisations, it is true to say that the new singular model of governance being promoted by the Department of Health will embody some of the characteristics listed above. However, this should not be a reason to dismantle or dilute the effectiveness of the organisations which already operate in this way, in fact it is recommended that the effectiveness of the Voluntary service providers should be improved through a strengthening of engagement between policy-makers and service providers.
It is our belief that a democratic society benefits from the existence of an alternative to State-run hospitals. Voluntary hospitals’ independence allows them to speak out against health system failures and challenges to patient safety. This right to speak out as institutions on key healthcare and social issues is vitally important in protecting vulnerable service users, in raising wider standards of healthcare provision and in ensuring that at a societal level questions such as ‘what is the appropriate overall level of resourcing for healthcare?’ are raised and debated.
We also stress the importance of ownership when it comes to governing and leading an organisation. Ownership creates a much stronger sense of affiliation among an organisation’s Governors and can foster an environment which promotes positive competition. We believe that the implementation of a standardised ‘one size fits all’ governance model across the health system, particularly in relation to the formation of Hospital Groups, will result in an unduly passive governing ethos that will be focused on a set of bureaucratic reporting processes and thus remove any sense of loyalty and ambition from those who will be best placed to encourage such behaviour throughout their organisations.
On the other hand, having in place a system with diverse governance structures and where funders and policy-makers are rightly focused on outcomes not processes, will ensure that there is constant refinement of governance processes as the performance of the models can be compared to each other and improved if necessary. The unique nature of Voluntary healthcare organisations, and the importance of their contribution to our society (which is presented in more detail in Chapter 5), are therefore at the core of our motivation for endeavouring to preserve Volunteerism in the Irish health system.
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Voluntary organisations in the Irish healthcare system
Voluntary organisations have a significant presence in all areas of health and social care in Ireland today. In some specialist fields they are the dominant providers, in fact. Since its foundation, the State has followed a diversity principle in using a combination of Voluntary, statutory and private providers to meet the healthcare needs of citizens across the spectrum from GP services to acute care and into areas such as disability, mental health and long-term residential care. Although the weight of voluntary participation remains substantial, it is generally unquantified and unrecognised in the data available at a national level.
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We have presented above some of the statistics that are available in relation to the acute hospital sector in order to gain an understanding of the role that Voluntary organisations play in the delivery of vital health services8
The strong presence of National speciality services within a number of Voluntary acute hospitals is also a clear indication of the importance of these organisations within the Irish healthcare sector and shows their ability to ensure clinical excellence on a national scale while guaranteeing the provision of strategically critical health services.
National Specialty Services Provided by Voluntary Acute Hospitals
Voluntary organisations are also present in all non-acute care sectors and feature among the leading providers in the following sectors:
8 Funding and staffing levels in Voluntary hospitals reflects then resource intensity weighting under the Hospital Casemix funding system ______16 Enhancing Volunteerism www.VoluntaryHealthcareForum.ie
National Services Provided by Voluntary Non-Acute Service Providers
Although the vital contribution made by Voluntary organisations to non-acute care services in Ireland is commonly accepted, supporting quantitative data for the sector are hard to obtain, due primarily to the varying nature and scale of the organisations involved. In the next section we look in some more detail at Voluntary participation in one non-acute sector, Disability.
Disability Sector – an example
The table above shows the breadth of Voluntary involvement in the Non-Acute sectors. To shed some light on the scale of the voluntary contribution to non-acute care in Ireland, we have compiled data from recent reviews of the Disability sector, by way of example. As of December 2012 we estimate that there are almost 300 voluntary disability service providers in the Republic of Ireland. These agencies provide services for both intellectual and physical disability and are responsible for just over a total of €1,1bn spending through approximately 730 service/grant agreements, giving some sense of the significance of the sector in the health economy as a whole.
The data presented below are sourced from the Department of Health’s 2012 Value for Money and Policy Review of Disability Services in Ireland9.
9 http://healthupdate.gov.ie/wp-content/uploads/2012/07/VFM-of-Disability-Services-Programme-July- 2012.pdf ______17 Enhancing Volunteerism www.VoluntaryHealthcareForum.ie
The Review analysed data from 217 specialist disability service providers with SLAs and GAAs. In addition to these agencies, a further 105 private for-profit providers had a total of 115 contracts with the HSE in 2009. Expenditure on disability services increased from €1.28 billion net in 2005 to € 1.68 billion net in 2009. A significant percentage (76%) of that funding was provided to non-statutory service providers. Total disability services funding in 2009 was €1.859 billion. The Review estimated that 23,840 whole-time equivalent (WTE) staff were employed by disability agencies in Ireland. The Review examined 111 agencies to arrive at a total cost per service user. The 111 agencies analysed spent €1.225 billion on pay in 2009, an average of €11 million payroll annually per agency reviewed.
Looking at the figures above, the number of SLAs and GAAs and the fact that 76% of disability funding in 2009 was provided to non-statutory service providers illustrates the extent to which the HSE relies on voluntary agencies to provide a diverse range of care options in local environments to Irish people affected by disability. Further, approximately 24,000 Irish citizens rely on disability agencies for direct employment.
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Developments impacting the future role of Voluntary Healthcare Providers In this section we have presented four key areas of development within the Irish healthcare sector which will impact heavily on Voluntary healthcare providers and on which Government engagement with the relevant stakeholders has been somewhat limited. It is important to note that the Voluntary Healthcare Forum’s position on each of these areas represents our initial view and we would welcome engagement with policy-makers on these issues.
Universal Health Insurance
At the core of the Government’s health reform programme is a planned introduction of Universal Health Insurance (UHI) in 2019. The introduction of UHI requires that health insurance with a private or public insurer will be compulsory. This will enable a “money follows the patient” (MFTP) system where Hospital Groups and later, Independent Hospital Trusts, will compete for patients and their insurance cover. As the UHI concept is about ensuring that service users have universal access to any willing or qualified care provider, it will eliminate the two tier system (public-private split) that exists in Ireland today.
Taking these factors together, any move to a one-size-fits-all governance model appears to be unnecessary. In the transition to UHI, we will also witness the separation of purchaser and provider as the role of funding Hospital services and primary care moves from the HSE to the proposed Healthcare Commissioning Agency. Will it be the case that in a UHI system the State will insist on insurers buying only from providers with certain governance constructs? The rationale is not clear to us. It is worth noting that the HSE’s Nursing Home Support Scheme (“Fair Deal”) is being explicitly pointed to by the Department of Health as a working example of the ‘money follows the patient’ scheme in action.
Yet 65% of the service paid for under Fair Deal comes from private commercial providers, with no requirement for specific governance constructs laid down. It, therefore, seems unnecessary for the Government to push for homogeneity of governance models during this time. ______19 Enhancing Volunteerism www.VoluntaryHealthcareForum.ie
It is worth noting that, the thinking behind the role of the Voluntary hospitals in the current healthcare reform programme appears to be a marked departure from the position that Fine Gael held in their 2009 Fair Care policy document. In this document Fine Gael recognised the value and role that the Voluntary hospitals can play in implementing UHI: “Voluntary Hospitals will continue to be run by their Boards. The evidence from other countries is that these independent, not-for-profit hospitals tend to do best under systems of universal health insurance. The reasons for this are not fully understood, but it appears that the caring ethos of not-for-profit hospitals leads to higher quality treatment and greater trust among patients and their insurance companies.10” We urge policy-makers to review the rationale behind their current thinking on the role of Voluntary hospitals in a UHI system and to ensure the participation of these essential institutions in this important aspect of the Reform Programme is secured.
Participation in Hospital Groups
In May 2013 the Government published its report on “The Establishment of the Hospital Groups as a transition to Independent Hospital Trusts”. The report, based on the recommendations provided by Prof. John Higgins and the Strategic Board, set out the establishment of six large Hospital Groups covering acute hospitals across the country. The three paediatric hospitals are to be merged in a separate group in advance of the move to the new National Children’s Hospital. In forming the Hospital Groups, the Government has initiated the process for the integration of State governed and Voluntary hospitals’ functions and services with the ultimate ambition of establishing not-for-profit Hospital Trusts.
The Voluntary Healthcare Forum acknowledges the Government’s recognition in the Higgins report of the diversity of governance structures that exist within the Hospital Groups. However, significant uncertainty remains in relation to the future of Voluntary acute hospitals and their Boards as the Hospital Group model progresses. The report references the need for each Group to consider “the most appropriate form for this non-executive
10“Report of the investigation into the quality, safety and governance of the care provided by the Adelaide and Meath Hospital Dublin incorporating The National Children’s Hospital (ANNCH) for patients who require acute admission “ ______20 Enhancing Volunteerism www.VoluntaryHealthcareForum.ie
challenge” in relation to the rights and obligations of the Voluntary Boards but clarification on this issue is still required.
The report also states that “as the Group management team begins to deliver Group corporate functions, it should be possible for Voluntary hospital Group members to begin to reform their management teams within an overall agreed framework for the Group”. It can be deduced from this statement that the issue of Group participation will be largely determined on an individual Group basis, but this approach will not obviously benefit Voluntary organisations which are in the minority within a Hospital Group. We feel that the Government should not distance itself from decisions relating to Voluntary participation but that it should engage directly with Voluntary organisations to agree a system-wide approach to facilitating Voluntary participation in the Hospital Group model.
Service Level Agreements
Over time the State has provided increasing levels of funding to Voluntary hospitals to the point that all public Voluntary hospitals are completely financially dependent on the State.
As the State’s share of operating costs increased, so too did the degree of direct control sought by the funder for completely understandable reasons of accountability and stewardship of public interests. The annual ‘contract’ between the State and the Voluntary hospitals takes the form of a Service Level Agreement (SLA). It seems likely that this mechanism will be used again at least in the initial stages of the formation of the Hospital Groups. However, in recent years, increasingly fractious discussions around the nature and form of Service Level Agreements for annual funding purposes have taken place. With the establishment of the HSE and the legal obligation on it to operate within voted expenditure limits, pressure has also come on Voluntary providers to use their remaining flexibility to borrow, providing a financial ‘safety valve’ for the publicly funded system as a whole. Although there is a need to continually ensure that healthcare institutions provide the best level of care possible, there is also a need for the Government to recognise that HSE demands are placing undue pressure on the Voluntary organisations which come under the SLA contract.
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As a result of this situation, we would welcome clarity from the Department of Health on the contract mechanism that will apply to Voluntary organisations under the Hospital Groups model.
Emerging Models of Governance
In 2011, the Board of Tallaght Hospital, a Voluntary institution established on a Statutory basis, was effectively replaced when the hospital got into severe financial and other difficulties. The 2012 review by HIQA of Tallaght Hospital10 is evidence of the drive for increased State control, where, in its final report it was recommended inter alia that:
‘The chairpersons of all hospital boards (in the first instance) in receipt of State funds should be line managed by a nationally designated post-holder for the purpose of holding the chairperson and the board accountable for the provision of well governed and effectively managed services and in relation to the appointment, performance and termination of the chief executive (this post- holder may be, for example, the Director General of the new HSE structure, or equivalent).’
This suggestion that Chairs of Voluntary organisations should be directly accountable to a ‘nationally designated post-holder’ is an unusual governance approach and just one of any number of examples of worrying features of the governance prescription from HIQA which is being adopted nationally, and which would in practical terms, to negate the role and input of the members of the Voluntary organisations. HIQA specifically advised that its recommendations should have national application:
Recommendations – Board Governance - Governance Arrangements of Boards:
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7. “The Department of Health should ensure that any required legislative amendments to the constitution of existing healthcare organisations in receipt of State funds take account of these recommendations.”11
Further, HIQA appear to propose a single framework for the governance of Hospital Groups: 8. “The establishment of boards of ‘Hospital Groups/Networks’ should be in accordance with the recommendations of this Report
Overall, the report implies that Voluntary hospitals currently in receipt of State funding may be required to comply with these recommendations. Although the HIQA report does not have any formal legal standing and the above recommendations are merely recommendations, the report was the first clear articulation of the desired intention and ambition of Statutory funders to assume a very extensive degree of both operational and governance control, regardless of the independent legal status of the Voluntary organisations.
This report was subsequently followed by the work on establishing the Hospital Groups and it is now stated in the Hospital Groups report that the “Interim group board (i.e. each of the new hospital groups) must proceed towards full implementation of the governance recommendations in the HIQA Tallaght Hospital Investigation Report (HIQA, 2012) and other recommendations as contained in but not limited to the Ethics in Public Office Act”. The Department has, again, yet to provide guidance to the Hospital Groups on how to implement the recommendations. More importantly, neither has it seriously engaged with the Voluntary healthcare providers on this significant shift in governance arrangements.
In summary, the Voluntary Healthcare Forum are concerned that policy-makers have yet to fully consider the implications of driving through a single model of governance. There is no evidence on which to base a belief that the best response to adverse clinical incidents or financial indiscipline is a rigid and singular governance model. We believe that effective governance models are designed and are successful because they are based on a set of core
11 Report of the investigation into the quality, safety and governance of the care provided by the Adelaide and Meath Hospital Dublin incorporating The National Children’s Hospital (ANNCH) for patients who require acute admission “ ______23 Enhancing Volunteerism www.VoluntaryHealthcareForum.ie
principles, principles which support and guide those that work within them and which can be achieved through a variety of governance models.
In addition, the thrust of policy discourse in the wider public sector and in the health sector is to focus on the outcomes desired and to execute policy accordingly. With this in mind, we believe the Government should be setting uncompromising outcome targets and standards, creating an environment in which acute and non-acute care organisations can adapt and capitalise on their own particular strengths and learn from the successes of others. The Government should ensure that whatever constructs for care provision are in place are judged by their results, not by shape of their governance structure.
At present, the Voluntary Healthcare Forum see the Government’s Reform Programme having the most significant impact on governance structures in acute and non-acute care. However, there is also the potential threat to the diversity of governance models that exist within the social care sector. The nearly completed review of the Integrated Service Areas and proposed establishment of Community Healthcare Organisations is likely to provide some clarity on the financing and governance models relating to the provision of social care services. It is also likely to raise concerns over how Voluntary social care providers will interface with the Hospital Groups and the Government’s intention in relation to social care governance models in terms of potentially limiting diversity of participation in the future.
It is developments such as those outlined above that lead the Voluntary Healthcare Forum to believe that it is timely and helpful to develop this paper and to seek clarity as to the intention of the Government to support the sustainable participation of Voluntary healthcare providers in Irish healthcare.
______24 Enhancing Volunteerism www.VoluntaryHealthcareForum.ie
Conclusion This paper was designed to articulate the important contribution and role that Voluntary organisations play in the provision of healthcare and, in turn, support the case for enhancing Voluntarism and diversity in the Irish healthcare system. .
The Voluntary Healthcare Forum (VHF) feels that o there is a future role for Voluntary participation in Irish Healthcare o it is important to promote the role of Voluntary participation through collegiality o a coherent set of messages and a coordinated set of specific actions are required to support and preserve this role Inaction is likely to result in the elimination or a severe reduction in the scale of Voluntary participation in Irish healthcare. In the medium term, shifts in funding approaches will actually make increased diversity in service provision possible – but Voluntarism needs to be protected during this transition. At present, discussions on new models of governance are skewed towards a single ‘statutory model’ as a default option. The weight of the existing Voluntary providers is extremely significant and brings with it the obligations to speak with one voice on common concerns. Policy thinking is at a fluid and developmental stage which can be shaped through thoughtful input. Staff and patients of Voluntary providers care about choice and about the values their organisations espouse. As stated throughout the document, the Voluntary Healthcare Forum believe that early engagement with relevant stakeholders in the health system is essential to ensuring that there is an open, positive dialogue on the issues facing Voluntary healthcare providers in the current operating environment. Through engagement on the issues, the Chairmen of the VHF hope to develop a partnership approach with policy-makers to ensure the enhancement and sustainability of Voluntarism within the Irish healthcare system.
______25 Enhancing Volunteerism www.VoluntaryHealthcareForum.ie
Scope of Actions The Voluntary Healthcare Forum have agreed a series of joint actions designed to achieve the common purpose of enhancing Voluntarism and diversity of participation in Irish healthcare.
Engaging, as a coalition, with policymakers and commissioners in relation to the implications for Voluntary providers of governance and funding reforms Defining / refining the governance principles which we believe should be underpinning new approaches to healthcare governance Issuing of statements or making formal submissions representing views of members in relation to major issues Putting forward alternative / existing governance constructs which we feel match these principles Promoting and supporting wider public and political debate around the issue of Voluntarism and diversity in healthcare through a structured programme of publications / events / briefings etc. Building the case and evidence on an ongoing basis as to why Voluntarism makes a difference; hospital staff surveys, patient surveys, research in Ireland and abroad, best practice examples from Irish healthcare etc. Developing options to broaden the coalition further across the acute and non-acute sector within agreed timelines and principles
______26 Enhancing Volunteerism www.VoluntaryHealthcareForum.ie