The decision by the last Government in 2011 to take away the power of the National Treatment Purchase Fund (NTPF) to buy treatment for public patients in private hospitals was intended to herald a new era for the health service. The NTPF’s role in reducing waiting lists was deemed to be an expedient measure that did not address the structural flaws within the public system. Instead of covering up these flaws by utilising capacity within the private sector, the Government sought to address them directly with the creation of the Special Delivery Unit (SDU). The Unit’s role, with the support of a diminished NTPF, was to support hospitals in managing their waiting lists by implementing better processes, providing incentives, and, in certain cases, helping allocate funding.
The new policy direction had a positive impact initially, but waiting lists have been creeping up steadily for the past two years and have now hit the highest levels ever recorded. Figures at the beginning of August showed a record 530,000 people were on a public hospital waiting list for inpatient, outpatient or day-care, with thousands waiting over 12 and 18 months for treatment. In response to the continual rise in patients waiting for treatment, the new Partnership Government has committed to provide the NTPF with at least €15 million in 2017 to tackle waiting lists. Minister for Health Simon Harris even went as far as to say that the decision to end the Fund’s role in purchasing private care for public patients was “regrettable”. So what does this mean for the future of the NTPF? And how exactly did it end up regaining a role that had seemingly been permanently removed?
<h3><strong>Fine Gael’s plan</strong></h3>
The NTPF was established in 2002. The mission of the Fund was simply to decrease waiting lists in the Irish public healthcare system by paying for public patients to obtain treatment in private hospitals in Ireland or abroad. Other functions related to nursing homes were added later on. Between 2002 and 2009 the Fund provided over 150,000 public patients with inpatient procedures and outpatient appointments and drastically reduced waiting times. In 2009, the median waiting time for medical and surgical procedures across the public health system had reduced from 2.5 years to a record low of 2.4 months.
Despite these gains, the Fund consistently attracted criticism. The NTPF was seen by some to be part of a Government agenda to bolster the role of the private sector in healthcare provision at the expense of the public system. The value for money provided by the Fund was questioned. It was accused of offering perverse incentives, such as in cases where it paid for patients to see the same consultant whose public list they were on, privately. The Comptroller and Auditor General (C&AG) reported in 2009 that for 8.5 per cent of treatments provided under the NTPF, the consultant referring the patient from the public system and treating the patient privately was the same. However, some consultants pointed out that in niche specialties and paediatrics such occurrences were inevitable. The Fund also made little progress in tackling outpatient waiting lists, with patients waiting months for appointments.
<h3><strong>Downgrade</strong></h3>
Fine Gael’s FairCare policy, which was launched in 2009, was designed to radically restructure the Irish health system. One of the document’s targets was the NTPF. According to FairCare, the reliance on the NTPF had introduced “huge distortions” into the healthcare system.
Instead of relying on the private sector to relieve pressure on public hospitals, the SDU within the Department of Health would be created to help the hospitals themselves better manage waiting lists. The NTPF was, in turn, to be placed within the SDU to ensure that inefficient hospitals were not rewarded with funding by failing to reach targets. Soon after the Fine Gael/Labour Government was formed in 2011, the then Minister for Health Dr James Reilly announced that the NTPF was entering a period of transition. It would continue to fund patient treatments but would shift its focus to target waiting lists more strategically with the assistance of the SDU.
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<strong>Former Minister for Health Dr James Reilly</strong>
“It is unacceptable that hospitals leave some patients on waiting lists for very long periods of time, safe in the knowledge that the NTPF will eventually pick up the tab,” stated Minister Reilly.
“I will no longer tolerate this attitude to patients – hospitals need to become accountable for the listing decisions of their surgeons. As part of the changes I am announcing today, I am requiring all hospitals to ensure that they have no patient listed as waiting over 12 months for treatment by the end of the year. Where they fail to do so, the NTPF will source the necessary treatments and the hospitals’ budgets will be reduced by a corresponding amount in 2012.”
The NTPF was to no longer routinely accept referrals for those patients waiting over three months, but would instead target specific backlogs within the system. The requirement that the NTPF purchase 90 per cent of treatments in the private sector was ended. The SDU was to introduce a more focused strategy to target treatments for patients, which required new data systems, a new accountability framework and a focus by clinical and management leaders in hospitals to reduce lists themselves. In effect, the change meant an end to the role of the NTPF as a purchaser/provider, to a supporting role to the SDU. As a result the commissioning role of the NTPF diminished significantly, with the Fund, aside from continuing to be involved in the administration of the nursing home Fair Deal scheme, expanding its remit in the areas of data and analytics, audit, and quality assurance.
In 2012 the NTPF commenced collecting public hospital waiting lists data, publication of which started in March 2013. All acute hospitals submit weekly data to the NTPF for inpatient, day-case, planned admissions, and outpatients.
Meanwhile, the new SDU-led strategy initially made significant progress. In 2012 three specific targets were identified – that no adult should be waiting over nine months for an inpatient procedure, no child should be waiting over 20 weeks for a procedure and no patient should be waiting over 13 weeks for a GI endoscopic procedure. All but five hospitals achieved these targets, reducing adult waiting times over nine months by 98 per cent on the previous year, child waiting times over 20 weeks by 95 per cent on the previous year and GI endoscopy waits over 13 weeks by 99 per cent. In addition, the national median waiting time for patients was the lowest ever reported at 2.1 months and overall waiting lists moved from 59,353 in December 2011 to 51,708 in December 2012, a reduction of 13 per cent. By the end of 2013, there was a 98 per cent reduction in the number of adults waiting over eight months for inpatient treatment, a 95 per cent reduction in the number of outpatients waiting over 12 months for treatment, 95 per cent of all children waiting on an elective waiting list were waiting less than 20 weeks, and 99 per cent of patients on a GI endoscopy waiting list were waiting less than 13 weeks.
However, at this stage, the SDU had lost its original autonomy and funding power and was integrated into the HSE’s Acute Hospital Division. The National Director of the Division Mr Ian Carter was now head of both the SDU and the NTPF. By 2014 it was impossible to ignore that not only had progress in reducing waiting lists stalled, but lists were once again increasing. By this stage Mr Jim O’Sullivan had taken over as NTPF CEO. He wrote in the Fund’s Annual Report for the year: “Up to the end of 2013, these [waiting list] targets were broadly achieved by the year-end. However, during 2014, achievement of these targets proved to be quite problematic for a number of hospitals, particularly in some specialties. Despite the best efforts of all concerned, 15,576 patients did not receive their inpatient and day-case treatment within the maximum waiting times. Likewise 61,400 patients did not receive their first outpatient appointment within the targeted time. In order to address these challenges, the system needs to develop new and innovative ways to ensure that patients can be treated faster and in the most appropriate settings. We, in the NTPF, continue to look at ways in which we can support the health services in its efforts.”
<h3><strong>Full circle</strong></h3>
Although the practice reduced dramatically with the creation of the SDU and the diminished role of the NTPF, the purchasing of care within the private sector for public patients never entirely ceased. Having public patients treated privately was often necessary for hospitals to meet waiting list targets set by the Minister for Health.
Last year, the NTPF started to feel that its own role could be expanded. Meetings were held with the HSE, Department of Health, and Minister about the future direction of the Fund. The HSE Primary Care division approached the NTPF in relation to potential involvement in a minor surgery pilot programme with a number of GPs for the treatment of patients currently on hospital inpatient/daycase waiting lists. A big indication that the role of the Fund was to expand came when the NTPF CEO met with the HSE and the Department of Health in May 2015 with regards to the Fund’s potential involvement in a waiting list clearance initiative involving private hospitals. Under the initiative, an allocation of €51 million was approved for the HSE to fund supplementary treatment capacity in order to reduce waiting times to a maximum of 15 months by the end of December 2015. In addition to process improvements and in-sourcing across and between hospital groups to ensure maximum utilisation of capacity, the funding also outsourced activity to private hospitals. While this was a HSE initiative, the NTPF provided an oversight role in relation to invoice approval and validation and administrative support for the initiative. The Department of Health confirmed that it was happy for the NTPF to perform these tasks, which were set out in a formal memorandum of understanding.
According to HSE figures, a total of 46,398 outpatient appointments were provided under this initiative, 35,193 of which were first-time outpatient appointments and the balance (11,205) of which related to pre- and post- surgery appointments. A total of 5,105 inpatient or day-case procedures were also provided.
In 2015, the HSE National Director of Acute Hospitals Mr Liam Woods approached the NTPF requesting support in assisting on a similar potential GI endoscopy initiative. The aim was to have no patient waiting longer than 12 months for a scope at the end of December 2015. The Executive advocated the NTPF take a direct leadership role as opposed to the HSE in managing the initiative. The move marked the NTPF’s return to purchasing healthcare in the private sector. In January this year, it was reported that compliance stood at 95 per cent on the inpatient/day-case waiting list and there was 93 per cent compliance on the outpatient waiting list.
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<strong>Prof Charles Normand</strong>
According to the NTPF Board minutes for January, seen by the <strong><em>Medical Independent</em></strong> (<strong><em>MI</em></strong>): “Whilst acknowledging the achievements at the end of 2015 the Board expressed concerns in respect of increasing waiting lists both from a short- and long-waiter perspective, once compared with previous year’s figures.”
The formation of a new Government in May 2016 and the appointment of a new Minister for Health was an apt occasion for the future direction of the Fund to be revisited. An immediate priority for the Government was to address increasing waiting lists. In April, Fianna Fáil Deputy Lisa Chambers called for the NTPF to be part of the solution. She pointed out that the latest figures from the HSE revealed a 15 per cent increase in the number of people waiting more than 12 months for an outpatient appointment at Mayo University Hospital between February and March this year. The Programme for Partnership Government committed to continued investment of €50 million per year to reduce waiting lists further, which included €15 million in funding for the NTPF. In July, an NTPF Endoscopy Waiting List 2016 Initiative was established. The project is a continuation of the work performed by the NTPF in this area last year. Funding of just over €1 million is being ring-fenced by the NTPF to outsource endoscopy procedures for those patients who are currently waiting over 12 months, or who would have been waiting over 12 months by the end of this year. It is expected that around 3,000 patients will be cared for under the project. The extent to which the NTPF will be involved in the commissioning of further private healthcare is as yet unclear. While at least €15 million has been committed to the Fund for next year, the final amount could include, some, if not all, of the €50 million to be devoted to waiting list management. Speaking to <strong><em>MI</em></strong>, NTPF CEO Mr Jim O’Sullivan said that negotiations were still taking place with the Department over how that money will come under the remit of the Fund. He admitted that the Fund has been eager for some time to make a bigger contribution to solving the waiting list problem, but is conscious of Government policy.
“As a Government agency we don’t go against Government policy. What we were saying, however, is that we were willing, ready, and able to do this. That was one of the options. It was also about leveraging the experience that we have in waiting list management, because we just didn’t only do patient commissioning. So we are looking at expanding waiting lists into the community for diagnostics and also doing more demand and capacity planning and more in the pricing area, for long-term residential care. We were basically saying these are areas we could get involved in if the Department wished. The Department was very supportive of some of those areas so we are progressing along that route. In the meantime the Programme for Government came out, which specifically provided for us to go back into the commissioning role. That was effectively a change in Government policy. So we are working with the Department on what exactly that means. That funding does not kick in until next year. So we are working with the Department and the HSE to look at how best to spend the €50 million that is earmarked in the Programme for Government. That is an ongoing discussion.”
The Department has also indicated it will consider the role the NTPF could potentially play in the pricing of care for other services, in addition to the Fund’s current remit for long-term nursing home care. The potential use of a patient helpline is currently being considered in conjunction with the Department in the context of the re-activation of the NTPF’s role in commissioning patient treatment.
<h3><strong>Resources</strong></h3>
Taking on additional responsibility for waiting lists will obviously have resource implications for the NTPF.
The Fund’s budget was drastically cut in line with its new functions. When it was responsible for commissioning care in the private sector in 2010, 2011, and, to a limited extent, in 2012, its budgets were €90.09 million, €85.59, and €40.59 million respectively. In contrast, its allocation from the Department of Health was €17.39 million in 2013, and was further reduced to €5.10 million for the past three years.
Regarding staffing, the NTPF employed 47 people in 2011. Following the change in the Fund’s role within the health service, a number of staff were initially seconded to other health agencies. Since 2011 a number of staff have opted for career breaks or taken positions outside of the NTPF.
The net effect of all these changes is that the NTPF currently has 28 direct staff. Some of the secondments also remain in place. The Fund is currently preparing its operational plan for 2017 so will need clarity as to what exactly its role will be regarding waiting lists.
“We will have a look about how we are going to operate,” confirmed Mr O’Sullivan.
“I don’t think we will necessarily operate in the same way we did the last time. It was a new venture back then, there was a lot of handholding, if you want to call it that. We wouldn’t be as involved in that. It was pretty much an unproven medium at that stage so what we would be more involved in now would be the identification of the patients and negotiating the rates with the hospitals and getting people treated that way. So we wouldn’t have as big a clinical input into it. But we haven’t worked out exactly the number of staff we will need yet, but I think it won’t be excessive because we have a number of staff who will come back from secondments.”
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<strong>Mr Simon Nugent, PHA</strong>
<h3><strong>Criticism</strong></h3>
Not everybody is happy the Fund is more actively involved again in helping reduce waiting lists. The Irish Cancer Society has already expressed concern that the NTPF is being used as “a sticking plaster solution” and that the Government needs to develop a comprehensive, well-resourced plan to tackle the waiting list problem in the public health system. INMO General Secretary Mr Liam Doran has also voiced scepticism about reactivating the NTPF’s involvement in commissioning care. Edward Kennedy Chair in Health Policy and Management in Trinity College Prof Charles Normand told <strong><em>MI</em></strong> that he understands the motivation to look to the private sector to address growing waiting lists given the scale of the problem. While Prof Normand conceded the Government was attempting to lay down a road-map for the future direction of the health service with the imminent 10-year cross party strategy, he said that empowering the NTPF indicates a lack of vision.
“At the moment we have a bit of a policy vacuum,” according to Prof Normand.
“Because it is clear we are not really going down the route of the White Paper [for Universal Health Insurance] and the direction it was suggesting, but we don’t have a clear consensus as to what the alternative would be. In fairness, this attempt to develop a 10-year strategy is an attempt to have enough consensus across the political spectrum that we might be able to make more progress than we did when there were instant changes in direction. But at the moment there is not a clear vision. Where there was a very clear vision before, albeit a misguided one, now we have got no underlying strategy there, so again it is not surprising that you get all the short-term tactics re-emerging.”
Prof Normand also acknowledged the concern that treatment purchased in private facilities could be more expensive than that provided in public hospitals, but the size of current waiting lists means there are few obvious alternatives to tackling the problem in the short-term.
“At a very simple level, some of the public hospitals are running physically almost to 100 per cent capacity,” he said.
“We know that a sensible safe use of beds is clearly below 90 per cent occupancy and some hospitals are running above that. Unless we can change significantly both the availability of public facilities and to some extent improve the efficiency of their use, we cannot probably expect to get lengths of stay in hospital down further. Nevertheless, all those things are quite time consuming. If you want a quick solution, it is almost certainly going to be something like the NTPF, but at a cost of each of these procedures probably being more expensive than they need to be.”
Private Hospitals Association CEO Mr Simon Nugent rejected this assertion, stating that treatment in private facilities represents value for money. He pointed to a review by the C&AG, which stated that prices paid to private hospitals for procedures carried out under the NTPF system matched closely with those contracted for, with variations from the contract price being generally explained by the circumstances of the case. He welcomed the Fund’s recent involvement regarding GI waiting lists, and said that there is capacity in the private sector to take significant pressure off the public system.
“The point we would make to the Minister and we made when we published a document in April was that really the more long-term planning that applies to something like this, the better,” Mr Nugent told <strong><em>MI</em></strong>.
“Long-term planning allows hospitals to be more effective because one can timetable procedures for times of the year when there is spare capacity.”
In conclusion, Mr O’Sullivan said while the problems in public hospitals that are causing large waiting lists need to be addressed, there is also the need to treat patients on those lists as soon as possible. He feels the NTPF is ready to be part of the solution.
