The ‘Money Follows the Patient’ policy: What are the implications for midwifery and nursing?
The ‘Money Follows the Patient: A Policy Paper on Hospital Financing’1 was launched this year as part of the government’s structural reform of the health services. These reforms are based on the principles of fairness, efficiency, transparency, equity of access and value for money for the taxpayer. The policy is outlined in ‘Future Health: A Strategic Framework for Reform of the Health Service 2012-2015’ and commits the government to service, structural and financial reform.2
Background
The Health Act 1970 provides for the
provision of public healthcare to people
who normally reside in the State.3 An
estimated 46% of people in Ireland also
have private health insurance, though
this is reducing in the recession. Funding
of public health services has come via the
public exchequer, through taxation. With
decreasing income from taxation, this
funding needed to be overhauled.
Policy recommendations
1. Defining the service to be delivered
The policy recommends that all hospital-
based care (excluding emergency care,
outreach services, teaching and research)
will be covered by the policy. But, the cost
should be based on how complex the care
is and not where the care is delivered.
2. Designing the price of services
The pricing structure includes: pay
costs; non-pay costs; diagnostics costs;
overheads; and costs of the clinical indemnity
scheme. Price should be based on
‘best practice pathways’, but this may not
be possible at the start, so ‘average costs’
will be used, based on diagnosis related
groups (DRG), as per the Hospital Inpatient
Enquiry (HIPE) system.
3. Governance structures
Governance structures are key to the
success of the policy. Independent pricesetting
and purchasing bodies should be
established. The new National Information
and Pricing Office (NIPO) will be responsible
for setting national DRG prices based
on activity and cost data. NIPO will have
key stakeholder and clinician involvement.
The Healthcare Commissioning Agency (HCA), formed from the HSE, will commission and pay for target-driven services within the health budget. These targets will be underpinned by timely and quality service provision. All processes will be evaluated by audit, and penalties or rewards offered for the delivery of efficient, quality patient care.1
4. Implementation
The introduction of a shadow system
in 2013 with a full roll out of the policy by
2014 is recommended. A document outlining
the formation of the new hospital
groups was launched in May this year.4
5. Next steps in the reforms
Systems need to be put in place to
achieve the ‘price formulation’ and ‘claims
management’ recommendations. This
includes coding, grouping and pricing
DRGs, and introducing hospital and
national claims management and auditing
systems. The Department of Health
realises that not all hospitals have the necessary
information and communications
technologies (ICT) to roll out the system.
Policy evaluation
The policy is commendable given the
fiscal constraints in Ireland’s hospitals –
even the most efficient are motivated to
produce cost savings.5 But, attempts to
save money without adequate regulation
and monitoring could result in poor-quality
care.6 This has been the experience
from target-driven UK trusts.7
It is inadvisable to rely only on a costsaving system; governance structures must be in place to prevent adverse patient outcomes. Bankruptcy is another peril for new hospital trusts.6 In July 2013, the administrators of the stricken NHS Mid Staffordshire Trust advised that it would be dissolved because it was not clinically or financially sustainable.8 The UK experience teaches valuable lessons.9
Another key aspect to be addressed by the policy is adequate clinician involvement, training, and buy-in from the beginning.10 Some staff (especially doctors, nurses and midwives) failed to realise the potential for clinical service improvements with the system and saw DRGs solely as an administrative burden.11 The most successful clinicians were those who embraced the change and innovation of the new system.
Middle and higher healthcare management must realise that there are more than just economic considerations when considering the introduction of another radical overhaul of the health services.
Nurses and midwives play a key role in successfully implementing the ‘Money Follows the Patient’ policy, especially if the government plans on sanctioning hospitals with increased readmission or healthcare-acquired infection rates.12
Nurses and midwives are advised to move towards a more ‘real-time’ collection of patient acuity data to best utilise valuable staff resources, rather than relying on retrospective data collection.12 This requires their input from the start and an arrangement for the integration of nursing and midwifery care within the hospital billing system.
In the future, nurses and midwives may be called on to justify clinical nursing and midwifery costs to health trust boards in order to receive funding.12
The policy has an admirable philosophy: To deliver safe, effective care in the most cost effective way. To implement such radical reforms requires buy-in from all stakeholders – clinicians and the public. Greater emphasis must be put on changes the management structures and processes necessary to achieve these aims.
The Department of Health may need to rethink the timeframe for implementation and engage with stakeholders in earnest.
Margaret Murphy is a lecturer at the School of Nursing and Midwifery in UCC
References available on request from nursing@medmedia.ie (Quote: Midwifery Matters; WIN 2013; 21(7): 40)
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