National Health Services Plan

The Status of this Document

As at 1 May 1994, this National Health Services Plan (NHSP) is issued as a strategic plan for rationalizing the health services. The main components of the plan result from combined efforts of the Consultant and the Ministry of Health. This NHSP document now adds further detail to those agreed plans including more detailed costings and represents an agreed strategic plan.

The NHSP is based on targets for levels of services the follow from a combination of the policy context, the services delivery strategy and international norms of good practice – controlled for what is presently known abut need and demand factors in Trinidad & Tobago. These targets include hospital closures and reductions in hospital staff numbers, growth in primary services and staff, the development of some new facilities and renovations in hospital and primary care services.

It is recognized that it may not be possible to achieve all the elements of this NHSP or that it may take many years to achieve. The investment required to undertake all elements may not be available. The NHSP provides, therefore, a priority programme for implementing elements of the whole plan in an organized and cost-effective way.

Health & Life Sciences Partnership
22 Old Street, London EC1V 9HL
Unit 1F, Eric Williams Medical Sciences Complex, Mount Hope

Contents

1.0                Background, Policy Context & Summary              
                1.1                Background         
                1.2                The Policy Context                
                1.3                Summary              
                                1.3.1                Services                
                                1.3.2                Recurrent Costs   
                                1.3.3                Capital Costs      
                                1.3.4                Rationalisation Programme                
2.0                 The Existing Services Context                
              2.1                The Public Sector                                
               2.2                The Private Sector               
3.0           The Primary Health Care Plan                
                3.1                The Overall Strategy                
                3.2                The Services Plan                
                3.3                Recurrent Costs   
                3.4                Capital Costs      
4.0           The Hospital Services Plan        
                4.1                The Overall Approach               
                4.2                The Hospital Services Plan       
                4.3                Recurrent Costs   
                4.4                Capital Costs      
5.0           Dental Services 
5.1                Oral Health Status                
5.2                Current Dental Services                
5.3                Towards an Oral Health Strategy                
6.0           The Rationalisation Programme                
                6.1                The Programme                
                6.2                Recurrent Cost Plan                
                6.3                Capital Cost Plan                
Appendices
Appendix 3.2 (1):                The Model Polyclinic                
Appendix 4.2.2 (1):          Hospital Recurrent Costs Regression Model    
Appendix 4.2.2 (2):          Hospital Bed Distribution: Optional Appraisal                
Appendix 4.2.2 (3):          Hospital Catchment Populations & Patient Flows                
Appendix 4.2.2 (4):                Specialty Bed Allocations for Option Appraisal          
Appendix 4.4 (1):                Capital Costs of Hospital Options  
Appendix 4.4 (2):                Functional Content & Costs Per Hospital

N.B. Numbering System: The tables and appendices of this Annex take their numbering from the section of the main Annex text in which they are first referred to (e.g. Appendix 4.2.2 (2) is the second Appendix referred to in section 4.2.2 of this Annex).

1.0                 Background, Policy Context & Summary

1.1                Background

The various components of this National Health Services Plan (NHSP) have been prepared by HLSP with the Ministry over the last few months. This NHSP now assembles these into one document. Proposals for the Hospital Services Plan, the Primary Care Plan and the plan for preventive and other national programmes have undergone extensive consultation with the Ministry of Health and the professions. This NHSP presents the integrated plan for services and the broad programme for implementation recognizing that there will be detailed changes as services are rationalized and as more is known about health status as a result of current national survey efforts.

1.2                 The Policy Context 

Policies for the Health Sector

The policy context within which the services strategy and plan have been developed is described in the Main Report. In summary, the key elements of national policy influencing the services plan are that:

•   The provision and financing of services will work towards achieving a more equitable system – a system that equalizes the chances of all citizens receiving services when they are needed. Access will be on the basis of need. The system of financing of services and rewarding providers will aim to match demands to need.

•  Government will maintain a key provider role at all levels of health care services. Since 50% of the population dies before the age of 65 mainly of preventable disease (and with commensurate levels of preventable morbidity), public services will emphasis prevention including provision of information influencing lifestyles and demand for services. The pattern of investment and expenditure will be reallocated from tertiary and secondary care to primary care.

•  Government will encourage the private sector to participate more in the provision of services and will ensure quality and value-for-money by maintaining strong public sector competition, by purchasing services from the private sector on behalf of patients and through regulatory mechanisms.

•  Through a balance of direct provision and regulation, Government will endeavour to ensure that a basic package of services is available to all citizens – this will cover preventive, primary, hospital, support and rehabilitative services. Expenditure on services and the use of regulatory mechanisms will be directed by criteria established through objective health needs assessment. Technology assessment and cost-effectiveness criteria will be asserted through payment and regulatory mechanisms.

The Strategy for Health Services

The NHSP is based on achieving a significant shift in resources from hospital to ambulatory and primary care (including prevention). Statistical analysis of hospital bed numbers and the need to achieve a shift from impatient to outpatient care (including more day surgery) indicate that a significant reduction in hospital beds is desirable. Audit exercises have indicated that the present utilization of hospital beds is inappropriate with up to 50% of inpatient admissions being unnecessary if suitable primary and ambulatory care were available. At the same time, the quality of services in the smaller hospitals is inadequate with insufficient throughput of patients to maintain staff skills.

The NHSP is based on achieving an appropriate reduction in bed numbers, transferring the savings into primary care and concentrating skills within the remaining hospitals to raise clinical quality and operational efficiency. Maximum savings are possible if whole hospitals can be closed rather than bed numbers reduced in each. This centralization will be balanced by the development of specialist outpatient clinics, diagnostic facilities and out-of-hours emergency services at a local level through the establishment of a network of polyclinics.

The NHSP takes into account the likely availability of new technology in the future and in particular its capacity to shift surgical procedures to a day-case basis. It also takes into account the international evidence that the chronically ill elderly are best managed in their own homes.

Health services will be provided by new regional health authorities and, to some extend, by the private sector. Five regions will own and operate primary, secondary and tertiary services. They will have much freedom to manage their services, staff, facilities, supplies and budgets so as to respond to local needs and problems. They will be free to acquire services from the private sector.

The role of the Ministry of Health will become that of service ‘purchaser’ – acquiring services for the public from the regions on a contracted basis defining services volume and quality.

1.3                 Summary of Services Plan

1.3.1            Services

The plan for health services provision is based on the year 2000.

Primary Health Care

The major causes of mortality and morbidity are preventable and the strategy and financial allocations of the NHSP aim to focus on prevention. The epidemiological profile is documented in Annex 1.0: The Health of Trinidad and Tobago. This forms the scientific base for a target-led disease prevention and health promotion programme that will have two components – one aimed at the population as a whole and the other delivered on an individual basis as part of a personal primary clinical care programme.

The population-based programme requires an intersectoral approach as the health sector alone cannot achieve the necessary measures. The Ministry should be the lead agency for the programme backed by formal collaborative arrangements at all levels of Government. This should include a cabinet-level committee chaired by the Minister of Health and including appropriate other Ministers.

The Health of Trinidad and Tobago sets out the key areas included in the primary care strategy and sets targets to be achieved by the year 2004. The priorities are:

1.  Coronary Heart Disease and Stroke

2.  Diabetes

3. Cancer

4. Injury

5. AIDS/STDs

6. Mental Health

In addition, it will be important to maintain and develop existing programmes such as infectious disease control, environmental health and maternal and child health. Existing national services (environmental health and maternal and child health. Existing national services (environmental health etc) will undergo significant rationalization as operational aspects are devolved to the RHAs. Policy and programme monitoring and development functions will be performed by the Ministry. A vital task of the newly reformed Ministry will be to refine both national and regional targets and design action programmes for what will be delivered through personal primary clinical care programmes and what will be delivered on a population basis. Some of the latter work will be delivered nationally e.g. seat belt legislation and other media based health promotion work. Some will be delivered through the Regions and municipalities.

Primary Clinical Care Services

The plan for primary health care provides for a network of polyclinics and health centers each of which would serve a large enough catchment population to allow the creation of a full-time health team. They will, therefore, serve larger catchment populations than health centers do at present. Health centers will serve catchment populations of between abut 10,000-30,000 depending on population density and accessibility factors. The average catchment population would be around 20,000. These centers will also run outreach centers at which services will be provided on an intermittent but regular basis.

Polyclinics will provide a similar range of services to local catchment populations of about 20,000-30,000 but will also provide additional services to a wider catchment area with a population up to about 135,000. These comprise out-of-hours services over a 24 hour period, school health and dental services, radiological and laboratory services and visiting hospital specialists and therapists. Details are provided in section 3.2 The planned distribution of facilities is summarized in Table 1.3 (1).

Table 1.3.1 (1) Summary of Primary Care Facilities by RHA

North West RHA:
Diego Martin, San Juan, Port of Spain     
Existing Health Centres Open                17           
Proposed Polyclinics                1                St. James
Proposed Health Centres  11
Proposed Outreach Centres                3
Total Proposed                15

Central RHA:
Tunapuna/Piarco, Couva/Tabaquite/Talparo, Arima, Chaguanas           
Existing Health Centres Open    30    including new centres at La Horquetta and Maloney
Proposed Polyclinics                3                 Chaguanas, Couva, Arima
Proposed Health Centres  15
Proposed Outreach Centres                9
Total Proposed                27 

Southern RHA:
Princes Town, Penal/Debe, Siparia, San Fernando, Point Fortin    
Existing Health Centres Open                24
Proposed Health Centres  3                 Point Fortin, Siparia, Princes Town
Proposed Health Centres  13
Proposed Outreach Centres                5
Total Proposed                21

Eastern RHA:
Sangre Grande, Mayaro/Rio Claro               
Existing Health Centres  16
Proposed Polyclinics                1                Rio Claro
Proposed Health Centres  4
Proposed Outreach Centres                11
Total Proposed                16

Tobago RHA:
Existing Health Centres  18
Proposed Polyclinics                1
Proposed Health Centres  4
Proposed Outreach Centres                13
Total Proposed                18

Full details of the planned locations of primary clinical care facilities and the catchments they serve are given in Table 3.2 (4).

Private sector doctors will be able to offer their services to RHAs to supplement the care provided by the health centres and polyclinics directly managed by the RHAs. The RHAs will enter into service agreements with those doctors who wish to do this and who can offer the required quality – including preventive services. These agreements will encourage private doctors to join together forming small joint practices and to provide nurse and other health team support. Over time, these agreements will become a capitation payment system with incentives for specific preventive work.

Hospital Services

It is targeted that public sector hospitals should provide a total of approximately 1.5 beds per 1000 population for acute care, plus 1.2 beds per 1000 population for extended care. These targets represent a reduction from the 1991 use of approximately 1.9 acute beds and 1.3 extended-care beds per 1000 population. Although the population of the country is projected to rise by 10 percent by 2000, total bed requirements will fall by about 800. More efficient use of beds, including better bed management and reduction of unnecessary admissions, reduced average length of stay and the growth of day care or same-day surgery, will allow the reduced bed provision to handle an increase level of activity. Details of the make-up of the proposed bed index by specialty and the projected inpatient day-case activity in 2000, are given in Section 4.2 (Table 4.2.1 (1)). The planned distribution of those beds is summarised in Table 1.3.1 (2) below.

Acute Services

In the interests of improved quality and more efficient use of resources, acute inpatient services will be concentrated at four general hospital sites in Trinidad – Port of Spain, Mount Hope, Sangre Grande and San Fernando – and one in Tobago. Acute inpatient services currently provided from small District hospitals are underutilised, restricted in the quality of service they can provide and offer poor value for money. These services will be transferred to one of the general hospital sites as will acute inpatient services currently provided from isolated single-specialty sites. The distribution of beds by specialty is shown in Section 4.2 (Table 4.2.2 (2)).

TABLE 1.3.1 (2): Target Hospital Beds by Site

Region	General	Acute Mental	Other Mental	Long Stay	Total	Exist	Change
Hospital	Acute	Illness	Illness	Elderly		1991
North West RHA
Port of Spain	471				471	923	-452
St. Ann’s		104	505		609	1020	-411
Other				77	77	340	-263
Central RHA
MH/MHMat	734	144			878	668	+210
Other			99	74	173	462	-289
Southern RHA
San Fernando	747	153			900	661	+239
Other			153	114	267	133	+134
Eastern RHA
Sangre Grande	108		29	21	158	161	-3
Other						12	-12
Tobago RHA
Scarborough	62		16	12	90	146	-56
Total Projected	2123	401	802	298	3624	4526	-902
Existing	2848	412	825	441	4526
Change	-725	-11			-22	-143	-902

NB: Other Mental Illness includes long stay, rehabilitation, elderly mental ill, forensic psychiatry, mental handicap and substance abuse.

Mental Health Services

The plan for mental illness proposes reducing the size of St. Ann’s and converting the hospital into a specialist unit providing forensic services, services for the elderly mentally ill, rehabilitation services and an admissions unit for Tobago. Acute admissions for Trinidad will be provided by acute units at St. Ann’s, Mount Hope and San Fernando. There will be small long stay units in each region and a much strengthened community support network.

Long Stay Elderly Care

The policy will be to maintain the elderly in their home environment as far as possible. Nevertheless, there will be an increasing number of elderly who will require residential care. This will be provided in the main by the voluntary and private sectors with Government financial support where necessary. It will take some time for this to be developed and until that happens services will be provided within the public sector. The number of places is set out above.

Ambulance Services

A key component of the reformed health services will be an ambulance service linking health centres, polyclinics and hospitals and based at the polyclinics. It will provide an emergency service for accidents and for transfer of acutely ill patients. It will not provide a service for ambulatory patients apart from mentally and physically disabled patients attending day hospitals. The service will be manned by paramedics with the ability to provide emergency care on-the-spot. There will be approximately five ambulances per region working 24 hours a day. Special training will be provided under the pre-loan and early implementation phases to get the service started on a pilot basis. A training course will be established to provide ongoing training and retraining linked to a career structure with regional employment.

1.3.2 Recurrent Costs

Primary Health Care

Interim estimates suggest that a budget of around TT$8m for the new national population-based programmes can be allocated from the existing ‘national programmes’ expenditure of TT$59.66m and savings made in other areas. This budget will be held by the Ministry and spent by the Directorate of Policy, Planning and Health Promotion on intersectoral and media efforts and on developing new skills within primary care targeted at priority chronic disease control and management. The remainder of the TT$59.66m will be split between RHAs where other preventive service are performed, a contribution to the ambulance services and a small amount at Ministry level for policy, programme development and monitoring.

Primary Clinical Care Costs

The total recurrent annual cost of the primary clinical care plan is TT$112.74m (compared with TT$46.5m in 1992). The distribution of costs by region is shown in Table 1.3.2 (1) below.

Table 1.3.2 (1): Primary Clinical Care Annual Costs (TT$m)

Region	Staff	Goods & Services	Drugs	Total
I	16,298,305	1,768,285	3,194,636	21,270,226
II	28,716,745	3,149,078	7,986,853	39,852,676
III	24,005,488	2,632,442	7,221,834	33,859,764
IV	7,821,253	857,679	2,784,181	11,463,113
V	4,150,447	455,138	1,686,733	6,292,919
Total	80,983,239	8,880,622	22,874,237	112,738,098

Hospital Services Costs

The plan for hospital services will cost an estimated TT$426.0m per annum to operate distributed as shown below and compared to approximately TT$455.6m in 1992. Although based on 900 fewer beds than at present, the plan costs assume higher patient throughput rates and full staffing on improved terms and conditions. The distribution of recurrent costs by RHA is shown in Table 1.3.2 (2).

Table 1.3.2 (2): Hospital Services Plan Annual Recurrent Costs (TT$m)

Hospital                                Costs (TT$m)
North West RHA
Port of Spain                          69.1
St. Ann’s                               37.4
Region 1 Extended Care         3.8

Central RHA
Mount Hope                           130.0
Region II Extended Care             8.7

Southern RHA
San Fernando                         132.0
Region III Extended Care           14.0

Eastern RHA       
Sangre Grande                         19.8 

Tobago RHA
Tobago                                    11.3

TOTAL                                   426.0

Ambulance Services

The total annual cost of the ambulance service will amount to TT$20m.

1.3.3 Capital Costs

Primary Care

Total capital investment required for the plan is TT$136.0m distributed as shown in Table 1.3.3 (1). Although certain components of the plan (particularly the polyclinics and key health centres) are required as soon as possible, the whole plan will be spread over a 10 year implementation period. These are costs for an ideal plan of primary care facilities based on the policy to raise quality by concentrating services into units larger than at present to provide full primary care teams. This will require much reconstruction as existing health units are too small to permit this.

Table 1.3.3 (1): Primary Care Plan Capital Costs (TT$m)

Region                                Cost TT$m
North West RHA                  30.3
Central RHA                        46.1
Southern RHA                     39.8
Eastern RHA                       13.1
Tobago RHA                         6.8
Total                                 136.0

Hospital Services

Table 1.3.3 (2) below shows the capital costs of implementing the whole hospital plan and, again this is envisaged over a 10 year period. It is important that some elements of the plan are implemented as soon as possible as there provide the needed capacity increases or other changes that will allow overall hospital reductions. Other elements are mainly aimed at improving environmental standards and these can be delayed to meet the constraints of financial considerations.

Table 1.3.3 (2): Hospital Services Plan Capital Costs

	Build Costs	Prof Fees	Equipment	Other Costs	Total Costs
North West RHA
Port-of-Spain	36.7	3.7	24.3	0	64.7
St. Ann’s	10.0	1.0	1.6	0.0	12.6
Other Extended Care	12.7	1.3	2.0	0.0	16.0
Central RHA
Mount Hope/MH Mat	22.2	2.2	13.9	20.1	58.5
Extended Care	2.8	0.3	0.4	0.0	3.6
Southern RHA
San Fernando	115.1	42.8	11.5	0.0	169.4
Extended Care	39.6	3.9	6.3	0.0	49.7
Eastern RHA
Sangre Grande	77.5	7.8	15.2	0.0	100.4
Tobago RHA
Scarborough	63.5	6.4	11.9	0.0	81.8
Total Extended Care	55.1	5.5	8.7	0.0	69.3
Total	380.1	38.1	118.4	20.1	556.7

1.3.4 Rationalisation Programme

The rationalisation programme is based on the need to expand the primary care sector as rapidly as possible so that savings can be made in the secondary care sector. Polyclinics are an important feature of the programme in that they will take over the services of the smaller hospitals destined for closure. Table 1.3.4 (1) shows the effects of the programme on annual recurrent costs of the public sector.

The Total Annual Equivalent Cost line of the table shows that the plan can be achieved at approximately current levels of expenditure to cover recurrent costs plus loan repayments (capital and interest) for an IADB loan to finance the infrastructure improvements – in fact with reductions until 1999. No account is taken of the potential for annual efficiency savings (cost improvements) that the Ministry would demand from RHAs. These should be 1-2% annually and would eliminate the increase shown in the table for 1999 and thereafter.

In approximate terms then the NHSP is achievable at around the current levels of expenditure on health providing the plan is adhered to – services are transferred, polyclinics opened and the smaller hospitals closed according to the schedule of the plan. As a safeguard and as a way of rapidly influencing demand for services (and therefore costs) work will be undertaken on a simple user charging system for consumables (x-rays, laboratory tests and drugs) to cover any reasonable deficit. In addition, there is much flexibility in some of the proposed capital investment that is for qualitative improvement rather than capacity. Investment in this can be pushed further forward in time if necessary.

Table 1.3.4 (1): Annual Health Sector Recurrent Costs 1993 – 2004 by Region (|TT$m)

	Notes	1993	1994	1995	1996	1997	1998	1999	2000/ 2004
North West RHA
Port of Spain		122.20	118.60	108.70	88.80	84.20	85.90	87.70	71.10
St. James		19.00	18.40	18.90	9.90
Other Extended Care					4.10	4.10	4.20	4.20	4.00
Primary Care		11.80	13.10	14.50	15.80	17.20	18.60	19.90	21.30
Central RHA
Mount Hope		50.40	61.90	77.00	92.20	91.30	90.60	89.80	106.90
Mount Hope Maternity		22.70	21.60	21.90	22.10	22.40	22.60	22.90	23.10
Arima		2.40	2.30
Arima Rehabilitation		2.80	2.70	2.80
Couva		11.10	10.60
Caura		20.50
Tacarigua		3.10	2.90	2.90	3.00	3.00	3.00	3.00	2.90
Other Extended Care					6.90	6.90	7.00	7.10	6.80
Primary Care		11.10	15.20	19.30	23.40	27.50	31.60	35.70	39.90
Southern RHA
San Fernando		99.70	94.40	94.70	95.00	111.90	112.30	112.70	126.30
Princes Town		4.40	4.20
Pt. Fortin		13.40	12.80	13.00	8.40
Other Extended Care					7.30	12.90	13.00	13.20	12.60
Primary Care		12.10	15.20	18.30	21.40	24.50	27.70	30.80	33.90
Eastern RHA
Sangre Grande		17.70	17.40	18.10	18.90	24.10	25.10	26.20	25.80
Mayaro		2.70	2.60
Primary Care		6.40	7.10	7.80	8.60	9.30	10.00	10.70	11.50
Tobago RHA
Scarborough		18.10	17.60	18.10	18.70	18.20	18.70	19.10	18.50
Primary Care		4.80	5.10	5.30	5.60	5.80	6.00	6.30	6.50
National Programmes	1	59.66	59.66	59.66	59.66	59.66	59.66	59.66	59.66
MoH	2	31.10	31.10	31.10	31.10	31.10	31.10	31.10	31.10
Total Recurrent Costs	3	594.66	580.56	578.56	583.26	597.36	610.16	623.46	630.16
%Change Over 1993	4		(2.37)	(2.71)	(1.92)	0.45	2.61	4.84	5.97
Total PHC (inc above)	5	46.20	55.70	65.30	74.80	84.30	93.90	103.40	112.90
Total Hospitals (inc above)	6	457.70	434.10	422.60	417.70	422.30	425.50	429.30	426.30
HSRP Capital Spending	7	85.70	97.70	119.10	161.90	84.90	22.40	22.40	56.14
Total inc Capital Prog	8	680.36	678.26	697.66	745.16	682.26	632.56	645.86	686.30
Total Ann Equiv Cost	9		680.36	678.26	653.65	667.75	680.55	693.85	700.55
% Change Over 1993	10		(0.31)	(4.62)	(3.93)	(1.85)	0.03	1098	2.97

Notes:

1         Service elements will be regionalised but total costs are assumed to stay constant.
2   MoH costs will reduce but some will transfer to RHA management costs and stay constant in total.
5/6 Primary care and hospital costs are included in line 3 totals.
7   Costs for the optimum building programme.
8   Total annual recurrent costs plus capital costs to meet HSRP plan.
9   Total annual recurrent costs plus loan repayments for the capital required to met HSRP plan.

Table 1.3.4 (2) shows the annual capital investment required to achieve the target services plan.

Table 1.3.4 (2): Annual Capital Costs 1995 – 2000+ by Region (TT$M)

	1995	1996	1997	1998	1999	2000+	Totals
North West RHA
Port of Spain						64.70	64.70
St. Ann’s						12.60