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Proposals for the Future Health-Related Services of Trinidad & Tobago — October 1993 A document prepared for the Ministry of Health by Health & Life Sciences Partnership, London & Port of Spain "Towards a healthy Nation" proposes specific reforms and organisational structures that will achieve:
Seeking Your Views This document, "Towards a Healthy Nation", heralds a landmark in the development of health services in Trinidad & Tobago. It follows a lengthy period in which there has been a growing consensus within all major political parties that something must be done. The public is in no doubt that services leave much to be desired. "Towards a Healthy Nation" proposes what is to be done to reform and restructure the health services of Trinidad & Tobago. It is written by the consultant firm Health & Life Sciences Partnership (HLSP) engaged by the Ministry of Health to assist in defining and planning the reforms needed — but the fundamental approach to reform and improvement follows that advanced by the Ministry itself. The proposals of the document, therefore, have varying status. The central notions — the broad thrust of the reform — follow Ministry proposals. They are the result of collaboration between the Ministry and the Consultant team and action has already been taken to start the process of implementation. Some of the more detailed ways of achieving the reforms still have the status of proposals by the Consultant to the Ministry and are therefore readily amenable to change and improvement as additional views are heard and details worked out. The proposals will have
significant and far-reaching implications for all those involved in the
provision and consumption of health services including Ministry
employees, doctors, nurses and other professionals and, most of all, the
citizens of the nation who stand to gain immeasurably by the successful
implementation of the reforms. "Towards
a Healthy Nation" addresses all these groups.
It sees the nation's support for achieving the needed changes and
the nation's views on their detailed design and implementation. Views
of professional organisations and individuals are sought by the 20th of
December 1993. These
submissions, "Towards a Healthy Nation" and other more
technical papers will be used as resource material over the coming
months for a series of national meetings and workshops to further
development of the proposals for reform. Submissions should be sent to: Roger England "Bobots
say he don't know how all of ah sudden everybody gettin' all hot up
'bout bush medicine. He say
for years he usin' bush. If
he eh drinkin' it, he say,
is because he bathin' in it. But
he say as usual de big boys an' dem wouldn't bother to come an' ask he
Bobots 'bout all dat. Dey
only flyin' all over de world to medical conference an 'ting, gettin'
all kind ah bad advice from people who don't know ah damn ting 'bout
medicine, den comin' back here an' sudden, sudden so discoverin' dat dey
have medicine growin' right in dey back yard.
Well he say dat now dat dey officially know dat dey have medicine
growin' in de place, he want to see wha' dey go do 'bout it." Paul Keens-Douglas, Back to Bush Contents * Introduction A series of technical annexes to "Towards a Healthy Nation" will be issued over the coming months as more detailed work is completed. These will cover areas including health services by region, information systems, staffing and the costing of implementation. Moving the health service from:
and moving towards:
Introduction Improving Services for All "Towards a Healthy Nation" deals with no less than the health of the nation's population — in ensuring that increasingly large numbers of people are able to enjoy a better quality of life and to avoid premature death. There have been many gains in the nation's health status over the last two decades, achieved through a combination of social, economic and educational improvement, public health measures and communicable disease control efforts including immunisation and maternal and child health programmes. However, it is not socially or economically acceptable in today's Trinidad & Tobago that nearly half of the population dies before the age of 65 — and that for each of these premature deaths there are many more individuals who suffer illness and disabilities from the same causes. As communicable diseases have declined, chronic diseases have come to the fore and those that now kill and debilitate large numbers of the population include heart disease, cerebrovascular disease, cancers, injuries and accidents, diabetes and hypertension. If these diseases are not avoided through changes in individual lifestyles, and if they are not identified and appropriately managed by the providers of primary care, they result in admissions to hospitals followed by expensive episodes of illness, often leading to permanent disability or death. HLSP's own studies suggest that up to half the patients now in a hospital bed in Trinidad & Tobago are there unnecessarily — unnecessarily in the sense that a better system of primary care would have prevented their admission for diagnosis or clinical management. A well-designed primary care service, operated by well rewarded staff, is the key to real improvement in the nation's health services and will allow exposure of the popular myth that "better health care is equitable with more hospital beds". Those with knowledge of the workings of health services — in Trinidad & Tobago and internationally — know that simply injecting more money into the public health care system is not the whole answer. Injecting more money into an organisation is not a wise investment until that organisation demonstrates efficiency and can show that capital input now will raise output and quality or result in revenue savings — or both. Significant changes are required to the health service before large-scale capital investment can have this effect. These changes must ensure that health services are operated within a structure that best harnesses the skills, experience and dedication of health professionals (public and private) and other staff and that gives them the authority and responsibility for performing their work so that decisions can be made and actions taken as close as possible to where that work is undertaken. At all levels, managers — including clinical managers — must be able to control their resources and allocate them to achieve efficient and responsive services. Above all, the changes must add up to a structural reform of the whole health sector (not only an overhaul of the Ministry) and they must be indigenous — a Trinidad & Tobago solution that takes full account of international experiences but that recognises the particular strengths and weaknesses of government and private sector involvement in this country. The Key Elements of Change Decentralisation Health Services will be managed closer to the point at which they are delivered in order to: make services more responsive to consumer needs and preferences introduce general management — the delegation of decision making to appropriate levels of management and, in the case of operational matters, to those actually providing the services. The main units of decentralisation will be regional health authorities which will be responsible for providing services, but general management principles will also be developed at all the individual service units within a region. Target-led Financing Finance will follow the explicit identification of health care needs (through health needs assessment) not the existing pattern of facilities and services — the financing function will drive the change towards addressing the nation's health priorities. Ministry as Policy Body With the recognition that the nation's hospitals and health centres must be run by "hands on" local management and not by distant civil servants (and the devolving of operational responsibility to service units under regions), the Ministry's real work must become that of setting the national framework and priorities. The Ministry will set policies, agree on strategies and targets with regions and will allocate finance to regions on the basis of a "contract" for services of a specified quantity and quality. Better Primary Care The new role of the Ministry will facilitate the promotion of investment in primary care including the shift of resources from hospitals to primary care. The new role of regions as provider of both will allow them to achieve the shift. There will be fewer but better-staffed health centres and regions will be free to sub-contract with independent physicians to provide the services they need for their populations. Fewer and Better Hospitals There are serious problems of quality and safety in many of the smaller hospitals where the volume of specific types of patients is insufficient for staff to develop the necessary experience in diagnosis or treatment and where support services — X-ray and laboratory services — cannot be provided adequately. Quality will rise dramatically if skilled consultants and staff are concentrated, better resourced and managed — and this is what is proposed. There will be fewer hospitals but they will be of higher quality and take more account of the convenience of the consumer (by introducing outpatient appointment systems for example). Money saved on hospitals will be redirected to primary services aimed at keeping people out of hospitals in the first place. The Eric Williams Medical Sciences Complex (Mount Hope) will become owned by a regional health authority and, eventually, will play its part in providing the health services of the nation as a whole subject to the same policy guidelines as other health services institutions. National Ambulance Service A more centralised and higher quality hospital service will require a good ambulance service. It is proposed that this becomes an important priority under the reformed health services, fully integrated with regional emergency services and manned by paramedics who are trained to provide services on the spot. Harnessing the Private Sector Neither the new Ministry (as purchaser or contracting agent) nor the regions (as providers of services) need to undertake directly all the services they are responsible for — they will be able to commission others to provide them. The Ministry will actively promote the sub-contracting of services — to research organisations, training institutes, Non-Governmental Organisations (NGOs) and the private sector. Regions will be free to acquire services from wherever they can obtain the best combination of quality and cost — for equipment maintenance and supplies for example, as well as for clinical service from independent physicians and others. More Information for Decision-Making Better management of clinical and non-clinical resources requires better information but the historically centralised and "command" driven nature of the health services has prevented the development of modern information systems geared to real user needs. It is not an exaggeration to say that no one knows the real costs of any of the clinical procedures undertaken in the public hospitals and this is because cost information is not collected in the ways related to health care activities. With the centralised system, in which wages and salaries and bills for supplies are paid from 'on high', there has been no incentive to develop such systems. All this will now change. As managers become charged with controlling their own budgets they will have to know what money is being spent on, they will have to know what the outcome of that expenditure are and they will have to evaluate whether practical information systems will become a major priority in the new health services — not technology-led but growing out of the real needs of users. Audit and Review Measurement of the performance of the health services is a vital part of policy development, planning and budgeting. The performance of the new regions will be reviewed by the Ministry in terms of how money is being spent and with what gain to the health of the patients served. This review process will form a major input to a region's 'contract' with the Ministry and the basis for budget allocation. Performance review has an equally vital role to play in the direct care of patients. Around the world, physicians are themselves developing forms of 'medical audit' to analyse the quality of medical care delivered, the use of resources, the value of the procedures and technologies employed for diagnosis and treatment - and the results for the patient. Audit will be actively promoted in the new health services of Trinidad and Tobago - not from 'on high' as a policing function but from within the medical and other professions - building on the initiatives already taken by leaders of the professions. Background to the Reforms Why the Reforms? Independent Trinidad and Tobago has inherited a highly centralised civil service - including the health service. With the Public Service Commission, centralised employment, centralised decision making, centralised tendering of supplies and services, centralised payment of salaries and wages... etc., centralisation has been enshrined to such an extent that it is legitimate to ask whether the whole edifice of the public health service exists more for those employed within it than for the patients it is intended to serve. This is not the fault of the individuals working within the service. There are many skilled, well- educated and trained men and women but within this centralised structure, they are not empowered to act - to do what they know how to do. They are frustrated and demoralised and it is not in anyone's interest that they are asked to continue to work in a system that has such massive structural defects. "At this hospital we have a number of laboratory technicians on the payroll but we no longer have our own laboratories so there is not really very much for them to do. Of course we cannot terminate their employment and use that money to hire the nursing and other staff we desperately need! It would be really funny if we were not talking about people's lives." A hospital consultant. Service managers are asked to manage and to improve services but they have been never given the tools with which to do this. They are prevented from controlling their own finances so that they cannot shift money around within their organisations to solve problems and get better value; they are prevented from rewarding talent and dedication; they are prevented from taking appropriate disciplinary actions against inadequate or incompetent staff; they are obliged to acquire goods and services through centralised, bureaucratic and lengthy proceedings; they have no incentive to know the real costs of what their institutions are doing. "Because staff are not paid or controlled from the hospitals at which they work, local managers have no ability to improve efficiencies - and consequently little interest. The managers at this hospital do not know that $1m per annum is spent on security staff." A hospital staff member. "We had a labourer who hardly ever turned up for work and when he did, may as well not have bothered. After endless warnings, evaluation by two experienced Hospital Administrators and a senior and very experienced P&IRO plus corroboration and endorsement by an Administration Officer IV (IR), he was relieved of duty. Soon after, he was reinstated by the Chief Personnel Officer and the reason given for this was 'because he has children'! I mean am I being asked to run a hospital or a social security agency? And the public wonder why we can't keep the place clean? This is not an unusual event and can you imagine what effect this sort of thing has on other workers - the good and the bad?" A hospital manager. One of the main consequences of the constraints on management imposed by centralisation is tremendous inefficiency and waste, including the large-scale under-utilisation of many of the health care facilities and services. In addition to the self-inflicted constraints imposed by over-centralisation, established service patterns have become outmoded by changes in the problems managers have to address and the solutions available for them. As mentioned earlier, the health profile of the population has changed as successes in controlling communicable diseases have given way to the problems of chronic illness. These new problems demand new clinical interventions and patient management activities and these in turn require new organisational and provider incentive systems in which to operate effectively. But success also requires new attitudes towards 'wellness' by the population at large, combined with new information that will influence their behaviour. Along with these changes, medical technology has been driven by rich countries to ever more expensive possibilities that even they cannot afford. No country can now allow what is technically possible to be universally available. Trinidad & Tobago is no exception and principles of equity demand a rethinking and restructuring of priorities and access to services. During this time of rapid change in health needs and technology, the economic climate of the country has not been good. Government expenditure on health has declined in real terms and there has been effectively no capital investment for almost a decade. Tougher times economically inevitably force more patients into the public health sector as private care becomes unaffordable. The International Perspective International Concerns All over the world countries are concerned at the performance of their public health services and many countries are embarking on significant reforms of the way services are financed and delivered. Concerns are expressed in terms of equity, quality of care, cost effectiveness of services and rising costs and expenditures resulting from factors that include: * bureaucratic and outmoded structures for the delivery of public health services where centralisation, remote control and 'command' administration have prevented the development of modern management practices, innovation and responsive organisations * pressures to provide new technologies (including new drugs) many of which are proving effective but expensive; doctors want to provide them and the public want access to them * concern that much health investment is not sufficiently directed at priority problems and at achieving real health gains, with health sector investment following instead the old established patterns where existing services dictate resource allocation regardless of their effectiveness * the increasing proportion and the absolute numbers of elderly in the population who absorb a significant proportion of medical and community support services (often it is the elderly who are most able to benefit from the new and expensive medical advances) * the increases in medical efficiency that have occurred without effective rationing or cost control mechanisms being in place Governments are trying to get more value for money by seeking restructuring that creates cost-saving incentives and by harnessing the efficiency gains in medical practice that have enabled patient throughput in hospital beds to double. These are allowing Governments to cut costs by closing hospitals and reducing bed numbers whilst maintaining or increasing the numbers of patients treated. International Solutions A number of countries are embarking on structural changes and a number of elements have emerged that are common to some of these reforms and that appear to offer prospects for improvement. These include: Separating Purchaser and Provider Functions Several countries have concluded that there are advantages in a clear separation of functions between responsibilities for providing services and those of acquiring services. This separation attempts to exercise more influence over the cost and quality performance of the units providing care by making them accountable to separate funding agencies charged with acquiring care on behalf of a defined population. An element of competition for funds is introduced since purchasing agencies can redirect their funding to providers who perform better. Experience is showing that it is essential to develop a strong purchaser function by attracting expertise if providers are to be encouraged to provide those services that are really needed. Devolving the Management of Provider Functions The significant devolution of planning and management is common to most reforms internationally. Well-run provider organisations are decentralising their management as much as possible to obtain the benefits of local management and decision making within the overall policy context set by governments and the control exercised via the purchasing function. Controlling the Size of the Provider Function International comparative analysis indicates clearly that too many providers can mean too much care (pressured in the interests of providers rather than consumers) and result in spiralling costs for governments committed to paying for it. Control over the numbers of providers is best exerted where governments own most of the services or have sufficient influence over providers by controlling most of the expenditure on health and retaining veto powers over major investment and capital schemes. Most countries engaged in reforms are also concluding that some controls on the expansion of the private sector may also be necessary - through competition with a well-run public sector or by quotas or financial veto. Technology Assessment Similarly, many countries are of the view that some control is necessary over the type as well as the extent of services offered since public funds directed to providers via a purchaser should not be used for ineffective (or not very effective) medical and surgical procedures. New technologies have driven cost rises and, for this reason, many countries are undertaking assessment of the cost effectiveness of new (and some old) technologies to better decide whether they are worth paying for. Again, many countries are taking the view that this control must also be exercised over the private sector to some extent. If private providers offer very expensive procedures to rich people, it is never long before the public and the press are proclaiming 'two-tier medicine' and pressures build up to provide those services at public expense. Proposals for Trinidad and Tobago Contracts for Change The proposed structure for decentralisation of the health sector in Trinidad & Tobago takes the lead from the Ministry's document, 'Decentralisation of the Ministry of Health, 1992', and takes account of international trends and experience. The functions of providing health care services are to be devolved to new regional health authorities - four for Trinidad and one for Tobago. The Regional Health Authorities (RHAs) will own and operate primary and secondary (and in some cases tertiary or more specialist) services. The regional health authorities will have ownership of Government health assets and will be given a high degree of autonomy in planning and management. They are to be the mechanism through which Government discharges its responsibilities for delivering health care for the whole population. The Ministry will remain ultimately responsible and accountable to Parliament. New Roles for the Ministry The Ministry of Health will no longer run health services directly but will ensure that they are run by regions on behalf of the population. The Ministry's role shifts from operational responsibility to setting policy, goals and targets for regions based on the assessment of real health needs. The mechanisms by which it will fulfill that role are: * annual service contracts, with each region specifying the type and volume of services regions must provide * budgetary allocations tying each region's financing to those contracts * review of performance as the basis for subsequent contract negotiation with regions The Ministry will exert minimal interference in the operations of each region, leaving them free to manage resources to best achieve their goals and targets. The Ministry will be more concerned with achievement of those goals and targets - with the outcome produced by each region in terms of health care - than with the details of a region's management and day-to-day operations. Nevertheless, the Minister of Health retains the power to direct a region in the national interests. The Ministry will fulfill this role on the basis of national policy, aiming to direct health care financing towards priority health needs that have been formulated through health needs assessment that the Ministry will undertake. In addition the Ministry will monitor the performance of regions and ensure that they act in the full public interest. The New Regional Authorities Regional Health Authorities (RHAs) will be established as autonomous bodies with responsibilities for providing primary health services for the population within their defined regions and hospital services for this population and the national population as agreed by the Ministry. Ownership of land, buildings and equipment will be transferred from the Ministry to the RHAs. The RHAs will be able to set their own terms and conditions for employment of all staff and will be able to appoint, discipline and dismiss staff without recourse to any other agency save that there will be an appeal mechanism against unfair dismissal. RHAs will negotiate contracts with the Ministry on an annual basis. These will specify the activities and target service workloads to be undertaken by the RHA, the levels of quality required and the budget to be provided by central government. Budgets will vary between RHAs to take account of the services they provide (some will have large hospitals, some will not). Regions will be free to contract independent health care providers to provide health care services for them and it is expected that they will do this. By offering contracts to independent providers regions will be able to influence the quality and the cost at which needed services are obtained. New Possibilities for Financing As the health services become more efficient, the case for higher levels of financing will become more persuasive and the Ministry is investigating the possibilities for new sources of financing. Studies on the viability and most appropriate form for a national health insurance system (NHIS) are taking place alongside the Health and Life Sciences Partnership's work on health sector reform. The NHIS work aims to investigate possibilities for increasing the future budget of the public health sector based on contributions from employees, employers and Government. It is generally felt that while some TT$550 million annually is spent on health by the public sector, another TT$520 million is spent in the private sector and that, if the public sector service was improved, there would be public acceptance that some of this private sector expenditure could be gathered and used more effectively to finance a combination of public and independent services. As the NHIS develops, it may well take over some of the new contracting and performance review functions of the Ministry - in addition to its finance raising role. For the foreseeable future, it is recommended that a NHIS operates through the regions so that regions can retain full control over their financial resources in their efforts to achieve more cost-effective services, to shift spending to high priority services including primary care and to be able to manage effectively, including the ability to act at short notice and based on local knowledge. Clearly it is vital that new revenues generated by a NHIS are not applied to an inefficient public health service, otherwise massive cost inflation will result. The structural reform proposed in this document are necessary before a NHIS is established and are independent of the precise form of NHIS. As many countries have found, NHIS is not a panacea but, if appropriately designed and implemented, a NHIS could reinforce the effectiveness of devolved management, the new balance sought between public and private sectors and the necessary shift towards cost-effective interventions. It must be phased in a timely manner, allowing the detailed design of its structure and operating systems to take full account of the results of the evolving sector reforms. The Major Players Regions: Driving the Change for Patients Objective The whole purpose of creating regions is to achieve better services for patients and more job satisfaction for health care staff - with the resources available. They will allow hospitals, health centres and other services to be owned and managed closer to the consumer so that managers and health care staff are more responsive to the needs and wishes of those who are served. The regions will be operationally independent and will be able to make their own management decisions in much the same way as any independent and dynamic organisation can - without recourse to undue instructions from remote civil servants or bureaucratic rules. Functions The functions of regions are to provide primary, secondary and, in some cases, tertiary or specialist services. They will collaborate with teaching and research institutions and with municipalities. Regions will be able to:
The Five Regions There will be 5 such regional health authorities and their borders will coincide with those of the 14 municipalities within Trinidad (Tobago will be a single regional health authority) as follows: The North-West RHA Municipalities: Diego Martin an Juan/Laventille City of Port of Spain The Central RHA Municipalities: Tunapuna/Piarco Couva/Tabaquite/Talparo Borough of Arima Borough of Chaguanas The South-West RHA Municipalities: Princes Town Penal/Debe Siparia City of San Fernando Borough of Point Fortin The Eastern RHA Municipalities:Sangre Grande Mayaro/Rio Claro The Tobago RHA Island of Tobago Accountability With such a significant shift in responsibilities to the regions and with the freedom given to the regions to manage, it is important that they are held fully accountable to the public. this accountability will be retained to Parliament through the Minister of Health. The regions are being established under the Regional Health Authorities Act which sets out their powers and the degree of control to be exercised by the Minister. There are several constructs and procedures by which accountability will be maintained. Policy Regions must comply with the general policy guidelines issued by the Minister. Legal identity Regions are corporate bodies and legal action may be taken against a region in civil law. Financial Accounts Regions must submit annual audited accounts to the Minister within six months of the end of each financial year. Annual Report Regions must submit annual reports on the previous year's performance containing such information relating to the policies and operations of the region as the Minister may require. Business Plan The Minister will require each region to prepare an annual business plan, setting out the region's plans for the provision and development of services (including any proposed capital plans), the costs of those plans and the sources of finance proposed to put them into effect. Ministerial Directives The Minister may issue specific written directions and a region must exercise its functions in accordance with such directions. It is not intended that these powers will be employed in any routine way but more under exceptional circumstances. Nevertheless, this power may be used to cause regions to produce financial monitoring information and statistical data to facilitate the proper monitoring of a region's activities, if it is felt that the routine reporting procedures outlined above are inadequate for any reason. Regulations Under the Act The Minister may make regulations under the Regional Health Authorities Act with which regions must comply. Management The Board A region will be run by a Board of Directors appointed by the President. Individuals will be selected for their ability to steer a complex and dynamic organisation and will have skills in areas such as finance, management, personnel, law or health care. Boards will be small (7-9 members) plus a Chief Executive ex officio, but who does not vote. The functions of the Board are: * to set the overall policies of the RHA within national guidelines set by the Ministry of Health * to ensure the execution of those policies and to monitor performance * to maintain the financial viability of the RHA * to appoint a Chief Executive on such terms and conditions as the Minister may approve and to appoint any other senior management staff. Board members are appointed for up to five years but are eligible for re-appointment and they are to be paid for their work with such remuneration as the Minister approves. Members will be non-executive and will focus their limited time on the critical policy, planning and resource allocation decisions that will shape the services to be provided. they will review and critically question recommendations submitted by the Chief Executive and other executive directors, decide on policy and priorities within the framework of national policy, and review and challenge performance against agreed targets. The Board must control the performance of its executive directors through a process of individual or team performance review, ensuring that progress is according to agreed objectives, targets and budgets. Performance incentives including remuneration will be used to achieve these aims and this will be a particular responsibility of the Chairman of the Board. Executive Management The RHA Boards will delegate executive responsibility for the operation of services to the Chief Executive and other executive directors who will collectively form the Regional Management Executive. Executive management will be conducted according to principles of general management and will aim to: * establish firm control over the RHA's strategic direction, its resources and its performance * create a vision for the development and improvement of services based on objective health needs assessment and consumer preferences * tone up all operational management at all levels within the region in order to stimulate initiative, urgency and vitality and to obtain value for money through improved efficiency and performance whilst maintaining a 'human face' * involve clinicians, nurses and other professional staff in the practice of management Chief Executive Regions shall have a Chief Executive (or CEO) appointed by the Board for a term not exceeding five years but with eligibility for re-appointment. The Board may delegate to the CEO such functions and powers as it deems desirable for the effective day-to-day management of the RHA and the services it provides through its facilities, staff and sub-contracts. The Chief Executive will supervise corporate and business planning, internal performance review, policies and priorities. Other Senior Management A region may appoint other members of a senior management team as it sees fit and as its budget will allow — remembering that it is not the objective of decentralisation to produce five overstaffed structures but to introduce effective general management, ie - the authority and ability to manage as well as the responsibility. In terms of guidance to regions, it is proposed that the desired objectives will best be achieved by the organisation of management below the Chief Executive into two distinct streams: * operational management: the day-to-day operation of the hospitals and primary care services * corporate management: the strategic planning, internal performance review, finance control and personnel development functions. Operational Management This should be seen as the cutting edge of service delivery, requiring management and leadership skills to stimulate initiative and results through improved efficiency and performance. It will be headed by a General Manager (Hospital Services) and a General Manager (Community Services), both with executive director status and accountable directly to the Chief Executive and with authority to manage their services and their budgets. As full members of the Management Executive, they will also contribute to and be consulted about development plans, contracts, services specifications and business plans. The Director of Finance will nominate a management accountant to support each of the two General Managers in the management of their budgets and in developing pricing policies. Corporate Management It is proposed that there should be three executive directors below the Chief Executive: Director of Finance, Director of Health and Director of Human Resources. Their roles are to undertake the corporate functions of the RHA in developing policies, priorities and plans and in constructing and negotiating annual contracts with the Ministry. They will also provide support and advice to the two General Managers. It is thus proposed that each region should support essentially four new senior management level staff — the three Corporate Directors mentioned above plus the Chief Executive. The General Managers for operational services would not be new additions in the sense that they would not duplicate existing hospital administrators or senior primary care staff presently working for the Ministry. Nevertheless, to provide comprehensive resources in all the areas or responsibility of these Directorates would be unnecessarily costly and the expertise may not be available. It will be prudent to share some functions with other regions and to take advantage of Ministry support that is now being planned to assist regions. This support may include payroll services, financial services, statistical and epidemiological services, information systems, training and education. Key functions within each Directorate will include: Director of Finance * financial advice/policy * business accounts * budgets and budgeting * value for money * contract pricing * business planning * assets valuation * capital control * investment Director of Health * development of health policy * assessment of health needs * public health advice and advocacy * demographic and activity data analysis * research & development * services evaluation * health promotion and prevention * support for planning & contracting * liaison with clinicians Director of Human Resources * personnel policy and advice * support for operational managers * employment practices * industrial relations * negotiations on terms and conditions of employment * establishment control * organisational development * health and safety * staff development and training Advisory and Consultative Machinery It will be helpful to have mechanisms for obtaining collective advice from professional staff working within the region, and RHAs may wish to nominate a senior individual to provide such input and to confer titles in addition to those of their operational roles — Regional Nursing Advisor — for example. Management of Operational Service Units Other than the small senior management team outlined above, it is not envisaged that regions will develop any intermediate tiers of management — there will be no hospital boards for example. Structures below the two General Managers should be flexible to allow future adaptation and to fit the differing circumstances of regions. Certain principles should guide the development of management arrangements, however, as outlined below: * the two General Managers will be the managers of all operational staff within the region (for hospital or community care services), achieving this through heads of departments (in hospitals) and services with accountability clearly defined and allocated. * the two General Managers will be the budget holders for the services concerned but will endeavour to devolve budgets to departments and services within their responsibilities and hold the heads of those departments and services accountable for control of those budgets — budgets will be based on expected outcomes. * the Chief Executive will promote new management methods for Directors, General Managers and other senior regional staff — for example entering into "contracts for change" based on business plans or performance targets, leaving the managers concerned more freedom to solve their own problems locally and thus achieve maximum devolution to the lowest possible levels in the organisation. * clinical heads of services must be involved in management and eventually manage their own budgets * other staff should also be involved in management, at least in consultation and advisory capacities and this should include professional staff, including nursing, professional advisory bodies and staff representation bodies. * should develop the presentation of a caring attitude towards its consumers and establish mechanisms for assessing patient satisfaction as a measure of service quality. Hospitals The Management Executive should move as rapidly as possible towards establishing clinical units at the heart of the management of hospital services. This emphasises the patient orientation of management and places clinicians at the centre of both the clinical activity and the management practice of their departments so that clinical decisions are equated with resource implications. All other clinical and non-clinical support services exist to service this patient activity and should be set up as service centres, providing clinical departments with services at agreed unit prices. Each clinical head should manage their own department totally and would have a budget agreed annually with the General Manager (Hospital Services) which would be based on workload agreements, objectives and targets. Performance review is a vital part of this approach to management. The clinical heads will receive managerial assistance in this task from the General Manager and, in the formative stages, the Ministry will provide support in tools, techniques and training. The budget of clinical departments are made up of three major elements: * direct expenditure representing salaries of all staff working in the department and its directly consumed materials * expenditure for services rendered by clinical and non-clinical support departments like X-ray, laundry etc. * a contribution to central overheads The support units will need to be clearly identified and run as managerial units. A simple division will include: * clinical support services: pathology, radiology * patient services: reception/admissions, records * hotel services: cleaning, portering, catering, laundry, security supplies * estates management Primary Care Primary care services will undergo a rapid transition in the early years of regionalisation as regions develop the right balance between their primary and secondary services and as they are free to engage the services of the independent sector. The organisational structure of primary care must cover the existing disposition of services but must have a strong built-in service development capability to maximise the strengthening and rationalisation of services. Major primary care service centres should eventually become budget holders, free to organise their own care and to plan the best use of their agreed resources including contracting with the independent sector. The targets agreed with the General Manager (Community Services) will include the development and operation of cost-effective sharing of care between primary and hospital levels to achieve a desirable referral system, avoiding unnecessary hospital admissions. Regional Finance Commercial Accounting * Regions will operate under more commercial accounting arrangements than have prevailed under the centralised public sector: * Regions will receive no automatic 'subvention' from Central Government but will 'earn' their income through contracts with the Ministry to provide services. These contracts will be based on specified volumes of services. * A region's accounts must follow commercial accounting principles including depreciation Regions may borrow subject to the approval of the Minister of Finance for purposes of acquiring or replacing assets (the purpose of the loan will, of course, have to be approved by the Minister of Health) * Regions may retain operating surpluses and depreciation and invest these in capital improvements or to repay loans. Revenue It is foreseen that the vastly greater part of a region's income will be earned through its contracts with the Ministry of Health. However, regions will be allowed to generate some income from other sources including: * providing services to other regions or the private sector * supporting research, education or teaching activities * renting property to private sector users or non-governmental organisations (charitable organisations) * charging for services to private patients * donations and grants These income generating activities are subject to approval by the Minister and to their not adversely affecting a region's public sector obligations. Public Contract Pricing The 'prices' employed in a region's contract with the Ministry of Health will be agreed with the Ministry based on cost covering, including depreciation. The Ministry will monitor pricing across the regions to establish comparative measures. Regions will not be required to pay capital charges on the value of the assets vested in them by Government when they are set up. Financial dealings with the private sector will be at market prices. Asset Valuation Buildings and land in operational use by a region will be valued at their replacement cost. Those surplus to requirements must be returned to Government ownership but, if they are declined by Government, may be disposed of at open market value for the most valuable use. Regions will be required to maintain asset registers. The tangible fixed assets of a region (medical equipment, furniture etc.) will be valued at their current replacement cost. Borrowing In addition to finance generated by retained operating surpluses and depreciation (or from the sales of surplus assets) regions may also borrow to expand or improve facilities or to obtain working capital. Approval will be required from the Ministry of Health for the purposes of such loans and to ensure that the financial viability of the region is maintained. The Ministry will wish to be assured that the purpose of the loan conforms with national policy (to avoid duplication of expensive facilities for example) or that it does not introduce undesirable medical technologies that would have a deleterious effect on demand and equity. Approval from the Ministry of Finance will be required for the terms and conditions of the loan. In particular, regions will not be allowed to borrow in foreign currency unless approval is given, they will not be able to risk their assets by using them as security, and they will not be allowed to use loans for speculative purposes. Where the Ministry of Health wishes to encourage the development of a new facility in the national interest, it may provide the capital or guarantee a loan by a region. Business Plans The business plan will become one of the main planning tools of the regions and for Ministry assessment of a region's plans as the basis for sound contracting between the two. Regions will prepare annual business plans covering the five years ahead. They will be submitted to the Ministry two months prior to the start of the RHAs' financial year (1st January and the same for all regions) to allow the total national health sector financing requirement to be properly considered. Regional business plans will be required to: * Demonstrate clear assumptions about the region's service plan, costs and revenue, including that from Ministry contracts and any from other income generation activities * Indicate assumptions about inflation and cost increases over the plan period * Justify the plans for any capital developments and funding arrangements including a basic option appraisal exercise to demonstrate the costs and benefits of alternatives. Accounts Regions must keep full and proper accounts. As statutory bodies RHAs are bound by the Exchequer & Audit Act which prescribes much of the format for these accounts. In view of the special considerations of the RHAs, however, and to encourage them to actively vie between budget heads in the interests of flexible and responsive management, the Ministry of Health will develop guidelines specifically for regional accounts. The Exchequer & Audit Act allows for this. A region's accounts must be audited annually by an auditor (a practicing member of the Institute of Chartered Accountants of Trinidad & Tobago) and these audited accounts presented annually to the Minister of Health to lay before Parliament. Human Resources One of the prime reasons for establishing regions is to create more challenging and worthwhile job opportunities for staff in which they use their skills to the utmost and where operational decision making is delegated as fully as possible. Devolved management creates a higher performance by staff and results in better and more caring services for the public. To achieve these gains, regions will employ all their staff directly, setting their own terms and conditions. Over time, regions will offer employment packages that are sufficiently attractive to ensure that they can recruit the staff they will need. They will want to develop a new skills mix so that highly qualified staff — and this particularly applies to nurses — can do the jobs for which they are trained, leaving more routine tasks to others. When regions are created, staff presently working at any of the provider units vested in a particular region will transfer to the employ of that region on or before the date that region becomes operational. They will retain their existing terms and conditions of service. Pension rights will be preserved and regions are obligated to establish a pension scheme or to arrange for membership in an existing scheme. For any new staff they employ, regions are free to set the terms and conditions of services. Land & Premises Regions will become the legal owners of all health care land and buildings and their contents situated in that region's geographic area. It is then for the region to manage and maintain those assets and they will be able to charge a depreciation element in the price of their contracts with the Ministry. Regions are free to buy and sell their premises subject to approval from the Minister. In the case of disposal, premises that are surplus to needs and that were acquired by the region from the Ministry for no consideration (or a nominal consideration) shall be transferred back to the Ministry for the same amount. Those that were purchased by the region shall be offered to the Ministry at a fair market price and, if declined, may be sold on the open market. In the case of new capital developments, regions must make the case for capital investment in their annual business plans. In practice they will work in collaboration with the Ministry to ensure that their proposals will meet the Ministry's requirements as the purchaser of services. Regions will have to show that their proposals are the most cost-effective way of achieving the aims and will have to demonstrate that they have appraised different options for this. Regions will be responsible for managing the procurement of new premises through construction or purchase and will be responsible for their maintenance and upgrading. They are free to buy those services from the private sector or from any services agency the Ministry may decide to establish to assist regions in this or other functions they may have in common. Tobago Whilst it is intended that all of the above should equally apply to Tobago, it is recognised that it will have to be achieved within a slightly different context. Finance for health services in Tobago is presently handled by the Tobago House of Assembly (THA), directly from the Ministry of Finance. It would seem that the simplest future arrangement would be for the Tobago RHA to provide services for the THA as purchaser. However, the THA does not have the required purchaser skills and it would be unnecessarily expensive to develop them alongside those of the Ministry of Health. Instead, it would be possible for the THA to receive the required assistance and guidance on health needs assessment, contracting and performance review from the Ministry of Health whilst retaining its role of purchaser. In view of the relatively small population, the Tobago RHA would also look for some savings in the management structure proposed for the four regions of Trinidad. The Ministry: Sharply Focused The New Culture The whole "culture" of the Ministry of Health is about to change as regions become the owners of health care facilities, the employers of health care staff and the providers of health care services through their service units. The Ministry will aim to achieve performance in quality and cost through a combination of support, control and influence over the regions whilst leaving them largely free to develop their own operational strategies and effect their own day-to-day management. The Ministry will achieve this by: * Establishing national health care policy based on health needs assessment to determine health service priorities * Contracting with each region to supply volume service contracts for agreed amounts of money and by setting specific targets for improvement that follow needs assessment priorities * Reviewing the performance of regions in meeting their targets and the cost effectiveness with which they do so or the reasons for their failing to do so * Offering regions technical support to assist them in their new functions * Promoting and sponsoring research and the development of methods — in information technologies, management information systems and financial control, for example * Coordinating technology assessment (evaluating the efficacy and cost effectiveness of medical technologies) maximising use of the findings of other countries rather than initiating original trials. Key Aspects of the Ministry's New Roles The Ministry will have no operational responsibilities for the provision of health care services. This will be devolved to the autonomous regional health authorities as outlined above. The main role of the Ministry of Health — that of developing an overall health strategy for the country and ensuring that it is delivered — will be split into the functions outlined below. Developing National Health Policy & Strategy The national policy will be based on health needs assessment and the strategies for achieving policy goals will form the basis of setting objectives and targets, resource allocation and specialist manpower planning. Allocating Resources Resources will be allocated to individual regions on the basis of "service contracts" agreed between the Ministry and the individual region. These will direct expenditure towards the priorities of the national health policy and strategies. This will be backed up by development of a national information system able to ensure that financial resources are deployed in the manner intended and that would allow comparative costed outcome data to be produced. Objective Setting and Performance Review Specific objectives will be set for the achievement of health priorities and specific outcome targets would be agreed with individual regions. Annual performance review will be undertaken to establish how well objectives and targets are being achieved and to identify problems and possibilities for improvement in the next contract cycle. This will include the development of organisational and clinical audit to allow standards and targets to be set and monitored. R&D, Sponsorship and Regulation The Ministry will provide support to key individuals and organisations in activities aimed at achieving national health priorities. This will include health services research and development and the activities of certain NGOs as well as promoting the use of information technology. The Ministry will also provide certain regulatory functions aimed at quality and standards. These will include regulation of the private health sector. Regulatory frameworks for pharmaceuticals and the assessment of new technologies will be introduced. The Ministry will retain a veto power over large capital investment by regions. Following the introduction of a National Health Insurance System (NHIS), a number of these functions could be taken over by the NHIS agency. Ministry Skills Base Successful undertaking
of the functions outlined above will require a smaller staff in the
Ministry and a different overall skills mix. In broad terms, skills will
be required in the following areas: Epidemiology The Ministry will strengthen its capability to undertake on-going health needs assessment, to direct and support the regions in identifying what the health needs of their residents are and to assess how effectively they are meeting them — particularly what outcomes and health gain are being achieved. Policy Health needs assessment must drive the development of clear and explicit policies and strategies to meet the needs identified. These include broad policies covering access and entitlement, through to detailed policies on specific areas of clinical care to guide resource allocation and therefore planning by regions. Planning Policy and strategies must be developed into specific, timed and costed plans detailing how the Ministry's resources will be allocated so that these can be used by regions to arrive at their own clear goals and objectives. The Ministry's planning function will also ensure that these objectives and targets are being achieved. This will require a regional performance review mechanism and accountability via the contracting system. Economic/Financial The Ministry's internal skills base must move from not only managing the Ministry's external and internal budget-setting mechanisms but must encompass evaluation in terms of the cost effectiveness and efficiency of existing and new methods of health care delivery and the introduction of new technology. Cost-effective practice and clinical protocols will be developed. Quality Assurance & Clinical Audit There are currently no programmes in place to monitor the quality of health care being delivered in either the public or private sectors. Although these programmes should be developed by health care staff themselves at the operational levels of regions, this will require development support from the Ministry. They should include organisational and clinical audit and the development of multidisciplinary quality assurance programmes. Human Resource Planning & Management The Ministry must ensure that the specialist manpower needs of the health service will be met — both in terms of the numbers and of the skills available for recruitment by regions. This does not apply to non-specialist manpower for which the health service needs are no different from those of other organisations. Leadership The Ministry must provide a national vision of the way forward and must develop the ability to inspire the multiplicity of individuals and organisations responsible for delivering services. It must provide leadership in such difficult areas as rationing, innovation and the introduction of new methods. The style of leadership should be one of empowering and supporting regions and these qualities should feature in the selection criteria and training programmes for senior Ministry managers. Communication and Public Relations The health goals and policies of the Ministry should be widely disseminated and understood to ensure that there is public input into the preparation of policies and support for them. The public will need to feel confident that the Ministry is in control of health expenditure and quality of services — even if it sponsors regions and other providers to deliver it. Organisational Structure The organisational structure of the Ministry will be as simple as possible, emphasising that the Ministry is to become a slim, strategic and regulatory body responsible for "purchasing" or acquiring health care for the population (through a performance contracting mechanism) rather than directly providing it. The Ministry has recently undertaken a "retreat" at which senior staff have grappled with the structure of the new Ministry. The structure proposed in this document "Towards a Healthy Nation" takes full account of the work of that retreat and is very similar in most respects. Any key differences are identified and will be discussed with the Ministry in more detail in the coming months. The Permanent Secretary A Permanent Secretary should be maintained whose duties remain similar to those of the PS in all ministries, including essential liaison with other ministries and holding ultimate responsibility in civil service terms. The PS will remain deeply involved in supporting the Minister in his constitutional and political responsibilities and will need to be free from the burden of everyday responsibility. A Chief Executive It is proposed that a new key post of Chief Executive is created, reporting to the Permanent Secretary and whose role is to lead and coordinate the work of all Technical Directors. This role emphasises that the various new functions of the Ministry - particularly health needs assessment and the use of contracts to drive change — must be integrated into coherent and directed strategy. Responsibilities previously vested (sometimes by earlier legislation) in the post of Chief Medical Officer will now be vested in the Chief Executive. Management strengths will be sought for this post which will not be limited to candidates with medical or other health professional qualifications. Technical Directors Five (lean) Technical Units will report to the Chief Executive, each headed by a Director: 1 - Policy, Planning & Health Promotion; 2 - National Service Coordination, 3 - Quality Assurance & Value for Money, 4 - Human Resources, 5 - Finance & General Administration. 1 - Policy Planning & Health Promotion It is this key Technical Unit that will drive the activities of the new Ministry. Its functional areas will fall into three Divisions: Needs Assessment This Division will be charged with generating the information necessary for the identification of priorities and the planning of services. It will cover health needs assessment, epidemiology and policy formulation. Planning & Contracting This Division will control the long and short-term planning of services and their achievement through contracting with regions. It will need to orchestrate the contributions of other Divisions to these central tasks — health services evaluation, quality assurance, financial assessment etc. It will cover planning, contracting, information systems, performance review and technical cooperation. Health Promotion This Division will be charged with promoting the non-personal services aspects of health aimed at achieving behavioural change. Because it will develop communication skills to do this, it will also coordinate the Ministry's public relations functions generally. It will cover health promotion, social marketing, intersectoral action, communications & public relations. 2 - National Services Coordination This is the Technical Unit responsible for ensuring the delivery of any services that are not devolved to regions — at least initially. These might include national environmental health functions, national laboratory services, national blood bank services, some vertical health programmes and coordination of national ambulance services. Separate arrangements may be made for some of these services — the National Blood Transfusion Service may operate under contract to the Ministry for example — whilst others may be taken over by regions in due course. The Technical Unit is also responsible for offering certain support functions to regions where these may be provided more cost-effectively nationally. These might include information technology support, medical equipment maintenance and supplies. The Unit may offer these services in a variety of ways including commissioning them from the private sector or NGOs. These support functions will be provided on commercial lines with tariffs set for services provided — even if these are nominal initially. Regions will have the choice of acquiring services from the Unit or from elsewhere. 3 - Quality Assurance & Value for Money This important Technical Unit will orchestrate the raising of standards of care and achieving value for money. It will promote good practice and data collection including regional comparative data relating costs to patient activity data. Specific functional areas will include clinical audit functions, promotion of standards, protocols and procedures, health services evaluation, cost effectiveness, research & development including technology assessment and complaints review. 4 - Human Resources As the number of people employed in the Ministry declines, the volume of work in this Technical Unit will move from the employment, compensation and industrial relations functions presently required in a large civil service department to functions of manpower planning and development. Specifically, the functions of the Unit will include specialist manpower planning, education & training arrangements, staff development and personnel functions. 5 - Finance & General Administration The Unit is responsible for the financial probity of the Ministry and for ensuring external and internal budget constraints are met annually. In terms of external financing (mainly of the regions), the Unit will work closely with the contracting function of the Policy, Planning & Health Promotion Unit. Specifically its functions will encompass budgeting (external and internal), capital control, accounting, financial control and office management. The Ministry Management Executive Although the Ministry will remain part of the civil service, it will aim to adopt as much of modern management practice as civil service structures will allow. In particular, the Chief Executive will chair a Management Executive charged with guiding the Ministry, approving all significant changes from policy to action plans, reviewing national and regional performance including the results of innovation etc. The Management Executive will consist of the Directors of the Technical Units and others who may be appointed or co-opted as appropriate, including a representative from each of the major professions co-opted from management or service positions in regions for specific time periods. The Management Executive will report to the Minister through the Permanent Secretary. Assessment of Regional Plans A region's annual business plan forms the basis for the following year's contract for services and will be scrutinised by the Ministry with this in mind. Specifically the Ministry will be appraising a business plan in terms of: * consistency with national policy and priority strategies and programmes * consistency with the region's declared policy and strategy * accountability and the achievement of financial targets * internal consistency, financial viability and risk avoidance in terms of revenue and expenditure * viability of any capital investment proposals including the appraisal of options, borrowing requirements and cost recovery proposals. Allocation of Funds to Regions Public finance will be channelled to regions on the basis of their annual contracts with the Ministry. A region's finance will be calculated on a combination of factors including: * The region's population to be provide |
