The provision of services to persons with learning disability in Ireland has a particular history which is significant for the level of involvement by voluntary service providers. While the statutory sector also provides services, and in some cases significant services, it has also traditionally occupied the role of funder. This has obviously led to the development of particular relationships over a long number of years which were, perhaps, only really examined and formalised with the publication of Enhancing the Partnership in 1996. This document was produced at a time when the Department of Health and Children were passing responsibility for the voluntary agencies over to the health boards. It is not insignificant that the bulk of the recommendations in the document relate to funding.
At the time when the document was drafted, the fourteen largest voluntary providers had a direct funding relationship with the Department of Health and Children. By 1 January 2000, this had been fully transferred to the health boards. The numerous smaller service providers maintained their direct-funding relationship with the boards, with the exception of four providers in the East who came under the remit of the newly established Eastern Regional Health Authority on 1March 2000-
In general, budget allocations were calculated from a historical base which acknowledged that at least the same level of service would be maintained, with additions to be made in respect of pay awards, increments or inflation. It should be pointed out that it took many years for smaller agencies to automatically secure such payments.
The Planning Committees in each health board then undertook to distribute development funds for new services, based on the agreed plan drawn up in conjunction with voluntary service providers. In the event that development funding was awarded to an agency directly funded by the Department, notification was sent from the health board to adjust the base budget of that organisation to reflect the additional funding.
It is fair to comment at this point that not a great deal of adjustment was made to base budgets, which generally increased on an incremental basis. The major concern for agencies transferring to health board responsibility was to clearly establish an agreed baseline budget and mechanisms for future negotiation. The factor which was to impact most on this was the introduction of service agreements. While there appears to be some variance in the level of signed agreements achieved around the country, the underlying principles are consistent.
Funding is directly linked to the quantum of services provided and adjustments can be made in respect of changes to the pattern of service delivery. The financial statement forms an important part of the agreement and must reflect all financial pressures such as pay awards, increments and any pertinent non-pay items. The agreement is then signed-off by the health board or authority CEO and the CEO of the voluntary service provider.
The development funding for new services are still channelled through the Planning Committees which are now a twofold structure, following the implementation of Enhancing the Partnership.
A Consultative Committee—which should include broad representation from agencies, health boards, FÁS, Department of Education and Science and parents—makes recommendations based on agreed plans and priorities. These are considered by the Development Committee, which consists of service provider representatives and is chaired by the health board. This group advises the CEO of the health board on the distribution of development funds.
Level of funding
It is the view of many that the level of funding provided to maintain and develop services is inadequate. One of the key bones of contention is the per-capita rate applied to the provision of new day, residential and respite places. Put simply, a fixed rate is applied in respect of each new place. This takes little cognisance of level of dependency or complexity of the actual resources required to provide such a placement.
It should be acknowledged, however, that in recent years when health boards have agreed their provider plan with the Department, a degree of flexibility has been allowed in relation to the total number of places to be provided to reflect the issues raised above. Despite this, there are still significant shortfalls in the per-capita rate required to provide a place for any service user who requires additional supports to maintain a placement. Obviously, these people must be cared for adequately; this can and does lead to budget deficits which place a severe strain on a provider’s finances.
The primary way in which this is addressed is to provide ‘once-off contingency’ funding to the service provider in the year in which the costs arise. This cost then becomes a ‘first charge’ on development funding the following year in order to secure funds into the base budget. The effect of this is to reduce the number of places available for new developments, and perhaps to perpetuate the problem.
The issue of funding health services in general is a complex and difficult issue. The particular factors that pertain to funding in the learning disability sector include the differing levels of dependency and need, the ageing population and the levels of challenging behaviour presenting. All of these factors significantly impinge upon a provider’s ability to cater for all at a fixed per capita rate.
I am aware that work has been carried out in various quarters to establish links between service provision and costs, in an effort to properly cost the various elements of service. While this is far from a simple exercise, it is well worth pursuing from the perspective of both funders and providers.
Given the picture outlined above, both funding authorities and service providers have to endeavour to maximise both funding sources and the use of available resources. A number of initiatives have emerged, which I briefly outline below:
Shared Services—the concept of one or more service providers sharing common services such as payroll, information technology or human resources to spread costs and effect a reduction overall.
Value For Money—providers are encouraged to look at all areas of service and, particularly, at contracts which are entered into for goods or services. In some cases providers may join together to avail of better terms for provision of such goods or services.
Sourcing Grants—providers are encouraged to avail of appropriate schemes such as those available from the Department of the Environment (housing), Department of Education and Science (schools), Department of Justice, Equality and Law Reform (integrated services), FÁS (Community Employment Schemes) and other schemes such as National Lottery, People in Need and appropriate EU Schemes.
The availability of such funds has reduced the total dependency on the health budget and has enabled agencies to progress service development. These initiatives have shown the willingness of service providers to seek other methods of financing services and maximise available resources.
In conclusion, there are difficulties in the funding of learning disability services which will take time to overcome. The substantial investment by government in 2000 and 2001 enabled significant service developments to take place and resolved a number of outstanding issues. As it not considered possible to continue that level of development in 2002, there is a serious danger that the progress made during the previous two years will be eroded and many of the previous difficulties will re-emerge.