Last July, shortly after government minsters, TDs and senators went on their summer holidays, the Value for Money and Policy Review of Disability Services (VFM) report was published to little or no fanfare, discussion in the media or, conveniently, debate in the Dáil. This long-awaited review, commenced in 2009, is not an easy read, but for those willing to go through its over-300 pages, there are many illuminating nuggets of information. The Review puts to bed the myth that services for people with intellectual disability are provided by poorly-paid service providers struggling valiantly with insufficient resources to provide quality services to meet increasing demand.
This myth was first debunked in 2005 when the Comptroller and Auditor General (C&AG) highlighted the scandalous lack of transparency and accountability when it came to funding not-for-profit organisations. Money was allocated by the HSE to services without any proper audit of money spent or services provided and no tendering or measurement of outcomes achieved. A system of block funding existed, in which annual funding for a specific service was based on what had been received the previous year, with a bit more added on. In the early 2000s , I recall being told by a provider that each time a person came off the waiting list, the funding for that new place was linked to that person. I now find out that this was patently untrue, as the VFM report shows that once allocated, the funding did not remain associated with the individual, but was absorbed into the agency’s base funding (Finding 3.11 of the VFM Report). Despite the evidence of the C&AG Report, money continued to flow into this discredited system.
The VFM report shows that total gross expenditure on disability services increased by 34% from €1.34bn in 2005 to €1,789bn in 2009. Expenditure for 2011 is estimated at €1.708 bn. Pay costs account for up to 85% of this spending. While in the last two years there have been pay reductions and a moratorium on recruitment , the amount of these reductions (approx 5%) is significantly less than the 34% increase over the 6-year period.
Some changes were introduced on foot of the C&AG Report, most notably the establishment of Service Level Agreements (SLAs) with the HSE. However, the VFM Review notes that the information from the SLAs is not collated at a national level and does not contribute to any national monitoring of performance. It also says that there has been no objective evaluation of the operation of this new process, which took over five years to be established, against considerable opposition from some large providers.
The imperative to reform was simply not there. As long as money was flowing freely, nobody cared. It is now clear that little of the extra cash was being allocated on the basis of rigorous analysis, evaluation or consideration of value for money. Much of the spending was targetted at pleasing vested interest or buying them off, the main vested interest being voluntary service providers, trade unions, professional groups, and quangos, who all have done extremely well out of the disability sector in the last ten years and continue to do so with the protection offered under the Croke Park Agreement. The failure of the HSE and the Department of Health to monitor this use of tax payers’ money can only be termed gross negligence.
However, it is not surprising, given that we live in a country where the political system, as recently (Oct 2012) described by Stephen Collins, political correspondent of the Irish Times, has the propensity ‘to be captured by narrow interests rather than act for the common good’.
It is unlikely that issues of excess in spending, waste or accountability would have raised their ugly heads if the government had not run out of money. The VFM Review provides us with a great deal of information which we did not have before. The Review had great difficulty in obtaining basic information from both the HSE and voluntary disability providers which would enable conclusive findings to be made in many areas. Consequently, the Review had to undertake original data collection itself, which added considerably to the time it took to be completed.
Not surprisingly, two of the Review’s key implementation priorities relate to the urgent need for better data collection in two key areas:
— The financial reporting system where allocations and expenditure can be tracked, analysed and compared at national, regional and local levels, and
— SLAs which are streamlined for immediate improvements to basic information gathering and performance monitoring.
The failure to have such basic systems in place for a ‘billion-euro industry’ is a clear indictment of successive Ministers for Health and senior officials in the Department of Health and the HSE.
Much is made in the Review about the need to facilitate individualised service provision, and it is encouraging to read that the Review recommends that the HSE should drive this through the SLA process. Disappointingly, it does not say how this should be done. The only way to ensure individualisation is to link it to the service providers’ annual funding allocation each year: providers would agree with the HSE a percentage of their allocation to be spent on individualised planning and budgeting. Failure to meet the agreed target would then cause a proportion of the allocation to be withheld or withdrawn.
I disagree with the implementation priority of seeking more demonstration or pilot projects to look at person-centred models of support. The country is awash with such projects, whose end results benefit a few, but which will have no real impact on the 4000 still living in congregated settings. An independent VFM review of all the pilot projects is essential.
To change policy requires action by government to real reform at a national level. This will require strong leadership from the top and a Minister for Disability who has the full support of the government to stand up to the vested interests. I posed the question in the title of this article, whether the Review offers hope for the future, or whether it is just another damp squib—something that fails to live up to expectation. Unless people with disabilities mobilise into a cohesive group, making alliances along the way with others, as they so ably did outside Government Buildings last summer, I fear this Review, worthy and all as it is, will end up on the shelf gathering dust—just like all the other reports of the last twenty years.