Reforming the Irish
Health System:
Current Issues
Tony O’Brien,
Chief Operating Officer, Special Delivery Unit, Department of Health
Adjunct Associate Professor, Health Policy and Management,
Trinity College Dublin
Presentation
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Policy Objectives
Key Challenges
Existing Foundations
Indicative Timelines
Using the lens of the HIQA “Tallaght” Report
Discussion
Why reform?
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Inequitable access to care; long delays in ED and on
waiting lists
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Capability & management deficits
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Inadequate governance & financial systems
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Challenging financial and HR resource environment
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Very significant increases in expectations & demand
The Opportunity
To completely transform our health system
3. Equal Care
A Single Tier UHI System
2. Higher Quality
Care
Clinically Lead, Rigorous
Performance Management
1. A New Model of Care
Treatment at the Lowest Level of Complexity
that is Safe, Timely, Efficient and as Close to
Home As Possible
What of Kind of Reform
Traditional
Approach to Reform
Current Approach
to Reform
• Incremental
• Dictated by Resources
• System Focused
• Comprehensive
• Led by Innovation
• Patient Focused
A New Vision For Irish Healthcare
• Strategic Areas for Reform
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Increased focus on Health and Well-being
Structural Reform
Financial Reform
Service Reform
• Reforming the Delivery System
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Hospitals
Primary Care
Continuing Care
Public Health
Capability Deficit
Progress to Date on Health Reform
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SDU established & making good progress:
• 19.8% reduction in the number of patients waiting on trolleys (Q1 2012 vs Q1 2011).
• 99% of adults waiting less than 12 months for inpatient & day case treatment (79%
waiting <6months).
• 98% of children waiting less than 12 months for inpatient & day case treatment (74%
waiting <6months).
• Performance management system (CompStat) currently being introduced across the
system.
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Universal Health Insurance:
• Implementation Group on UHI established & working intensively on ‘Money Follows the
Patient’.
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Primary Care:
• Universal Primary Care Project Team established by Minister Shortall.
• Government approval for policy of phased extension of GP care without fees starting
with those with defined long-term illness in 2012.
• Legislation to abolish restrictions on GPs wishing to become contractors under GMS
commenced.
• Drafting of Bill to provide for designation and substitution of interchangeable medicines
well advanced.
Progress to Date on Health Reform
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Fair Deal
• Funding now solely used to fund long-term residential care.
• Centralised management of funding for public nursing homes.
• National placement list established (ensures equity).
• New IT system across all 18 nursing home support offices.
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Disability
• VFM & Policy Review on target for publication end Q2 2012, after which
reforms to the system of financing & delivering services (including
individualised budgets) will commence.
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Mental Health:
• 12 ‘old’ psychiatric hospitals across the 4 regions have either closed
completely or closed to new admissions.
• €35m special allocation in 2012, part of which will be used to strengthen
community mental health teams.
• Additional 414 staff to be put in place in 2012, together with appropriate
clinical care programmes based on early intervention & a recovery
approach.
National Clinical Programmes:
Mission & objectives
1. Improve Quality
2. Improve Patient Access
3. Reduce Cost e.g. reduce average length of stay , reduce bed utilisation.
Key principles
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Clinically led – empower clinicians to lead the change
Structured programme management approach
Nationalise existing best practice
Engage Patients
Align stakeholders – Government, Management, Colleges, Unions,
Patients, etc
Clinical Programmes
Primary Care
Pediatrics
Obstetrics and Gynecology
Other clinical services
Audiology
OPAT IV Therapy Program
Pathology
Blood Transfusion
Safety
HCAI
Medication Management
Chronic Diseases
Stroke
Heart Failure
Acute Coronary Syndrome
COPD
Asthma
Diabetes
Dermatology
Rheumatology
Neurology
Epilepsy
Renal
Mental Health
Unscheduled pathway
Ambulance service
Emergency Medicine
Acute Medicine
Acute Surgery
Radiology
Critical Care
Rehab
Palliative Care
Care of the Elderly
Elective surgery
Surgery
Orthopedics
Public Service Agreement
• Revised Health Sector Action Plan accepted by
national level Implementation Body
• Key Challenges:
• Reviews of rosters, skill mix, productivity & staffing levels &
increased use of redeployment
• Reductions in overtime/allowances/agency staff spend
• Consultants – work practice changes & more flexible
attendance patterns
• Productivity increases in Primary Care – enhanced and more
cost effective integrated care
• Reduction in management layers
• 3.5% target for absenteeism (4.9% in 2011)
Command and Control
• Widespread feeling that Command and Control
has disempowered the frontline, removed
accountability and reduced transparency
• AIM to devolve as much power as possible within
the health system
• shift the focus from:
• Inputs to Outcomes
• The Centre to the Local
• The System to the Patient
Governance: Radical Change in 2012
• 7 New Directorates
• Hospitals, Primary Care, Social Care, Mental
Health, Children, Public Health, Shared Services
• Directors will have a crucial job of work
• To prepare the system for move to the Integrated
Care Agency in 2013
• RDOs will retain their crucial systems role
Governance: Key Changes
• Continue the move to hospital groups across the country
• This is already happening in the West
• The Clinical Care Programmes will move to the
Department of Health
to ensure the closest possible cooperation between the
SDU and the Clinical Programmes
• A new Programme Management Office will be established
in the Department
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It will be a crucial driver of reform
Changing the Model of Care
Primary Care
• First phase of Free GP Care
• For people who receive medicines under
Long Term Illness scheme
• First phase of Chronic Disease
management for diabetes
• Cut the cost of medicines
• For consumers and the State
Changing the Model of Care
Social Care
• Mental Health
• Implement Vision for Change
• Shift to Primary Care
• Older People
• A whole of Government approach
• Shift to Home Care
• Disability
• Value for Money reform
• Shift to Personalised Budgets
Reforming the Insurance Sector
• Full Risk Equalisation will be introduced
• Work with the Insurance Companies to
significantly reduce costs
• Measures to create balanced market for
insurance
An Ambitious Political Timeline for
Reform
2016
UHI Free
2015
Free GP Care
2014
Money Follows The
Patient
2013
Integrated Care
Agency
2012
Key Reform
Priorities
2011
Creation
of the
SDU
Indicative Health Reform Timelines 2012 - 2015
2012
2013
Patient Experience
(i)
Less than 9 hour ED wait
for all & 95% to wait no
longer than 6 hours
(ii)
No patient will wait more
than 9 months for an
inpatient or day-case
procedure
(iii)
Phased extension of GP
care without fees begins
with those with defined
long-term illnesses
Patient Experience
(i)
No patient will wait more
than 12 months for an
outpatient appointment by
March 2013
(ii)
Extension of GP care
without fees to those
people prescribed
medicine under the HighTech Drugs Scheme
Q1/Q2
(i)
HSE Board abolished
(ii)
Programme
Management Office
established in DoH
(iii)
Introduce new initiative
for management of
chronic care in the
community - diabetes
Q1/Q2
(i)
Vote returns to the DoH
(ii)
Reformed Risk
Equalisation Scheme
introduced
(iii)
All hospital groups fully
formed and operating
Q3/4
(i)
New directorate structure
introduced in HSE
(ii)
First wave of hospital
trusts established
(iii)
New Children’s Agency
established
(iv)
ICA established and
operating in DoH
(v)
Zero-based strategic,
operational and financial
review competed
(vi)
PSA established on
Admin Basis
2014
2015
Patient Experience
(i)
Subsidised GP access for
all introduced
Patient Experience
(i)
Free GP care extended to
all
Q1/Q2
(i)
Purchaser/Provider split
established through
creation of Integrated
Care Agency
(ii)
Review of arrangements
for hospital trusts
(iii)
Bundled payment system
for chronic illness
introduced
Q1/Q2
(i)
All hospital groups will
have appointed their CEO
through an independent,
competitive process
2016
U
H
Q3/4
(i)
Legislation to abolish
HSE introduced
(ii)
Money Follows the
Patient introduced for
elective procedures
Q3/4
(i)
Money follows the patient
extended to outpatients
and diagnostics
(ii)
New initiative for
management of chronic
disease in the community
– cardiac, respiratory and
neurological conditions
Q3/4
(i)
All hospitals managed in
independent trusts
I
Governance
Integrated Care Agency
HSE
ICA
Integrated
Funding
Funds
e.g. Primary Care Fund
Department of
Heath
Providers
Hospital Groups/Trusts
Integrated
PCOs
Service
Social Care
Delivery
Developing a new accountability
framework
PERFORMANCE IMPROVEMENT
We hold leaders
personally accountable
for performance against
KPIs
WHEEL
Escalation
Intervention
We clarify sanctions
and incentives (an
essential part of the
leadership challenge)
We start here with
simplified, clearer
targets that better
reflect the patient
journey
Numeric
Objectives
Monitoring:
Frequency,
Quality, Lag
We establish
systematic,
comprehensive and
high frequency
weekly monitoring
systems
OUTLINE OF NEW PERFORMANCE
REGIME
Definition
Persistent performance
issues or no confidence
standards will be delivered
Significance
Special
measures
Ongoing performance
issues or low confidence
standards will be delivered
Expectation of change
in hospital leadership
Very high frequency
monitoring, high
concern
Some performance issues
or medium confidence
standards will be dlievered
Closer monitoring,
elevated concern
On trajectory or high
confidence standards will
be delivered
Light touch monitoring,
hospital entitled to
priority for strategic
developments
This scheme requires the introduction of a hospitallevel scorecard with hard targets…
Quality, access, finance:
The basis of the new scorecard
QUALITY
Safe, high quality,
patient centred
service
ACCESS
FINANCIAL BALANCE
Home Page
National PTL
St. Vincents – On Target
Level 1:
National PTL
Level 2:
WEST
Level 3:
Galway University Hospital
Level 4:
All Specialities
Level 5:
General Surgery Speciality
Level 6:
General Surgery Consultants
Level 7:
Individual Consultant
Level 8:
Outstanding Procedures
HIQA REPORT –
TALLAGHT HOSPITAL
KEY POINTS TO CONSIDER
SCOPE OF REPORT
• Situation in Tallaght hospital
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Governance
ED situation
Board performance
Executive management
Planning
• Relationship between hospital and HSE
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Governance
Performance management
Service planning – national and Dublin
Oversight
SCOPE OF REPORT
• National perspective
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SDU Performance management
Oversight committee for report
Special Measures
Operating Framework
MAIN ISSUES
• Poor leadership, governance,
performance and management of
hospital
• Need culture of patient safety
established
• Need to modernise and improve
• Establish Oversight Committee to
ensure recommendations implemented
KEY MESSAGES – Unscheduled Care
• No more trolley waits in unsuitable areas and
work towards zero tolerance of all waits
• Establish and transfer clinical responsibility for
patients
• HSE/SDU must measure key performance
indicators:
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6 hour waiting time with key points
Patients who left without being seen
Reattenders
% of patients admitted from ED
Profile of patients attending ED
KEY MESSAGES – Unscheduled Care
• Work to implement EMP
recommendations – must be centrally
co-ordinated with other Clinical
programmes by HSE/SDU
• Eliminate inconsistencies in data and
measurements
• Improve IT systems and production of
data and information
• Use information to manage situation in
KEY MESSAGES – Unscheduled Care
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Utilise Manchester Triage in all EDs
Introduce NEWS for every admitted patients
Implement Clinical Decision Units
Improve Emergency consultant cover in ED and
ensure all on call teams appropriately available
• Manage and review patient streaming,
discharge arrangements and access to
diagnostics
• Involve GPs in Emergency Departments
KEY MESSAGES – Unscheduled Care
• Extended and expanded roles for
nursing and allied health professionals
• Ensure Ambulance handover times are
met
KEY MESSAGES – Scheduled Care
• Hospitals must engage with key stakeholders to
ensure appropriate referral processes
• Ensure SDU co-ordinates Clinical Programmes
• Timely access to diagnostics was poor – needs
to improve in Tallaght and nationally
• Surgical ward rounds early in the morning with
patients allocated to appropriate speciality
wards
KEY MESSAGES- Scheduled Care
• Ensure there is active discharge planning
• Introduce nurse led discharge
• HSE/SDU enable access to continuing care
services in the community
• Implement voice recognition and alert software
• Outpatient planning and monitoring must be
introduced:
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DNA rates
New/Follow up ratios
Clinic schedules
National benchmarking
KEY MESSAGES – Scheduled Care
• Pre assessment of scheduled patients
• Establish clear waiting list planning
policies and procedures and monitor and
validate regularly
• Day case rates
• Analysis required of activity, demand and
utilisation of diagnostic services
• National and regional review of high
demand low capacity diagnostics required
KEY MESSAGES – Board Governance
• Replace current Charter with fit for purpose
Board legislation
• Implement proper Board procedures, especially
related to Corporate Governance and meetings
structures and responsibilities
• All hospital Chairs should report to national line
manager
• Develop Boards into Hospital Groups
• Performance management required for
hospitals
KEY MESSAGES – Board Governance
• Boards should be of sufficient size and appointed
by State using independent process
• Introduction of mandatory Board induction
programme with ongoing development programme
• Clearly define roles and responsibilities of the
Board
• Board members must understand their
responsibilities and accountability
• Board should have access to appropriate
information including development of a quality and
safety framework
KEY MESSAGES – Board Governance
• Boards should oversee building of
strategic partnerships
• Clear lines of accountability to executive
team
• Establish systems to receive and review
concerns raised by staff or patients
• Chair must ensure annual objectives in
place for Chief Executive and effective
process for monitoring performance
KEY MESSAGES – Executive
Management
• Need clear lines of responsibility, performance
management and accountability
• Chief Executive and team must implement
strategy and agree objectives across the
organisation
• Clear clinical management
• Clear career progression for leaders and
managers
• Chief Executive appointments must be
overseen by Board and National Director
KEY MESSAGES – Planning,
Governance and Oversight
• Dept of Health must develop National plan for tertiary and
quaternary services
• Comprehensive analysis and redistribution of services
across Dublin
• Population and policy informed needs based allocation of
resources for health services must be introduced
• Improve relationships between hospital and HSE
• Improve financial control and budgetary management
• Poor definition of statutory and non statutory contribution
of hospitals to HSE service plans
KEY MESSAGES – National Perspective
• Operating Framework required
• Invest in new and current leaders with
clear training and development
opportunities
• Deploy a resource to support
challenged hospitals
• Establish Special Measures Framework
• SDU – responsibilities to improve
situation