Limerick 1970’s
Limerick 1950’s
Limerick 2010
Our Lady of Lourdes
South Tipperary General Hospital
RTE Newsflash:
….. recent reports that the ongoing violence has moved off the streets
of Limerick, and spread elsewhere in the country, are apparently true….
Reconfiguration in South East
Reconfiguration in South East
Dept of General Surgery, STGH
National Surgical Reconfiguration Project
D.I.Y. 2010
Reconfiguration of Acute Hospital Care:
just what is it all about anyway ? …
Reconfiguration:
Modernisation ?
Improvement of Services ?
Altering the Role ?
Gaining Control ?
Where is the evidence that the patient benefits
? …
or, is it just about downgrading… !
History of Successful Reconfiguration in Irish Health Services
- FEDERATED HOSPITALS
- MANCH
- JERVIS St / RICHMOND
- SOUTH DUBLIN
- CORK
- WRH
So what’s the common theme ?
Reconfiguration of Acute Services
Evidence of benefit
Urban vs Rural
Road Network 2000 vs Motorway Network 2010
Celtic Tiger 2000 era vs Anglo world 2010
Motorway & Major Road Network 2010
Has there been successful reconfiguration of acute
Services in Smaller hospitals ? ….
What defines a ‘smaller’ Hospital ? ..
- Bed numbers
- Activity
- Complexity of work
- Budget
-Geography
-Hospitals now well flagged
Independently Resourced Hospitals
Blackrock Clinic
MPH
Beacon
Bons Secours Hospital Group
Hermitage Clinic
Whitfield
Mount Carmel Hospital Group
Galway Clinic
….. and others
The real question is can we or should we reconfigure
Acute core services in the Intermediate-sized Hospitals
-Kilkenny
-Portlaoise
-Portiuncula
-Tullamore
-South Tipperary ( Reconfiguration 2007)
-Kerry
-Wexford
-North Western group
-Naas
-Mullingar
Drivers of Reconfiguration
‘The Claims’
Critical Mass
Outcomes
Government Policy / Transformation Programme
Safety / Licensing
Specialism
Working Time Restrictions
Diminishing pool of Doctors / Professionals
Costs
Training
‘Drivers’ of Reconfiguration
‘The Counter Claims’
- Critical Mass
Differs hugely in every western country
- Outcomes
No Evidence for vast majority of acute conditions
- Safety
Read the papers
- Specialism
Recognized ceilings
- Working Time Restrictions
Mostly being achieved
- Diminishing pool of Doctors / Professionals
Fault is one of policy / manpower embargo
- Costs
No Savings
- Training
Ask the trainees
Reconfiguration should be about :
What services are working well
vs
What services would work better in central located hopsital
vs
What financial benefits are accrued from reconfiguration
Getting the balance correct
Necessary Reconfiguration
vs
Unnecessary Reconfiguration
vs
Unsafe Reconfiguration
Stranger things happen ! ...
So what have we done ? …..
South Tipperary General Hospital
S.T.G.H.
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1940 Surgical Hospital Cashel
1952 Medical/Maternity Hospital in Clonmel
1969 Acute Psychiatric Unit integrated in Clonmel
1996 High Court agreement to reconfigure all acute care
2007 Reconfiguration finally happens
2008 May: Official opening STGH by Minister Mary
Harney
Demographics STGH
Population Served
Med/surg/mat/gynae/paeds: 110,000
Psychiatry: 150,000 (planned 88,000)
Pop.Profile: Mixed urban/rural (70% rural)
Major manufacturing farming equine centre
Geographic Area: Approx 1,000 sq miles
National Statistics
In-patient
Discharges
18,000
16,000
14,000
12,000
10,000
8,000
6,000
4,000
2,000
Wexford
Mater
St. Luke's
St. Vincents
Kerry
Cavan
South
Portiuncula
Midland
Midland
Mercy
Connolly
South
Naas General
Our Lady's
St. Michaels
Merlin Park
Roscommon
Louth
Ennis General
Nenagh
St.
Mallow
St. John's
Monaghan
Bantry
0
Overview Statistics 2009 STGH
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Discharges 12,794 + 3%
Day Cases 8,430 + 46%
Radiology Procedures 74,557 + 20%
E D Attendances 34,911 + 6%
Deliveries 1,365 + 15% (+36%/3 years)
OPD Attendances 47,045 + 6%
G I Endoscopies 3,993 + 1%
Services
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Surgery General
Surgery Urology
Obstetrics & Gynaecology
Paediatrics & Neonatology
Acute Psychiatry
E.D.
Imaging including 24 hour CT
Laboratory
Services
General Medicine
Cardiology
Diabetes/Endocrinology
Gerontology
Acute Stroke Unit
Gastroenterology
Rheumatology
MAU
E D Workstation
ED Minor Injuries
Adult resus
Emergency Department Activity
2007
2008 2009 % change
New Atts 25,943 29,116 31,832
Return
Total
2,692
2,830
3,079
28,185 31,946 34,911 +9
National Statistics
ED Attendances 2007
Longford/Westmeath
Wexford General
Sligo General
Kerry General
St. Luke's Hospital,
Connolly Hospital
Letterkenny General
Midland Regional
Mayo General
South Tipperary
Naas General
Cavan General
Mercy Hospital,
St. Columcilles
South Infirmary
Portiuncula Hospital,
Our Lady's General
Ennis General
St. John's Hospital,
Louth County
Nenagh General
St. Michaels
Roscommon County
40,000
35,000
30,000
25,000
20,000
15,000
10,000
5,000
0
1 of 4 New Theatres
Surgery
Admissions
2007
2008
2009
% Change
2,744
2,732
3,006
+ 10
Average Length of Stay
Day Cases
4.58
2,341
2,459
2,527
+5
Major
832
792
981
+ 23
Minor
1,538
1,393
1,694
+ 21
Endoscopies
1,774
2,336
2,281
-2
Operations
Out-Patients
New Attendances
2,363
Return
4,166
Surgical Department South East Comparative
Statistics Jan-Nov 2008
Waterford
Wexford
Kilkenny
Clonmel
Inpatient
Discharges
2552
2982
3426
3006
Daycases
2317
1985
2305
2322
(2527:2009)
A.L.O.S.
(Days)
6.41
4.9
4.37
4.58
% Surgical
Daycases
of Total
2007
31%
18%
30%
34%
(45%:2009)
% Surgical
Admission
s with no
procedure
31%
36%
38%
20%
Day Ward
Endoscopy
1 of five new inpatient wards
Medical Department
Admissions
2007
2008
2009
% Change
4,996
5,331
4,864
- 10
6.29
6.25
Average Length of Stay
Day Cases (inc MIC*)
2,348
2,680
2,861
Medical Oncology
NA
NA
2,336
+7
5,197
Day Cases Total
Out-Patients
New Attendances
2,295
Return
7,900
TOTAL
10,195
Endoscopies
1,332
1,625
1,712
+5
Medical Departments S E Hospital Comparisons
General Medical Jan-Nov ‘08
Waterford
Wexford
Kilkenny
Clonmel
Admissions
4686
6856
5667
5331
ALOS
(Days)
9.0
6.45
5.81
6.29
Daycases
2534
1403
1447
2464
(5197:2009)
Casemix
Index
.95
.86
.76
.96
New Intensive Care Unit
ICU Activity Snapshot
Patients
Bed Days Used
Occupancy (%)
2006
42
695
48
2008
135
1627
84
Anaesthetics Activity Snapshot
Surgical
Anaesthetics
% Change
2008 2185
2009 2675
Gynaecology
Anaesthetics
% Change
1594
% Change
226 (’06)
1379
22
Obstetric
Anaesthetics
16
521
130
Obstetrics
2008
2009
% change
Admissions
1,957
2052
+5
Average Length
of Stay Days
3.17
3.16
Births
1,178
1,365
+15
Gynaecology
Activity
2008
2009
% change
Admissions
845
783
639
Average Length
of Stay
2.7
2.64
Number of
Procedures
1379
1594
16
+32
Day Cases
139
259
347
Total
984
1032
986
Outpatients
1,141
New
Return
2,085
Total
3,226
-13
Paediatric Party
Paediatrics Activity
2007
2008
2009
%
Chan
ge
Admissions
1,381
Average Length of
Stay
Day Cases
15
1,742
1,492
2.62
2.58
109
109
- 15
0
Psychiatry Activity
Acute
Admissions
Out-Patients
2007
2008
2009
602
663
661
845
X – Ray Dept
Imaging Activity
2008
2009
% Change
X-Rays
46,517
53,541
+15
CT Scans
3,846
5,990
+59
Ultrasounds
10,752
13,651
+30
Dexa Scans
1,003
1,375
+37
Total
62,550
74,557
+20
New Oncology Ward
In Hospital Visiting Consultant Led Services
Oncology
 Palliative Care
 Dermatology
 Haematology
 Microbiology
 Orthopaedics and Fracture Clinics

New physio gym
In Hospital Associate Specialties:
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Cardiac Investigation
Dietetic
Laboratory
Pharmacy
Physiotherapy
Occupational Therapy
Speech and Language Therapy
Library
Academic Links

UCC
Integral Teaching Hospital

U.Lim
Integral Teaching Hospital 1st Aug 2010

UCD
Paediatrics Medical School

U.Lim
Midwifery Training Placements

U.Lim
Physiotherapy Placements

WIT
General Nurse Training Placements

WIT
Strategy Development

WIT
Research/Service Evaluation Training

DIT
Cardiac Technician Placements

Medical Unit Morbidity/Mortality
Conference 26/03/10
Innovations STGH
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1969 One of the first acute mental health inpatient units
integrated into general hospital
1985 First County Hospital fully developed diabetes/endocrine
service
1986 First rheumatology service S. E. 1986
1987 First dietetic service S. E.
1992 First open access GI endoscopy service Ireland
1992 First multi disciplinary infertility clinic outside Dublin
1994 First colposcopy service S.E.
2001 First pulmonary rehab service outside Dublin
2002 First joint inflammatory bowel disease clinic Ireland
2007 Syncope assessment service
2009 Acute stroke unit with thrombolysis
2009 First fracture liaison service in non-orthopaedic centre
S E Hospitals Comparison 2009
Waterford
Wexford
Kilkenny
Clonmel
Beds
572
283
330
276
Occupancy %
85.16
93.44
83.73
94.59
ALOS
5.7
4.3
4.8
5.6
Inpatients
Discharged
21,281
14,347
15,788
12,794
Day cases
Discharged
18,721
6,589
9,281
6,680
52,369
48,241
45,241
OPD Attendance 114,087
New OPD
Attendance
23,580
12,201
15,972
12,594
Return OPD
Attendance
90,507
40,168
32,269
32,677
Number of
Deliveries
2,608
2,414
2,201
1,365 (’09)
Projected Annual Activity of
Regional Centre of Excellence South East
Elective Inpatients
Non- Elective
Total Inpatients
Deliveries
ED Attendance
12,290
48,700
60,990
8,900
127,000
(Allowing for 50% reduction from peripheral hospitals)
Estimated Requirement for Acute Day & Local
Rehabilitation Beds
Regional Centre of Excellence SE
Acute Inpatient Beds
Day Beds
Rehab
Total
Current Total
900
48
128
1076
572
New Bed Requirement 496
(Based on Horwath/Teamwork Report HSE Mid-West 2008)
Conditions for Reconfiguration SE
Hospitals Acute Services
1 No acute service withdrawn until regional centre
resourced & ready to deliver service
2 The PCCC resourced, developed & working to
international best practice standards in & out of hours.
3 Ambulance service has fully developed mobile response
capabilities by training advanced paramedics and
deploying them to all areas of SE
Conditions for Reconfiguration
4 Helicopter medical emergency service is
fully integrated into emergency care system SE.
5 Advanced nurse practitioner & clinical
nurse specialist workforce in place – network of
local nurse led urgent care centres.
6 Effective partnership across all elements of prehospital & hospital systems.
Conclusions
Thriving 3 year old hospital with outstanding
ethos of service & innovation
 Ever expanding local & outreach work
 Vital part of infrastructure of a major population
& industrial centre
 Impossible to provide adequate alternative
services without very major expenditure

Thomond Park 2005
Teamwork
Leaders
Backup !
Catch …..
Turn….
Now , Do You want to be the player scoring the goal, or
the one throwing the stick ? …..
Unnecessary Reconfiguration in Ireland 2010
Doomed