Aine Carroll, National Director of Clinical Strategy & Programmes, HSE


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The Challanges of Clinical Leadership in Ireland

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Aine Carroll, National Director of Clinical Strategy & Programmes, HSE

  1. 1. The challenges of Clinical Leadership in Ireland Áine Carroll National Director Clinical Strategy and Programmes Division HSE
  2. 2. Why Reform?  Government policy (Future Health, Healthy Ireland…)  Need to improve service delivery  Integrated models of care  Shift focus towards health & wellbeing  Existential economic challenge for health systems  People who use and work in the Health Service expect things to improve
  3. 3. Department of Health Health Commissioning Agency · Healthcare needs analysis · Models of care · Core service definition · Quality & Standards · Commissioning Intentions · Contract Management · Performance Management Regulators · HIQA · MHC · IMB Health Service Providers Hospital Groups Community Health Care Organisation Grant Funded Agencies Primary Care Providers HIQA · Licensing and compliance monitoring of residential and specialist ambulatory services for children, older people and people with disabilities. · Develop standards. · HTAs to evaluate new technologies and · Advise on the collection and sharing of information across the healthcare services. National Information and Pricing Office · Separate pricing from purchasing / commissioning · Hospital Inpatient Enquiry Scheme (HIPE) (maintained by ESRI) · National Casemix Programme Patient Safety Authority · Subsume National Clinical Effectiveness Committee (NCEC) · Sets guidelines for eligibility for treatment under UHI Support Services · Strategy to be developed · Shared Services · PCRS · Electronic claims management system · Finance Operating Model · MTPF / UHI eClaims · HR · ICT (eHealth) · Audit · Parliamentary Affairs · Informatics Healthcare Commissioning Agency · Subsume HSE service directors · Convert National Services Framework into detailed performance targets · Commission services through MFTP and block allocation contracts · Subsume NTPF and SDU · Divest some responsibilities on move to UHI Public Hospitals · 6 adult and 1 Paeds hospital groups · Each with a hub that is an academic medical centre · 48 hospitals (29 statutory and 16 voluntary acute) · Mix of public and private care Private Hospitals · Role of private providers under UHI to be defined · 21 private hospitals (acute and mental) · Approx 3,500 beds · 1 in 6 of all acute beds Community Health Care Organisations · Successor to ISAs · Review of role of 17 ISAs (32 Local Health Offices) Grant Funded Agencies · Status and commissioning of grant funded agencies to be defined · Over 2000 separate grant funded agencies Primary Care Providers – Public and Private · GPs · Dentists · Pharmacists · Opticians Professional Regulators · Medical Council · An Bord Altranais (Nursing & Midwifery Board of Ireland) · Dental Council · Pharmaceutical Society of Ireland · Health & Social Care Professionals Council Other Regulators · HIQA (see above) · Mental Health Commission · Food Safety Authority of Ireland · Irish Medicines Board · Health Insurance Authority Professional Bodies · RCSI · HMI · Therapies · IADNM · RCPI · ICGP · Forum of Post Graduate Training Bodies Other Agencies · NTPF (move to HCA) · Health Research Board · Irish Blood Transfusion Service · Safefood · Institute of Public Health Commercial State Company · VHI (UHI provider) Emerging Future Health System UHI Providers · Claim settlements · Payments Support Services · System wide common services · Shared services & PCRS · MFTP / UHI Claims National Pricing Office · Price Informatics · Tariff Setting · Pricing Economic Regulation Patient Safety Authority Health Insurance Authority Payment SLA Contract& PerformanceMgt Performance Reporting Paymentforitemsnot coveredbyUHI Ensure quality and safety standards across system Recommendstarriff Tariffs & Pricing Policy PerformanceReporting CostData Approves payment Funding SLA Regulates the market Payment Ensures operational effectiveness and financial stability. Authorises Trust status (tbc) Claims Payments Ambulance Key to text · Current organisations · Significant changes Representative Groups · IMPACT · IMO · INO · IHCA · SIPTU · Unite · IDA · PNA · TEEU Employers · Google, HP, etc
  4. 4. OUR Enablers and Challenges  Thousands of dedicated and able people across the health service  Many major and minor improvements achieved – Cancer, Stroke  Many people have a good experience of the health service  Elements aligned  Great desire among people to see change  Poor history of working in a co- ordinated way – fragmented; fractured  High levels of distrust and apprehension  Sense of lack of connection between the top and the bottom  General lack of credibility  Have we lost sight of our purpose?  ‘We have heard it all before’ Enablers Challenges
  5. 5. Rules for transformation  Effective leadership  Data feedback  Honour the work  Engage clinicians  Involve patients and families Large-System Transformation in Health Care: A Realist Review ALLAN BEST, TRISHA GREENHALGH, STEVEN LEWIS, JESSIE E. SAUL, SIMON CARROLL, and JENNIFER BITZ1 The Milbank Quarterly, Vol. 90, No. 3, 2012 (pp. 421–456)
  6. 6. IOM Aims of redesign Timely Care Efficient Care Family-Centred care Effective Care Equitable Care Safe Care Priority #1
  7. 7. National Clinical Programmes: Mission & objectives 1. Improve Quality 2. Improve Patient Access 3. Value
  8. 8. Key principles 1. Clinically led – empower clinicians to lead the change 2. Structured programme management approach 3. Nationalise existing best practice 4. Engage Patients 5. Align stakeholders – Government, Management, Colleges, Unions, Patients, etc
  9. 9. Why?  Partnership between HSE and Clinicians through the Forum of Postgraduate training colleges  Partnership with Irish Association of the Directors of Nursing and Midwifery and the Therapy Professions Committee  Partnership with patients
  10. 10. Some Achievements To DateNational Clinical Programme for Acute Medicine: • Introduction of the National Early Warning Score (NEWS): received public service excellence award from Taoiseach • Total length of stay reduced by 21% between 2005 and 2012 with the introduction of Acute Medical Assessment Units in every acute hospital • Overnight length of stay reduced by 8% between 2005 and 2012 National Clinical programme for Epilepsy  Received an international nursing award for its description of the new national epilepsy service of Ireland (the ‘limelight’ award is part of the international care challenge series by Sanofi which allows nurses from around the world showcase nursing innovations) National Clinical programme for Rheumatology/MSK • Physiotherapy led Musculo-skeletal clinics are reducing waiting lists by up to 70% • 10,000 new patients triaged and treated from orthopaedic and rheumatology waiting lists in one year National Clinical Programme for COPD • COPD Outreach Model of Care and Pulmonary Rehabilitation Model of Care, Bundles of Care, and patient information materials developed and issued for adoption. • Average Length of Stay (AvLOS) reduction from 9.1 days in 2009 to 7.6 in December 2012 • Pulmonary rehabilitation available in 37 sites. Access to Pulmonary Rehabilitation in 56% of sites (2012) has exceeded the target set (25%). Further work ongoing to target areas without access. National Clinical Programme for Medicines Management • The Medicines Management Programme has identified an additional 2 drugs, ace inhibitor (Ramipril) and angiotensin 11 receptor (Candesartan) as part of the ‘Preferred Drugs Initiative’. The Programme is aiming to secure €20 million in savings in 2013.
  11. 11. Some Achievements To Date National Clinical Programme for Stroke  27 out of 28 hospitals admitting patients with stroke requiring acute care now have a stroke unit. This is an increase from 18 in July 2010.  Thrombolysis available in all model 3 and model 4 hospitals either directly or via ambulance access protocols.  Thrombolysis rates have increased from 2.4% in 2007 to 9.5% in 2013 exceeding targets and leaving Ireland with one of the highest rates in the world (UK is 5%, Sweden 6.6% and USA 2.4%)  1.5% increase in patients discharged to home in 2011 (110 patients/yr, 2 patients/week)  2% decrease in case-fatality in 2011 i.e. 70 patients/yr. This was also sustained in 2012.  2.9% decrease in stroke Nursing Home admissions i.e. 150-160 patients/yr National Clinical Programme for Diabetes  Diabetes Retinopathy Screening has commenced in quarter 1 of 2013 and this aims to screen 30% of the diabetic population in 2013.  A national model of care to deliver CS11 therapy to children with type 1 diabetes under 5 years of age has been developed and implemented. Retrieval & Transport Medicine • Neonatal retrieval extended to 24/7 nationally in 2013 • Paediatric retrieval due to commence a 5 day daytime service in 4th quarter 2013 • National model for adult retrieval designed to support hospital groups. Implementation planned for 1st quarter 2014 in Dublin, Cork and Galway providing a 7 day daytime service National Clinical Programme for Audiology • National screening of 99% children within 4 weeks of birth National Clinical Programme for Acute Coronary Syndrome • 4 24/7 PCI centres operational
  12. 12. Don Berwick
  13. 13. Problems  Lack of integration  Resources  Hierarchy  Disconnect between strategy and operations  HR  Finance  Procurement  Data management
  14. 14. Reform CSPD Programme Structure Director General CSPD Team Forum PGTBI Project Sponsor Systems Reform Group Training Bodies Project Team HR & Finance Est. end ‘13 “Establish the NCP as the Clinical Design Authority for Health Service”
  15. 15. Director of CSPD Operations Office of NCPs MH lead PC Lead SC Lead Acutes Lead H&Wb Lead Nursing Lead NMPDU ICP 1 ICP 2 ICP 3 Programme Programme ICP 4 Programme Programme Programme Governance of NCSP: The Health Services Clinical Design Authority Stakeholder Group Enabling Functions: HR, ICT, Finance, Performance Assurance. Structured interface
  16. 16. Principles of Health and Well being User and Provider Integration and Standards Educated, Healthy Supported Temporary/ Transient Low- Medium Support & Management. Temporary/ Transient Medium to High Support & Management. Rehabilitation or Permanent Support. Enablers; Information, Resource, Tools. Communication and Stakeholder Engagement in Care Planning Dignified, Healthy, Safe Living Draft Generic ICP Framework
  17. 17. Emerging Themes
  18. 18. Older Persons Children Women’s Health Chronic Diseases Patient Flow Health & Wellbeing Primary Care Acute Hosps Social Care Mental Health ICPs as related to Service Divisions- Horizontal Integration
  19. 19. Older Persons Children Women’s Health Chronic Diseases Patient Flow Health & Wellbeing Primary Care Acute Hosps Social Care Mental Health Programmes ICPs – Vertical Integration e.g. EWS
  20. 20. Health & Wellbeing Primary Care AcutesSocial Care Mental Health Single Assessment Tool Integrated Community and Acute Model of Care Dementia Care Delayed Discharges Positive Aging Rehabilitation Older Persons
  21. 21. Don Berwick's top ten tips 1. Patients first 2. Stop restructuring 3. Strengthen the local health care systems– community care systems–as a whole 4. To help do that, reinvest in general practice and primary care 5. Don’t put your faith in market forces 6. Avoid supply-driven care like the plague (institutional self interest) 7. Develop an integrated approach to the assessment, assurance, and improvement of quality 8. Heal the divide among the professions, the managers, and the government 9. Train your health care work force for the future, not the past 10. Aim for health not care
  22. 22. Managers and Clinicians We are stewards together of healthcare resources
  23. 23. The needs of the patient come first
  24. 24. “We must be the change we wish to see.” Ghandi
  25. 25. Thank you