The challenges of Clinical The challenges of Clinical Leadership in IrelandLeadership in Ireland

Áine CarrollNational Director

Clinical Strategy and Programmes DivisionHSE

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

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 carePrivate 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

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Ensure quality and safety standards across system

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Tariffs & Pricing

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Cost

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Approves payment

Funding

SLA

Regulates the market

Payment

Ensures operational effectiveness and financial stability.Authorises Trust status (tbc)

Clai

ms

Paym

ents

Ambulance

Key to text· Current organisations· Significant changes

Representative Groups· IMPACT· IMO· INO· IHCA· SIPTU· Unite· IDA· PNA· TEEU

Employers · Google, HP, etc

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

Rules for transformation Effective leadership Data feedback Honour the work Engage clinicians Involve patients and families

Large-System Transformation in Health Care: A Realist ReviewALLAN BEST, TRISHA GREENHALGH, STEVEN LEWIS, JESSIE E.

SAUL, SIMON CARROLL, and JENNIFER BITZ1 The Milbank Quarterly, Vol. 90, No. 3, 2012 (pp. 421–456)

IOM Aims of redesignTimely CareEfficient CareFamily-Centred careEffective CareEquitable CareSafe Care Priority #1

National Clinical Programmes:Mission & objectives1. Improve Quality2. Improve Patient Access3. Value

Key principles1. Clinically led – empower clinicians to

lead the change2. Structured programme management

approach3. Nationalise existing best practice4. Engage Patients5. Align stakeholders – Government,

Management, Colleges, Unions, Patients, etc

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

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.

Some Achievements To DateNational 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

Don Berwick

Problems Lack of integration Resources Hierarchy Disconnect between strategy and operations HR Finance Procurement Data management

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”

Governance of NCSP: The Health Services Clinical Design Authority

Stakeholder Group

Enabling Functions: HR, ICT, Finance, Performance Assurance.

Structured interface

Stru

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inte

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e

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

Emerging Themes

Health & Wellbeing

Primary Care

Acute

Hosps Social Care Mental

Health

ICPs as related to Service Divisions- Horizontal Integration

Health & Wellbeing

Primary Care

Acute

Hosps Social Care Mental

Health

Programmes

ICPs – Vertical Integration e.g. EWS

Health & Wellbeing

Primary Care

Acutes Social Care Mental Health

Single Assessment Tool

Integrated Community and Acute Model of Care

Dementia Care

Delayed Discharges

Positive Aging

Rehabilitation

Older Persons

Don Berwick's top ten tips1. Patients first2. Stop restructuring3. Strengthen the local health care systems– community care systems–as a

whole4. To help do that, reinvest in general practice and primary care5. Don’t put your faith in market forces6. Avoid supply-driven care like the plague (institutional self interest)7. Develop an integrated approach to the assessment, assurance, and

improvement of quality8. Heal the divide among the professions, the managers, and the government9. Train your health care work force for the future, not the past10. Aim for health not care

Managers and Clinicians

We are stewards together of healthcare resources

The needs of the patient come first

“We must be the change we wish to see.”

Ghandi

Thank you