M Power National Clinical Lead Critical Care Programme National Clinical Programmes Clinical Strategy and Programmes Division

bull 1 Critical Care Model

bull 2 Irish healthcare politics

bull 3 lsquoMacrorsquo delivery evidence

bull 4 lsquoMacrorsquo delivery policy elsewhere

Critical Care Programme Hospital Group lsquohub-and-spokersquo

Critical Care Model

CCS = Critical Care ServiceCritical Care Retrieval- safe inter-hospital critically ill patient transportNational Ambulance Service NAS Pre-Hospital Emergency Care PHEC transport and bypass procedures

Levels of Critical Care

Joint Faculty of Intensive Care Medicine of Ireland (JFICMI) National Standards define

Critical Care Service

ldquoappropriate for the care of patients requiring Level 2 3 and 3(s) critical carehellipgenerally delivered within a High-Dependency Unit (HDU) or Intensive Care Unit (ICU)rdquo

HSEProspectus

2009 Adult Critical Care Report

Critical Care Programme Hospital Group lsquohub-and-spokersquo

Critical Care Model

CCS = Critical Care ServiceCritical Care Retrieval- safe inter-hospital critically ill patient transportNational Ambulance Service NAS Pre-Hospital Emergency Care PHEC transport and bypass procedures

Ennis Mallow Tallaght Galway

bull HIQA recommends systemic acute hospital and critical care service delivery and organisation arrangements to improve outcomes

bull ldquoThe HSE must take immediate action to put arrangements in place for the implementation of national mandatory patient transfer and acceptance protocols to ensure the immediate and safe transfer of critically ill patients to a unit providing ICS level 23 critical care Consideration should be given to a national managed critical care network to optimise critical care capacity regionally and nationallyrdquo

HIQA lsquoMallowrsquo 2011 Recommendation SOC5

Patient Level 0

Ward

Level 1

Observation

Level 2

Single organ failure

Level 3

Invasive ventilatory support

Multi-organ support

Critically ill patient

critical care need- BypassTransfer

Critically ill patient

critical care need- BypassTransferHIQA lsquoEnnisrsquo report

Recommendation cluster 4

critical care services

Critical Care Pathway

Critical Care Service-

Level of Critical

Care- 23

Critical Care Service-Level of

Critical Care-23 plus CRRT

Critical Care Service-Level of

Critical Care-23 3s

Model 3 Hospital

Model 4 Hospital

Model 4 Hospital

(supra-regional)

Model 2 Hospital

ldquoDifferentiated low-riskrdquo patients

No Critical Care Service

Transport bidirectional Advanced Paramedicine Critical Care Retrieval

CRITICALLY ILL PATIENTSBYPASS

procedure

Fragmentation

ldquoAll politics is localrdquo Senator Thomas P ldquoTiprdquo OrsquoNeill Speaker US House of Representatives 1977-86

Public policy- decentralisation or lsquosubsidiarityrsquo

bull 1 Critical Care Model

bull 2 Irish healthcare politics

bull 3 lsquoMacrorsquo delivery evidence

bull 4 lsquoMacrorsquo delivery policy elsewhere

Critical Care Programme Hospital Group lsquohub-and-spokersquo

Critical Care Model

CCS = Critical Care ServiceCritical Care Retrieval- safe inter-hospital critically ill patient transportNational Ambulance Service NAS Pre-Hospital Emergency Care PHEC transport and bypass procedures

Levels of Critical Care

Joint Faculty of Intensive Care Medicine of Ireland (JFICMI) National Standards define

Critical Care Service

ldquoappropriate for the care of patients requiring Level 2 3 and 3(s) critical carehellipgenerally delivered within a High-Dependency Unit (HDU) or Intensive Care Unit (ICU)rdquo

HSEProspectus

2009 Adult Critical Care Report

Critical Care Programme Hospital Group lsquohub-and-spokersquo

Critical Care Model

CCS = Critical Care ServiceCritical Care Retrieval- safe inter-hospital critically ill patient transportNational Ambulance Service NAS Pre-Hospital Emergency Care PHEC transport and bypass procedures

Ennis Mallow Tallaght Galway

bull HIQA recommends systemic acute hospital and critical care service delivery and organisation arrangements to improve outcomes

bull ldquoThe HSE must take immediate action to put arrangements in place for the implementation of national mandatory patient transfer and acceptance protocols to ensure the immediate and safe transfer of critically ill patients to a unit providing ICS level 23 critical care Consideration should be given to a national managed critical care network to optimise critical care capacity regionally and nationallyrdquo

HIQA lsquoMallowrsquo 2011 Recommendation SOC5

Patient Level 0

Ward

Level 1

Observation

Level 2

Single organ failure

Level 3

Invasive ventilatory support

Multi-organ support

Critically ill patient

critical care need- BypassTransfer

Critically ill patient

critical care need- BypassTransferHIQA lsquoEnnisrsquo report

Recommendation cluster 4

critical care services

Critical Care Pathway

Critical Care Service-

Level of Critical

Care- 23

Critical Care Service-Level of

Critical Care-23 plus CRRT

Critical Care Service-Level of

Critical Care-23 3s

Model 3 Hospital

Model 4 Hospital

Model 4 Hospital

(supra-regional)

Model 2 Hospital

ldquoDifferentiated low-riskrdquo patients

No Critical Care Service

Transport bidirectional Advanced Paramedicine Critical Care Retrieval

CRITICALLY ILL PATIENTSBYPASS

procedure

Fragmentation

ldquoAll politics is localrdquo Senator Thomas P ldquoTiprdquo OrsquoNeill Speaker US House of Representatives 1977-86

Public policy- decentralisation or lsquosubsidiarityrsquo

Critical Care Programme Hospital Group lsquohub-and-spokersquo

Critical Care Model

CCS = Critical Care ServiceCritical Care Retrieval- safe inter-hospital critically ill patient transportNational Ambulance Service NAS Pre-Hospital Emergency Care PHEC transport and bypass procedures

Levels of Critical Care

Joint Faculty of Intensive Care Medicine of Ireland (JFICMI) National Standards define

Critical Care Service

ldquoappropriate for the care of patients requiring Level 2 3 and 3(s) critical carehellipgenerally delivered within a High-Dependency Unit (HDU) or Intensive Care Unit (ICU)rdquo

HSEProspectus

2009 Adult Critical Care Report

Critical Care Programme Hospital Group lsquohub-and-spokersquo

Critical Care Model

CCS = Critical Care ServiceCritical Care Retrieval- safe inter-hospital critically ill patient transportNational Ambulance Service NAS Pre-Hospital Emergency Care PHEC transport and bypass procedures

Ennis Mallow Tallaght Galway

bull HIQA recommends systemic acute hospital and critical care service delivery and organisation arrangements to improve outcomes

bull ldquoThe HSE must take immediate action to put arrangements in place for the implementation of national mandatory patient transfer and acceptance protocols to ensure the immediate and safe transfer of critically ill patients to a unit providing ICS level 23 critical care Consideration should be given to a national managed critical care network to optimise critical care capacity regionally and nationallyrdquo

HIQA lsquoMallowrsquo 2011 Recommendation SOC5

Patient Level 0

Ward

Level 1

Observation

Level 2

Single organ failure

Level 3

Invasive ventilatory support

Multi-organ support

Critically ill patient

critical care need- BypassTransfer

Critically ill patient

critical care need- BypassTransferHIQA lsquoEnnisrsquo report

Recommendation cluster 4

critical care services

Critical Care Pathway

Critical Care Service-

Level of Critical

Care- 23

Critical Care Service-Level of

Critical Care-23 plus CRRT

Critical Care Service-Level of

Critical Care-23 3s

Model 3 Hospital

Model 4 Hospital

Model 4 Hospital

(supra-regional)

Model 2 Hospital

ldquoDifferentiated low-riskrdquo patients

No Critical Care Service

Transport bidirectional Advanced Paramedicine Critical Care Retrieval

CRITICALLY ILL PATIENTSBYPASS

procedure

Fragmentation

ldquoAll politics is localrdquo Senator Thomas P ldquoTiprdquo OrsquoNeill Speaker US House of Representatives 1977-86

Public policy- decentralisation or lsquosubsidiarityrsquo

Levels of Critical Care

Joint Faculty of Intensive Care Medicine of Ireland (JFICMI) National Standards define

Critical Care Service

ldquoappropriate for the care of patients requiring Level 2 3 and 3(s) critical carehellipgenerally delivered within a High-Dependency Unit (HDU) or Intensive Care Unit (ICU)rdquo

HSEProspectus

2009 Adult Critical Care Report

Critical Care Programme Hospital Group lsquohub-and-spokersquo

Critical Care Model

CCS = Critical Care ServiceCritical Care Retrieval- safe inter-hospital critically ill patient transportNational Ambulance Service NAS Pre-Hospital Emergency Care PHEC transport and bypass procedures

Ennis Mallow Tallaght Galway

bull HIQA recommends systemic acute hospital and critical care service delivery and organisation arrangements to improve outcomes

bull ldquoThe HSE must take immediate action to put arrangements in place for the implementation of national mandatory patient transfer and acceptance protocols to ensure the immediate and safe transfer of critically ill patients to a unit providing ICS level 23 critical care Consideration should be given to a national managed critical care network to optimise critical care capacity regionally and nationallyrdquo

HIQA lsquoMallowrsquo 2011 Recommendation SOC5

Patient Level 0

Ward

Level 1

Observation

Level 2

Single organ failure

Level 3

Invasive ventilatory support

Multi-organ support

Critically ill patient

critical care need- BypassTransfer

Critically ill patient

critical care need- BypassTransferHIQA lsquoEnnisrsquo report

Recommendation cluster 4

critical care services

Critical Care Pathway

Critical Care Service-

Level of Critical

Care- 23

Critical Care Service-Level of

Critical Care-23 plus CRRT

Critical Care Service-Level of

Critical Care-23 3s

Model 3 Hospital

Model 4 Hospital

Model 4 Hospital

(supra-regional)

Model 2 Hospital

ldquoDifferentiated low-riskrdquo patients

No Critical Care Service

Transport bidirectional Advanced Paramedicine Critical Care Retrieval

CRITICALLY ILL PATIENTSBYPASS

procedure

Fragmentation

ldquoAll politics is localrdquo Senator Thomas P ldquoTiprdquo OrsquoNeill Speaker US House of Representatives 1977-86

Public policy- decentralisation or lsquosubsidiarityrsquo

Joint Faculty of Intensive Care Medicine of Ireland (JFICMI) National Standards define

Critical Care Service

ldquoappropriate for the care of patients requiring Level 2 3 and 3(s) critical carehellipgenerally delivered within a High-Dependency Unit (HDU) or Intensive Care Unit (ICU)rdquo

HSEProspectus

2009 Adult Critical Care Report

Critical Care Programme Hospital Group lsquohub-and-spokersquo

Critical Care Model

CCS = Critical Care ServiceCritical Care Retrieval- safe inter-hospital critically ill patient transportNational Ambulance Service NAS Pre-Hospital Emergency Care PHEC transport and bypass procedures

Ennis Mallow Tallaght Galway

bull HIQA recommends systemic acute hospital and critical care service delivery and organisation arrangements to improve outcomes

bull ldquoThe HSE must take immediate action to put arrangements in place for the implementation of national mandatory patient transfer and acceptance protocols to ensure the immediate and safe transfer of critically ill patients to a unit providing ICS level 23 critical care Consideration should be given to a national managed critical care network to optimise critical care capacity regionally and nationallyrdquo

HIQA lsquoMallowrsquo 2011 Recommendation SOC5

Patient Level 0

Ward

Level 1

Observation

Level 2

Single organ failure

Level 3

Invasive ventilatory support

Multi-organ support

Critically ill patient

critical care need- BypassTransfer

Critically ill patient

critical care need- BypassTransferHIQA lsquoEnnisrsquo report

Recommendation cluster 4

critical care services

Critical Care Pathway

Critical Care Service-

Level of Critical

Care- 23

Critical Care Service-Level of

Critical Care-23 plus CRRT

Critical Care Service-Level of

Critical Care-23 3s

Model 3 Hospital

Model 4 Hospital

Model 4 Hospital

(supra-regional)

Model 2 Hospital

ldquoDifferentiated low-riskrdquo patients

No Critical Care Service

Transport bidirectional Advanced Paramedicine Critical Care Retrieval

CRITICALLY ILL PATIENTSBYPASS

procedure

Fragmentation

ldquoAll politics is localrdquo Senator Thomas P ldquoTiprdquo OrsquoNeill Speaker US House of Representatives 1977-86

Public policy- decentralisation or lsquosubsidiarityrsquo

HSEProspectus

2009 Adult Critical Care Report

Critical Care Programme Hospital Group lsquohub-and-spokersquo

Critical Care Model

CCS = Critical Care ServiceCritical Care Retrieval- safe inter-hospital critically ill patient transportNational Ambulance Service NAS Pre-Hospital Emergency Care PHEC transport and bypass procedures

Ennis Mallow Tallaght Galway

bull HIQA recommends systemic acute hospital and critical care service delivery and organisation arrangements to improve outcomes

bull ldquoThe HSE must take immediate action to put arrangements in place for the implementation of national mandatory patient transfer and acceptance protocols to ensure the immediate and safe transfer of critically ill patients to a unit providing ICS level 23 critical care Consideration should be given to a national managed critical care network to optimise critical care capacity regionally and nationallyrdquo

HIQA lsquoMallowrsquo 2011 Recommendation SOC5

Patient Level 0

Ward

Level 1

Observation

Level 2

Single organ failure

Level 3

Invasive ventilatory support

Multi-organ support

Critically ill patient

critical care need- BypassTransfer

Critically ill patient

critical care need- BypassTransferHIQA lsquoEnnisrsquo report

Recommendation cluster 4

critical care services

Critical Care Pathway

Critical Care Service-

Level of Critical

Care- 23

Critical Care Service-Level of

Critical Care-23 plus CRRT

Critical Care Service-Level of

Critical Care-23 3s

Model 3 Hospital

Model 4 Hospital

Model 4 Hospital

(supra-regional)

Model 2 Hospital

ldquoDifferentiated low-riskrdquo patients

No Critical Care Service

Transport bidirectional Advanced Paramedicine Critical Care Retrieval

CRITICALLY ILL PATIENTSBYPASS

procedure

Fragmentation

ldquoAll politics is localrdquo Senator Thomas P ldquoTiprdquo OrsquoNeill Speaker US House of Representatives 1977-86

Public policy- decentralisation or lsquosubsidiarityrsquo

Critical Care Programme Hospital Group lsquohub-and-spokersquo

Critical Care Model

CCS = Critical Care ServiceCritical Care Retrieval- safe inter-hospital critically ill patient transportNational Ambulance Service NAS Pre-Hospital Emergency Care PHEC transport and bypass procedures

Ennis Mallow Tallaght Galway

bull HIQA recommends systemic acute hospital and critical care service delivery and organisation arrangements to improve outcomes

bull ldquoThe HSE must take immediate action to put arrangements in place for the implementation of national mandatory patient transfer and acceptance protocols to ensure the immediate and safe transfer of critically ill patients to a unit providing ICS level 23 critical care Consideration should be given to a national managed critical care network to optimise critical care capacity regionally and nationallyrdquo

HIQA lsquoMallowrsquo 2011 Recommendation SOC5

Patient Level 0

Ward

Level 1

Observation

Level 2

Single organ failure

Level 3

Invasive ventilatory support

Multi-organ support

Critically ill patient

critical care need- BypassTransfer

Critically ill patient

critical care need- BypassTransferHIQA lsquoEnnisrsquo report

Recommendation cluster 4

critical care services

Critical Care Pathway

Critical Care Service-

Level of Critical

Care- 23

Critical Care Service-Level of

Critical Care-23 plus CRRT

Critical Care Service-Level of

Critical Care-23 3s

Model 3 Hospital

Model 4 Hospital

Model 4 Hospital

(supra-regional)

Model 2 Hospital

ldquoDifferentiated low-riskrdquo patients

No Critical Care Service

Transport bidirectional Advanced Paramedicine Critical Care Retrieval

CRITICALLY ILL PATIENTSBYPASS

procedure

Fragmentation

ldquoAll politics is localrdquo Senator Thomas P ldquoTiprdquo OrsquoNeill Speaker US House of Representatives 1977-86

Public policy- decentralisation or lsquosubsidiarityrsquo

Ennis Mallow Tallaght Galway

bull HIQA recommends systemic acute hospital and critical care service delivery and organisation arrangements to improve outcomes

bull ldquoThe HSE must take immediate action to put arrangements in place for the implementation of national mandatory patient transfer and acceptance protocols to ensure the immediate and safe transfer of critically ill patients to a unit providing ICS level 23 critical care Consideration should be given to a national managed critical care network to optimise critical care capacity regionally and nationallyrdquo

HIQA lsquoMallowrsquo 2011 Recommendation SOC5

Patient Level 0

Ward

Level 1

Observation

Level 2

Single organ failure

Level 3

Invasive ventilatory support

Multi-organ support

Critically ill patient

critical care need- BypassTransfer

Critically ill patient

critical care need- BypassTransferHIQA lsquoEnnisrsquo report

Recommendation cluster 4

critical care services

Critical Care Pathway

Critical Care Service-

Level of Critical

Care- 23

Critical Care Service-Level of

Critical Care-23 plus CRRT

Critical Care Service-Level of

Critical Care-23 3s

Model 3 Hospital

Model 4 Hospital

Model 4 Hospital

(supra-regional)

Model 2 Hospital

ldquoDifferentiated low-riskrdquo patients

No Critical Care Service

Transport bidirectional Advanced Paramedicine Critical Care Retrieval

CRITICALLY ILL PATIENTSBYPASS

procedure

Fragmentation

ldquoAll politics is localrdquo Senator Thomas P ldquoTiprdquo OrsquoNeill Speaker US House of Representatives 1977-86

Public policy- decentralisation or lsquosubsidiarityrsquo

bull HIQA recommends systemic acute hospital and critical care service delivery and organisation arrangements to improve outcomes

bull ldquoThe HSE must take immediate action to put arrangements in place for the implementation of national mandatory patient transfer and acceptance protocols to ensure the immediate and safe transfer of critically ill patients to a unit providing ICS level 23 critical care Consideration should be given to a national managed critical care network to optimise critical care capacity regionally and nationallyrdquo

HIQA lsquoMallowrsquo 2011 Recommendation SOC5

Patient Level 0

Ward

Level 1

Observation

Level 2

Single organ failure

Level 3

Invasive ventilatory support

Multi-organ support

Critically ill patient

critical care need- BypassTransfer

Critically ill patient

critical care need- BypassTransferHIQA lsquoEnnisrsquo report

Recommendation cluster 4

critical care services

Critical Care Pathway

Critical Care Service-

Level of Critical

Care- 23

Critical Care Service-Level of

Critical Care-23 plus CRRT

Critical Care Service-Level of

Critical Care-23 3s

Model 3 Hospital

Model 4 Hospital

Model 4 Hospital

(supra-regional)

Model 2 Hospital

ldquoDifferentiated low-riskrdquo patients

No Critical Care Service

Transport bidirectional Advanced Paramedicine Critical Care Retrieval

CRITICALLY ILL PATIENTSBYPASS

procedure

Fragmentation

ldquoAll politics is localrdquo Senator Thomas P ldquoTiprdquo OrsquoNeill Speaker US House of Representatives 1977-86

Public policy- decentralisation or lsquosubsidiarityrsquo

Patient Level 0

Ward

Level 1

Observation

Level 2

Single organ failure

Level 3

Invasive ventilatory support

Multi-organ support

Critically ill patient

critical care need- BypassTransfer

Critically ill patient

critical care need- BypassTransferHIQA lsquoEnnisrsquo report

Recommendation cluster 4

critical care services

Critical Care Pathway

Critical Care Service-

Level of Critical

Care- 23

Critical Care Service-Level of

Critical Care-23 plus CRRT

Critical Care Service-Level of

Critical Care-23 3s

Model 3 Hospital

Model 4 Hospital

Model 4 Hospital

(supra-regional)

Model 2 Hospital

ldquoDifferentiated low-riskrdquo patients

No Critical Care Service

Transport bidirectional Advanced Paramedicine Critical Care Retrieval

CRITICALLY ILL PATIENTSBYPASS

procedure

Fragmentation

ldquoAll politics is localrdquo Senator Thomas P ldquoTiprdquo OrsquoNeill Speaker US House of Representatives 1977-86

Public policy- decentralisation or lsquosubsidiarityrsquo

Critical Care Pathway

Critical Care Service-

Level of Critical

Care- 23

Critical Care Service-Level of

Critical Care-23 plus CRRT

Critical Care Service-Level of

Critical Care-23 3s

Model 3 Hospital

Model 4 Hospital

Model 4 Hospital

(supra-regional)

Model 2 Hospital

ldquoDifferentiated low-riskrdquo patients

No Critical Care Service

Transport bidirectional Advanced Paramedicine Critical Care Retrieval

CRITICALLY ILL PATIENTSBYPASS

procedure

Fragmentation

ldquoAll politics is localrdquo Senator Thomas P ldquoTiprdquo OrsquoNeill Speaker US House of Representatives 1977-86

Public policy- decentralisation or lsquosubsidiarityrsquo

Fragmentation

ldquoAll politics is localrdquo Senator Thomas P ldquoTiprdquo OrsquoNeill Speaker US House of Representatives 1977-86

Public policy- decentralisation or lsquosubsidiarityrsquo

Public policy- decentralisation or lsquosubsidiarityrsquo

bull lsquoThe Health Service Reform Programme announced in June 2003 represents the most ambitious programme of change for the Irish health system in over 30 yearsrsquo

bull lsquomain elementrsquo ndash lsquomajor rationalisation of existing health service agencies to reduce fragmentationrsquo

bull Should the Government Statement not read lsquoin over 75 yearsrsquo

bull Does lsquorationalisationrsquo mean integration or centralisation

These are my principles

If you donrsquot like themhellip

Wellhellip I have others

Groucho Marx

These are my principles

If you donrsquot like themhellip

Wellhellip I have others

Groucho Marx

Centralisation and decentralisation public policies can impact greatly on critical care delivery

Acute healthcare systemlsquoCounty jerseyrsquo fragmentation -v- andRationality integration centralisation

ldquoToo many institutions must not be allowed to specialise along the same lines to the neglect of other less popular branches of curative medicine The central specialised hospitals must be made available for all and the poor must get the use of them free The local hospitals must be developed to afford the maximum of utility without a high degree of specialisation and their geographical organisation must be carefully plannedrdquo

Dr FC Ward Parliamentary Secretary [Junior Minister for Health] to the Minister for Local Government and Public Health Second (Committee) Stage Public Hospitals Bill Daacuteil Debate 28th April 1933

Strategy- Commissioning access affordability tiering geography

Hospitalsrsquo Commission

1936 (published)

Rare Book Archive TCD

lsquoDISTRICT HOSPITALSrsquo

lsquoCOUNTY HOSPITALSrsquo

lsquoREGIONAL HOSPITALSrsquo

lsquoMAIN HOSPITAL CENTRESrsquo

1968 lsquoFitzgeraldrsquo Report

ldquoReforming the organisation of hospital servicesrdquo

ldquoThere is convincing evidence that the best results in treatment are achieved when patients are treated by staff working as part of a multi-disciplinary specialist team and that better clinical outcomes are achieved in units with appropriate numbers of specialist staff with relevant skills and experience high volumes of activity and access to appropriate diagnostic and treatment facilitiesrdquo

Acute hospital emergency care

No

Yes

Yes

Yes

1 1936 Hospitals Commission

2 1968 lsquoFitzgeraldrsquo Report

3 2003 lsquoHanlyrsquo Report

4 2013 HospitalModels and Smaller Hospital Framework

lsquoDistrict Hospitalrsquo

lsquoDistrict Hospitalrsquo

lsquoLocal Hospitalrsquo Model 2

lsquoCounty Hospitalrsquo

lsquoGeneralHospitalrsquo

lsquoGeneral Hospitalrsquo

Model 3

lsquoRegionalHospitalrsquo

lsquoRegional Hospitalrsquo

lsquoMajor Hospitalrsquo Model 4

lsquoMain hospital centrersquo

lsquoMedical teaching centrersquo

lsquoNational and supraregionalservicesrsquo Major Hospital

Model 4 supraregional national

Countervailing local political forces

Crowds protest closure of Bantry General

Thousands protest cuts at Navan Hospital

2000 protest against Portlaoise hospital cutbacks

Big bang

MosaicIncremental

Blueprint

SimultaneousGradual PACE

SCALE

2012 HSCA2003-2013-

1936

1947

1953

1970

2003

1991-2010

Tuohy lsquoaccidental logicrsquo of healthcare organisation

Large

Small

2010 PPACA

ldquoToo many institutions must not be allowed to specialise along the same lines to the neglect of other less popular branches of curative medicine The central specialised hospitals must be made available for all and the poor must get the use of them free The local hospitals must be developed to afford the maximum of utility without a high degree of specialisation and their geographical organisation must be carefully plannedrdquo

Dr FC Ward Parliamentary Secretary [Junior Minister for Health] to the Minister for Local Government and Public Health Second (Committee) Stage Public Hospitals Bill Daacuteil Debate 28th April 1933

Strategy- Commissioning access affordability tiering geography

Hospitalsrsquo Commission

1936 (published)

Rare Book Archive TCD

lsquoDISTRICT HOSPITALSrsquo

lsquoCOUNTY HOSPITALSrsquo

lsquoREGIONAL HOSPITALSrsquo

lsquoMAIN HOSPITAL CENTRESrsquo

1968 lsquoFitzgeraldrsquo Report

ldquoReforming the organisation of hospital servicesrdquo

ldquoThere is convincing evidence that the best results in treatment are achieved when patients are treated by staff working as part of a multi-disciplinary specialist team and that better clinical outcomes are achieved in units with appropriate numbers of specialist staff with relevant skills and experience high volumes of activity and access to appropriate diagnostic and treatment facilitiesrdquo

Acute hospital emergency care

No

Yes

Yes

Yes

1 1936 Hospitals Commission

2 1968 lsquoFitzgeraldrsquo Report

3 2003 lsquoHanlyrsquo Report

4 2013 HospitalModels and Smaller Hospital Framework

lsquoDistrict Hospitalrsquo

lsquoDistrict Hospitalrsquo

lsquoLocal Hospitalrsquo Model 2

lsquoCounty Hospitalrsquo

lsquoGeneralHospitalrsquo

lsquoGeneral Hospitalrsquo

Model 3

lsquoRegionalHospitalrsquo

lsquoRegional Hospitalrsquo

lsquoMajor Hospitalrsquo Model 4

lsquoMain hospital centrersquo

lsquoMedical teaching centrersquo

lsquoNational and supraregionalservicesrsquo Major Hospital

Model 4 supraregional national

Countervailing local political forces

Crowds protest closure of Bantry General

Thousands protest cuts at Navan Hospital

2000 protest against Portlaoise hospital cutbacks

Big bang

MosaicIncremental

Blueprint

SimultaneousGradual PACE

SCALE

2012 HSCA2003-2013-

1936

1947

1953

1970

2003

1991-2010

Tuohy lsquoaccidental logicrsquo of healthcare organisation

Large

Small

2010 PPACA

Hospitalsrsquo Commission

1936 (published)

Rare Book Archive TCD

lsquoDISTRICT HOSPITALSrsquo

lsquoCOUNTY HOSPITALSrsquo

lsquoREGIONAL HOSPITALSrsquo

lsquoMAIN HOSPITAL CENTRESrsquo

1968 lsquoFitzgeraldrsquo Report

ldquoReforming the organisation of hospital servicesrdquo

ldquoThere is convincing evidence that the best results in treatment are achieved when patients are treated by staff working as part of a multi-disciplinary specialist team and that better clinical outcomes are achieved in units with appropriate numbers of specialist staff with relevant skills and experience high volumes of activity and access to appropriate diagnostic and treatment facilitiesrdquo

Acute hospital emergency care

No

Yes

Yes

Yes

1 1936 Hospitals Commission

2 1968 lsquoFitzgeraldrsquo Report

3 2003 lsquoHanlyrsquo Report

4 2013 HospitalModels and Smaller Hospital Framework

lsquoDistrict Hospitalrsquo

lsquoDistrict Hospitalrsquo

lsquoLocal Hospitalrsquo Model 2

lsquoCounty Hospitalrsquo

lsquoGeneralHospitalrsquo

lsquoGeneral Hospitalrsquo

Model 3

lsquoRegionalHospitalrsquo

lsquoRegional Hospitalrsquo

lsquoMajor Hospitalrsquo Model 4

lsquoMain hospital centrersquo

lsquoMedical teaching centrersquo

lsquoNational and supraregionalservicesrsquo Major Hospital

Model 4 supraregional national

Countervailing local political forces

Crowds protest closure of Bantry General

Thousands protest cuts at Navan Hospital

2000 protest against Portlaoise hospital cutbacks

Big bang

MosaicIncremental

Blueprint

SimultaneousGradual PACE

SCALE

2012 HSCA2003-2013-

1936

1947

1953

1970

2003

1991-2010

Tuohy lsquoaccidental logicrsquo of healthcare organisation

Large

Small

2010 PPACA

lsquoDISTRICT HOSPITALSrsquo

lsquoCOUNTY HOSPITALSrsquo

lsquoREGIONAL HOSPITALSrsquo

lsquoMAIN HOSPITAL CENTRESrsquo

1968 lsquoFitzgeraldrsquo Report

ldquoReforming the organisation of hospital servicesrdquo

ldquoThere is convincing evidence that the best results in treatment are achieved when patients are treated by staff working as part of a multi-disciplinary specialist team and that better clinical outcomes are achieved in units with appropriate numbers of specialist staff with relevant skills and experience high volumes of activity and access to appropriate diagnostic and treatment facilitiesrdquo

Acute hospital emergency care

No

Yes

Yes

Yes

1 1936 Hospitals Commission

2 1968 lsquoFitzgeraldrsquo Report

3 2003 lsquoHanlyrsquo Report

4 2013 HospitalModels and Smaller Hospital Framework

lsquoDistrict Hospitalrsquo

lsquoDistrict Hospitalrsquo

lsquoLocal Hospitalrsquo Model 2

lsquoCounty Hospitalrsquo

lsquoGeneralHospitalrsquo

lsquoGeneral Hospitalrsquo

Model 3

lsquoRegionalHospitalrsquo

lsquoRegional Hospitalrsquo

lsquoMajor Hospitalrsquo Model 4

lsquoMain hospital centrersquo

lsquoMedical teaching centrersquo

lsquoNational and supraregionalservicesrsquo Major Hospital

Model 4 supraregional national

Countervailing local political forces

Crowds protest closure of Bantry General

Thousands protest cuts at Navan Hospital

2000 protest against Portlaoise hospital cutbacks

Big bang

MosaicIncremental

Blueprint

SimultaneousGradual PACE

SCALE

2012 HSCA2003-2013-

1936

1947

1953

1970

2003

1991-2010

Tuohy lsquoaccidental logicrsquo of healthcare organisation

Large

Small

2010 PPACA

1968 lsquoFitzgeraldrsquo Report

ldquoReforming the organisation of hospital servicesrdquo

ldquoThere is convincing evidence that the best results in treatment are achieved when patients are treated by staff working as part of a multi-disciplinary specialist team and that better clinical outcomes are achieved in units with appropriate numbers of specialist staff with relevant skills and experience high volumes of activity and access to appropriate diagnostic and treatment facilitiesrdquo

Acute hospital emergency care

No

Yes

Yes

Yes

1 1936 Hospitals Commission

2 1968 lsquoFitzgeraldrsquo Report

3 2003 lsquoHanlyrsquo Report

4 2013 HospitalModels and Smaller Hospital Framework

lsquoDistrict Hospitalrsquo

lsquoDistrict Hospitalrsquo

lsquoLocal Hospitalrsquo Model 2

lsquoCounty Hospitalrsquo

lsquoGeneralHospitalrsquo

lsquoGeneral Hospitalrsquo

Model 3

lsquoRegionalHospitalrsquo

lsquoRegional Hospitalrsquo

lsquoMajor Hospitalrsquo Model 4

lsquoMain hospital centrersquo

lsquoMedical teaching centrersquo

lsquoNational and supraregionalservicesrsquo Major Hospital

Model 4 supraregional national

Countervailing local political forces

Crowds protest closure of Bantry General

Thousands protest cuts at Navan Hospital

2000 protest against Portlaoise hospital cutbacks

Big bang

MosaicIncremental

Blueprint

SimultaneousGradual PACE

SCALE

2012 HSCA2003-2013-

1936

1947

1953

1970

2003

1991-2010

Tuohy lsquoaccidental logicrsquo of healthcare organisation

Large

Small

2010 PPACA

ldquoReforming the organisation of hospital servicesrdquo

ldquoThere is convincing evidence that the best results in treatment are achieved when patients are treated by staff working as part of a multi-disciplinary specialist team and that better clinical outcomes are achieved in units with appropriate numbers of specialist staff with relevant skills and experience high volumes of activity and access to appropriate diagnostic and treatment facilitiesrdquo

Acute hospital emergency care

No

Yes

Yes

Yes

1 1936 Hospitals Commission

2 1968 lsquoFitzgeraldrsquo Report

3 2003 lsquoHanlyrsquo Report

4 2013 HospitalModels and Smaller Hospital Framework

lsquoDistrict Hospitalrsquo

lsquoDistrict Hospitalrsquo

lsquoLocal Hospitalrsquo Model 2

lsquoCounty Hospitalrsquo

lsquoGeneralHospitalrsquo

lsquoGeneral Hospitalrsquo

Model 3

lsquoRegionalHospitalrsquo

lsquoRegional Hospitalrsquo

lsquoMajor Hospitalrsquo Model 4

lsquoMain hospital centrersquo

lsquoMedical teaching centrersquo

lsquoNational and supraregionalservicesrsquo Major Hospital

Model 4 supraregional national

Countervailing local political forces

Crowds protest closure of Bantry General

Thousands protest cuts at Navan Hospital

2000 protest against Portlaoise hospital cutbacks

Big bang

MosaicIncremental

Blueprint

SimultaneousGradual PACE

SCALE

2012 HSCA2003-2013-

1936

1947

1953

1970

2003

1991-2010

Tuohy lsquoaccidental logicrsquo of healthcare organisation

Large

Small

2010 PPACA

Acute hospital emergency care

No

Yes

Yes

Yes

1 1936 Hospitals Commission

2 1968 lsquoFitzgeraldrsquo Report

3 2003 lsquoHanlyrsquo Report

4 2013 HospitalModels and Smaller Hospital Framework

lsquoDistrict Hospitalrsquo

lsquoDistrict Hospitalrsquo

lsquoLocal Hospitalrsquo Model 2

lsquoCounty Hospitalrsquo

lsquoGeneralHospitalrsquo

lsquoGeneral Hospitalrsquo

Model 3

lsquoRegionalHospitalrsquo

lsquoRegional Hospitalrsquo

lsquoMajor Hospitalrsquo Model 4

lsquoMain hospital centrersquo

lsquoMedical teaching centrersquo

lsquoNational and supraregionalservicesrsquo Major Hospital

Model 4 supraregional national

Countervailing local political forces

Crowds protest closure of Bantry General

Thousands protest cuts at Navan Hospital

2000 protest against Portlaoise hospital cutbacks

Big bang

MosaicIncremental

Blueprint

SimultaneousGradual PACE

SCALE

2012 HSCA2003-2013-

1936

1947

1953

1970

2003

1991-2010

Tuohy lsquoaccidental logicrsquo of healthcare organisation

Large

Small

2010 PPACA

Countervailing local political forces

Crowds protest closure of Bantry General

Thousands protest cuts at Navan Hospital

2000 protest against Portlaoise hospital cutbacks

Big bang

MosaicIncremental

Blueprint

SimultaneousGradual PACE

SCALE

2012 HSCA2003-2013-

1936

1947

1953

1970

2003

1991-2010

Tuohy lsquoaccidental logicrsquo of healthcare organisation

Large

Small

2010 PPACA

Crowds protest closure of Bantry General

Thousands protest cuts at Navan Hospital

2000 protest against Portlaoise hospital cutbacks

Big bang

MosaicIncremental

Blueprint

SimultaneousGradual PACE

SCALE

2012 HSCA2003-2013-

1936

1947

1953

1970

2003

1991-2010

Tuohy lsquoaccidental logicrsquo of healthcare organisation

Large

Small

2010 PPACA

Thousands protest cuts at Navan Hospital

2000 protest against Portlaoise hospital cutbacks

Big bang

MosaicIncremental

Blueprint

SimultaneousGradual PACE

SCALE

2012 HSCA2003-2013-

1936

1947

1953

1970

2003

1991-2010

Tuohy lsquoaccidental logicrsquo of healthcare organisation

Large

Small

2010 PPACA

2000 protest against Portlaoise hospital cutbacks

Big bang

MosaicIncremental

Blueprint

SimultaneousGradual PACE

SCALE

2012 HSCA2003-2013-

1936

1947

1953

1970

2003

1991-2010

Tuohy lsquoaccidental logicrsquo of healthcare organisation

Large

Small

2010 PPACA

Big bang

MosaicIncremental

Blueprint

SimultaneousGradual PACE

SCALE

2012 HSCA2003-2013-

1936

1947

1953

1970

2003

1991-2010

Tuohy lsquoaccidental logicrsquo of healthcare organisation

Large

Small

2010 PPACA

Out-of-hospital cardiac arrest Trauma Acute stroke care Critical care

London Ambulance Service LAS- pop 8m Clinical pathways ldquoChain-of-Survivalrdquo and

ldquoHeart Attack Hospitalrdquo

Bystander CPR AED deployment

Fast pre-hospital emergency care response and hospital bypass procedure

Extra 222 patients ldquosurvived to hospital dischargerdquo in 5 years (VF survival- 12 increased to 32)

Editorial- ldquoIt takes a system to save a victimrdquoFothergill Resuscitation 2013

Stages Advanced Paramedicine

for life-threatening conditions inc home field workplace nursing home urban rural and remote locations

Resuscitation Bystander and Early CPR Early defibrillation AED

Transport Acute Hospital- ED

ICU and critical care Therapeutic hypothermia

If a public access defibrillation programme is introduced in Ireland it should be considered in conjunction with measures to increase the utilisation of publicly accessible AEDs such as increased public awareness expanded CPR and AED training and an EMS-linked AED register Any prospective programme should start by targeting the mandatory deployment of AEDs to locations with the highest incidence of out-of-hospital cardiac arrest

Hyper-acute

stroke unit

HASU

London Ambulance Service LAS- pop 8m Clinical pathways ldquoChain-of-Survivalrdquo and

ldquoHeart Attack Hospitalrdquo

Bystander CPR AED deployment

Fast pre-hospital emergency care response and hospital bypass procedure

Extra 222 patients ldquosurvived to hospital dischargerdquo in 5 years (VF survival- 12 increased to 32)

Editorial- ldquoIt takes a system to save a victimrdquoFothergill Resuscitation 2013

Stages Advanced Paramedicine

for life-threatening conditions inc home field workplace nursing home urban rural and remote locations

Resuscitation Bystander and Early CPR Early defibrillation AED

Transport Acute Hospital- ED

ICU and critical care Therapeutic hypothermia

If a public access defibrillation programme is introduced in Ireland it should be considered in conjunction with measures to increase the utilisation of publicly accessible AEDs such as increased public awareness expanded CPR and AED training and an EMS-linked AED register Any prospective programme should start by targeting the mandatory deployment of AEDs to locations with the highest incidence of out-of-hospital cardiac arrest

Hyper-acute

stroke unit

HASU

Stages Advanced Paramedicine

for life-threatening conditions inc home field workplace nursing home urban rural and remote locations

Resuscitation Bystander and Early CPR Early defibrillation AED

Transport Acute Hospital- ED

ICU and critical care Therapeutic hypothermia

If a public access defibrillation programme is introduced in Ireland it should be considered in conjunction with measures to increase the utilisation of publicly accessible AEDs such as increased public awareness expanded CPR and AED training and an EMS-linked AED register Any prospective programme should start by targeting the mandatory deployment of AEDs to locations with the highest incidence of out-of-hospital cardiac arrest

Hyper-acute

stroke unit

HASU

If a public access defibrillation programme is introduced in Ireland it should be considered in conjunction with measures to increase the utilisation of publicly accessible AEDs such as increased public awareness expanded CPR and AED training and an EMS-linked AED register Any prospective programme should start by targeting the mandatory deployment of AEDs to locations with the highest incidence of out-of-hospital cardiac arrest

Hyper-acute

stroke unit

HASU

Hyper-acute

stroke unit

HASU

Mortality at RLH decreased from 2000 to 2005 by 48 from 342 to 179

specialist trauma service 2003

direct local hospital ED referral to RLH trauma service was associated with a 53 decrease in mortality

Davenport BJS 2010

Performance improvement

The use of data and information Process and practice changes Planning Communication and engagement Leadership and Governance

DGH District General Hospital

Performance improvement

The use of data and information Process and practice changes Planning Communication and engagement Leadership and Governance

DGH District General Hospital

DGH District General Hospital

NHS FIVE YEAR FORWARD VIEW 2015

Radical upgrade in prevention and public health

When people do need health services patients will gain far greater control of their own health care

The NHS will take decisive steps to break down the barriers in how care is provided

Multispecialty community provider

Primary and Acute Care Systems

Urgent and emergency care services

Smaller hospitals Primary Care National Leadership Meaningful local flexibility Innovation

Smaller Hospitals

ldquoEngland is too diverse for a one size fits all care model to apply everywhere But nor is the answer to let lsquoa thousand flowers bloomrsquo Different local health communities will instead be supported by the NHSrsquo national leadership to choose from amongst a small number of radical new care delivery options and then given the resources and support to implement them where that makes senserdquo

ldquoMajor trauma which is dealt with regionally

Emergency intervention most commonly associated with the 999 ambulance service and

Urgent care Out of Hours care where a difficulty exists but it does not initially present as life threatening and includes minor injuriesrdquo

Transforming Your Care TYC 2011

bull 1 Critical Care Model

bull 2 Irish healthcare politics

bull 3 lsquoMacrorsquo delivery evidence

bull 4 lsquoMacrorsquo delivery policy elsewhere

Evidence

Learning

Knowledge

Innovation

Design

Commissioner

Model

Context

Voluntary sector

Decentralisation legacy

Finance mechanisms

Organisation hierarchy

Capacity Capability

bull Funding

bull Communication Engagement

bull Governance

bull Leadership

bull Process

Activity

Outputs

Outcome

bull Survival

bull Impact

bull Performance

bull Accountability

bull Legitimation

bull Data Information

bull Value

bull Improvement

bull Ethic

bull Equity

GovernmentRegulationLegislation

Inputs

Structure- INTEGRATOR

Process- TRANSFORMATION

Different hospital site

System Transport Retrieval

Elective surgeryAmbulatory (lsquobasketrsquo) surgery

Same hospital centre

EmergencyUrgent

Major deferred complex surgery

Sametime-criticalunscheduled

Different time

Space

Time

Towill 2005

Hospital Chain structure

Johari window

Organisation

integration

Service

integration

Functional

integration

Clinical

integration

Clinical and service integration

The route to improved outcomes

Curry amp Ham 2010

Integrated care

to the patient

lsquoThe health reforms introduced by DH

showed a clear determinationhellip

to decentralise healthcarersquo (p9)

Financial Secretary to the Treasury

Minister of State at Communities and Local Government

with responsibilities for Decentralisation and Planning Policy

Director of Policy for the Conservative Party 2012

Integration is a coherent set of methods and models on the funding administrative organisational service delivery and clinical levels designed to create connectivity alignment and collaboration within and between the cure and care sectors The goal of these methods and models is to enhance quality of care and quality of life consumer satisfaction and system efficiency for patients with complex long term problems cutting across multiple services providers and settings The result of such multipronged efforts to promote integration for the benefit of these special patient groups is called lsquointegrated carersquo

Kodner et al 2002

Integration crosses the boundaries of healthcare

governance delivery finance professions and geography

Radical upgrade in prevention and public health

When people do need health services patients will gain far greater control of their own health care

The NHS will take decisive steps to break down the barriers in how care is provided

Multispecialty community provider

Primary and Acute Care Systems

Urgent and emergency care services

Smaller hospitals Primary Care National Leadership Meaningful local flexibility Innovation

Smaller Hospitals

ldquoEngland is too diverse for a one size fits all care model to apply everywhere But nor is the answer to let lsquoa thousand flowers bloomrsquo Different local health communities will instead be supported by the NHSrsquo national leadership to choose from amongst a small number of radical new care delivery options and then given the resources and support to implement them where that makes senserdquo

ldquoMajor trauma which is dealt with regionally

Emergency intervention most commonly associated with the 999 ambulance service and

Urgent care Out of Hours care where a difficulty exists but it does not initially present as life threatening and includes minor injuriesrdquo

Transforming Your Care TYC 2011

bull 1 Critical Care Model

bull 2 Irish healthcare politics

bull 3 lsquoMacrorsquo delivery evidence

bull 4 lsquoMacrorsquo delivery policy elsewhere

Evidence

Learning

Knowledge

Innovation

Design

Commissioner

Model

Context

Voluntary sector

Decentralisation legacy

Finance mechanisms

Organisation hierarchy

Capacity Capability

bull Funding

bull Communication Engagement

bull Governance

bull Leadership

bull Process

Activity

Outputs

Outcome

bull Survival

bull Impact

bull Performance

bull Accountability

bull Legitimation

bull Data Information

bull Value

bull Improvement

bull Ethic

bull Equity

GovernmentRegulationLegislation

Inputs

Structure- INTEGRATOR

Process- TRANSFORMATION

Different hospital site

System Transport Retrieval

Elective surgeryAmbulatory (lsquobasketrsquo) surgery

Same hospital centre

EmergencyUrgent

Major deferred complex surgery

Sametime-criticalunscheduled

Different time

Space

Time

Towill 2005

Hospital Chain structure

Johari window

Organisation

integration

Service

integration

Functional

integration

Clinical

integration

Clinical and service integration

The route to improved outcomes

Curry amp Ham 2010

Integrated care

to the patient

lsquoThe health reforms introduced by DH

showed a clear determinationhellip

to decentralise healthcarersquo (p9)

Financial Secretary to the Treasury

Minister of State at Communities and Local Government

with responsibilities for Decentralisation and Planning Policy

Director of Policy for the Conservative Party 2012

Integration is a coherent set of methods and models on the funding administrative organisational service delivery and clinical levels designed to create connectivity alignment and collaboration within and between the cure and care sectors The goal of these methods and models is to enhance quality of care and quality of life consumer satisfaction and system efficiency for patients with complex long term problems cutting across multiple services providers and settings The result of such multipronged efforts to promote integration for the benefit of these special patient groups is called lsquointegrated carersquo

Kodner et al 2002

Integration crosses the boundaries of healthcare

governance delivery finance professions and geography

Smaller Hospitals

ldquoEngland is too diverse for a one size fits all care model to apply everywhere But nor is the answer to let lsquoa thousand flowers bloomrsquo Different local health communities will instead be supported by the NHSrsquo national leadership to choose from amongst a small number of radical new care delivery options and then given the resources and support to implement them where that makes senserdquo

ldquoMajor trauma which is dealt with regionally

Emergency intervention most commonly associated with the 999 ambulance service and

Urgent care Out of Hours care where a difficulty exists but it does not initially present as life threatening and includes minor injuriesrdquo

Transforming Your Care TYC 2011

bull 1 Critical Care Model

bull 2 Irish healthcare politics

bull 3 lsquoMacrorsquo delivery evidence

bull 4 lsquoMacrorsquo delivery policy elsewhere

Evidence

Learning

Knowledge

Innovation

Design

Commissioner

Model

Context

Voluntary sector

Decentralisation legacy

Finance mechanisms

Organisation hierarchy

Capacity Capability

bull Funding

bull Communication Engagement

bull Governance

bull Leadership

bull Process

Activity

Outputs

Outcome

bull Survival

bull Impact

bull Performance

bull Accountability

bull Legitimation

bull Data Information

bull Value

bull Improvement

bull Ethic

bull Equity

GovernmentRegulationLegislation

Inputs

Structure- INTEGRATOR

Process- TRANSFORMATION

Different hospital site

System Transport Retrieval

Elective surgeryAmbulatory (lsquobasketrsquo) surgery

Same hospital centre

EmergencyUrgent

Major deferred complex surgery

Sametime-criticalunscheduled

Different time

Space

Time

Towill 2005

Hospital Chain structure

Johari window

Organisation

integration

Service

integration

Functional

integration

Clinical

integration

Clinical and service integration

The route to improved outcomes

Curry amp Ham 2010

Integrated care

to the patient

lsquoThe health reforms introduced by DH

showed a clear determinationhellip

to decentralise healthcarersquo (p9)

Financial Secretary to the Treasury

Minister of State at Communities and Local Government

with responsibilities for Decentralisation and Planning Policy

Director of Policy for the Conservative Party 2012

Integration is a coherent set of methods and models on the funding administrative organisational service delivery and clinical levels designed to create connectivity alignment and collaboration within and between the cure and care sectors The goal of these methods and models is to enhance quality of care and quality of life consumer satisfaction and system efficiency for patients with complex long term problems cutting across multiple services providers and settings The result of such multipronged efforts to promote integration for the benefit of these special patient groups is called lsquointegrated carersquo

Kodner et al 2002

Integration crosses the boundaries of healthcare

governance delivery finance professions and geography

ldquoMajor trauma which is dealt with regionally

Emergency intervention most commonly associated with the 999 ambulance service and

Urgent care Out of Hours care where a difficulty exists but it does not initially present as life threatening and includes minor injuriesrdquo

Transforming Your Care TYC 2011

bull 1 Critical Care Model

bull 2 Irish healthcare politics

bull 3 lsquoMacrorsquo delivery evidence

bull 4 lsquoMacrorsquo delivery policy elsewhere

Evidence

Learning

Knowledge

Innovation

Design

Commissioner

Model

Context

Voluntary sector

Decentralisation legacy

Finance mechanisms

Organisation hierarchy

Capacity Capability

bull Funding

bull Communication Engagement

bull Governance

bull Leadership

bull Process

Activity

Outputs

Outcome

bull Survival

bull Impact

bull Performance

bull Accountability

bull Legitimation

bull Data Information

bull Value

bull Improvement

bull Ethic

bull Equity

GovernmentRegulationLegislation

Inputs

Structure- INTEGRATOR

Process- TRANSFORMATION

Different hospital site

System Transport Retrieval

Elective surgeryAmbulatory (lsquobasketrsquo) surgery

Same hospital centre

EmergencyUrgent

Major deferred complex surgery

Sametime-criticalunscheduled

Different time

Space

Time

Towill 2005

Hospital Chain structure

Johari window

Organisation

integration

Service

integration

Functional

integration

Clinical

integration

Clinical and service integration

The route to improved outcomes

Curry amp Ham 2010

Integrated care

to the patient

lsquoThe health reforms introduced by DH

showed a clear determinationhellip

to decentralise healthcarersquo (p9)

Financial Secretary to the Treasury

Minister of State at Communities and Local Government

with responsibilities for Decentralisation and Planning Policy

Director of Policy for the Conservative Party 2012

Integration is a coherent set of methods and models on the funding administrative organisational service delivery and clinical levels designed to create connectivity alignment and collaboration within and between the cure and care sectors The goal of these methods and models is to enhance quality of care and quality of life consumer satisfaction and system efficiency for patients with complex long term problems cutting across multiple services providers and settings The result of such multipronged efforts to promote integration for the benefit of these special patient groups is called lsquointegrated carersquo

Kodner et al 2002

Integration crosses the boundaries of healthcare

governance delivery finance professions and geography

bull 1 Critical Care Model

bull 2 Irish healthcare politics

bull 3 lsquoMacrorsquo delivery evidence

bull 4 lsquoMacrorsquo delivery policy elsewhere

Evidence

Learning

Knowledge

Innovation

Design

Commissioner

Model

Context

Voluntary sector

Decentralisation legacy

Finance mechanisms

Organisation hierarchy

Capacity Capability

bull Funding

bull Communication Engagement

bull Governance

bull Leadership

bull Process

Activity

Outputs

Outcome

bull Survival

bull Impact

bull Performance

bull Accountability

bull Legitimation

bull Data Information

bull Value

bull Improvement

bull Ethic

bull Equity

GovernmentRegulationLegislation

Inputs

Structure- INTEGRATOR

Process- TRANSFORMATION

Different hospital site

System Transport Retrieval

Elective surgeryAmbulatory (lsquobasketrsquo) surgery

Same hospital centre

EmergencyUrgent

Major deferred complex surgery

Sametime-criticalunscheduled

Different time

Space

Time

Towill 2005

Hospital Chain structure

Johari window

Organisation

integration

Service

integration

Functional

integration

Clinical

integration

Clinical and service integration

The route to improved outcomes

Curry amp Ham 2010

Integrated care

to the patient

lsquoThe health reforms introduced by DH

showed a clear determinationhellip

to decentralise healthcarersquo (p9)

Financial Secretary to the Treasury

Minister of State at Communities and Local Government

with responsibilities for Decentralisation and Planning Policy

Director of Policy for the Conservative Party 2012

Integration is a coherent set of methods and models on the funding administrative organisational service delivery and clinical levels designed to create connectivity alignment and collaboration within and between the cure and care sectors The goal of these methods and models is to enhance quality of care and quality of life consumer satisfaction and system efficiency for patients with complex long term problems cutting across multiple services providers and settings The result of such multipronged efforts to promote integration for the benefit of these special patient groups is called lsquointegrated carersquo

Kodner et al 2002

Integration crosses the boundaries of healthcare

governance delivery finance professions and geography

Evidence

Learning

Knowledge

Innovation

Design

Commissioner

Model

Context

Voluntary sector

Decentralisation legacy

Finance mechanisms

Organisation hierarchy

Capacity Capability

bull Funding

bull Communication Engagement

bull Governance

bull Leadership

bull Process

Activity

Outputs

Outcome

bull Survival

bull Impact

bull Performance

bull Accountability

bull Legitimation

bull Data Information

bull Value

bull Improvement

bull Ethic

bull Equity

GovernmentRegulationLegislation

Inputs

Structure- INTEGRATOR

Process- TRANSFORMATION

Different hospital site

System Transport Retrieval

Elective surgeryAmbulatory (lsquobasketrsquo) surgery

Same hospital centre

EmergencyUrgent

Major deferred complex surgery

Sametime-criticalunscheduled

Different time

Space

Time

Towill 2005

Hospital Chain structure

Johari window

Organisation

integration

Service

integration

Functional

integration

Clinical

integration

Clinical and service integration

The route to improved outcomes

Curry amp Ham 2010

Integrated care

to the patient

lsquoThe health reforms introduced by DH

showed a clear determinationhellip

to decentralise healthcarersquo (p9)

Financial Secretary to the Treasury

Minister of State at Communities and Local Government

with responsibilities for Decentralisation and Planning Policy

Director of Policy for the Conservative Party 2012

Integration is a coherent set of methods and models on the funding administrative organisational service delivery and clinical levels designed to create connectivity alignment and collaboration within and between the cure and care sectors The goal of these methods and models is to enhance quality of care and quality of life consumer satisfaction and system efficiency for patients with complex long term problems cutting across multiple services providers and settings The result of such multipronged efforts to promote integration for the benefit of these special patient groups is called lsquointegrated carersquo

Kodner et al 2002

Integration crosses the boundaries of healthcare

governance delivery finance professions and geography

Different hospital site

System Transport Retrieval

Elective surgeryAmbulatory (lsquobasketrsquo) surgery

Same hospital centre

EmergencyUrgent

Major deferred complex surgery

Sametime-criticalunscheduled

Different time

Space

Time

Towill 2005

Hospital Chain structure

Johari window

Organisation

integration

Service

integration

Functional

integration

Clinical

integration

Clinical and service integration

The route to improved outcomes

Curry amp Ham 2010

Integrated care

to the patient

lsquoThe health reforms introduced by DH

showed a clear determinationhellip

to decentralise healthcarersquo (p9)

Financial Secretary to the Treasury

Minister of State at Communities and Local Government

with responsibilities for Decentralisation and Planning Policy

Director of Policy for the Conservative Party 2012

Integration is a coherent set of methods and models on the funding administrative organisational service delivery and clinical levels designed to create connectivity alignment and collaboration within and between the cure and care sectors The goal of these methods and models is to enhance quality of care and quality of life consumer satisfaction and system efficiency for patients with complex long term problems cutting across multiple services providers and settings The result of such multipronged efforts to promote integration for the benefit of these special patient groups is called lsquointegrated carersquo

Kodner et al 2002

Integration crosses the boundaries of healthcare

governance delivery finance professions and geography

Organisation

integration

Service

integration

Functional

integration

Clinical

integration

Clinical and service integration

The route to improved outcomes

Curry amp Ham 2010

Integrated care

to the patient

lsquoThe health reforms introduced by DH

showed a clear determinationhellip

to decentralise healthcarersquo (p9)

Financial Secretary to the Treasury

Minister of State at Communities and Local Government

with responsibilities for Decentralisation and Planning Policy

Director of Policy for the Conservative Party 2012

Integration is a coherent set of methods and models on the funding administrative organisational service delivery and clinical levels designed to create connectivity alignment and collaboration within and between the cure and care sectors The goal of these methods and models is to enhance quality of care and quality of life consumer satisfaction and system efficiency for patients with complex long term problems cutting across multiple services providers and settings The result of such multipronged efforts to promote integration for the benefit of these special patient groups is called lsquointegrated carersquo

Kodner et al 2002

Integration crosses the boundaries of healthcare

governance delivery finance professions and geography

lsquoThe health reforms introduced by DH

showed a clear determinationhellip

to decentralise healthcarersquo (p9)

Financial Secretary to the Treasury

Minister of State at Communities and Local Government

with responsibilities for Decentralisation and Planning Policy

Director of Policy for the Conservative Party 2012

Integration is a coherent set of methods and models on the funding administrative organisational service delivery and clinical levels designed to create connectivity alignment and collaboration within and between the cure and care sectors The goal of these methods and models is to enhance quality of care and quality of life consumer satisfaction and system efficiency for patients with complex long term problems cutting across multiple services providers and settings The result of such multipronged efforts to promote integration for the benefit of these special patient groups is called lsquointegrated carersquo

Kodner et al 2002

Integration crosses the boundaries of healthcare

governance delivery finance professions and geography

Integration is a coherent set of methods and models on the funding administrative organisational service delivery and clinical levels designed to create connectivity alignment and collaboration within and between the cure and care sectors The goal of these methods and models is to enhance quality of care and quality of life consumer satisfaction and system efficiency for patients with complex long term problems cutting across multiple services providers and settings The result of such multipronged efforts to promote integration for the benefit of these special patient groups is called lsquointegrated carersquo

Kodner et al 2002

Integration crosses the boundaries of healthcare

governance delivery finance professions and geography