Those of us who attended the HMI/RCPI Leadership Briefing on 5^th March last in RCPI can only have been impressed by what was an inspiring and riveting afternoon.  The briefing was conducted by Mr. Michael Dowling (President and Chief Executive) and Dr. Lawrence Smith (Executive Vice President and Physician in Chief) who preside over a healthcare network of 16 hospitals and over 270 ambulatory care centres in greater New York. We gazed in wonderment.

Richard Dooley, President, HMI

The scale of the operation, their achievements from the get go and their capacity to sustain the enterprise as a high performing system were clearly based on two foundation pillars: Leadership and Autonomy.  Leadership of the system at all levels is actively underwritten by the early identification and streaming of selected staff into developmental pathways, by the active and visible affirmation of the systems values into all its processes and by fostering and reinforcing a culture of openness, transparency and accountability.  Hand in hand with this leadership is an autonomy that ensures, for the most of metropolitan New York, that the health care delivery remains value and mission focussed at all times and that any barriers preventing this are resolutely and promptly dealt with.  Yes, it may be described as a highly personalised leadership style with an autonomy bordering on the rampant.  But the lessons nonetheless are salutary and valid when measured against the sizeable shift required to bring our systems close to this plane.

Now that we are finally (?) on the cusp of a cabinet decision regarding the reshaping of our acute hospitals into groups and ultimately into independent Trusts, it is time for an honest debate and statement of what the leaders of such Trusts require to be in place so that they can deliver to, and beyond, the desired level. Many good things have been achieved over the past 8 years of the HSE’s existence and this would not have happened without the (initial) requirement to centralise and control.  The biggest test now is for control to be ceded back to the new hospital groups so that a new confidence is locally built across the service support functions and that service development and delivery can flourish within new geographic confines.  Has the centre the capacity and the will to do this ?

The absence of real autonomy for the leaders of Hospital Groups will be a lifetime opportunity lost.  It will condemn the new groups/trusts to a stunted growth and allow partisan agendas to emerge bringing about little real success and much mediocrity.  We will again be left to gaze in wonderment at what others can achieve.  We all deserve better.

Richard Dooley
President
HMI

Like many expressions we use in Ireland  ‘fair play to you’ is a weasel term; a compliment on an achievement rather than a good wish. Just as well perhaps; fair play isn’t something we can boast about here. Ask the Magdalens, the victims of child abuse or the female public servants who had to resign from their jobs when they married, as recently as 1973. I could go on but I hardly need to! Many of the improvements in employment terms here didn’t stem from the efforts of governments and the trades unions; they resulted from our membership of the EU. Fair play!

Denis Doherty

And yet it all began so promisingly. In the mid 1920s the founding fathers of our State set up the Civil Service and Local Appointments Commissions. These bodies succeeded admirably in safeguarding senior public appointments from party political influence. They were sometimes portrayed as bureaucratic and at times slow but they were viewed as being fair. The commitment of the politicians of the time to fairness in the making public appointments was admirable.

The Civil and Local Appointments Commissions were replaced by the Public Appointments Service, which has established a reputation for fairness, efficiency and best practice. Reassignment of staff is now a feature of the public service as downsizing takes effect. It is not easy to demonstrate that fairness is being achieved in these circumstances but there doesn’t exist a sense of unfairness either.

The threat of legislation that may be more draconian than Croke Park ll, if that deal is not accepted, seems to me to be an unedifying and an unbecoming way to conduct industrial relations.

What a pity then that Croke Park 2 not only involves further cuts in the income of most public servants but has created a perception of unfairness by appearing to treat similar circumstances differently and unfairly. There has been talk that fire fighters and prison officers got side deals on premium pay. If that’s true a prison officer on escort duty with a prisoner in a hospital will receive a higher premium than the doctor or the nurse treating the same patient. An ambulance crew at the scene of a road traffic accident will have their premium payments calculated on a less favorable basis than their fire service colleagues attending the same accident. That’s unfair, if that’s what’s planned. The statement attributed to a government minister that the unions that left the negotiating table left their members high and dry is hardly fair either. The threat of legislation that may be more draconian than Croke Park 2, if that deal is not accepted, seems to me to be an unedifying and an unbecoming way to conduct industrial relations at a time when goodwill by workers ought to be valued.

Our government constantly demands greater fairness in the bail out terms applying to Ireland. The political parties in government and the trades unions who stayed at the negotiating table are not blameless for the sorry state our economy is in but, that is not a consideration when bail out terms are  being negotiated. So, why penalise some parties in pay negotiations at home.

The potential negative effects of perceived unfairness by the government towards some groups of public servants could be immense. On the ground, very many public servants continue to show exceptional commitment and goodwill in their dealings with members of the public.  The vocational dimension they bring to their jobs is very evident in lots of settings. There is still a high level of innate care as distinct from a less tangible duty of care being experienced in our public services that is much less obvious in public services in other jurisdictions.  We’re promised our economy will recover and I believe it will. Should we lose some of the commitment, genuine caring attitude and kindness stemming from high morale in our public services I fear it may be more difficult to re-establish.  Perhaps the importance of ‘fair play’ in what we wish for may be recognised before too much damage is caused.

HSE appoints Chief Operations Officer

Laverne McGuinness

Ms. Laverne McGuinness has been appointed Chief Operations Officer of the HSE.

She is a member of the Board of the Executive, as well as its top management team and was formerly its Director of Integrated Services.

An accountant by profession, Ms. McGuinness joined the HSE at the time of its establishment when she was appointed Director of Shared Services.  She previously worked as Asst. Chief Executive at the former Northern Area Health Board.

Mercy Urgent Care Centre opened

The Mercy Urgent Care Centre at St. Mary’s Health Campus (former St. Mary’s Orthopaedic Hospital), Gurranabraher, Cork has been officially opened by the Minister for Health, Dr. James Reilly.

The centre has treated over 8,500 patients since it opened on March 20, 2012. The average turnaround time from registration desk to discharge is currently 65 minutes and the most common injuries seen are hand and ankle. Just over half were self-referrals with the remainder being referred by other services such as general practitioners (GPs).

Dr Gerard McCarthy, Consultant in Emergency Medicine, Mr. Peter O’Callaghan, IT Manager Mercy University Hospital, Ms. Sinéad Glennon, HSE South Executive Lead for Re-organisation of Acute Hospital Services, Ms. Noreen O’Sullivan, Assistant Director of Nursing Mercy University Hospital, Mr. Mark Kane Estates Manager HSE South, Ms. Lorraine O’Sullivan Project Manager Mercy University Hospital, Mr. David Murray Finance Manager Mercy University Hospital and Ms. Nuala Coughlan CNM3 Mercy Urgent Care Centre.

The centre treats patients aged over 10 with minor injuries such as suspected broken bones, minor burns, scalds and cuts requiring stitching.

Open each day from 8.00am to 6.00pm, Monday to Sunday, the Mercy Urgent Care Centre is led by Dr. Gerry McCarthy, a consultant in emergency medicine and caters for people suffering from minor injuries in Cork city and county. Forming part of the network of emergency services in Cork city and county the centre is under the governance of the Mercy University Hospital (MUH).

It is run by 15 staff including doctors, nurses, physiotherapists, radiographers and other health care professionals. They treat adults presenting with non–emergency conditions that are unlikely to require hospital admission. Patients are treated quicker than emergency departments and the normal €100 charge applies to people without medical cards and those not referred by their GP or Southdoc.

Minor injuries comprise typically around 40% to 50% and sometimes as high as 70% of patients who present to emergency departments, most of whom present during the day. The Urgent Care Centre has the capacity to treat 10,000 people with minor injuries annually and has helped alleviate waiting times and volumes at CUH and MUH.

Mr. Jim Corbett, Deputy Chief Executive Officer Mercy University Hospital said: “The Mercy Urgent Care Centre represents a new departure for Mercy University Hospital. This is the first time that the hospital has undertaken the establishment of a new service in its traditional catchment area in the Northside of Cork city away from its historic campus. The opening of the Mercy Urgent Care Centre provides a re-affirmation of the Mercy ethos to care for the people of Cork in new and innovative ways and we look forward to developing additional new services into the future.

“This new service is fully operational and to date the statistics show that people attending with injuries that are unlikely to require hospital admission are seen quickly and discharged. Those requiring hospital admission have the benefit of the Mercy Urgent Care Centre’s link with the Mercy University Hospital’s 24/7 emergency department and the full range of acute hospital services we offer. The Mercy Urgent Care Centre reaffirms Mercy University Hospital’s pivotal role in the provision of emergency services in the Cork region.

Dr. Gerry McCarthy, Consultant in Emergency Medicine, who is the lead medic responsible for opening the new centre said: “We are delighted that the experience to-date has shown that users of this service have been very pleased with the treatment and rapid turnaround. Experience has also shown people attending the centre with injuries that are unlikely to require hospital admission are avoiding unnecessary attendances at our emergency departments.”

Mr. Pat Healy, Regional Director of Operations, HSE South said “The Mercy Urgent Care Centre is becoming firmly established in the mindset of patients in Cork city and beyond as a top class facility to treat minor injuries swiftly. Great credit is due to all those involved with the Mercy Urgent Care Centre particularly the staff who are the cornerstone on which its positive reputation is building”.

The Mercy Urgent Care Centre is open seven days a week (Monday to Sunday) from 8.00am to 6.00pm. It treats patients aged 10 and over with minor injuries such as suspected broken bones, minor burns, scalds and cuts requiring stitching. Unlike some minor injuries units the centre has facilities to take x-rays and apply plaster casts. It does not treat small children who should be taken to the Emergency Department at the Mercy University Hospital or Cork University Hospital.

New Mater Emergency Department

The new Emergency Department of Dublin’s Mater Hospital, which is part of the €284 million Mater Campus Hospital Development, has been opened.

Accommodation in the new Emergency Department includes:

• A resuscitation room – the resuscitation capacity of the new department provides an increase in excess of 60 per cent capacity compared to the previous capability, reflecting the increase in the number of patients attending with critical illness and injury.
• Fifteen new single patient examination and treatment cubicles for patients with complex and urgent medical complaints.
• A dedicated CT / X-ray suite.
• An ambulatory care area for management of low impact trauma cases and ambulant patients suffering from less serious medical conditions.
• Space for liaison personnel (e.g. psychiatric liaison nurse, GP liaison nurse and a social worker).

A 12 bay acute medical assessment unit is accommodated in the acute floor in line with Clinical Care Programmes. Special attention has been paid to the quality of the physical environment for patients, staff and visitors, reflecting contemporary architecture and design. Importance has been placed on the maximisation of natural light into the facility. The design team has adopted an integrated design approach to support a low energy and sustainable design solution. Specific concepts were adopted at the outset of the design process. The work on these concepts within this project is of considerable significance because of the scale of savings in the energy consumption and associated reductions in CO₂ emissions and its potential replication in Ireland and elsewhere.

The Mater’s Emergency Department provides a 24-hour emergency service, 365 days a year, and sees in the region of 50,000 patients annually. Approximately 21 per cent of patients attending are admitted to hospital for in-patient treatment.

Phoenix Care Centre opened

The Phoenix Care Centre, the HSE’s new Mental Health Facility at Grangegorman, Dublin  has been officially opened by the Minister for Health, Dr. James Reilly, T.D. and the Minister of State, Ms. Kathleen Lynch T.D.

This new state of the art facility built at a cost of approx €21m will provide a replacement mental health facility for St. Brendan’s Hospital on the campus of Grangegorman.

It is expected the move of both the staff and patients of St. Brendan’s to the new facility will commence towards the end of the first quarter 2013.

The closure of St. Brendan’s Hospital, the first public psychiatric hospital in Ireland, will end 199 years of continuous provision of care and treatment to those with a mental illness.

This marks a significant milestone as it is not only an end of an era for St. Brendan’s but it is the first major building project to be completed as part of the overall Grangegorman re-development project.

The date chosen for the official opening coincided with the day the first patient was admitted to St. Brendan’s Hospital on 28^th February, 1814.

The new 54 bed purpose built facility, which includes a Psychiatric Intensive Care Unit, will provide patients with their own single bedrooms and en-suite facilities, therapy and rehabilitation spaces, enhanced with courtyard settings and a light filled environment to maximise the recovery journey for patients.

Investment needed in preventive eye care

The Irish College of Ophthalmologists (ICO) has welcomed the findings of a new report released by the International Federation on Ageing (IFA) describing the health, social and economic burdens of vision loss on a global society that is ageing rapidly. The report calls for increased public education and awareness programs, improved public policies and greater integration of preventive eye health interventions into public health systems.

The IFA report, titled ” The High Cost of Low Vision: The Evidence on Ageing and the Loss of Sight,” highlights that vision loss is no longer an inevitable part of the ageing process, as people can now age with strong, healthy vision, given 21st-century innovations in diagnosis, biomedicine, nutrition, technology and preventive care.

Speaking in relation to the new report findings, Siobhan Kelly, CEO of the ICO commented; “This report reinforces the positive message to the public that over half of the causes of sight loss are preventable with early diagnosis and treatment. With our ageing population, it is imperative that investment is made in preventive eye health care if we are to avoid an unnecessary over burdening and future dependency on our health care services.

Breast cancer diagnosed in 832 women

Eight hundred and thirty two women were diagnosed with breast cancer, through BreastCheck in 2011, representing 6.6 cancers per 1,000 women screened, according to the National Breast Screening Programme 2011-2012 report.

Free mammograms were provided to 125,329 women aged 50-64.The overall acceptance of invitation to screening was 72.2 per cent, in excess of the programme target of 70 per cent. Of the 125,329 women screened, 5,242 were re-called for assessment. For 37,429 women it was their first BreastCheck mammogram and 87,900 women had previously had at least one BreastCheck mammogram nationally.

Welcoming the publication of the report, Dr. Susan O’Reilly, Director of the National Cancer Control Programme (NCCP), said: “We were delighted that during 2011, a challenging year, we screened over 4,500 more women than the previous year and again surpassed our target uptake of 70 per cent.

“The programme performed strongly against most commitments in the BreastCheck Women’s Charter during this time of sustained resource shortages, thanks to staff dedication and innovation. While BreastCheck aims to offer a woman her first mammogram within two years of becoming known to the programme and her subsequent mammograms every two years, this does not always happen, however we are pleased that 94 per cent of women were re-invited for their next mammogram within 28 months.”

In Ireland over 2,700 women are diagnosed with breast cancer each year. Where women were diagnosed with a breast cancer following a BreastCheck mammogram, Dr. Ann O’Doherty, Lead Clinical Director, BreastCheck said: “A significant improvement has been made in terms of the percentage of women with cancer offered hospital admission within three weeks of diagnosis, which is just outside of the standard of 90 per cent, a significant improvement on last year and we are grateful for the ongoing collaboration with host hospitals to develop a service response to this issue.”

Since BreastCheck began screening in February 2000 to end 2011, the programme has provided 835,598 mammograms to 371,208 women and detected 5,484 breast cancers.

What’s in a name?

HIQA has published for consultation a draft national standard on how to collect accurate information on patients and healthcare clients.

Professor Jane Grimson, Director of Health Information with HIQA, said: “Currently there is no standardised or agreed guidance on the collection of demographic data. There are real risks to patient safety and welfare because there is a lack of consistency in how people are identified across our health and social care system. For example, there can be significant variations in how names are recorded leading to the risk of misidentification and putting patients at risk.”

“Having the right information recorded that correctly identifies an individual is essential as it is key to ensuring that each person receives the right care at the right time. This information is also vital for health and social care professionals so that they can make the right decisions about your care, while at the same time ensuring the privacy and confidentiality of your information.”

“There are two essential elements to ensuring correct identification of individuals: A unique number and an associated standard set of information, such as name, date of birth, and gender,” Professor Grimson said. “The forthcoming Health Information Bill is expected to introduce legislation to enable the introduction of the unique number and the document we are launching for consultation today sets out what that standard set of information should be.”

The lack of a national demographic dataset has resulted in each health and social care provider designing its own rules for the data items it wishes to collect on each individual. This results in varying approaches to the data items collected and the formats of same, with each data item having the possibility for many permutations and combinations.

For example, the name McGrath can be collected as McGrat, Mc Grath, Macgrath and so forth, leading to a potential for duplication and/or misidentification. It is therefore crucial to have a single national standard for collection of such important demographic data in order to ensure standardised, accurate identification of each individual.

The benefits for people are safer, better care for patients from having accurate, complete information available when it is needed; the removal of the need to provide demographic details again and again on each visit to the health or social care service provider and reduced time wasting as the information will only be collected once.

The benefits for GPs will include enabling the collection of more accurate and consistent demographic data and improved reliability of information; it will assist in more complete patient identification, therefore preventing duplication or misidentification errors, and less duplication of testing/prescribing and will allow information to be exchanged between information systems, therefore reducing administrative tasks.

Hospitals will also benefit from having more complete and accurate information on which to base potentially life-critical clinical decisions; reductions in significant levels of duplication of administrative effort, less wasting of patients’ time and resources and hence greater efficiencies, and more accountability and improved communications.

“Having information that is complete and accurate about each person will reduce duplication in medical records, appointments, testing and prescribing. This results in time-saving for the patient and administration and cost savings for the system,” Professor Grimson said.

Health service managers can submit comments by completing the online consultation feedback form or alternatively downloading and completing the consultation feedback form, both accessible from www.hiqa.ie. The closing date for receipt of comments is 5pm on Friday 12 April 2013.

Referral thresholds for surgical procedures

Draft recommended referral thresholds for a number of surgical procedures have been published for consultation by the Health Information and Quality Authority (HIQA).

The draft reports are on varicose vein surgery, tonsillectomy, grommet insertion and adenoidectomy, and cataract surgery. This is the first phase of a series of health technology assessments (HTAs) of scheduled surgical procedures being undertaken by HIQA at the request of the HSE.

These HTAs evaluate the potential impact of introducing clinical referral or treatment thresholds for such procedures within the publicly funded healthcare system.

HIQA’s Director of Health Technology Assessment, Dr. Máirin Ryan said, “The purpose of these assessments is to ensure that the patients most in need of surgery receive the required treatment as quickly as possible. For scheduled surgical procedures, it is vital that the right patients are referred for treatment at the right time, potentially releasing capacity and resources without causing harm or reducing benefit.”

“The reports provide evidence-based advice on potential referral or treatment thresholds for procedures where effectiveness may be limited for some patients unless undertaken within strict clinical criteria and we are interested in receiving feedback on them.”

“The need and demand for healthcare services continues to increase and given Ireland’s changing demographics, demand is likely to grow in the foreseeable future. As a result, pressure on national waiting lists continues to grow despite increases in activity levels. Providing increased clarity around referral or treatment thresholds for general practitioners and patients should minimise, where possible, referral of patients who do not proceed to surgery.”

HIQA convened a multidisciplinary Expert Advisory Group to oversee the process of the rapid health technology assessments and to provide access to expert advice and information as required. The completed evaluation will be submitted to the HSE and to the Minister for Health.

The consultation on these draft recommended referral thresholds for certain scheduled surgeries will run until 13 March 2013. The reports, along with details on how to take part in the consultation, are available from www.hiqa.ie.

National Paediatric Hospital Development Board Members

Dr. Fergal Lynch, Deputy Secretary, Department of Health, has been appointed to chair the National Paediatric Hospital Development Board.

The other members of the Board are Ms. Bairbre Nic Aongusa, Assistant Secretary, Department of Health, Ms. Fionnuala Duffy, Acute Hospitals Policy Unit, Department of Health, Mr. Charlie Hardy, Acute Hospitals Policy Unit, Department of Health, Mr. Jim Curran, Head of Estates, HSE and Mr. Gerry O’Dwyer, Regional Director of Operations, DML.

Under the terms of the National Paediatric Development Board (Establishment) Order 2007, the term of office for Board members is five years. However the above appointments are interim appointments and expected to be for a period of up to six months.

A prospective case-based payment system (Diagnosis Related Group system) will replace the current block grant allocation payment to public hospitals; it is proposed in the Government’s new Money Follows the Patient consultation document.

The paper says that the scheme should start in shadow form this year, when shadow funding should be rolled out to the hub hospital of each new hospital group.

Maureen Browne

To run the new system, a National Information and Pricing Office with multi-stakeholder oversight and strong clinical representation would set national DRG prices for the year ahead using activity and cost data and a  separate purchasing entity, the Healthcare Commissioning Agency would be grown from within the HSE.

The MFTP consultation document recommends the new payment system should ultimately apply to episodes of care provided in a Medical Assessment Unit/Acute Medical Assessment Unit/Acute Medical Unit, Clinical Decision Unit, day ward or inpatient ward and all comparable episodes of care which are, or could be, delivered on a side-room or outpatient basis.

Emergency Department and Minor Injury Units, outreach services, teaching and research costs and long term residential care should all be financed separately and outside of the ‘Money Follows the Patient’ system.

Emergency Department and Minor Injury Units, outreach services, teaching and research costs and long term residential care should all be financed separately.

The paper says that, in addition, outpatient services which are ancillary to a defined treatment or episode of care (e.g. initial consultation, assessment and follow up) should not be bundled into the main payment for reasons of complexity, although this approach should be kept under review.

It says that services should be defined and priced by reference to complexity-adjusted episodes of care and not by reference to setting. The same service should attract the same price whether it is delivered in a daycase ward or a side-room/ outpatient setting and prices should not differ depending on the category of hospital.

The MFTP consultation document states that this approach is consistent with the immediate creation of Hospital Groups and is central to the longer-term policy intention of Hospital Trusts operating on a level playing field.

In terms of the classification system, episodes of care should be defined using the existing Hospital Inpatient Enquiry Scheme (HIPE) and the related AR-DRG grouper. The system should also be underpinned by quality guidelines in terms of defining how a service should be delivered – a ‘best practice’ approach.

In line with Government policy, it is proposed that mental health care should be treated in a similar manner to other acute episodes of care and funded on a ‘Money Follows the Patient’ basis. However, given the many challenges involved in transitioning towards case-based payments, it is suggested that ‘Money Follows the Patient’ begin with the existing AR-DRG system and transition towards the inclusion of acute mental health treatment.

In line with the ultimate goal of a value-based purchasing system, it is recommended that prices should be based on best practice pathways.

It is recommended that the new system should encompass an outlier payment mechanism to take account of exceptional high cost cases.

“When aligned with trading rules, this approach can provide a powerful tool for driving optimal quality of care. It is also fair, efficient and transparent in that prices are based on pre-agreed, published guidelines and hospitals are then appropriately reimbursed for providing services to that standard. As such, the approach is also consistent with the proposal to develop prices which are independent of setting and which support provision of care in the most appropriate setting. Moreover, the approach could also represent a logical starting point for the future development of integrated payment systems.”

“However, the major disadvantage associated with best practice pricing is the time required to achieve consensus on what constitutes ‘best practice’ and to develop robust guidelines. As such, it is proposed that the system should begin by setting prices by reference to average costs but with a view to implementing best practice prices on an incremental basis.

In calculating prices, it is recommended that the existing approach of indirect price-setting using relative weights should be maintained. However, the approach will have to take account of the move towards best practice pricing.

Generally speaking, the price for an episode of care should encompass all costs appropriately associated with the delivery of that care. It is, therefore, recommended that the price should encompass:

• Pay costs (Consultants, NCHDs, Nursing, Paramedical, Administration, Support Services, Catering, Porters and Maintenance).
• Non Pay Costs – such as medicines, blood, medical and surgical supplies, radiology, laboratory equipment and supplies, heat, light and power etc.
• Costs of diagnostics, medical services, theatres, laboratories, wards and overhead allocations as appropriate.
• Costs of the clinical indemnity scheme as it relates to public hospitals (although a mechanism for including such costs may need to be developed over time).

It is recommended that certain other costs should be excluded from the calculation of the price in the initial years of the scheme, including capital and depreciation, superannuation and bad debts. However, it is suggested that these matters should be kept under review, particularly, in the context of moving to a single-tier UHI system involving both public and private providers.

“In the interests of fairness and sustainability”, it is recommended that the new system should encompass an outlier payment mechanism to take account of exceptional high cost cases. Outlier payments should be based on length of stay thresholds and should be linked to medical necessity, i.e. once a patient is deemed medically fit for discharge, no payment should apply for further time spent in an acute hospital setting.

In line with international evidence, it is recommended that the price-setting function should be independent of the purchasing function. It is, therefore, proposed that a new National Information and Pricing Office with multi-stakeholder oversight and strong clinical representation be established. This Office would set national DRG prices for the year ahead using activity and cost data.

A separate purchasing entity, the Healthcare Commissioning Agency, should be grown from within the HSE before being established as a new statutory agency. The Agency would use the national DRG pricelist, in addition to the global hospital budget and service targets handed down by the Minister, to conclude annual performance contracts with each public Hospital Group.

These annual performance contracts would set out activity targets by quarter to be funded at national DRG prices. They would also include quality targets underpinned by financial sanctions. The Healthcare Commissioning Agency would then pay Hospital Groups the national DRG price on receipt of confirmation that pre-agreed activity had been delivered. “In this way, hospitals would receive a fair and transparent price for the care they deliver and would be encouraged to provide quality care in the most efficient manner.”

The paper states that where, as part of the global hospital budget, the Minister provides funding for additional targeted activity, and this should have to be pre-approved by the Healthcare Commissioning Agency and could be paid at rates other than the national DRG price.

Only hospitals which meet their activity in the previous quarter would be eligible to bid for this additional funding. In other words, if a hospital had a waiting list, then people could be taken off it and treated elsewhere but the funding would have to follow the patient.

The information submitted by Hospital Groups for the purposes of payment would be subject to audit and would also be used (i) to set national prices for the coming year and (ii) to inform structured consultation with all stakeholders on any proposed changes to the DRG system. “In this way, the pricing system would be subject to continual modification so that it remains fair and fit for purpose.”

The consultation document says that successful introduction of the new policy is also crucially contingent upon a number of other policy initiatives, in particular the development of Hospital Groups.

In acknowledgment of the time required to create new Hospital Groups and to develop the building blocks outlined above, it is proposed that ‘Money Follows the Patient’ would start in shadow form in 2013. This would involve hospitals continuing to receive their existing base budget under a vote cashing system. However, a process would be put in place to compare, on a systematic and periodic basis, (i) actual hospital activity against pre-agreed baseline activity targets and (ii) hospital expenditure against pre-agreed DRG prices. In this way funding variances and potential impacts would be highlighted although no changes would be made to a hospital’s budget on foot of the exercise.

HSE allocations to voluntary hospitals have been particularly controversial this year, following the HSE decision to “re-balance” hospital budgets, rather than continuing to fund the hospitals on a largely historical basis.

The move away from “historic budgeting”, which resulted in some hospitals being forced into the red each year by budgets which had been clearly shown to be unworkable over many years has been generally welcomed. However, the way it appears to have been carried out has resulted in allegations of unfairness by some hospitals which “lost out”.  Even not all the so-called “winners” are happy, with some saying that while the re-balancing is an excellent idea in principle, it should have gone further and taken historic deficits into account.

There is also general annoyance at the lack of information provided to the hospitals, with many managers saying they were well into their normal budget planning when they discovered the new system was on the way.

While the principles on which the re-balancing was carried out are not known, it appears in many cases to have been based on the 2012 outturn, minus three per cent.

This has led to complaints that some hospitals were being rewarded although they had run up deficits in 2012.

The HSE regional plans for its four administrative areas outline details of €721 savings for 2013, which were signalled earlier this year in the HSE national service plan. Despite the cuts, the HSE said extra beds would be opened in some hospitals.

In Dublin Mid-Leinster, some hospitals are facing substantial cuts, with Naas General, St. Vincent’s and Loughlinstown Hospitals both just under 5% down on their spending for last year, and Tallaght Hospital down 4.2%. The service plan for Dublin North-East shows funding this year will be cut by 3.5% for acute hospitals

Mallow Hospital’s emergency department is to close shortly and Bantry Hospital’s ED will be replaced by an urgent care centre with emergency surgery moving to Cork University Hospital. Mallow and Bantry hospitals will continue to provide services that “are appropriate for the hospitals and for the local population, delivering non-complex care as close as possible to patients’ home”, according to the HSE.

In the south east, implementation of the national clinical programmes will allow for the opening up of additional beds in Wexford, Kilkenny and South Tipperary, with Waterford set to gain new consultant posts in areas such as emergency medicine, dermatology and acute medicine.

In mental health, 102 acute inpatient beds will be closed, although inpatient services for children and adolescents are being increased.

Among the capital projects due to be completed this year are a 44-bed psychiatric unit at Beaumont Hospital and accommodation for 54 residents at Grangegorman.

Some €383 million is to be cut from the budget for community schemes such as medical cards.

The following are the 2013 allocations:

• The Children’s University Hospital, Temple Street, Dublin, €76.688m
• The Adelaide & Meath Hospital, incorporating the NCH, Tallaght, Dublin, €173.851m
• Coombe Women and Infants University Hospital, Dublin, €47.564
• Our Lady’s Children’s Hospital, Crumlin, Dublin, €117.310m
• St James’s Hospital, Dublin, €299.890m
• St Vincent’s University Hospital, Dublin, €193.463m
• St Michael’s Hospital, Dun Laoghaire, €24.600m
• National Maternity Hospital, Holles Street, Dublin, €44.235m
• Royal Victoria Eye & Ear Hospital, Dublin, €19.786m
• National Rehabilitation Hospital, Dublin, €24.224m
• Dublin Dental School and Hospital €5.790m
• Leopardstown Park Hospital, Dublin €3.676m
• The Royal Hospital Donnybrook, Dublin, €12.753m
• Our Lady’s Hospice & Care Services, Dublin, €22.419m
• St John of God Hospital, Dublin €81.534m
• Peamount Hospital, Dublin, €21.043m
• Stewarts, Dublin, €41.238m
• St Columcille’s General Hospital, Loughlinstown, Co. Dublin, €37.435m
• Naas General Hospital €54.479m
• Midlands Regional Hospital Mullingar, €56.547m
• Midlands Regional Hospital Tullamore, € 80.944m
• Midlands Regional Hospital Portlaoise, €45.234m
• Beaumont Hospital, Dublin €238.14 million
• Cavan/Monaghan Hospital Group €81.27m
• Connolly Hospital, Dublin €84.72m
• Mater Hospital, Dublin €209.6m
• Cork University Hospital Group (inc MGH & CUMH), €269.281m
• Bantry General Hospital €16.966m
• Mercy University Hospital, Cork, €55.421m
• South Infirmary Victoria University Hospital, Cork, €43.905m
• Kerry General Hospital, €68.097m
• Waterford Regional Hospital, 132.939m
• Wexford General Hospital €47.792m
• St. Luke’s General Hospital (incl. Kilcreene Hospital) €54.875m
• South Tipperary Hospital €45.532

A Programme Management Office and a Health Reform Programme Board are being established in the Department of Health as part of the overall governance structure for the programme of reform, Health Minister, Dr. James Reilly told the 9th National Health Summit in Dublin.

Dr. James Reilly, T.D.

The reform programme board will be chaired by Dr. Ambrose McLoughlin, Secretary General of the Department of Health and include Mr. Tony O’Brien, Director Designate of the HSE.

The Minister said the Programme Management Office would plan all the projects within the health reform agenda.  It would focus on timing, sequencing and milestones for each project, prioritise, monitor and report on the health reform programme and highlight areas that might fall behind and need action.

He said the Patient Safety Agency (PSA) would also be established within the year to deliver “visible and distinct leadership responsibility for patient safety and quality at national level. It will be modelled on international examples such as the Canadian Patient Safety Institute, where patient safety is developed through shared learning and interventions known to reduce avoidable harm.”

The Minister said that a whole-of-government approach to health issues demanded the development of a comprehensive health and well being policy framework.

“We need to address the very serious issues facing us in relation to, for example the levels of obesity in Ireland. Formalised governance arrangements for a whole-of-government and cross sectoral approach to health and well-being is a major element in contributing to a vision of an Ireland where everyone can enjoy physical and mental well-being to their full potential.  Subject to government approval I’ll publish a framework around this shortly. Nowhere is this more necessary than with alcohol and tobacco.”

It would focus on timing, sequencing and milestones for each project, prioritise, monitor and report on the health reform programme and highlight areas that might fall behind and need action.

The Minister said that he planned to establish a Children’s Hospital Group, with its own board, budget, management team etc.

He said the three existing paediatric hospitals had stated their commitment to becoming a single service before the new hospital was built. This commitment was very welcome and he was conscious of the need to support the hospitals’ efforts in this regard with effective governance arrangements.

“I am pleased to say that the Chairs of the three paediatric hospitals have welcomed my proposal to establish a Children’s Hospital Group. They have said that they believe it is both possible and appropriate for the three hospitals to drive the establishment of a Children’s Hospital Group Board very quickly and have been positively engaging with the Department to progress this.”

In view of this the rationale for maintaining the range of functions of the National Paediatric Hospital Development Board, as originally established no longer existed. Therefore he intended to restructure the Board to focus specifically on the capital project. The restructuring of the Board would require primary legislation and he intended to bring heads of a Bill to Government in the near future. In the meantime he had appointed senior officials from the Department of Health and the HSE to the Board.  “This is an interim measure aimed at ensuing effective governance and decision-making for the project at this important initial stage.

In the meantime he had appointed senior officials from the Department of Health and the HSE to the Board.

“I also believe that, having regard to the size and importance of this project, independent national and international expertise must also be available to it. Accordingly, I am establishing a Strategic Advisory Group to provide external objective advice and expertise to the project. This will ensure that the project has regard to international best practice, particularly on developing trends in paediatric healthcare.”

Dr. Reilly said that  he was gravely concerned about costs in the private health insurance industry, particularly as we prepared for UHI and the VHI was shortly to submit to him a targeted cost containment plan – audit, clinical audit, pay per procedure and cost of procedure.

A policy paper on “Money follows the patient” (MFTP)  had been approved by the Cabinet committee on Health and would be publicised for consultation shortly and the Bill to allow for the extension of free GP care to people with prescribed illness would be published early this year.

He said that there had been significant improvement in hospital access targets including:

• A reduction of 23.6 per cent in the number of patients waiting on trolleys in 2012 compared to 2011.
• The number of adults (excluding endoscopy) having to wait more than nine months for inpatient and day case surgery was down to 86 at the end of December 2012 from 3,706, a 98 per cent decrease. The target for 2013 was a maximum wait time guarantee of eight months
• The number of children (excluding endoscopy) waiting over 20 weeks was down to 89 at the end of December 2012, from 1,759 in December 2011, a 95 per cent decrease
• The number of patients waiting over 13 weeks for a routine GI endoscopy procedure went down from 4,590 in December 2011 to 36 at the end of December 2012, representing a 99 per cent decrease.
• The target for November 30, 2013 was that no patient should be waiting more than 52 weeks for a first time consultant led appointment.

One of the greatest challenges facing the Irish health services was to ensure that diminishing resources were absolutely focused on the core business of the health service, Mr. Tony O’Brien, Director Designate HSE told the Conference.

Tony O'Brien

He said that if the services were to lose another 5,000 or 6,000 people in the year ahead, it would be necessary to see what should and should not be provided with core health service personnel.

“There are things which the health service needs but are they things that we need to provide ourselves? These are discussions which we must have in the context of the Croke Park Agreement.”

He said that there had been a total reduction in the HSE budget of €3.3 billion since 2008. This year’s budget had been reduced by €721 million. The hospitals had an incoming deficit of €271 million which was sufficiently large to destabilise all our health services and last August had forced the HSE to take decisions such as reducing home helps etc., which were not in the best interests of people.

Primary care schemes had a cost reduction challenge of €383 million this year and in part this would be met by Government decisions in areas such as trebling prescription changes.

“Workforce modernisation in line with Croke Park is clearly going to be part of how we navigate continued diminution of resources.

“This year, we need to see a gross reduction of 4,000 WTEs under a voluntary exit scheme. Staff levels have already been reduced by over 22,000 or a little over ten per cent of our workforce since September 2007.

“Under this exit package, there will be the ability to refuse to sanction applications to leave but the challenge will be great.

“We have the dual challenge of reducing costs while at the same time improving patient outcomes. Patient safety is paramount. We will continue to introduce models of care across all services and care groups and we will continue with workforce modernisation in the context of the PSA. Patients are being treated faster and far more are spending less time on trolleys, partly due to the Clinical Care Programmes which are improving quality of care, changing models of care and reducing the time patients spend in hospital.

“Workforce modernisation in line with Croke Park is clearly going to be part of how we navigate continued diminution of resources. More and more is being asked of our staff at a time when they can legitimately claim they have given considerable amounts. Without them, the service would not be performing as it is at present and I have no doubt our services are more efficient than before and there is far more activity per euro being spent.”

“First we will have hospital groupings, and then we need to do the same in primary care and other services.

Mr. O’Brien said that we were heading in the direction of money following the patient and we had to confront the reality that over a successive number of years the common orthodoxy had been to cut and cut at hospital budgets without regard to where they had started or if the hospitals could deliver, even in the face of international evidence that hospitals could never deliver a 7 – 11 per cent reduction in a single year.

He said that this year the HSE had shifted a considerable resources from other sectors to the hospitals and distributed them not evenly but to avoid recurrence of last year’s deficit by ensuring that all service managers had a realistic gap to bridge between last year’s outcome and this year’s activity.  Cuts ranged from 2 -1 3.9 per cent.

“The bottom line is that when a hospital inherits a budget which was never based on anything in particular and which guarantees a deficit which could destabilise all our health services, there is no option but to redistribute.  Hospitals cannot plan for deficits and there are no circumstances where I want myself next August having to contemplate cuts in home help or similar areas.”

Mr. O’Brien said that the evolution of hospital groups, similar to what had happened in Galway and the Mid-West were very important in transforming the way our hospital services were managed. “I have long argued that in its infancy, the HSE was driven towards a degree of centralisation which was not conducive to maximising freedom of action close to where decision making should take place.

“First we will have hospital groupings, and then we need to do the same in primary care and other services.”

He said that our rate of generic prescribing was very low and as a result we were spending far more money on medicines than we needed to do and there would be a focus on this.

Tallaght Hospital in Dublin doubled the number of patients going through its Emergency Department between March and September last year, the hospital CEO, Ms. Eilish Hardiman told the Conference.

Ms Eilish Hardiman, Dr. Ambrose Mcloughlin and Prof. John Crown

Ms. Hardiman, who was one of three panellists speaking on “Leading Large Scale Change in such Challenging Times“ said that the percentage of patients seen in three hours had doubled from 30 to 60 per cent.  The hospital was admitting about 120 fewer medical patients a month on foot of the implementation of its acute medicine programme.

She said that she took up the post of CEO 18 months ago and since then the focus of the Board in had been on patient safety, good governance, strong financial stewardship and the management competencies and capabilities to deliver on this had been implemented.  Seventy per cent of the HIQA recommendations had been implemented by the end of last year.   No patients were waiting more than nine months for in-patient care.    A financial strategy with a two year plan was being implemented and the hospital hoped to break even this year.

“My vision is to focus on population health. The acute system will not and cannot deliver on its own. There needs to be total alignment with community services.”

“Tallaght could not have made these changes in the last 18 months without the commitments of the 3,000 people working there to make changes. I am very heartened by our committed workforce, our clinical leadership is phenomenal. We need to facilitate and allow staff to make changes and give them the reins to do so.

“My vision is to focus on population health. The acute system will not and cannot deliver on its own There needs to be total alignment with community services.”

Dr. Ambrose McLoughlin, Secretary General of the Department of Health told the Conference that everybody in the system was highly valued and everybody had the opportunity to make a contribution.

“I believe the Health Management Institute has a very important role in ensuring continuing professional development for their members.”

“I believe the Health Management Institute has a very important role in ensuring continuing professional development for their members.”

He said he would like to see seventy to eighty Primary Care Health Teaching Centres attached to teaching hospitals around the country. He believed alignment between the new hospital groups and the medical schools was profoundly important.

Ultimately, it was the leadership role of all the clinicians, including doctors, nurses etc, that really delivered the change surge.

“We will be looking at fairly significant governance changes and new structures which will mean that we will have to move ultimately to an executive role for clinical people.

“Patients must be at the heart of decision making and their care and treatment processes and we must encourage active involvement by patients and their families in their own care and treatment.

“We also need to build relationships that will endure with communities. We have to have dialogue about alcohol and physical activity. This is about everybody working together on the same agenda and delivering for patients.”

The ultimate logic of a system that empowered patients by universal insurance was that there would be mass unemployment of people who were currently designated as officials as they would not be needed.

He said the Clinical Care Programmes were truly magnificent and he would like to compliment former HSE Director, Dr. Barry White and all the Clinical Leads for their work in implementing them.

“We will be enhancing and supporting the clinical leadership and the general leadership.”

He said a medicines management programme was in place in the HSE to address the most cost effective prescribing. He also said that the pharmaceutical industry had 100,000 staff and contributed €40 million annually to the country.

Senator Prof. John Crown, Consultant Oncologist, St. Vincent’s University Hospital, Dublin said that the ultimate logic of a system that empowered patients by universal insurance was that there would be  mass unemployment of people who were currently designated as officials as they would not be needed and power would be transferred to the clinicians and the people. He said that under this system we would not have a national consultant contract.  Some consultant would become full time, others would have different arrangements.

He said that one of the problems was that all consultants in Ireland were co-equal, as there was no appropriate career progression system once consultants were appointed

He did not share the certainty of many in the audience that administrative and organisational changes would actually fix the problems of the health services. “I don’t think they will make a big difference.”  He criticised the fact that there was not one medical person on the UHI implementation group. He said that he did not see the cancer programme working and that was the only one about which he could speak.

“There are economies of care and more seamless complex care can be delivered when hospitals come together.  We have probably two to three too many hospitals in Dublin and the population has two or three times more medical schools than the European average.  We have one medical school for 1 million population while the European average is one for 1.5 million.

He hoped every press consultant would be sacked and every PR person fired, so that people in authority would have to come out and face the media themselves.

The system of funding the Irish health services needs a seismic overhaul, Mr. Brian Fitzgerald, CEO, St. James’s Hospital, Dublin, said. The health services would have significant problems until we had transparency in the allocation and use of resources.

Speaking on a panel discussion on “The Opportunities & Challenges to Delivering Better Outcomes & Cost Savings,” he said “Our cost system in this country is too rigid, with too much emphasis on a fixed cost base.  We need significant engineering of financial management across the country. We are very outdated in the structures, processes and procedures we bring to managing our finances in the health services.”

Mr. Fitzgerald, who was previously Director of Finance at St. James’s said that you could not manage financial issues if you were changing strategy or if you had strategies which cut across or overlapped. We have tried to implement many strategies in recent times.

“We need better cost allocation models if we want to have a true partnership between clinicians and those who have been traditionally responsible for resources.”

Mr. Fitzgerald responded to a question on the feasibility of implementing Universal Health Insurance in the time frame and the economic situation.   “UHI is an enormous multi faceted project. We should definitely implement a new resource model and then look to the implementation of full UHI model if possible.

“While we build a resource model we should not be building a data model purely for funding. It needs to be built for quality and clinical audit at the same time. For example there may be a model being developed by HIQA for quality and a separate data model for funding. I would accelerate that programme but in the context of one data model for both.

The Irish health system requires significant investment in ICT to underpin quality and efficient patient services “For example, we should have had e-prescribing in this country a decade ago.  We also need to harness international collaboration.”

Dr. Una Geary, National Clinical Lead, HSE Emergency Medicine Programme, said her message was one of hope. “We have grounds in Ireland for cautious optimism.  We have been putting together building blocks for improving quality of service and while we have a long road ahead, we are making significant progress.

She said the HSE Clinical Programmes were making significant progress and the National Office for Clinical Audit was another important recent development, while great strides had been made in developing the role of clinical directors.

She said we needed investment in IT systems to get better feedback and true systems intelligence. “We need better cost allocation models if we want to have a true partnership between clinicians and those who have been traditionally responsible for resources.  Sometimes, the conversation is too much about the cost of staffing rather than the value being delivered.

“I am impressed by the work being done in the UK including introducing financial management at undergraduate level. We have a lot of work to do on patient partnership, discussing treatment outcomes with patients and encouraging them to give us feedback.”

Ms. Laura McGarrigle, Principal Officer, Department of Health, who now leads the UHI unit there, said the UHI design was a multifaceted complex piece of work. It was not just a case of transplanting the Dutch model.

She said that the money following the patient policy would provide both opportunities and challenges.

“It can bring very significant opportunities.  Firstly, it can bring transparency and much greater fairness, enabling meaningful dialogue between finance managers and clinicians. It also provides an opportunity to drive efficiency. Its true potential and value lies in delivering a value based model. We want a model that supports the excellent work of the clinical programmes and the Special Delivery Unit.  The challenge is to design a funding model that supports the delivery model.”

Mr. David Ferguson, Principal Consultant, SAS Ireland examined the opportunities now available turn data into knowledge. He said that, for example, the UK now had an automated process to identify what might trigger falls.

More patient self-management will be a feature of the health services in the future, Mr. Kieran Ryan, CEO, Irish College of General Practitioners, told the Conference.

He said that many drugs which were now only available in hospital would become available at primary care and indeed home level, which would affect cost control and empower patients to manage their own health. Wellness was the way to go and primary care was the only place to focus on wellness.

“At present primary care teams are very much hit and miss and the definition and understanding of teams is very variable and there are not as many out there as we thought.”

Mr. Ryan said that 95 per cent of GP services used electronic patient management systems, but the lack of a unique patient identifier was a huge barrier to integration between primary care and the hospital services.

“We need to look at the business environment of primary care. By and large most GPs in private practice have invested in their own property and employ their own people. There are about 1,600 practices employing two to three people, which is a major benefit to the economy. There is great uncertainty about UHI, if GPs will be salaried and how will it affect the business.

If all existing private patients were to be converted to public patients at 2009 rates, the highest risk exposure would be about €800 million.

Mr. Stephen McMahon, CEO, Irish Patients Association said that they had estimated that if all existing private patients were to be converted to public patients at 2009 rates, the highest risk exposure would be about €800 million.  Prices had come down since then.

Ms. Laverne McGuinness, HSE National Director for Integrated Care said that 90 per cent of all health care could be provided in primary care rather than in hospitals. The Department of Health strategy was for 484 Primary Care Teams. There were 426 PCTs in place at present. Not all were fully staffed compared to what they should be. About 40 per cent would be fully functioning and working very well. Others were at different stages due to staff leaving and non replacement.  This year there was a budget of €20 million for about 250 era staff in PCTs.

“I would see the PCTs as the first step in putting together the infrastructure to deliver the primary care service we need here in Ireland, and to keep people well.  They are the core stepping stones.”

There were 426 PCTs in place at present. Not all were fully staffed compared to what they should be.

She said the HSE had put in place a national audiology programme as part of primary care. “Our aspiration is for 90 per cent of care to be delivered in the community, which is a big challenge. We need to negotiate a new GP contract and a mindset change that where appropriate, care in the community is as good as care in hospitals.