Senior Irish health managers are urging that the Minister for Health, the Department of Health and the HSE should open a broad engagement with staff on how the new hospital and community Trusts are to be established and structured – or indeed if they are necessary at all.

Maureen Browne

They say that the current lack of any structures for discussion or debate are truly shocking and the “news” on the grapevine is that none is planned and that decisions will be taken by a couple of people at the top and then foisted on the system as a whole.

The first item which managers believe should be down for discussion is that, in the event of the establishment of Universal Health Insurance, whether it is necessary for Trusts to be established at all.

There is also the question as to whether hospitals would be allowed to buy services from major centres of excellence outside their Trust or if they would be required to pay for this, as has happened in the UK

“Those at the top of the Department and the HSE seem fixated with structures,” said one manager. “In fact, you could introduce UHI without setting up Trusts. I see no cogent argument for Trusts, especially as there is no indication that the Government will allow Trusts to determine pay and conditions. Basically under UHI, providers will be buying services regardless of corporate status and if a hospital wants to provide a service which requires rationalisation, it should be up to the hospitals concerned to make these arrangements.

“I see two issues involved. It would facilitate rationalisation of services in the so called “voluntary hospitals,” which are now either state owned or rely on the state for the majority of their funding. But rationalisation should be driven by policy and large Trusts could make it more difficult to deal with hospitals in relation to national planning. I could see a situation developing where powerful Trusts would try to develop new specialties and introduce new procedures and insurance companies would not be able to keep funding them. There is already a move toward co-payments and with those covered by health insurance set to shrink to about 35 per cent, I just wonder where this will leave those in the lower socio economic groups and where the State will  get the money to pay their premia.”

There are expected to be challenges in establishing Trusts which would include state owned hospitals, the voluntary hospitals, most of which are now limited companies and private hospitals

There is also the question as to whether hospitals would be allowed to buy services from major centres of excellence outside their Trust or if they would be required to pay for this, as has happened in the UK

In the West and the Mid West, some  people see the new hospital arrangements – which to a large extent have moved back towards the old health board model – as a move towards establishing Trusts in those areas, but at present they are basically just management arrangements, without any clarity regarding autonomy.

The fate of hospitals around the country, particularly the smaller hospitals, the possible rationalisation of their services, the breakup of networks and local loyalties are complex issues. There are very real fears that some existing integrated acute hospital networks may be chopped and pulled apart without any proper analysis of these issues. While it is freely admitted that all the networks are not perfect, they say it is being forgotten that they are operationally inter-dependent, have clinical governance links and joint consultant appointments.

There are expected to be challenges in establishing Trusts which would include state owned hospitals, the voluntary hospitals, most of which are now limited companies and private hospitals, whether Trusts should include a range of hospitals providing different services, whether specialist hospitals would group together in Trusts and if geography should be a determining factor in establishing Trusts.

There are very definite fears that smaller specialty hospitals could be “swallowed up” by Trusts dominated by large acute general hospitals. As one manger said “If you were to bring Dunlop and Ferrari together, there is really no reason why Ferrari should run Dunlop. We must also consider what size an organisation should be to be effectively managed. What is important is that we have uniformity and consistency and a level playing pitch. If we are to set up Trusts, it is also essential that we move to multi-annual funding.”

There are a number of possible configurations in Dublin. On the northern side of the city, discussions are well advanced on an amalgamation of services between Beaumont and Connolly Hospitals in conjunction with the establishment of an Academic Health Centre with RCSI. There is the possible addition of Our Lady of Lourdes Hospital in Drogheda. There are already close links between the Mater Hospital, the National Orthopaedic Hospital in Cappagh, St. Vincent’s Hospital in Fairview and the Children’s University Hospital in Temple Street and it seems very possible that these could link up under one management.  If the Mater Private Hospital also became part of this conglomerate, these hospitals could become either one or two large north side Trusts.

There are very real fears that some existing integrated acute hospital networks may be chopped and pulled apart without any proper analysis of the issues involved

However, under another scenario, the Children’s University Hospital in Temple Street could join up with Our Lady’s Hospital in Crumlin and the National Children’s Hospital in Tallaght.  Then, there is the Rotunda Hospital and whether this would fit in with a north side trust or become part of a trust covering all the maternity hospitals is up for debate as are the implications for the Dublin maternity hospitals with long established Charters.

On the south side of Dublin, St. James, the St. Vincent’s Group, Tallaght, the Royal Victoria Eye & Ear and St. Columcille’s Hospitals could form the base for one or two Trusts.

Another aspect of the jigsaw which must be taken into account is the establishment of the new Academic Medical Centres.

Beaumont and Connolly and possible Drogheda, are set to amalgamate their services in conjunction with the establishment of an Academic Health Centre with the RCSI. The Mater & the St. Vincent’s Group have already announced that they will soon become part of an Academic Medical Centre, with a single board of management in conjunction with UCD.  St. James’s and Tallaght Hospitals and the TCD School of Medicine are re-organising their services into an Academic Medical Centre.

These are all areas which need broad debate and engagement with staff and this is not being carried out at present.

March 1 has come and gone and the much-vaunted ‘crisis’ in health service delivery, occasioned by the exodus of thousands of skilled staff, has passed in a relatively calm way.  The service adjustment (ongoing) remains a challenge, the manifestations of which will present as both problems and opportunities for service managers at all levels for some time to come.

Richard Dooley, President, HMI

The recent exodus, however, is but one in a series of actions and measures to hit the health services over the past four years.  From a national perspective, the necessity and rationale for such actions is evident and accepted.  However, the cumulative effect of these actions and measures, which have been blunt and non-discriminatory in their implementation, has been to spawn a level of control that is disproportionate and seems to erode the role of managers within the system; to dent system confidence in managers and ultimately the managers’ own self-confidence.  This, unwittingly perhaps, has potential to bring the delivery system into tricky territory where patient care imperatives can be put aside and where local managers do not have the latitude, flexibility or structural wherewithal to deploy their resources to the areas of greatest need.  The consequences for morale are enormous and challenging for managers more so now than ever.  It is a problem that cannot be ignored.

The urgencies around this must not be lost on policy makers.  The actions must be progressed to re-define structure and function for the shape our health service will take.  In parallel with this, and as stated oft-times before, there must be a formal and properly accredited health service management career pathway to develop the competencies (strategic, tactical and technical) to lead and manage health service delivery into the future.  This must be agreed and developed without further delay.

Richard Dooley,
President HMI

Trusts are to be formed as a feature of the reformed healthcare landscape here. How significant is that likely to be and what role will they play? Well, details of what is planned are sketchy, so it remains to be seen.

Denis Doherty

Trusts have been a feature of the NHS in the UK for a number of years now. They fall into two categories, some are commissioning trusts and others are commissioned trusts. Commissioning trusts commission services from service providers but some also provide some services themselves. Primary care trusts come into that category. Commissioned trusts, the majority of which are acute hospitals, usually provide secondary and tertiary care services. Mental health and ambulance services are also provided by trusts. In Northern Ireland services are commissioned by a health and social care board and are delivered by six trusts.

The word trust can mean different things depending on the circumstances in which it is used. In the NHS, the current fashion is to apply the word ‘trust’ to public health bodies in much the same way that words like ‘boards’ and ‘authorities’ were fashionable in the past. A board, made up of executive and non-executive directors, governs each NHS trust. Interestingly, non-executive directors are appointed following public advertisement.

In the Netherlands, mergers, facilities replacement and major modernisation programmes are commonplace

Trusts are not a feature of the Dutch healthcare model to which we aspire. Eight University Medical Centres, only two of which are in Amsterdam, form the top group of hospitals. There is a similar number of non-university ‘top clinical’ hospitals and there are also many local hospitals.

Here, the recently formed hospital groups in the west and the mid west could become trusts like those in the NHS by the appointment of boards of governors. Public hospitals in some other areas could also be grouped without much difficulty. The greater Dublin area is, as always, more complicated. Voluntary Hospitals, Public Voluntary Hospitals and Public Hospitals make up the publicly funded hospitals network there. There is also a concentration of significant private hospitals in the Dublin area. Increasingly more secondary and tertiary care to the populations of midland and north – eastern counties are being provided by Dublin hospitals. There may be sufficient or even a surplus of hospital beds in Leinster but, many are in the wrong locations and others are in hospitals that are old and no longer fit for purpose. The major system changes that are planned add urgency to the need to rationalise hospitals in Dublin and much of Leinster.

Those who commission and deliver services are often well placed and willing to lead effective change. On continental Europe, in countries where healthcare is funded by universal insurance, the health insurance companies drive efficiencies and value for money and the smart providers spot trends early and make the changes they believe will allow their hospitals to be sustainable into the foreseeable future. In the Netherlands, mergers, facilities replacement and major modernisation programmes are commonplace. We have been reluctant to adopt change of that sort but it looks like the status quo is no longer an option.

He warned that each acute hospital would be getting a trajectory of its performance each month and in cases where over a period of time there was “a sufficient absence of performance improvement” to the extent that the system no longer had confidence in the hospital management, there would be a discussion with the governing body of the hospital about changing the management involved.

Tony O'Brien

“Another part of our brief is the development of an accountability framework for all services and if a service is consistently failing on access and quality, the logical consequence of that will be a change of the leadership running that service”, he said.

There would be a simplified score card to establish if management was successful – the service provided must be safe, of a high quality and patient centred and equal weight must be given to quality, access and financial balance.

“For example, for several years the HSE service plan committed to six hour patient experience in emergency departments. We will now be holding people to account against these agreed plans.

“There will be a challenge in balancing finances without crushing quality and access. We want to change the thinking form ‘at all costs we must break even’ to ‘at all costs we must break even without crushing our service or our quality and access.’”

Where over a period of time there was “a sufficient absence of performance improvement” to the extent that the system no longer had confidence in the hospital management, there would be a discussion with the governing body of the hospital about changing the management involved.

Turning to the new Trusts, Mr. O’Brien said that in the acute sector, there would be 10 – 13 hospital groups nationally. There would be a big focus on enabling these groups to develop and if that progressed, legislation would be enacted to establish them as fully fledged trusts with their own governance.

“We would be encouraging them to take on a much more commercial view. We won’t be directly replicating what happened in the UK or in any other country but they will inform our thinking. There will not be a single blueprint for how a trust works as we see different blueprints for different locations rather than a once size fits all. Some will be a combination of statutory and voluntary hospitals and we want to see what power can be transferred to CEOs and what powers will be held centrally.

“There is a long term aim that a very real measure of control will be given to senior managers. The present government is determined to bring operations and policy closer together and to have decision making closer to the point of care rather than in Hawkins House, or Dr. Steevens and we are moving towards having hospitals grouped and the same will be true for primary care organisations, but this will only be possible when the Minister and the government believe they have a real grip on the value which they are getting.”

He said that while the country might have sufficient beds nationally there were some hospitals which did not have enough beds and some hospitals which did not have enough money and we must be brutally honest about this.

“There are three different approaches – take money from elsewhere, (some places are overfunded and there are some inequalities in resources), rebalance funding across the sector or we may have to talk to the Troika. But first we must demonstrate that each hospital is operating as efficiently as possible and I don’t accept that we have reached that stage yet.”

There were 27 staff in the SDU – 10 from the health services and 17 from the Department of Health, he told the audience, who packed the large lecture theatre at the Dublin University Dental Hospital.

“There is a long term aim that a very real measure of control will be given to senior managers. The present government is determined to bring operations and policy closer together and to have decision making closer to the point of care rather than in Hawkins House, or Dr. Steevens.”

The SDU had been created as a vehicle for achieving two simple crystal clear objectives which the Minister set a year ago – that by the end of 2011, every elective patient would receive treatment within 12 months (this target would be nine months by the end of September) and never again would there be 570 people on trolleys at 8 a.m. in the morning.

The aim was to interact very directly with the system and with the RDOs in a way that the Department of Health had not done since the establishment of the HSE.  At that time all operational matters were very much for the HSE, but the new government was determined on a different course, based on the Minister accepting direct responsibility and the SDU was the first step in the Minister making himself closer to the detailed work of the health services. Until the new legislation was enacted the HSE remained fully accountable for the services it funded and provided and the SDU had to carry out its interventions in a way that did not overly confuse the lines of accountability.”

New discharge/bed management systems were being put in place. “We have a whole range of systems, not just a single one and many of the solutions lie in our own systems among our own managers.”

“Last winter discharge/bed management networks were established, local capacity plans and escalations plans signed off with the hospitals.  There were resource re-allocations to support at risk sites and we focussed on those hospitals which clearly had challenges with trolley waits in recent years. We visited the sites, met with the leadership teams to ensure they were having the discussions they needed, to have to ensure hospitals would function effectively during Christmas and the New Year. Communications were established with communities where this had not been in place.

“On December 23, green, amber and red monitoring systems were introduced for trolley waits,  giving us the numbers over 24 hours (it’s now 18 hours) so we could see how the system was responding and the trends.

“We can now see national and local hospital wait times, we can see the journey time for each patient and how much of the journey is spent in each process.  This is not for us, we want hospital management teams to have this and make use of it.

“We are working with hospitals now on the basis that everybody listed for treatment on January 1 of this year will have their treatment completed by December 31 this year. We are asking hospitals that once they have dealt with clinically urgent cases that they then treat those on the waiting lists in chronological order. This means that the numbers waiting will go up while the patient waiting time will go down. We are significantly ahead of our targets right now.

“We can drill down and tell by specialty whether they are bang on trajectory. We can see how many patients there are waiting to see each consultant (at this stage we don’t wish to identify consultants. We can drill into each consultant list and see how many are on their list. Perhaps some might have massive waiting lists and others have little or none – this is a tool for hospitals rather than for us.”

There will be no room for ambiguity or debate.  There will be details on the adult elective waiting time, how it breaks down by specialty and consultant and it will enable us to show hospitals’ relative performance against each other and the whole system.”

Mr. O’Brien said that once the legislative arrangements on the HSE were changed they would be moving from the present Healthstat to more flexible CompStat, a much more adaptable system, which each month would allow the acute sector, the RDOs, the Area Manager and the leadership of the hospital in the region to have “an adult intelligent conversation on the challenges”.

There will be no room for ambiguity or debate.  There will be details on the adult elective waiting time, how it breaks down by specialty and consultant and it will enable us to show hospitals’ relative performance against each other and the whole system.”

He said that so far hospitals were ahead of the 12 month target time for elective admissions. They had been broadly met by the end of the year but this was not sustained in January and February and it was decided that in these cases patients would be treated elsewhere and the cost sent back to the originating hospital. It was realised that not every patient could be treated elsewhere so it was decided that in these cases patients would stay in the hospital, but the hospital would be levied €25,000 a month for each month they stayed. “I think this will only happen very rarely, but it changes the discussion.

“Trolley waits are consistently below previous years – cumulatively they are 20 per cent down on last year. We did take some extra money for more staff and for people on the cusp of getting Fair Deal approval. The HSE would see this as a moral hazard, but I think it is a moral hazard to have patents on a trolley for 17 hours.

Mr. O’Brien said that the HSE Board as at present constructed would be abolished in the next few months and the new Directorates created.

Senior managers from across the health services have proposed radical and innovative measures to alleviate the impact on the services of the current drastic cutbacks.

A HMI survey has shown that they are deeply concerned about the risks to patient safety in the present circumstances, feel that further hardship must not be inflicted on vulnerable patients and are completely disillusioned with what they see as a lack of honesty about which services are sustainable and which are not.

Political leaders need to tell the truth about what can reasonably be expected

A number of major threads emerge from the survey:

• We are well past the point of suggesting we can do more with less and the public must be informed which services are sustainable and which are not, as a result of the cutbacks.   Political leaders need to tell the truth about what can reasonably be expected.
• There should be an examination of what is the biggest waste of time in service provision e.g. DNAs and these issues should be addressed.
• There must be less micromanagement by the HSE corporately and local managers must be allowed to manage.
• Communication from the top to managers must be significantly improved. Managers are angry at the lack of information, engagement and consultation.
• There must be new and more flexible ways of working and the Croke Park Agreement must be reviewed if necessary to ensure ongoing service delivery.

The survey covered 135 managers. Eighty per cent were either senior or middle managers and twenty per cent were front line managers. They were broadly representative of staff views in all the major areas of the services.

There was general agreement that as one manager put it, “the moratorium  is a blunt and now dangerous instrument. It  was described succinctly as “a penny wise and pound foolish method of clawing back funding, whilst unwittingly increasing risk to safety.”

Managers also believe that it is a priority to now identify what is absolutely critical and attempt to protect those services from the worst of the cuts. A floor rather than a ceiling should be introduced for certain services.

National standards should be issued for service entitlement. Health managers should be outspoken rather than being apologetic for decisions made by others.

We should stop trying for large changes and look at what small advances can be made and allow more local autonomy with greater transparency and accountability.

They argue strongly that budgets must be devolved to frontline and service managers, that concrete national priorities should be agreed and there should be more consultation with local mangers to ensure more equity of funding to areas and between areas. Service managers should have more autonomy, with protected budgets to ensure that the staffing is better managed than currently.

The impact of education and training in the health sector for staff’s professional development must be acknowledged

Other recommendations include:

National standards should be issued for service entitlement. Health managers should be outspoken rather than being apologetic for decisions made by others.

Account must be taken of the level of services affected by vacancies/maternity leave and a minimum level set at which a service would be allowed to appoint locums. The organisation CEO /GM must be involved in HR. Filling of posts must be on an organisational wide basis according to the specific circumstances, clinical need and risk to the organisation.

There should be a complete look at top management with at least one layer and probably two removed.

HIQA actions should reflect a balanced approach prioritising safety issues in the current climate.

Clinical Care Programmes should be suspended where necessary until there is a clearer vision of how programmes will be delivered locally.

The ESRI should take a look at making an honest comparison between public and private services.

Lean Six Sigma tools and techniques should be adopted, as what we are doing at the moment is not working, so a new approach is required.

If necessary there should be a review of the Croke Park agreement to allow more flexible ways of working.

Outsourcing must be facilitated by the HSE, staff conditions must be loosened,

Annual leave should not be accrued during sick leave, maternity leave or unpaid leave.

There should be better sick leave management, major restrictions on excessive time off due to flexi leave and absenteeism with regard to uncertified sick leave should be reviewed.  There should be more flexible working hours especially for doctors/consultants to manage the crisis

Working hours should be extended to 39.

The number of AHPs being currently trained should be reviewed. Under resourced services cannot cope with

Higher Education Authority’s demands for clinical placements

IT data should be at client level rather than at top management level “which mainly functions to collect statistics”.

Services in the community must be improved to allow swift discharges and ensure community can buy relevant equipment for safe discharge.

The impact of education and training in the health sector for staff’s professional development must be acknowledged.

Some services such as maternity, paediatric and services for persons with intellectual disability are singled out for special mention. It is stated that maternity and paediatric services will find it impossible to respond to the growth in demand with year on year budget cuts in these services. This growth in demand is linked to the birth rate and increasing number of babies being born with very complex medical requirements (also linked to older age of mothers and IVF treatment, multiple birth outcomes).

There is also strong opposition to inflicting more hardship on persons with intellectual disabilities and their families with managers saying we have to question our core values as a society if we continue to target the most vulnerable for savage cuts.

The aim of the first Joint European Hospital Conference, which took took place in Dusseldorf, Germany in November,  was to gather together the decision-makers in European healthcare to exchange knowledge and ideas. It was organised by the three key associations in European Healthcare EAHM, HOPE and AEMH.

Lee Cambell

Divided into two parts, the morning session focused on current European health policy with a keynote presentation by Mars Di Bartolomeo, Minister of Health and Social Affairs in Luxembourg. The afternoon was devoted to the EU Directive on Patients’ Rights and its impact on hospitals.

For Di Bartolomeo, European integration has become self-evident as a development, “we are no longer scared of European health policy.” He did however admit that the European health market had provoked some heroic disputes and confessed to resisting health being restricted to market rules. Di Bartolomeo stressed the importance of first-rate medicine for all, long-term strategies for health (including the Europe 2020 strategy) and prevention.

Representatives from the three European associations also had the opportunity to give their opinion on European healthcare policy. George Baum, President of HOPE (European Hospital and Healthcare Federation) stressed that we, as Europeans, are far too unrestricted in our movement to be denied healthcare in another country when it cannot be treated at home. He also emphasised the need for balance in the movement of health professionals and patients citing the worry that some regions will be under a greater burden than others.

He also emphasised the need for balance in the movement of health professionals and patients, citing the worry that some regions will be under a greater burden than others

To speak on behalf of the EAHM (European Association of Hospital Managers) Mr. Heinz Kölking took the floor. He highlighted current personnel issues such as increased competition with other sectors and the scarcity of people willing to work in healthcare due to new levels of complexity and the high pressure environment. For EAHM, leading and supporting staff is a key task for hospital management.

Mr. Joao de Deus, President of AEMH (European Association of Senior Hospital Physicians) stressed that although different countries have different systems and hospital models, hospitals across Europe are all prime targets for cost-saving measures. For the AEMH the key goal is patient safety and quality. This includes risk management and improved pre and post graduate medical training.

After lunch, Annika Nowak from the European Commission was tasked with quite a responsibility; explaining the Directive on patients’ rights in cross-border healthcare. Putting the longevity of this contentious issue into context she explained how there have been 12 years of European Court of Justice rulings on patient mobility from Kohll and Decker in 1998 to Elchinov in 2010. Long after its proposal in 2008, the Directive finally entered into force in April 2011. It will now go through a 30-month transposition process (until 25 October 2013) with bilateral discussions and close monitoring by the Commission.

The Hungarian perspective focused on legal issues, calling for more legal provisions in the Directive, especially regarding the use of e-health

Nowak explained the three aims of the Directive:

• To help patients exercise their rights to reimbursement for healthcare received in another EU country.
• To provide assurance about safety and quality of cross-border healthcare.
• To establish formal cooperation between health systems.

The remainder of the afternoon gave Member States a chance to voice their opinions on the Directive and its impact in their countries. The UK does not expect to see a large increase in demand for healthcare from foreign patients but is concerned that longer waiting times in the UK could motivate patients to travel abroad for their care. Moving to France, Prof. Robert Nicodème from the French Medical Chamber expressed concern that healthcare personnel are missing from the Directive as are a universal set of competences to measure performance and ability.

The Hungarian perspective focused on legal issues, calling for more legal provisions in the Directive, especially regarding the use of e-health. Linguistic challenges are also not dealt with in the Directive. The representative from Greece, Dr. Kremalis agreed that there is a need for further clarification on the Directive and the healthcare provided but was confident that it is a step forward to the “Europeanisation” of healthcare.

The conference, and the session on this Directive in particular, has shown that the issue of cross-border healthcare is far from resolved but that progress can and will be made through further cooperation on a European level.

At recent Health Management Institute of Ireland Regional Meetings in Leitrim and Limerick, a representative of the Health Information and Quality Authority (the Authority) discussed the experience of regulation to date and potential learning for health and social care service managers of sectors that are due to be regulated in the future.

Finbarr Colfer

The Authority is required to “promote safety and quality in the provision of health and personal social services for the benefit of the health and welfare of the public” (Section 7, the Health Act 2007).

Regulation and inspection are used as a way of ensuring consistent standards of care and of ensuring the safety and wellbeing of service users. The regulation of residential services for older people commenced on July 1, 2009 and plans are in place for commencement of the inspection of child protection services, the regulation of children’s residential services and of residential services for people with a disability.

There are also public debates about the further extension of regulation to other sectors such as home help services and licensing of hospitals. In this context, it may be useful to reflect on the experience of the Authority to date.

A number of factors are used to determine the fitness of the provider and key senior managers

The Health Act 2007 placed HIQA on a statutory footing as an independent body reporting directly to the Minister for Health. The Authority has a national remit, across the private, voluntary and public sectors.

The Act includes the responsibilities of the Authority for registering and inspecting residential centres for children, older people and people with disability. Once registered, centres must apply for renewal of registration every three years. The Authority is also responsible for the inspection of special care units, detention centres and foster care provision. In addition, the Act sets out the responsibilities of providers and the sanctions for providers if they commit an offence under the Act.

A key requirement of the Act is the fitness of the provider and other key senior managers. Section 50 of the Act states that fitness is demonstrated through compliance with the Regulations, the Standards and any other enactments deemed relevant by the Authority.

A number of factors are used to determine the fitness of the provider and key senior managers including:

• Knowledge of the Act, the associated Regulations and the Standards.
• Demonstrating an understanding of contemporary principles of service provision.
• Providing the service in a safe manner.
• Providing sufficiently skilled staff who are supervised appropriately.
• Providing sufficient resources to the centre.
• Ensuring that the service is viable and consistent through adequate governance arrangements.

The Authority evaluates the fitness of providers and key senior managers against the Act, Regulations and Standards. Regulations are developed by the Department of Health, and providers must comply with the Regulations. It is an offence not to comply with them.

The Standards are developed by the Authority. Usually, these are developed by a working group consisting of service users, providers and other experts in the field. They are outcome-based and set out the quality goals that providers must seek to achieve.

Inspectors gather evidence that indicates whether the provider, person in charge and other key senior managers are fit. This is an ongoing process of monitoring and is not limited to inspection. For example, the provider is required to make certain notifications to the Authority immediately and is required to submit quarterly notifications of specified information. If areas of non-compliance are identified on inspection, the provider is required to submit an Action Plan on how the non-compliances will be addressed. The Authority also requires the provider to submit updates on progress on the Action Plan.

The Act also provides the Authority with enforcement powers which are used when there is a significant risk to the health or wellbeing of residents or where there is persistent non-compliance with the Regulations. These powers include the addition of restrictive conditions to the registration, the suspension or removal of registration and/or prosecution.

The focus of the Authority’s work is to promote the safety, wellbeing and quality of life of service users. The role of the Authority is to monitor and inspect centres, make judgments on whether there is compliance with the Act and the Regulations, and on the implementation of the Standards. These findings are included in the inspection reports and are published on the Authority’s website.

The experience to date is that when providers have a good knowledge of their legal responsibilities, of the Standards and of contemporary best practice, there is ongoing improvement in the overall quality of care and quality of life of service users, and the inspection and regulation process can be managed in a much more efficient manner.

The HSE published the report of its National Audiology Review Group (NARG) on April 13 last. The work undertaken by NARG constitutes the most extensive examination to date of audiology services in Ireland. The NARG examined audiology services currently provided to children and adults nationwide and undertook an extensive public consultation and assessed the needs of the population. It found that better use of existing resources, coupled with additional funding, improved education and training, and integration of services across hospital and community settings will deliver better value for money and represent a long term investment in providing the best possible care, with improved health and social outcomes for clients.

The NARG has developed a comprehensive set of recommendations to address the inconsistencies and inadequacies in audiology services. Arising from the recommendations of the NARG, work is now underway to improve access and deliver high quality, consistent audiology services around the country.  The report identified some inconsistencies and shortcomings in audiology services around the country including access issues, poor information, inadequate staffing levels, poor infrastructure and waiting times which have reached unacceptable levels in some areas.

The report identified some inconsistencies and shortcomings in audiology services around the country, including access issues, poor information, inadequate staffing levels, poor infrastructure and waiting times which have reached unacceptable levels in some areas.

The key recommendations made by the NARG include:

• The implementation of a National Newborn Hearing Screening Programme.
• Improvements in hearing aid and ear mould services.
• A restructuring of services and staffing to provide better integrated teams, with enhanced communication between professionals and patients.
• The appointment of a national clinical lead for audiology and four regional clinical leads to deliver the modernisation programme, and to implement new care pathways and improved clinical governance.
• A workforce review to confirm the extent of the required uplift of numbers of audiology professionals.
• Establishment of within-country training for audiology professionals, with professional registration.

The UK NHS Audiology service is the biggest procurer of hearing aids in the world and linking in with our UK procurement colleagues will result in achieving the best value for money in our procurement process

Progress on Implementation of Recommendations

Indeed, since publication, much progress has been achieved on the implementation of recommendations, in summary these include:

• Establishment of an Audiology Clinical Care Programme under the Clinical Strategy Programme.
• National and Regional Clinical Leads – Job specifications have been agreed and issued to the Department of Health and Children.  They are now linking with the Department of Finance on the approval of these posts.  Every effort is being made from the HSE perspective to secure approval for these critical posts.  These posts will provide the clinical governance required for the development of the service going forward including the roll out of Newborn Hearing Screening.  Prof. John Bamford provides direction under the remit of Interim National Clinical Lead on a part-time basis.
• The Audiology Programme, Project Manager is now in post. This post is pivotal to the implementation of recommendations and developments going forward.
• Regional Managerial Leads have been nominated by each RDO to progress implementation regionally (in the absence of clinical leads).
• 2011 Development Funding was released to services, this supported the following initiatives;
  • Sponsorship of candidates to pursue an accelerated MSc in Audiology in the UK.
  • Sponsorship of current audiology staff to upskill in preparation for the rollout of Universal Newborn Hearing Screening.
  • Completion of the rollout of UNHS in HSE South.
  • Additional funding was provided for national hearing aid budget.
• Audiology staff briefing sessions were held in each HSE Region which afforded staff and local managers to raise issues or seek clarifications on recommendations within the report.
• Formal information sharing meetings with IMPACT – formal meetings have been convened with IMPACT in relation to the report and the implementation of its recommendations.  A commitment to continued communication was given and will be complied with.
• Universal Newborn Hearing Screening – Newborn hearing screening is now in place in Cork University Maternity Hospital, Wexford and Waterford maternity hospitals.  The screen is being provided by an external contractor but all components of the screen is in compliance with the national model for newborn hearing screening as recommended by the NARG.  The coverage of these maternity hospitals in HSE South will provide coverage to approximately 19,384 births (including home births) representative of an average of 26 per cent of the national birth rate.  South Tipperary and Kilkenny have established the required planning local implementation groups with screening expected to commence in early 2012 (funding dependent).  Planning is also underway to extend the programme to a further region in 2012 (funding dependent).
• Revised procurement framework for hearing aids and accessories – the current hearing aid tender is due for renewal in 2012.  The UK NHS Audiology service is the biggest procurer of hearing aids in the world and linking in with our UK procurement colleagues will result in achieving the best value for money in our procurement process.
• Initial discussions were held with colleagues in the Department of Social Protection to address the duplication of funding between the Hearing Aid Grant Scheme funded via Social Protection and HSE Hearing Aid position.
• Initial discussions were also held with colleagues in the Department of Education and Skills on how best to meet the needs of younger children going forward as a result of the phased roll out of newborn hearing screening.
• A workforce planning exercise has now been completed. The findings indicate that an approximate doubling of the current workforce is required.  In addition, a proposal for a unified career structure for all audiology staff, existing and new has been developed. Both recommendations are currently being pursed with senior HSE Management.

The Audiology Clinical Care Programme looks forward to continuing improvements and progress in 2012. Please see our new website at www.hse.ie/go/audiology

Aisling Heffernan is currently the Speech & Language Therapy Manager at the National Rehabilitation Hospital and is on a part time secondment to the HSE to work as Programme Manager for Audiology.

The Programme will develop models of care, best practice clinical guidelines, process measures and quality indicators for Emergency Medicine.  It will draw upon best practice recommendations developed by other relevant QCCD programmes and will be implemented in an integrated manner with the Acute Medicine, Critical Care, Surgery and Medicine for the Elderly programmes.

Dr. Una Geary

The objectives of the Emergency Medicine Programme are to:

• Define and develop Emergency Care Networks within a National Emergency Care System with key collaboration between EDs and Pre-hospital care.
• Increase Consultant provided care in EDs.
• Introduce clinical guidelines for the top 20 emergency conditions (e.g. pain management, abdominal emergencies, head injuries etc.).
• Define quality indicators and process measures.
• Support implementation of QCCD National Programmes at 12 target sites (ten of which will have four or more Consultants in Emergency Medicine) with the achievement of six hour total ED Time target.
• Develop Paediatric Emergency Medicine
• Disseminate existing best practice through regional workshops, gap analysis and feedback
• Carry out workforce analysis and planning
• Develop multidisciplinary teams in Emergency Care

The Programme deliverables are:

• Standardised care in every ED
• Guidelines for top 20 conditions
• All critically ill patients will be seen by a Consultant in Emergency Medicine when on-site and Consultants will provide on-call support out-of-hours.
• Reduced numbers of patients on trolleys in EDs, which is achievable through implementation of the Acute Medicine and Chronic Disease Programmes, will save at least one life per week.

The Emergency Medicine Working Group consists of:

• Dr. Una Geary, Programme Lead
• Dr Fergal Hickey, Regional Lead
• Dr Gareth Quin, Regional Lead
• Dr Conor Egleston, Regional Lead
• Dr Gerry Mc Carthy, Regional Lead
• Dr John Mc Inerney, Regional Lead
• Professor Ronan O’Sullivan, Paediatric EM
• Dr Cathal O’Donnell, Pre- Hospital Care
• Mr Geoff King, Programme Member – PHECC
• Ms Maire Brid Casey, Programme Member – AHP
• Ms Fiona Mc Daid, Programme Member – Nurse Lead
• Ms Mary Forde, Programme Member – Nurse Lead
• Ms Valerie Small, Programme Member – ANP Representative
• Ms Suzanne Byrne, Programme Member – Service Planner and
• Ms Moira Flynn, Programme Member – Clinical Informationist

The Minister has also launched the St Luke’s Radiation Oncology Network, which operates across the three sites at Rathgar, Beaumont and St James’s Hospitals.

Health Minister, Dr. James Reilly and Dr. Susan O'Reilly, Director, NCCP at the opening of the new Radiation Oncology Centres

With an overall investment of €60m, the two new centres have the latest state of the art radiation oncology services – on a par with the most sophisticated available internationally. Developed by the National Cancer Control Programme, the new centres will ultimately increase radiation oncology treatment capacity in the east of the country by 50 per cent. For some patients the development will eliminate the need to travel abroad for services that will be available in Ireland for the first time.

Although this specific project was initiated with the establishment of the NCCP in 2007, much of the analysis and planning began over a decade ago. The two centres were completed and became operational in 2011. Over 500 specialist and support staff now work across all three centres in the network, with the NCCP having recruited 54 new staff over the past two years – including radiation therapists, physicists and clinical engineers. There has been significant investment in medical staff, bringing the total number of Consultant Radiation Oncologists across the network to 16. Over 4,000 patients were treated across all three centres in 2011.

Each new centre features four new state of the art treatment linear accelerators as well as two CT scanners and one MRI unit. The linear accelerators (each representing an investment of well in excess of €1m) differ slightly in their specifications. On the Beaumont site the specifications include an intra cranial stereotactic radiotherapy service operated in conjunction with the National Referral Centre for Neurosurgery. The St James’s centre houses a unit capable of delivering Total Body Irradiation for haematology patients attending the National Stem Cell Transplantation Centre.

The availability in the two new centres of Rapid Arc Intensity Modulated Radiotherapy (IMRT) for public patients also marks a significant development. Currently being used for the treatment of prostate cancer, Rapid Arc treatment technology allows precise delivery of the radiotherapy dose to the target area. It is designed to reduce the dose to nearby normal tissues and reduce the probability of side effects when compared with standard radiotherapy planning techniques.

According to Dr. Jerome Coffey, NCCP National Clinical Lead, Radiation Oncology, “This is a big advantage, particularly in cases where a high dose of radiation is required to treat a tumour that is close to normal organs.” A previous version of IMRT has been successfully used in St Luke’s Hospital in Rathgar for several years, but the addition now of the Rapid Arc treatment in the new centres improves the patient experience and allows for more patients to be treated. In the treatment of head and neck cancer in particular, treatment times each day are reduced by up to 80 per cent.”

Dr. Susan O’Reilly, Director NCCP, said the opening of the two new centres marked a “hugely significant” milestone for the programme. Acknowledging the many individuals who had contributed to the developments including Prof. Donal Hollywood and Prof. Tom Keane, Dr. O’Reilly said that in aspiring to provide world class cancer services, the creation of the St Luke’s Radiation Oncology Network showed how Ireland was matching the best.

Noting that since 2007, the NCCP had opened and consolidated 25 rapid access clinics at the eight designated cancer centres, Dr. O’Reilly pointed to the average primary cancer detection rate of over 35 per cent at the rapid access lung and prostate clinics. Dr. O’Reilly also commented on how, on average, 99 per cent of all urgent breast cancer cases were being seen within a two week timeframe, (exceeding the 95 per cent target rate) in the eight (plus the satellite in Letterkenny) breast cancer clinics. Dr. O’Reilly said that commitments were being met, better services being delivered and added that “all of which means better outcomes for our patients.”

With a projected growth of over 100 per cent in the numbers of cancers detected over the coming decade, Dr. O Reilly said it was essential that services continued to be developed and expanded. Commenting on the next phase of the national radiation oncology programme, she said that this would mean significant developments at the designated cancer centres in Cork and Galway. The NPRO plan will allow for investment in new radiation oncology equipment and facilities at both centres. Dr. O’Reilly acknowledged the announcement of funding for this phased development by the Minister last year.

Confirming that €175m will be spent on the development of the radiation oncology services in Cork and Galway – along with continued phased development of the centres in Dublin – over the coming five years, the NCCP Director said that it was clear that the commitment to cancer services was strong and evident.

She added that the NCCP and the Department of Health continue to liaise closely with the Northern Ireland authorities in the development of the new radiation oncology centre at Altnagelvin Hospital, Derry, providing cross border access for patients in the north west.

She said our survival rates in this country could improve by up to ten per cent if we successfully implement well organised cancer control systems