HSE Model of Care

Introduction
Factors that can influence the health and well being of the population.
Population Health priorities

Introduction

The traditional health and social care model is primarily episode-based and demand led. The Population Health model, adopted by the HSE, takes a more proactive approach by focusing on maximising the health and social well being of the population and providing opportunities to plan for better health.

Its primary focus is the promotion and protection of the health of the whole population and/or its subgroups, with particular emphasis on reducing health inequalities. It takes account of all the factors that can influence the health and well being of the population, such as demographics, socio economic factors, chronic disease, health technology and legislation. It also recognises that everyone has a responsibility to promote and protect their own health and the health of others.

With the Population Health approach the opportunities to sustain a healthy population can be increased when funding is rebalanced towards reducing health and social inequalities and disease prevention. Experience elsewhere suggests that this approach is likely to be the least expensive model in the long run (Click here to view Wanless (2004) Securing good health for the whole population)

This 'full engaged scenario' as described by Wanless also helps to prepare a health service that can meet the demographic and other changes that will take place during the next 10 - 20 years.

With this approach the primary point of contact between a person and the Health and Social Care System is through their local Primary Care Team (PCT). PCTs provide an expanded level of services and empower people to self care and promote their own healthy lifestyles. This reorientation enables more care to be provided in more appropriate settings.

The following sections outline in more detail the factors that can influence the health and well being of the population and, in this context, the Population Health priorities that have been used to guide the preparation of the HSE's estimates 2007.

Factors that can influence the health and well being of the population.

Key factors which determine the health and well being of the population and subsequently the need for services include demography, the changing health and social status of the population, the level and management of chronic illness, changing health technology and changing legislation, as outlined below.

Demography.

A key factor in the demand for health and social care services will be the structure of the population and how that is expected to change.
According to the 2006 census there are 4,234,925 people living in the Republic of Ireland, compared with 3,917,203 in 2002. This represents an increase of 8.1% in four years and is the highest number recorded since 1861.

HSE Dublin Mid-Leinster has the greatest share of the population at 28.7%, followed by HSE South at 25.5%, HSE West at 23.9% and HSE Dublin North-East at 21.9%.
Health Service Executive Estimates 2007
While the overall population has grown by 8.1% since Census 2002, the
Percentage growth in the population within HSE areas is as follows:
HSE Dublin North East + 11.5%, HSE South +7.7%, HSE West + 7.4% and HSE
Mid-Leinster + 6.7%.

For further information on demographic trends in Ireland visit the page on Our Population

Changing Demographic and Social Factors.

As the demographic profile of the population changes so too does the population's health and social status. It is expected that smaller family sizes will alter the ability of nuclear families to care for each other in a way that was possible in previous times. In addition, as a result of expected net positive migration over the period, the health and social care services will need to provide for a multi-ethnic mix of cultures in the delivery of health care. Other changes including increased marital breakdown, the need for both partners in marriage/relationship to be in paid employment, the need for long journeys to work etc., all effect the sense of well being of adults and children and the pressures on the health and social care services.

Health Improvements in Ireland.

Improvements achieved in our health status in recent years have given us a clear indication of the approach that is required. Heart disease is a good example, where Ireland has achieved major success in heart health status in the past 15 years, with a 40% reduction in deaths from heart disease. Only 44% of the reduction in the deaths from heart disease can be attributed to effective treatment of established heart disease. Reductions in population risk factors such as smoking, cholesterol and blood pressure have had a greater effect. The wider determinants of health will continue to have a greater impact on health than health services. This highlights the need for investment in a model of care which includes health promotion, primary care, hospital care, emergency care and rehabilitation.

Implications of Chronic Disease for the health services.

Worldwide there is an increasing incidence and prevalence of chronic diseases and conditions. Chronic diseases are those diseases which can only be controlled and not, at present, cured. They include diabetes, heart failure, some cancers, chronic obstructive pulmonary disease, dementia, asthma, arthritis and a range of disabling neurological conditions. The incidence of such diseases increases with age and many older people are living with more than one chronic disease. Approximately 25% of the population has a chronic disease and 60% of deaths are as a result of a chronic disease.

Life style factors such as smoking, alcohol, diet, obesity and inactivity have led to the increase in chronic diseases. Success in treating what were previously fatal diseases, such as heart disease, respiratory diseases and some cancers is also a factor that has led to the increase in chronic diseases. The care of people with chronic diseases consumes a large proportion of health and social care resources:

Chronic diseases account for 78% of all health costs (US data).
80% of G.P. consultations relate to chronic disease and patients with chronic disease or complications use over 60% of hospital bed days (UK data).
2 out of 3 patients admitted as medical emergencies have exacerbations of chronic disease.
People with multiple chronic diseases are extremely high users of acute services;
5% of in patients account for over a quarter of all inpatient bed days.

Formal generic chronic disease management programmes have been operational in the U.S. for over a decade, they are now spreading to health systems in Western Europe in various adapted forms. These programmes have been subject to evaluations and they have all shown positive improvements in service utilization indicators, cost reduction indicators and improvements in quality of care indicators, for example; up to 50% reduction in unplanned admissions and significant reductions in medication, Length of stay down by 31% and a reduction in total bed days used by the older persons of 41% , 35% reduction in urgent care visits and significant increases in patient and family satisfaction together with improvements in service integration, more appropriate referrals and faster response times.

Our current provision of primary care services is out of line with the epidemiology of chronic disease. Acute exacerbations of chronic disease are the cause of most emergency medical admissions to hospital in Ireland and contribute significantly to the difficulties facing Emergency Departments. Chronic disease management is therefore one of the biggest challenges facing the HSE and is a pre-requisite for a sustainable solution to the most effective use of hospital resources.

Health Technology.

The term health technology includes all health interventions including drugs, diagnostic equipment, programmes of care etc. New and highly effective health care interventions such as stents and statin drugs for heart disease, drugs for cancer, rheumatoid arthritis and metabolic diseases, diagnostic imaging techniques such as PET/CT scanning and other interventions, have added greatly to the cost of health care in Ireland in recent years. The literature suggests that health technology is a greater driver of costs than demography.

The future development of health care interventions is likely to have a significant influence in improving health outcomes for the population. These developments will require the HSE to be clear about the benefits of the existing technologies and to be able to predict, as far as possible, the potential costs and benefits of future technologies. The HSE will support the new Health Information and Quality Authority in conducting Health Technology Assessment, which is a methodology to consider the effectiveness, appropriateness and cost of technologies, and will ensure that such assessments inform the use of technology.

Changing legislation.

Another significant driver of services and costs is new legislation. European Union Directives and new and changing legislation has major implications across all sectors from child care to care of older persons to tobacco control.

Population Health priorities

Increasing the emphasis on primary care and health promotion.

By increasing its emphasis on primary care, the HSE can provide high quality care, through community-based primary care teams, to people with stable chronic disease, such as diabetes, heart disease, chronic obstructive airways disease within their own communities. In addition there are greater opportunities to introduce known preventative interventions to keep people healthy.

Freeing up the hospital care system.

By shifting care, where appropriate, from hospitals to the community, hospitals will be better positioned to focus on meeting acute secondary, tertiary and quaternary patient care needs, driven by international best practice and delivered through the integration of clinical practice, education and research.

Ensuring integrated care is provided in the right place, at the right time
Well integrated hospitals and primary, community and continuing care service will enable the health system to function as a single service delivery unit and make it easier for people to access the right service in the right place at the right time, through agreed care pathways, protocols for referral, joint planning for discharge etc.

Improving health outcomes.

By seeking to improve the health and well being of the whole population, and in particular the health of population sub groups, the HSE is seeking, for example, to improve survival rates from heart disease, five year survival from cancer, the social well being of older people and disadvantaged groups.

Improving quality & safety.

By strengthening quality and risk management governance structures and processes, the HSE can support the goal of improving the ability of all health and social care providers to offer a safe and seamless service to the highest international standards.

Promoting equity as a strong value in the health system.

There is a strong social class gradient in health status where those in the lowest socio-economic group have the highest death rates for all causes of death. The HSE is working to narrow this gap by influencing all the major factors which determine the health and well being of the population and by targeting resources to those most in need.

Developing services based on 'identified need' and evidence.

By adopting a 'formal needs assessment' approach to identifying service shortfalls, the HSE can establish the most appropriate investment options based on anticipated outcomes and cost. This approach, which makes its planning process more explicit, also ensures that evidence based interventions are put into practice.

Measuring investment returns.

By ensuring that specific and measurable health outcome targets are measured against achievements, the HSE can identify the health and social return accruing from its health investments. For example, in the implementation of the newly published Cancer Control Strategy, five year survival rates for different cancers will be monitored and compared to the level of investment provided for cancer services.

Improving user participation and empowerment.

This involves constructively engaging the public in the development and delivery of health and social care services. It requires, amongst other things, measuring user satisfaction, a statutory system of complaints handling, involvement of individuals and families in their own care and the participation of the community in decisions regarding health and social care services. Responding to the increasing trend for people to access health information from different sources such as pharmacies, the internet etc., the HSE will support local people to access high quality evidence based information on health promotion and self management of chronic and minor illnesses.