In January 2017, Tony O'Brien, Director General of the HSE, wrote an Sunday Business Post article about how to avoid ‘groundhog day’ in healthcare. In the course of the extensive media coverage, two questions were raised again and again:
In 2017, why have we not solved the overcrowding issue? Was the HSE not prepared for the inevitable winter pressures on hospitals?
Tony O'Brien responds here:
In relation to the second question; yes, considerable planning was undertaken through our Winter Initiative. However, the system’s ability to expand to meet a spike (expected or unexpected) in demand is currently limited by a number of factors that vary from hospital to hospital. These include not having enough beds in the system to deal with a surge, difficulties in recruiting nursing staff (which poses a challenge in opening some of our surge-capacity beds) and a shortage of certain services in some parts of the community such as diagnostics. And of course the significant rise in flu-like and respiratory illness and Norovirus (vomiting bug) during the holiday period did not help matters.
The first question requires a more considered response. I could have provided a facile answer and described the source of the problem as merely not having enough beds, enough nurses etc. While there is no disputing that there is a requirement for some additional beds in some hospitals, the situation is more complex and requires multi-pronged solutions at political, health service and societal levels.
Our health services model, as it currently exists, is no longer fit for purpose. It was designed for a time when we had a different demographic profile, with different patterns of health and care needs. Today our population (thankfully) is older and it is expected that the over-65s will increase by nearly 110,000 in the next five years. This is great news and is due in no small way to significant improvements in treatment and care provided by the health services. Unfortunately, a large proportion of this age group is living with two or more chronic conditions which makes many of our elderly more vulnerable and frail. Emergency Departments have seen evidence of this with an increase in the over-75s presenting at EDs.
Within a more responsive health system, many more people could be treated within the community, for example through an enhanced GP service. This would help to avoid much of the over-crowding experienced in our hospitals. Additional investment in the community would mean that many scans and tests could be done without people having to attend acute hospitals. More home supports could allow people to move out of hospital sooner and Community Intervention Teams could treat people in their own homes rather than in a hospital environment. However, this would involve a “decisive” shift away from - the most expensive form of treating and caring for people - the acute hospital system.
The decision by Government in 2011 and subsequent developments to move away from a centralised health structure towards a purchaser/provider model for health services has led to the establishment of seven Hospital Groups, nine Community Healthcare Organisations (CHOs) and a National Ambulance Service (NAS). This is an important step towards a more community-focused health system.
However, this newly-developed structure will not, of itself, be sufficient to achieve the required “decisive” shift away from a reliance on acute-hospital care. International evidence shows that a significant ring-fenced transformation budget is required to allow the shift to take place over a number of years while maintaining existing levels of service to all parts of the health services.
Major transformation programmes in any industry are costly. However, there exists a perception in certain quarters that the Irish health services can undertake effective major transformation and improvement programmes, not cut or reduce any existing services provided and do all of this without getting any additional money. The fact that this doesn’t happen in large industry and health systems internationally is instructive that transformation programmes need to be funded in order to succeed. Expecting major transformation without such additional investment would most likely collapse our entire system in a short space of time.
In the State of New York, they have undertaken such a funded transformation and improvement programme ($8bn investment over 5 years). The programme is called the Delivery System Reform Incentive Payment Programme (DSRIP) and is specifically designed to strategically build up services that keep people out of hospital, keep them in their own homes or deliver services much closer to home. To achieve this, they knew that they had first to build up their primary care services and invest up-front. In addition to delivering services closer to home, DSRIP plans to save the State $17bn over the five years using a roadmap of clear targets and deliverables. I make no apology for saying that if ongoing and future transformation is not funded in this country, particularly in an overstretched and growing healthcare economy, the transformation that the public rightfully expects and desires will not be achieved. To keep doing what we are doing currently is likely to result in costs spiralling out of control due to inherent inefficiencies in our system today. In the longer-term, we are likely to spend more on these inefficiencies than we would invest in order to transform to a more efficient system. However, on our side we need to prove to Government, through a clear roadmap for change that involves targets and deliverables, that we can both improve services and also make them more efficient.
A key priority as we enter 2017 is to ensure that the services we deliver are safe and of a high quality. The HSE’s annual National Service Plan sets out how we will deliver a volume of service within the available resources, recognising there are significant challenges to balance demands and needs within the resources and funding available to us. In terms of 2017, for the second year running, additional funding has been provided for the health services. This is indeed welcome and it allows us to provide the same level of services as we did in 2016 with some scope for new developments.
A focus over the past number of years has been to eliminate waste and to be as costefficient as possible in order to increase the quantum of services delivered. Amid all of the criticisms of the health services, it is often missed that we are delivering approximately 5% more services year-on-year in our hospital and community settings. We have secured significant savings on the costs of many drugs, have taken great strides towards better integrated care, and have introduced important new services including BowelScreen and Newborn Hearing Screening.
Another significant challenge for the upcoming year is in the staffing and industrial relations area. To provide the best healthcare possible we need sufficient numbers of appropriately trained and motivated staff in our system. Despite considerable effort throughout 2016, attracting and retaining certain categories of staff remains a considerable challenge, with every effort is being made at national, Hospital Group and Community Health Organisation level to make working environments more attractive for staff.
Other priority areas for 2017 include the continuation of the 700 eHealth projects which are using technology to improve our health services. As part of this programme, all public hospitals now have 24-hour electronic access to X-rays and we can expect that all hospitals will “go live” in a similar way with laboratory results later this year. This will provide a more efficient system overall and a better experience for our patients. The completion of the eHealth programme will require ongoing capital funding throughout 2017 and beyond. Therein lies one of the major challenges for the health services. There is an urgent need for a significant injection of capital funding in the health services. Such an injection is required, not alone to undertake some of the better-known mega-projects such as the National Children’s Hospital, but also for the upkeep and repair of many of our community nursing homes, mental health facilities and Emergency Departments. Furthermore, capital funding is required to replace equipment that we critically depend on every day. This includes x-ray machines, scanners and ambulances needed to maintain safety and quality of our services and in turn allow them to be more responsive. Planning estimates indicate that the health services will require in the order of €9bn in capital spend over the next ten years in order to overcome existing deficiencies. The scenes of overcrowding that we witness too often are distressing for both patients and staff and for that I, as Director General of the HSE, apologise. However, I will be apologising to the public next year and for many years to come unless we shift our model of healthcare away from its current hospitalcentric focus and towards the community. The establishment of the Future of Healthcare Committee by Minister Harris provides an appropriate starting point in order to effect this. I hope that this Committee will also be the starting point for other long-standing and badly needed changes in the health sector such as increased levels of capital investment, demand-led community-based social care and multi-annual planning and budgeting.
It would be remiss of me to complete this article without taking the opportunity to thank all of my colleagues right across the health services who work so diligently delivering services in such challenging circumstances.