'Services can improve despite cuts'

  • Niall Hunter, Editor

A senior HSE official has said in spite of recent health cutbacks, we still have the capacity within the health system to improve services with the existing resources available.

This is in spite of our healthcare budget being cut by one quarter over the past five years.

Dr Aine Carroll, who is HSE National Director of Clinical Strategy and Programmes, said the World Health Organization had made recommendations about the level of cuts that can be sustained within a healthcare system without impacting on services.

"The impression I would have is that we haven't reached that point yet. We have certainly got the capacity and the capability within our system to improve things with the resources we have."

The HSE's Clinical Programmes, to which Dr Carroll was appointed Director last October, were established in 2010, according to the HSE, to improve and standardise patient care throughout the health service by bringing together clinical disciplines and enabling them to share innovative solutions to deliver greater benefits to patients.

Dr Carroll, in an interview with irishhealth.com, pointed to improvements in care across a wide range of disease areas covered by the 33 programmes, including stroke, severe lung disease, epilepsy, heart failure and acute medicine.

However, in spite of this, there are still major access problems in terms of lengthening waiting lists and continuing pressure in hospital emergency departments.

Latest figures show the total number of patients waiting over six months for in patient and day treatment has jumped by 96% since the end of last year.

Asked about these pressures on the system, Dr Carroll, who is a consultant in rehabilitation medicine, said there had been an unusually large number of flu-like presentations in EDs through last winter and spring, putting extra pressure on the system. She said without the work done by the programmes, the pressure would have been worse.

On the Savita Halappanavar case, she warned about adopting too great a ‘blame culture' in trying to improve quality and safety, because if this was done, incidents night not be reported and there would therefore be less of a tendency to learn from these incidents.

What tangible benefits to patient care have been achieved by the HSE clinical programmes since their inception in 2010?

There are now 33 programmes and I believe there have been tangible benefits from each and every one of them. If I had to pick out one example I would cite the acute medicine programme, which has led to a more streamlined approach to admissions and a scheduled care pathway. Length of stay has been significantly reduced. With the stroke programme, in a very short timeframe, Ireland has gone from one of the worst thrombolysis (clot busting drug) rates to one of the best compared to other countries. We have also seen improvements in areas such as COPD (severe lung disease) with community outreach programmes, and improvements in epilepsy and heart failure services. Prof Don Berwick, who has been brought in to ‘fix' the NHS, has commented positively on what had been achieved in Ireland, specifically with reference to the stroke programme. And yet we don't hear that in our own country and that's a terrible shame.

But isn't that understandable? The perception among the public is, and the figures indeed show, that there are still major problems with accessing scheduled and unscheduled (emergency) care in general hospitals - in other words, growing waiting lists and still high trolley numbers.

Well, if you look at unscheduled care, internationally there is an issue with unscheduled care, and that is looking at the best healthcare systems right through to some of the worst. In Ireland, there has been an unseasonably large number of flu-like presentations in emergency departments over the winter period. There have been problems recently with pressures on the system and a larger number than anticipated admissions through EDs. If the acute medicine, emergency medicine and surgery programme hadn't done their work, then the pressure on our system recently would have been much higher than it actually was. So, has much been done? Yes. Is there more to do? Absolutely.

That would indicate that we are just keeping a lid on pressures on the system without getting to the root of the problems associated with access to hospital care. Are the clinical programmes going to make any progress towards getting to the bottom of these problems?

I would say, yes they are. The role of the programmes is to identify the correct care pathways and to provide that strategic vision for how services should be provided, with the operational side of the system then implementing those changes. Is it going to be easy to achieve? Of course not. But it is important to acknowledge that other countries have taken 15 to 20 years to implement the types of changes that have been seen in this country over the last couple of years.

Do you think that the clinical programmes and the Minister's Special Delivery Unit can if not, ‘fix' the health service, at least make it better within a relatively short time period?

I would certainly hope so and that is not just our ambition, but I believe every frontline member of staff would hope to improve services right across the board, and that is certainly the impression I have got as I have been going around the hospitals. There are no individuals who get up in the morning and plan to do a bad's days work. They all want to do the best they can for the patients they serve. Despite everything that is going on at the moment, they still care.

Will the target to reduce outpatient waiting lists to a one year maximum and treatment lists to eight months in 2013 will be achieved?

It's important to put targets into context. I think targets shouldn't necessarily be sticks to beat people with. Yes, we hope to achieve them; however, it is all about how you change-manage things that have been in place for a long time. We can and we will continue to improve. I hope we do achieve the targets, and the work of the programmes may help to facilitate the achievement of the targets, providing the pathways that might help that to become a reality. For example, outpatient waiting lists are being validated and once that is completed there will be a lot of numbers that can be removed from the lists.

So when the 370,000,000 currently reported as being on these lists is reduced to those who really need to see a consultant, does the system have the resources to deal with these patients?

There is a great deal we will be able to do, and the programmes will have an important role in setting out how that should happen.

You refer to improvements in acute medicine. Can you give concrete examples of achievements under this heading, given that so many admissions are acute medical cases, particularly among the elderly, and these often lead to pressures on the system?

For example, as a result of the work of the programme, there have been in excess of 50,000 bed day savings last year.

What does that mean in practical terms?

That is a calculation that is done - reduced length of stay is the easiest way to think about it. When you are thinking about value and cost-efficiency then I suppose bed day savings are a more understood currency. For a member of the public, it would mean-how long am I going to be in hospital?

So presumably the idea is to free up beds more quickly for people who need them. But aren't they still getting clogged up in spite of these efforts?

If you look at healthcare internationally, there is an increasing demographic. We are surviving longer with multiple conditions. So the likelihood is that there is going to be increased demand on our health services. In terms of planning these services we have got to take that into account. Unfortunately, nowhere in the world has managed to come up with a definitive answer.

But what can we do here in Ireland about improving access?

From my point of view it's quite straightforward- it's a matter of implementing the clinical programmes. We want services to be timely, efficient, effective. We want them to be equitable, patient-centred and the number one thing, safe.

But over one fifth of the health budget has been cut over the past five years. How can the system be improved, be made more efficient and safer, against a backdrop of such a massive cut in resources?

The financial situation is certainly a challenge, but we also have the challenge of an ageing population, of people surviving with more complex conditions and increasing expectations about what our health systems can provide. We have to have adaptability and flexibility in our services to take all those thing into account. Equitable access as well as efficiency and effectiveness is also very important. This is not just a challenge to us but a challenge to every health system in the world. I believe we can improve the quality of our services seven in constrained financial times, and we are doing that.

Is there not a worry that 'doing more with less' will have safety implications?

There will always be a concern on whether you can make so many cuts without compromising safety. But if you look at healthcare improvement throughout the world, it has been proven time and time again that actually, you can provide high quality services with less, but of course you are going to get to a certain point where you have to look at the balance between the two. You cannot provide quality services with no resource. If we truly value our healthcare system be should be investing in it, and investing in our staff if that is what we want. The World Health Organization has made recommendations about what types of cuts can be sustained within a healthcare system without impacting on services. The impression I would have is that we haven't reached that point yet. We have certainly got the capacity and the capability within our system to improve things with the resources we have.

Obstetrics has been in the news a lot lately. Are real improvements being made by the clinical programme in obstetrics?

Yes, we have produced a huge number of guidelines that are all being implemented in all the maternity units. The programme has developed the Irish Maternity Early Warning Score (IMEWS), which was introduced in April.

But it can be argued you can produce all the guidelines you want, it's a question of people following them. The HSE's report into the death of Savita Halappanavar found that guidelines were brought in locally for sepsis management in University Hospital Galway last year but they weren't followed.

Yes, that is an issue with guidelines and policy in general. It is not enough just to develop a guideline, you also have to have processes in place at local level to make sure that those recommendations are being adhered to. The Scottish patient safety group has been looking at things we are also very interested in looking at like sepsis, venous thromoembolism etc. Even though they would be seen as world leaders in the management of sepsis and other such conditions you don't get it right all the time and the important thing is being able to identify when it doesn't go right and to put in place steps to ensure that we learn from this. It would be nice to think that none of these incidents will ever happen but we will have to continue to strive to get to that point.

Were you personally shocked by the findings of the Arulkumaran report into the Savita case?

As a mother of two small children, what struck me is the tragedy of a young woman losing her life. What I would hope from this and any other incident is that we have got processes in place to learn from such tragedies so that we can try to avoid anything like that ever happening ever again.

While learning from these cases is necessary, is there not a need for accountability by staff at some stage in this process? There's a belief that people are seldom brought to account for serious failures they may have been responsible for.

If you look at the aviation industry, it has tried to crease a 'mindful' organisation, whereby any incident is reported and investigated without fear of retribution, and because they have spent 40 years developing that culture, they have now got one of the safest industries in the world. There is a lot to be learned from that. The Institute of Health Improvement in the United States recommends that we try to create a 'mindful' culture in health services. Because if you have a purely 'blame' culture, then incidents will not be reported, and there will be much less of a tendency to learn from incidents like this, so that we can make every effort to ensure they never happen again. In research that has been done on this, it is very well proven that if you do have a blame culture, the likelihood of reporting incidents is much reduced, because of fear of consequences. What we want is a situation where everybody feels they are able to raise concerns. It is not enough just to produce a report, you've got to make sure that the recommendations in any report are implemented, monitored and sustained.

But do you not accept that at some stage in some cases, if there are deficiencies in care caused by individual dereliction of duty, there should be consequences for individuals?

I believe that if there is any individual where there is a question over their professional competence then that is a matter for their regulatory body. But that is a separate thing to the idea of creating a mindful culture where you learn from adverse incidents. But absolutely, if somebody is clearly not fit to do their job then they shouldn't be doing it.

Regulatory bodies deal with doctors, nurses and other health professionals. What about non-clinical managers and other workers in the health system? Who regulates them?

There are disciplinary procedures in every organisation that would deal with such matters, and that is right and proper.

Do you think there has been enough progress in moving a good deal of hospital care to the community, with more patients looked after locally by GPs and other services?

I don't think things ever happen as quickly as people would like, but from linking in with the international Institute of Healthcare Improvement, I have been quite reassured about our rate of progress, because in talking to the experts there, they say that their journey has been one of about 20 years. This type of radical change takes time. If you think that in America, their journey towards reform been one of 20 years, I am very reassured about what we have managed to achieve in a very short period of time in terms of the programmes- around two and a half to three years.

But are the resources there to allow GPs to take on the care of more patients with serious long-term illnesses?

Yes, that is going to be a big challenge and I would hope that the Department will be moving ahead with negotiating a new GP contract, because that is going to be very important in this regard.

But the bottom line surely is that the Department doesn't have any extra money to give to GPs to do this extra work?

Well, that needs to happen. But I do think there is plenty we can be doing in terms of setting out how care can be provided in the community and looking at how far away from the ideal are what we can be doing in the meantime.

Do you think there is a need for more transparency in terms of telling the public how different hospitals perform and that the type of audits currently being planned should have their results openly published?

Personally, I think so, yes. I previously worked in the NHS and that is what I would have been used to, that the public should have access to that information. I think one of the challenges we have had in our health system in recent years is that there is a lack of trust. I think one of the best ways of rebuilding that trust is to be as transparent as we possibly can be. One of the ways to do that is to be open with our data. We have to be careful, with mortality data, about getting it right. It all comes down to the quality of your data and that the method you are using in gathering your data is comparing apples with apples, like with like, in terms of outcomes. For example, it is not feasible to compare the results of a very straightforward keyhole procedure to the same procedure on someone who might have had multiple abdominal procedures and also has heart disease, lung disease etc. You cannot directly compare those cases.

Do you not think the ultimate key to achieving equity in the system is sorting out eligibility in terms of universal health insurance, which is aimed at giving everyone equal access?

I think it is important that whatever we do that we ensure that our citizens have access to quality services, regardless of how we fund it. As a society and as citizens within that society, if we value our health services, we need to be prepared to pay for them. I am NHS 'born and raised' and I think it I extremely important that all individuals have access to the services they require when they need it and not based on ability to pay. I don't believe in a two-tier health system. It shouldn't be a case of 'public' or 'private' services, it should simply be 'our health services.'

How would you briefly describe the clinical programmes? Many members of the public might not be aware of their existence or exactly what they do.

Basically, the programmes are about looking at quality services, equity of access and also value for money and value for the patient.

And will it take 20 years to achieve this?

I think this is a journey that is effectively never-ending. It is important that we continue to strive to be the very best service that we can for the best value that we can with the best possible outcomes. While it might be a never-ending journey, that doesn't mean it's not a journey worth taking.

Waiting lists continue to rise








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