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Health and care services
Health and care services report
managers: “Coming in I thought the primary focus would be building leadership capacity across the organisation. I thought it might be 60 per cent leadership and 40 per cent management in terms of challenge but I’ve come to the view it’s more management; it’s probably 70:30 management to leadership in terms of challenge. We have to get the fundamentals right in management. That’s about how we manage people, the service and finance.”
Having launched a new service plan in mid-November Reid frankly states: “We are not providing the service that the Irish public needs or expects. That’s just a statement of fact.” However, he believes that this can mask “a lot of quite positive experiences”. From an overall health perspective Irish people are living longer, with a lot of key clinical diseases having better treatment. People are living longer, healthy lives which Reid says is positive. “That puts extra demands on the health service but overall, it’s a positive thing.”
The HSE carries out a national patient survey each year and it gives very positive experiences for those that have gone through the system with a hospital stay. Their experience is actually quite positive, with 84 per cent stating positive/satisfied experiences between out emergency department, admissions and discharge experiences. “There are a lot of positives about the Irish health service and we need to recognise and celebrate that more,” says Reid.
The last impression is that there is a real challenge to strengthen financial management process and controls “to ensure predictability for the funds that government gives us. It has been one of my early priorities”. When asked if that is the result of poor process or just a case of everyone thinks there is an endless supply of resources, he replies: “We don’t have an endless budget. We have to manage within budgets, each month, each unit. We don’t have strong financial systems that are not connected but that’s not the early solution. The early solution is good financial management month by month. It’s getting financial discipline. We’ve done some good work on that in the last six months.”
This is reflected in the fact that the budget overrun last year was €800 million and this year it is expected to be less than half that, which is a good turnaround in six months from Reid’s perspective. “We had over run in the first five months of this year. This [reduction in overrun] has given government confidence and it has helped me secure some extra funding for next year. We are building the trust and confidence with government in terms of financial management.”
Reid at the launch of the HSE’s mychild.ie service.
Reform
When asked does he feel management is sometimes held responsible for things that are more policy than management, Reid insists that “it’s not really a distinction”. “For example, looking at people on trolleys can be a function of how the system is managed and how the processes are run,” he says. “There can be huge variations between hospitals. Sometimes it’s variation in the local population but other times it’s down to operational issues. There are clear policy areas such as investment profile for health in the future.” this morning involving himself, the HSE board chair and the Minister. HSE has now a new board and it is very connected with policy formation, “because we know what’s happening”. “That’s something that will be important for me and the HSE board and executive will look to influence that. I fully respect the role of the Department in policy formation but, going back to my Civil Service days, you can’t have good policy unless you think the implementation through,” he says.
The HSE announced the formation of six regions as a key part of its reform plan in late 2019. Reid has much experience of reform, not least from his days at the Department of Public Expenditure and Reform, where he was chief operating officer. “The starting point for me is the patient. Those that are using the services. I start there and work back. I’ve done that in every job I’ve been in, whether in the private sector from a customer perspective, or my days in the not-for-profit sector with Trócaire. In looking at what patients want he says: 4
Reid with Minister for Health Simon Harris TD and HSE Chairman Ciarán Devane.
“The first thing they want is for the service to be delivered locally and they want to have a local connection and identity to services. Secondly, they want their services to be integrated. Currently, we have a hand-off for customer experience whereas it should be a handover. If they are in a primary care centre and they have to be referred to an acute setting, or vice versa, that should be a seamless handover. Patients want services local and integrated and that’s why I’m supportive of the [new] regions. It’s not about geography, it’s more about integrated devolved decision-making and budgets etc.”
Thirdly, Reid believes that HSE has to transform the way the patient engages with the system. He says that it has to move away from the primary care route into the acute setting through the emergency department towards community-based services. This means strengthening GP and pharmacy services and extending our primary care centres to have diagnostics. “That means fundamentally changing the route to market for the patient,” he adds.
Reid says that this will be reflected in future budgets, with more resources going to primary care.
This year’s budget has already started that shift and any extra funding this year reflects that new transition – this includes one million extra home help hours, extra nursing home support schemes, 1,000 staff into the community side – public health nurses and primary care nurses. “The best way to help the acute side is to build-up capacity on the community side.” When asked if this will be difficult as it will take time to move the centre of gravity of the health service from primary to secondary care, Reid says that they have no choice but to start this transformation now. “The reality is that we have 127 primary care centres around the country. Some of them are state-of-the-art buildings but don’t have the resourcing or capacity or diagnostics that they need and that can be a huge relief for the acutes. When you look at emergency department attendances there is a significant proportion that doesn’t need to be in the emergency department.”
Turing his attention to the corporate centre of the HSE, he has asked the question to colleagues, “what should the core be about?” He acknowledges that there will always be the need for central functions such as clinical standards, quality standards, controls of levels of employment and financial oversight. “We now have to look at the centre and see what we currently do. The primary test should be, ‘is it adding value from a patient’s perspective?’ If they are not adding value we have to stop them. We also have to strengthen the connection between the delivery system and the core. The core has to support the frontline services and not the other way around. I’m concerned how the centre has grown to what it is currently,” he states.
Moving on from structural issues, to softer issues such as changing the culture of such a large organisation, he replies: “Personally, where I get most of my energy from is working with the frontline teams and staff. We need to look at how we provide the supports they really need and to give visible leadership and focus on listening and the culture [of the organisation].” Reid acknowledges the huge challenge in changing the culture of an organisation of 119,000 people dispersed across the country.
A new board
Reid says he has just caught breath after an “intense” first six months. Looking to the future and, particularly 2020, he sees the new board of the HSE having a pivotal role. “We now have a new board in place, and they are mapping out their corporate plan for the next five years. That’s an important milestone and it will be a roadmap for our future.”
Looking to 2020, the detailed design and business case for the six new regions will be the focus. “However, you can’t have the whole system waiting for the new.” Therefore, some early priorities will include things that Reid can start now, such as strengthening clinical and medical resourcing and their voice within the organisation. This will also include strengthening the resources of the chief clinical officer, “a key function relating to quality of patient care and standards.” He will also start “that shift towards primary care and well as strengthening the leadership of the organisation and then recruit for the new regional organisations”.
Although there are many challenges in his new role, Reid is optimistic and says he has seen a lot of good practice and innovation that needs to be built upon. “We need to be a more process driven organisation. I see some great examples of care in hospitals and community settings. We need to scale these up and then roll them out across the system,” he concludes.
Members of the National Paediatric Hospital Development Board, including chairman Fred Barry, appeared before the Public Accounts Committee (PAC) in December in order to provide TDs with an update on cost controls for the project.
With the overall price of the project still unclear and constantly rising in estimations, Barry told the PAC that the cost would rise by €50 million as a result of inflation alone if current rates of 7 per cent remain.
The estimated cost of the project has risen from €800 million in 2014, to €983 million in 2017 and again to €1.43 billion in 2019. That figure rises to €1.79 billion when costs associated with equipping the building and IT are factored in. These estimates do not include the costs of family accommodation, a research centre, possible excess construction inflation or any other possible changes to clinical standards.
When asked by Sinn Féin TD Imelda Munster if it was true to say that nobody actually has any real idea of what the final cost would be, Barry answered that the matter is “not a yes or no” question. “The contractor will make claims, we will resist them,” he explained. “It would be a surprise if some of those claims don’t stick before the job is over. It’s true we can’t say exactly where it [the price] is going to end up.”
Munster responded: “I think from that response, it is fair to say that the €1.7 billion is aspirational rather than reality.” Munster further pressed Barry on why the minutes of meetings of the board where construction inflation had been discussed were redacted and on the board’s experience in building hospitals. “I have built no hospitals on a greenfield basis,” Barry responded.
When asked by Munster if this lack of experience would allow “contractors to play you [the board] for fools”, Barry responded: “I accept that there may be others much better than me at the job. But I was asked to do it, so I’m not really here to interview for the job.”
The board was also pressed on an expenditure of €285,000 up to October 2019 on public relations services, which were “extraordinary” according to the independent TD Catherine Connolly. “On a PR company, I think it is totally unacceptable, I think it is an absolute waste of taxpayers’ money,” the TD said. “There is something seriously wrong if you are resorting to a PR company.”
When asked by the Labour TD Alan Kelly about the resignation of Paul Quinn, the Government’s Chief Procurement Officer who resigned from the National Paediatric Hospital Development Board in August 2019, Barry replied: “I don’t want to say anything in the context of offering a critique, good or bad, of an individual who has left.”
Quinn, whose job it is to ensure that government is getting value for money in its investments and infrastructure projects, exited the board as costs were revealed to be spiralling once again. His resignation was not the first of the project, with original board Chairman Tom Costello and Project Director Joe Pollock having also tendered resignations before him.
should be increased, with each area better able to address issues most prevalent to its population.
The appointment of Paul Reid as Director General of the HSE has been welcomed, recognising his track record for delivery and his ability to bring fresh input into health reform.
In August, the Minister unveiled the Sláintecare Action Plan 2019, an ambitious document laying the foundations for the Government’s decade long plan for reform the health service. Amidst the many changes proposed within the document were plans to remove private healthcare from public hospitals, planned negotiation on a new GP contract to bring about universal free GP care by 2028 and an increase in hospital beds.
The Action Plan was followed by Budget 2020 which announced finding to recruit 1,000 frontline staff by 2021, the expansion of free GP care to children under eight years old, a €100 million investment to help reduce waiting lists and an additional one million home help hours.
However, many within the health sector were quick to read between the lines of the investment announcements. For instance, it’s estimated that such is the gap in supply and demand for home help hours that even with an additional one million hours, there will remain a deficit of roughly the same number again.
Critics point to the absence of a clear price on Sláintecare’s reform ambitions as a weakness in the proposals. Changes to the system will likely cost multiples of billions and without such funding being readily available, revenue raising initiatives, likely to be in the form of taxes, will be necessary.
Amidst a series of scandals, the Government has repeatedly portrayed Ireland as a high spender on healthcare. To some extent, this figure has been used to argue that increasing expenditure on healthcare is not achieving value for money. The OECD rates Ireland as one of EU’s highest spenders on healthcare per capita. However, what is often omitted is that these figures incorporate public and private spending. State-funded healthcare, on an individual basis, ranks Ireland much lower in comparison with its counterparts.
Harris has also moved to make the health system more accountable to patients where mistakes have been made. The Patient Safety Bill he brought forward has been approved by Cabinet and will make it mandatory for health service providers to disclose serious patient safety incidents to health watchdogs.
However, shadowing over proposed progress is a series of failures and crises that will dominate the legacy of the Minister’s tenure. The INMO recently conducted research that over 100,000 patients had already gone without beds in Irish hospitals in 2019 by October, only the second time the 100,000 figure has been breached. Challenges in delivering frontline services are set to increase as winter pressures intensify and the Minister will have to defend the Government’s policy direction.
On top of those acute pressures, public perception of the competency of the health service is in decline. The Royal College of Obstetricians and Gynaecologists review of CervicalCheck recently found that 15 per cent of cases reviewed were missed opportunities to prevent or diagnose cancer earlier, a final cost for the National Children’s Hospital has yet to be established and the future funding of Sláintecare is far from detailed. Reform of the health service will need to face these challenges if it is to deliver change.
Better communication means better patient outcomes
Communication is central to the smooth running of any industry but none more so than that of medicine, which depends on the sharing of clear concise information between doctors and their patients, writes Bill Prasifka, CEO of the Medical Council.
So often doctors meet with patients at difficult times when the communication of information is just as important as the manner in which it is delivered, and the support offered.
However, complaints to the Medical Council have illustrated the emergence of a concerning trend in modern healthcare in the form of poor communication from medical practitioners. As published in our annual report we received 396 complaints with 19 per cent of those falling into the communications category in 2018, the same percentage as in 2017.
Complaints relating to communications vary greatly and can include a misunderstanding, a disagreement or a personality clash. Sometimes a complaint may fall under other categories as well as communication. Issues of poor communication are not acceptable – either to the patient or the Medical Council and we are dedicated to improving the patient experience by supporting doctors to deliver the highest standard of care. Nobody is infallible, things do go wrong sometimes but it is how we approach these errors and communicate them to our patients and their families that will have the biggest impact on building the trust and confidence integral to the doctor-patient relationship. The Medical Council is determined to work with stakeholders to improve how doctors communicate with patients but outstanding problems concerning recruitment and retention must also be addressed to allow doctors to work effectively.
The Council provides guidance to doctors on matters relating to conduct and ethics through its Guide to Professional Conduct and Ethics for Registered Medical Practitioners. Good communication has always been considered essential by the Council. A quote from our ethical guide reads: “Good communication… is central to the doctor-patient relationship and essential to the effective functioning of healthcare teams.”
The relatively recent publication of the Scally report demonstrated that communications continues to pose a challenge to be addressed within the system. Dr Gabriel Scally’s findings tell us that better communication between doctors can only lead to better outcomes for patients in terms of both safety and experience.
Communication issues have arisen among doctors as well as in the doctor patient relationship in the form of bullying. The results of the Your Training Counts survey showed concerning prevalence of bullying among medical professionals. Over 40 per cent of respondents to Your Training Counts 2017 reported that they had experienced bullying and harassment in their post.
Bullying and harassment were not specifically defined as terms but were open to the interpretation shaped by personal experience of each trainee who responded. Since YTC began in 2014, reported bullying among trainee respondents has increased by over 6 per cent.
These figures do reflect experiences noted in published Medical Council reports into inspections of clinical training sites. The Medical Council has a zero tolerance approach to bullying at all levels among registered medical practitioners.
Here once again we see the need for a greater emphasis on communications skills. It may be that those involved are not aware they are behaving inappropriately as they struggle to work in an ever more pressurised environment. Given the pressurised environment of the modern medical profession in this country coupled with staff shortages and overcrowding it is unsurprising that the strain has started to show.
Doctors have a duty to protect and care for their patients but the environment in which they are now expected to do so is tougher than ever before as practitioner numbers dwindle. Worryingly as the numbers of applications to the register decrease the number of voluntary withdrawals continue to rise and we are now at a point whereby the flow of those leaving is likely to surpass those joining in the coming years.
We need a comprehensive and coordinated approach to managing this situation to ensure that we have the right doctors in the right place at the right time to care for the Irish public at the highest possible standard.
Although the standard of medical education remains high in Ireland, we are continuing to lose a large proportion of our highly trained graduates as they look abroad for better working conditions. Reports into hospital training sites reflect the high standard of medical education offered despite ongoing challenges in recruitment and retention within the healthcare system.
Data from our Workforce Intelligence Reports indicate that we are over reliant on foreign trained doctors in a bid to fill the gaps left behind by our emigrating graduates. We are trying to deal with these shortages by relying on costly alternatives such as locum services which can adversely affect the continuity and quality of patient care.
Evidence of this is seen in the swelling of the General Division of the Register resulting in a drop in the number of those engaged in specialist training and experts in particular fields within the profession. In 2018, there were 2,190 doctors who enrolled on the Medical Council register for the first time. The primary growth reported was in the General Division of the register.
Most new entrants to the register were on the General Division and educated outside of Ireland. Doctors from countries outside of the EU cumulatively contributed more new entrants to the Irish register of medical practitioners than Ireland.
This article is not about doctor shortages but rather about patient safety, however we have now reached a point in which neither can be mentioned independent of the other. Without adequate staffing resources we cannot protect patients and if patient safety standards are to be met it will necessitate an increase in practitioners.
We need more attractive working conditions and increased opportunities to enter medical training programmes in order to guarantee substantial, highquality workforce recruitment and retention, both short-term and long-term. Doctors leaving the register are citing resourcing shortages as well as a lack of appreciation and difficulties in obtaining work life balance among reasons for travelling abroad for work where such criteria are met.
We are essentially cultivating world class professionals and watching them leave to benefit another healthcare system to the detriment of our own. If Ireland continues to fail to address these cultural and practical challenges that exist within the system this situation will evolve, and the problems will escalate even further.
As the regulatory body for medical practitioners in Ireland the Medical Council remains committed to protecting patients and supporting doctors, especially in these difficult times.
Medical Workforce Intelligence Report 2018
3,000
2,500
2,000
1,500
1,000
500
0 1,958
546 2,576
828 2,714
2,547
948 1,054 2,190
1,453
2014 2015 2016 2017 2018
New entrants Voluntary withdrawl
T: +353 1 498 3100 W: www.medicalcouncil.ie
highlights a well-circulated statistic within HBS that the components of any digital project are only 20 per cent the technology, 30 per cent the process and 50 per cent culture and organisational change.
“Digital health, and indeed any type of digital transformation, is all about the people who are delivering the change. The technology, of course, is IT but the transformation and change itself is all about social and behavioural science. Embracing that is a positive way to move forward.
“It’s important for us to enable our people to be supported throughout change and to make sure they are confident and comfortable within it. If people are not happy with what we are doing, if they don’t see the vision or mission, then it won’t happen. People will be disengaged, and we won’t move forward.”
O’Loughlin outlines ongoing work to “make our culture our advantage” in HBS, adding that within the organisation “digital is every person’s job”.
With this in mind, she highlights that ‘why?’ is a reoccurring question behind any ambition for change and explains that the improvement of employee satisfaction, creation of innovation and a strengthening of reputation are key drivers.
“We need people to be confident and happy with what we are delivering. We want our staff to be proud of the organisation they work for and to achieve this we must engage with them on change.
“Organisations need to embrace change as an unending process. It shouldn’t be something that has a beginning and an end. This is why it is important to us in HBS to digitally transform. We need to continually foster a readiness for change.
“It is important that colleagues feel they have a combined influence to create the change. It also highlighted that employees want to input in change and to be part of the conversation at many points of time. If employees are supported to hold positive views about the need for organisational change and educated about the positive implications for themselves and the wider organisation, this can have a positive impact on the organisational climate and change readiness.” focus for introducing change: emotional, intentional and skills. On emotional, she describes the necessity for trust in the vision/mission. On intentional she adds the need for a key focus on collaboration, discussing the need for organisations to leverage the power of collaborative knowledge to stay attuned to an ever-changing environment.
“We are trying hard to be open and transparent in eHealth Ireland and to open up a social mindset that we have where we can collaborate cocreate and cooperate at a higher level than we have done before,” she says.
Adding: “The intentional element is about establishing the plan and getting an attitude for ‘let’s do something’. It’s also about establishing how we do it. If there is no plan, then there is no potential for people to buy in to the journey.”
Giving a context, O’Loughlin says that HBS are forward looking on their next strategy to 2023, talking to their staff about the strategy’s ambition, staff involvement and future planning. “Just as important to our plan will be our people strategy around how we are going to bring people along on the digital transformation journey and enable them to deliver on the three-year outlook. We do that through lots of engagement both within and outside of our organisation.
“A key component of any digital transformation will be the plan around data. We have lots of data within HBS and we have identified a desire to be a leader in data utilisation, however, we need a roadmap to get there and a plan to get our people there.” This element ties in with O’Loughlin’s third core area of focus in skills, which she explains is about ensuring that staff feel relevant and useful in a world where technology is changing the future of jobs.
“For us, it’s about communicating to our staff that digital transformation is not all technical. A lot of our skills going forward are going to remain human in nature and we are working to establish how can people work together to communicate, collaborate and be more analytical about the challenges we are facing.”
In a report on digital dexterity, Gartner highlights research that suggests 25 per cent of midsize enterprises will attain digital transformation leadership status by 2022 by systematically enhancing digital dexterity. A recognisable need for organisations to engage and take advantage of digital has seen the HSE roll out their ambassadors For Future Health Skills Programme, which was piloted within HBS and introduced customised upskilling plans in a range of areas including internet safety and security, online pay slips, GDPR and even for HBS pensioners.
Concluding O’Loughlin summarises: “While technology will be an enabler of digital transformation, the key component will be the ability to get people to feel like they are a part of change and to accept the chance to change. Transformation cannot be something that is forced on people, it’s something we want to work with them on.”
Fear of legal action, litigation, and insurance costs, can discourage candour, but if we think back to our mission, we need to learn from mistakes in order to improve patient safety outcomes. In light of recent developments in healthcare, there is now more reflection about whether there are better ways to deal with complaints. The Professional Standards Authority in the UK has been leading the way on this issue of what to do when something goes wrong, by looking at what regulators can do to embed a culture of candour. The regulators in the UK signed up to a statement in 2014 to encourage candour, and in the recent review we see that they have made progress in encouraging candour amongst their registrants since then.
NMBI: Planning for change
For us in NMBI, we need to be prepared for changes and we need to be agile in our response to them, but it cannot just be rhetoric: it has to be real and tangible. Those working in nursing and midwifery, and patients, need to see and feel it.
We are currently in the process of finalising our strategy for 2020-2022. This will set the direction for NMBI and nursing regulation for the next three years. It will have specific, associated yearly work programmes, to deliver on our role amidst all the changes and to respond to those changes.
Contribution to policy: data, research and evidence
It is important to emphasise that you cannot plan for the future without having an evidence base and data, and you cannot plan for the workforce of the future in healthcare without ensuring nurses and midwives have the right education and training.
We can all see the data gaps at this stage. In 2018 alone, we saw it with the Public Pay Commission for its report, the data limitations identified in the Health Service Capacity Review, and the recommendations by the Taskforce on Staffing and Skill Mix for Nursing about the need for more data, more evidence and frameworks.
Workstream Three of Sláintecare is, of course, looking at workforce planning, new ways of training and the teams of the future. NMBI is gearing up and preparing to develop and maximise our contribution to the big policy debates. We can do that by providing the evidence base and data for registered nurses and midwives working in Ireland. Here is where NMBI has a huge role to play, in collaboration with our other regulation colleagues, policymakers, nurses and midwives, and the public.
Our new digital system which will assist with all of this is under development. In making this investment we need to be sure that we are future proofing the Register, and the information we are holding on the Register.
NMBI Strategy 2020-2022
As part of our new strategy:
• Our new digital platform will capture the required data for all registered nurses and midwives;
• We will work with stakeholders to develop a regulatory framework that reflects the multi-disciplinary models of healthcare envisaged under
Sláintecare while also ensuring that nurses and midwives’ scope of practice remains understood, defendable and safe;
• We will continue to regularly review our code, education standards, and guidance, to ensure they remain relevant to what nurses and midwives are experiencing on the front-line; and
• We are going to streamline the process of engaging with NMBI for nurses and midwives, allowing them to pay online, giving easy access to records and data, and enhanced self-service.
Breakdown by training location of first time registered nurses and midwives
At the end of the day, patient safety is what drives the NMBI. There needs to be an evidence base to what we do regarding policy, and we need to be linked and fully integrated with the rest of the healthcare system and other regulators. The changes are coming and happening, and we need to be responding, to ensure nursing and midwifery can fully develop and expand as professions, and nursing regulation remains relevant.
Training location 2015 2016 2017 2018
Ireland
EU excl. Ireland
Non-EU
Total Overall
1,389 1,321 1,391 1,342
517 1,034 1,748 1,018
343 1,040 1,545 1,443
2,249 3,395 4,684 3,803 T: 01 639 8500 E: communications@nmbi.ie W: www.nmbi.ie
•Immediate discharge summary:
“This has huge benefit for patients. If you’re in secondary care or hospital or have been an outpatient, instead of having to take a handwritten letter to your GP, this enables a standardised letter to be sent to your GP at the instant you leave. So as soon as you get to your GP, they will know what medications you’ve been given, what treatment you’ve undergone and any follow-up treatment that they are required to give you”; and
•Cross-border radiology: “This is mainly for patients in the border areas in the west or in Donegal who might get treatment at the cancer centre in
Altnagelvin. Radiotherapy referrals can now be done cross-border and our counterparts in the south can make a referral for the north.”
It is, Colgan says, once you get passed the behind the scenes technical work that you begin to see the patient-facing benefits of digitisation and standardisation of care, including eTriage, and My Care Record, the patient portal version of the NIECR.
eTriage takes place when a patient attends their GP, who decides that they are unable to treat the patient and refers them to secondary care. What had previously been a paper-based system that created multiple opportunities for letters to get lost along the way is now done electronically, enabling the secondary care technician to see why the patient has been referred and allowing them to assign an appointment in minutes. “The best time that we’ve managed is somewhere around half an hour from the patient leaving the GP to having an appointment,” Colgan says. “That’s not the case for everyone but this has certainly reduced the timescale from a referral to getting an appointment.” The system was named an Award-Winning Solution at the 2018 UK Public Sector Paperless Awards.
The first phase of the rollout of My Care Record has been specifically targeted at dementia patients. “We’re taking the agile approach,” Colgan explains. “Phase one began August 2018 and what that includes is high-level information: your appointments, educational material about your condition, shared files that can be shared with those providing your care and a circle of care where you can nominate a family member or friend, which is particularly relevant for dementia patients, to be able to view your portal on your behalf and check your appointments and where you need to be.
“Phase two will start soon and introduce goal setting. You can set your own goals, dietary or fitness goals, or a clinician can set a particular goal in the case of your treatment or care. Hopefully in the summer, phase three will introduce medication – so you can check online what medication you should be taking and how much if you’ve forgotten or lost the box – and your laboratory results.”
While managing the present transitions, the Head of eHealth is also looking to the future: “We’ve got Citizen Identification. At the moment we’re in the pilot phase, where the clinician knows the patient sitting in front of them and they onboard them, but when we think about scaling this up for all Northern Ireland patients, we have to ask how we identify patients and how do we enable them to identify themselves to access their records?
“We need to think about consent, particularly for children, and ask at what point do we stop automatic parental access to their records? We’ve started with dementia patients, but we need to think about where we go next. We’re thinking possibly Diabetes, but there’s a queue of conditions and clinicians who want to be able to interact with their patients. It’s about capturing and evaluating the benefits so that two or three years down the line we have the evidence that this is working.”
This future vision involves a completely role-based system, where a specific clinician, such as a physiotherapist, will have certain access approvals. “This is going to be a regional system, in order to do that all care will now be standardised using the one system rather than variations of the one system,” Colgan says.
“The question is what happens to all that work in the other patient portal: the answer is that there’s a definite need to press ahead with that work because it will take at least five years to have full rollout of this programme and we want to be able to have patients move seamlessly from one programme to the other,” she concludes.
one being viewed by the clinician. This ability to support diagnosis rather than attempting to replace the clinician by carrying out the diagnosis has helped to break down the barrier to the use of AI in the treatment of patients.
Of course, the reduction in the cost of storage and the increased power of compute have also had a big impact, albeit from a cost and usability side rather than adoption by clinicians. That said, without these improvements in performance and reduction in costs, it would be much harder to embed the technology in mainstream patient care.
Dell Technologies is providing the technology infrastructure to support a digital imaging for pathology service which will aim to improve health outcomes for up to 3.2 million patients across the North East and North Cumbria (NENC). Working with seven NHS Foundation Trusts across the region, as part of their ambitious integrated care system (ICS), the service will be hosted on behalf of NENC and Teeside-based North Tees and Hartlepool NHS Foundation Trust. The organisation was awarded a contract funded by the Northern Cancer Alliance in a bid to improve health care through the Digital Care Programme.
Graham Evans, Chief Digital Officer who leads on digital strategy for the what has become the largest ICS in the country comments: “How we optimise health services and specifically improve diagnostic services for the benefit of the population we serve is a key priority. Our region has become renowned for advances we make within digital technologies and this move will further herald our commitment to the populations of the North East and North Cumbria.”
The same can be said for virtual and augmented reality. Until recently, these technologies have been primarily used in the labs to create a vision as to what healthcare in the future might look like. Now that the computing power to drive the software can be delivered in a standard laptop or tower PC, we are starting to see greater investment in the technology and more use cases being developed as to how it can improve patient care, improve research, improve treatment outcomes and support patients to understand the impact that any treatment might have on them in the longer term.
Companies are now working on the next generation of self-guided robots that no longer need supervision to carry out minor surgical procedures. This technology will be able to deliver lifesaving care in the most impoverished and remote regions across the globe, where access to a clinician is difficult or nearly impossible. Other technologies such as 5G and IoT will revolutionise the provision of care out in the patient’s home and other nonclinical settings. The Internet of Things is a maturing technology that is widely used in healthcare and improvements in digital outputs from monitors and reduction in the size of patient monitoring devices have really helped to accelerate adoption. Once 5G becomes a common standard across the globe, we will see a rise in the use of remote monitoring and mobile sensors as the ability to capture more data about the patient in a secure manner becomes possible.
What is needed to support adoption of these technologies amongst healthcare providers?
Having a plan, a strategy, commitment and budget is only the start of the transformation journey. Innovation throughout will be needed to meet growing challenges. To implement the solutions that can be delivered by these new technologies, healthcare providers need to focus in the first instance on modernising their core IT capabilities. The saying goes that ‘you can’t build a house on quicksand’. Well the same goes for a digital healthcare solution. Before any digital transformation can begin, it is important to look at the basics. If moving to a cloud operating model, you will need a balance of private cloud, hybrid cloud, and public cloud options mapped to a specific clinical or business workload. Some applications will need to stay on premise and that means maintaining some level on in house infrastructure.
Our automated, integrated approach to infrastructure inclusive of storage, backup, recovery, data protection, and archiving capabilities means that you can secure data, on-premise or in the cloud and better meet regulatory requirements while enabling data to be translated into meaningful insights faster to improve patient outcomes, further innovation, and position your organisation for what’s to come.
For more information contact Fergal Murray, Account Executive E: Fergal.Murray@dell.com
should have. You would hardly have thought of compliance as an issue and we have a department for that now to educate people in the Section 38s [the 23 non-acute agencies and 16 voluntary acute hospitals currently within the HSE Employment Control Framework funded under Section 38 of the Health Act, 2004] and 39s [non-acute/community agencies being provided with funding under Section 39 of the Health Act] to tell them that procurement is important and that money must be spent in the way that government has set out.”
It is a long way from where Swords began in his career, as he explains that innovation brought about by the Office of Government Procurement (OGP) and the centralisation of the health system has seen both his role and overall healthcare come a long way since the 1990s. “The bar has been raised, through the development of the OGP, the development of procurement in health and other developments. I go back to 1990 when I was with the Eastern Health Board, we were trying to get the eight health boards together at the time to move onto the HSE and a shared service to where we are now into Sláintecare and all the change and reform happening around that,” he says.
“Each of our areas are complex in their own right and you need professionals. Our way of working is combining all those professional approaches, of which we are probably the least recognised of all and at some stage, the most important. That gives a mix of how we should be doing our business. Recognition is a key part of that, and recognition comes in the form of winning or losing in court and thankfully we haven’t lost any recent cases, but they still go through everything, so it is a validation in its own right. The people within that play a major role in its development and brining a good service right down to the patient. Each of our areas rely strongly on the professionals around us.”
Such extensive scope means extensive spend. As Swords details, €3.2 billion addressable spend covers the Section 38s and 39s, with over 700 staff, 2,500 customers, 3,000 locations, 2,700 requests for procurement support and 1,000 deliveries every day. The 2,000 pharmacies around Ireland, delivered to once or twice a day, are not counted in that 1,000. Of the 2,700 requests for supports, Swords says: “That’s high, which is saying that we’re getting there in telling people that it’s important to follow procurement guidelines every day.
“Managing our spend means that we are accountable. It’s really important the bar is raised. All the work being done by procurement people is raising the bar,” he says. “We’re bringing in a programme of education from next year, from diploma to master’s degree. We need visibility for that. We have a single financial procurement system that is very successful. Procurement plays a huge role in this because purchase to pay is massive in this area. The professionalism it drives is incredible. If you start with a good base in regard to the catalogues. We have visibility of what complex workload to deal with, but “throw in the market and what’s happening in the world such as Brexit” and more complications arise, but this is an area Swords says Ireland is wellpositioned to deal with.
“A huge amount of work has been done in health for Brexit. We have been asked why we weren’t stockpiling as the UK were and the answer is because we spoke to industry,” he says. “We spoke to over 160 companies on the medical devices side and over 230 companies in relation to areas outside medical directives. Every single one of them said not to stockpile as it would crush the system and cause delays. We have two
we’re spending. That helps industry and helps us to explain what we’re looking for.
“We have about 213 frameworks because we do them from the point of view of health. We bring them to the Prison Service, for example, with things such as methadone, medics going into prisons, into social welfare, they’re covered by ourselves. Spend under management is the contracts involved in that, the mini competitions. We’re starting to get very good traction on that. If you’ve been coding on top of that and you have finance with pre-authorisation of orders, that brings a whole new spectrum to days gone by where everyone was ordering everything they wanted, and nobody could see what they were up against. Professionalising the whole service and the way we do our business cleans that whole area up and gives us direct access to what we want to buy in the future.”
With 49 hospitals, nine Community Health Organisations, the public sector and 12 corporates, Swords has a to three weeks stock in any given hospital and seven weeks stock in the national distribution centre in Tullamore and the companies have six onwards in their stock.
“We should be able to sustain the initial shock of Brexit. In the UK, by way of comparison, they stockpiled and are not centralised. They were at one stage but outsourced their logistics, contracting and systems, which was a massive mistake that we learned from. They are decentralised at the top because they have no directive. They’re reliant on people doing the same thing at the same time, which doesn’t happen. Medical devices were the area that caused the most concern because the EU decided that they weren’t going to give any derogations and basically pulled the chain on the UK. 50 to 60 per cent of our medical devices come through the UK and would be no longer recognised after Brexit, so we had to move to the EU, which was a massive task. We’re well placed by way of Brexit,” he concludes.
Irish children and adolescents are experiencing mental health issues at an alarmingly high rate. A Royal College of Surgeons Ireland (RCSI) study reveals that by the age of 13, one in three Irish children will experience a mental health difficulty (Cannon et al 2013). Demand for support is rising for issues such as anxiety, self-harm and suicidal ideation (Irish Times April 2019). The suicide rate amongst Irish teenagers is the fourth highest in Europe (UNICEF Report Card 2017).
The World Health Organisation (WHO) tells us that school is one of the most important places for promoting mental health and that schools are best placed to identify children who are experiencing emotional distress. While the Irish Government has been committed to developing programmes to strengthen young peoples’ coping skills and improve overall mental health and wellbeing there is, nonetheless, a lack of enough access to therapeutic supports for second level school children who may be experiencing mental health difficulties.
Evidence shows that a range of psychological interventions, including counselling and psychotherapy, are effective in the prevention of suicide and self-harm, and that timely access to them is crucial. We know that access to these therapies remains a significant challenge in Ireland, particularly access to the Health Service Executive (HSE) Child and Adolescent Mental Health Services (CAMHS).
The IACP proposes that second level school children would benefit from the introduction of an ‘on-call’ therapeutic counselling service, additional to existing arrangements. This service would complement and support the invaluable work already being carried out by principals, guidance counsellors, teachers and other professionals in our second level schools. It can also help to fill the identified gap in onward referrals from schools, where children are generally experiencing lengthy delays in accessing external and state services. The introduction of a funded ‘on-call’ support service connected to the school would enable access to essential mental health supports in a timely and seamless manner.
The Irish Association for Counselling and Psychotherapy (IACP), the largest representative body for counselling and psychotherapy in Ireland, is seeking a commitment from the Government that effective and timely therapeutic interventions will be made available so that vulnerable second level school children across Ireland can get the help they need, when they need it. Lisa Molloy, Chief Executive of the IACP, writes.
UK Experience with school counselling
School-based counselling is well established across the UK and has been proven to work and to be cost-effective. The cost of six school-based therapeutic counselling sessions in the UK, is estimated to be one tenth of the cost of a referral to a community CAMHS (child and adolescent mental health services) service. The UK Department of Health estimate that a targeted therapeutic intervention delivered in a school costs about £229 but derives an average lifetime benefit of £7,252. This represents a cost benefit ratio of 32-1. In Wales, 85 per cent of those who availed of school-based counselling did not require onward referral to CAMHS.
Safer services for patients
Members of the team who implemented electronic traceability of Special Feeds at CHI at Temple Street. (L to R): Sinead Moran, Bernadette O’Connor, Timea Varga, Deirdre Kane, Vilma Slavinskiene, Cherrylyn Panganiban, Marian Draper, Ruth Ennis.
Case study: Innovative traceability of infant feeds at Children’s Health Ireland (CHI) at Temple Street.
Risks to patient safety occur when there is a mismatch between a patient and the care they receive. Errors can occur at time of diagnosis, treatment or on-going care. Hospitals are using GS1 standards when implementing traceability solutions to ensure the reliability of data and to optimise processes. This in turn can reduce preventable errors, enhance Electronic Health Record management, support outcome-based medicine and comparative effectiveness, and provide transparency for better clinical and supply chain management.
The traceability solution supports the five patient rights: right patient; right drug or device; right time; right dose; and right route. Reducing the administrative burden on clinical staff
According to a recent survey (Cardinal Health Hospital Supply Chain Survey, 2019), clinicians report spending more than twice the amount of time they would like to on supply chain-related tasks, and as a result have less time with patients and increased stress levels. Barcodes can be used to automatically capture information identifying products, locations and patients, creating a more streamlined environment freeing up time for clinical staff to care for patients. Case study: Safer services for patients
The Special Feeds Unit (SFU) at CHI at Temple Street looks after the storing, preparation and delivery of prescribed feeds to infants with special dietary needs, some which require very specific care, such as metabolic patients, and it is vitally important that these patients receive the correct feeds.
The hospital implemented a GS1 standards-based traceability scanning system that captures the critical data about each product, location, staff member that delivered or prepared the feed and ultimately the patient that received it. This means the hospital now knows where each feed is, and, a product recall can be done in seconds resulting in a safer service for patients.
The previous process was paper-based and time consuming. If the hospital received a recall notice from a supplier, they had to manually hunt through paper records from the last six months to identify what patients had received that batch as well as to locate the tins of product with that batch number so that no further product could be distributed. Now, this can be done in seconds.
New controls within the system prevents the dispensing or preparation of any expired or recalled product. The intelligence built into the system prompts staff to select short-dated products should they be available, helping to promote better stock rotation, reducing waste and saving the hospital money. The movement of all products is recorded against a ward or patient, ensuring that wasteful, buffer stocks are not built up in several areas around the hospital. Added to this they estimate time savings equate to half a full-time member of staff every week.
Mona Baker, Chief Executive Officer, CHI (Children’s Health Ireland) at Temple Street, says: “Our staff take great pride in delivering the best care for patients. We know where each feed is, and a product recall can be done in seconds. This is an excellent example of innovation at CHI at Temple Street to improve patient safety.” Background
GS1 licences the most widely used system of supply chain standards, serving more than two million public and private sector organisations worldwide.
For more information, please contact: Siobhain Duggan, Director of Innovation and Healthcare, GS1 Ireland.
T: 01 208 0660 E: healthcare@gs1ie.org W: www.gs1ie.org/healthcare
