The Challanges of Clinical Leadership in Ireland

1. The challenges of Clinical Leadership
in Ireland
Áine Carroll
National Director
Clinical Strategy and Programmes Division
HSE

6. Why Reform?
 Government policy (Future Health, Healthy
Ireland…)
 Need to improve service delivery
 Integrated models of care
 Shift focus towards health & wellbeing
 Existential economic challenge for health systems
 People who use and work in the Health Service
expect things to improve

7. Department of Health
Health Commissioning
Agency
· Healthcare needs analysis
· Models of care
· Core service definition
· Quality & Standards
· Commissioning Intentions
· Contract Management
· Performance Management
Regulators
· HIQA
· MHC
· IMB
Health Service Providers
Hospital Groups Community Health Care
Organisation
Grant Funded Agencies Primary Care Providers
HIQA
· Licensing and compliance monitoring of
residential and specialist ambulatory services
for children, older people and people with
disabilities.
· Develop standards.
· HTAs to evaluate new technologies and
· Advise on the collection and sharing of
information across the healthcare services.
National Information and
Pricing Office
· Separate pricing from
purchasing / commissioning
· Hospital Inpatient Enquiry
Scheme (HIPE) (maintained
by ESRI)
· National Casemix
Programme
Patient Safety Authority
· Subsume National Clinical
Effectiveness Committee
(NCEC)
· Sets guidelines for eligibility
for treatment under UHI
Support Services
· Strategy to be developed
· Shared Services
· PCRS
· Electronic claims
management system
· Finance Operating Model
· MTPF / UHI eClaims
· HR
· ICT (eHealth)
· Audit
· Parliamentary Affairs
· Informatics
Healthcare Commissioning Agency
· Subsume HSE service directors
· Convert National Services Framework into
detailed performance targets
· Commission services through MFTP and block
allocation contracts
· Subsume NTPF and SDU
· Divest some responsibilities on move to UHI
Public Hospitals
· 6 adult and 1 Paeds hospital groups
· Each with a hub that is an academic
medical centre
· 48 hospitals (29 statutory and 16
voluntary acute)
· Mix of public and private care
Private Hospitals
· Role of private providers under UHI to be
defined
· 21 private hospitals (acute and mental)
· Approx 3,500 beds
· 1 in 6 of all acute beds
Community Health Care
Organisations
· Successor to ISAs
· Review of role of 17 ISAs
(32 Local Health Offices)
Grant Funded Agencies
· Status and commissioning
of grant funded agencies
to be defined
· Over 2000 separate grant
funded agencies
Primary Care Providers –
Public and Private
· GPs
· Dentists
· Pharmacists
· Opticians
Professional Regulators
· Medical Council
· An Bord Altranais (Nursing &
Midwifery Board of Ireland)
· Dental Council
· Pharmaceutical Society of Ireland
· Health & Social Care
Professionals Council
Other Regulators
· HIQA (see above)
· Mental Health Commission
· Food Safety Authority of Ireland
· Irish Medicines Board
· Health Insurance Authority
Professional Bodies
· RCSI
· HMI
· Therapies
· IADNM
· RCPI
· ICGP
· Forum of Post Graduate Training
Bodies
Other Agencies
· NTPF (move to HCA)
· Health Research Board
· Irish Blood Transfusion Service
· Safefood
· Institute of Public Health
Commercial State Company
· VHI (UHI provider)
Emerging Future Health System
UHI Providers
· Claim settlements
· Payments
Support Services
· System wide common services
· Shared services & PCRS
· MFTP / UHI Claims
National Pricing Office
· Price Informatics
· Tariff Setting
· Pricing
Economic
Regulation
Patient
Safety
Authority
Health
Insurance
Authority
Payment
SLA
Contract&
PerformanceMgt
Performance
Reporting
Paymentforitemsnot
coveredbyUHI
Ensure quality and
safety standards
across system
Recommendstarriff
Tariffs & Pricing
Policy
PerformanceReporting
CostData
Approves payment
Funding
SLA
Regulates the
market
Payment
Ensures
operational
effectiveness and
financial stability.
Authorises Trust
status (tbc)
Claims
Payments
Ambulance
Key to text
· Current organisations
· Significant changes
Representative Groups
· IMPACT
· IMO
· INO
· IHCA
· SIPTU
· Unite
· IDA
· PNA
· TEEU
Employers
· Google, HP, etc

8. OUR Enablers and Challenges
 Thousands of dedicated and able
people across the health service
 Many major and minor
improvements achieved – Cancer,
Stroke
 Many people have a good
experience of the health service
 Elements aligned
 Great desire among people to see
change
 Poor history of working in a co-
ordinated way – fragmented;
fractured
 High levels of distrust and
apprehension
 Sense of lack of connection
between the top and the bottom
 General lack of credibility
 Have we lost sight of our
purpose?
 ‘We have heard it all before’
Enablers Challenges

9. Rules for transformation
 Effective leadership
 Data feedback
 Honour the work
 Engage clinicians
 Involve patients and families
Large-System Transformation in Health Care: A Realist Review
ALLAN BEST, TRISHA GREENHALGH, STEVEN LEWIS, JESSIE E. SAUL,
SIMON CARROLL, and JENNIFER BITZ1 The Milbank Quarterly, Vol. 90, No. 3,
2012 (pp. 421–456)

10. IOM Aims of redesign
Timely Care
Efficient Care
Family-Centred care
Effective Care
Equitable Care
Safe Care Priority #1

11. National Clinical Programmes:
Mission & objectives
1. Improve Quality
2. Improve Patient Access
3. Value

12. Key principles
1. Clinically led – empower clinicians to lead the
change
2. Structured programme management approach
3. Nationalise existing best practice
4. Engage Patients
5. Align stakeholders – Government, Management,
Colleges, Unions, Patients, etc

13. Why?
 Partnership between HSE and Clinicians
through the Forum of Postgraduate training
colleges
 Partnership with Irish Association of the
Directors of Nursing and Midwifery and the
Therapy Professions Committee
 Partnership with patients

14. Some Achievements To DateNational Clinical Programme for Acute Medicine:
• Introduction of the National Early Warning Score (NEWS): received public service excellence award from Taoiseach
• Total length of stay reduced by 21% between 2005 and 2012 with the introduction of Acute Medical Assessment Units in every
acute hospital
• Overnight length of stay reduced by 8% between 2005 and 2012
National Clinical programme for Epilepsy
 Received an international nursing award for its description of the new national epilepsy service of Ireland (the ‘limelight’ award is
part of the international care challenge series by Sanofi which allows nurses from around the world showcase nursing innovations)
National Clinical programme for Rheumatology/MSK
• Physiotherapy led Musculo-skeletal clinics are reducing waiting lists by up to 70%
• 10,000 new patients triaged and treated from orthopaedic and rheumatology waiting lists in one year
National Clinical Programme for COPD
• COPD Outreach Model of Care and Pulmonary Rehabilitation Model of Care, Bundles of Care, and patient information materials
developed and issued for adoption.
• Average Length of Stay (AvLOS) reduction from 9.1 days in 2009 to 7.6 in December 2012
• Pulmonary rehabilitation available in 37 sites. Access to Pulmonary Rehabilitation in 56% of sites (2012) has exceeded the target
set (25%). Further work ongoing to target areas without access.
National Clinical Programme for Medicines Management
• The Medicines Management Programme has identified an additional 2 drugs, ace inhibitor (Ramipril) and angiotensin 11 receptor
(Candesartan) as part of the ‘Preferred Drugs Initiative’. The Programme is aiming to secure €20 million in savings in 2013.

15. Some Achievements To Date
National Clinical Programme for Stroke
 27 out of 28 hospitals admitting patients with stroke requiring acute care now have a stroke unit. This is an increase from 18 in July 2010.
 Thrombolysis available in all model 3 and model 4 hospitals either directly or via ambulance access protocols.
 Thrombolysis rates have increased from 2.4% in 2007 to 9.5% in 2013 exceeding targets and leaving Ireland with one of the highest rates
in the world (UK is 5%, Sweden 6.6% and USA 2.4%)
 1.5% increase in patients discharged to home in 2011 (110 patients/yr, 2 patients/week)
 2% decrease in case-fatality in 2011 i.e. 70 patients/yr. This was also sustained in 2012.
 2.9% decrease in stroke Nursing Home admissions i.e. 150-160 patients/yr
National Clinical Programme for Diabetes
 Diabetes Retinopathy Screening has commenced in quarter 1 of 2013 and this aims to screen 30% of the diabetic population in 2013.
 A national model of care to deliver CS11 therapy to children with type 1 diabetes under 5 years of age has been developed and
implemented.
Retrieval & Transport Medicine
• Neonatal retrieval extended to 24/7 nationally in 2013
• Paediatric retrieval due to commence a 5 day daytime service in 4th quarter 2013
• National model for adult retrieval designed to support hospital groups. Implementation planned for 1st quarter 2014 in Dublin, Cork and
Galway providing a 7 day daytime service
National Clinical Programme for Audiology
• National screening of 99% children within 4 weeks of birth
National Clinical Programme for Acute Coronary Syndrome
• 4 24/7 PCI centres operational

16. Don Berwick

17. Problems
 Lack of integration
 Resources
 Hierarchy
 Disconnect between strategy and operations
 HR
 Finance
 Procurement
 Data management

19. Reform CSPD Programme Structure
Director
General
CSPD Team
Forum
PGTBI
Project
Sponsor
Systems
Reform
Group
Training
Bodies
Project
Team
HR &
Finance
Est. end ‘13
“Establish the NCP as the Clinical Design Authority for Health Service”

20. Director of
CSPD
Operations
Office of
NCPs
MH lead PC Lead SC Lead
Acutes
Lead
H&Wb Lead
Nursing
Lead
NMPDU
ICP 1
ICP 2
ICP 3
Programme Programme
ICP 4
Programme Programme Programme
Governance of NCSP:
The Health Services Clinical Design Authority
Stakeholder Group
Enabling
Functions:
HR, ICT,
Finance,
Performance
Assurance.
Structured
interface

21. Principles of Health and Well being
User and Provider Integration and Standards
Educated,
Healthy
Supported
Temporary/
Transient
Low- Medium
Support &
Management.
Temporary/
Transient
Medium to High
Support &
Management.
Rehabilitation
or Permanent
Support.
Enablers; Information, Resource, Tools.
Communication and Stakeholder Engagement in Care Planning
Dignified, Healthy, Safe Living
Draft Generic ICP Framework

22. Emerging Themes

23. Older
Persons
Children
Women’s
Health
Chronic
Diseases
Patient
Flow
Health &
Wellbeing
Primary
Care
Acute
Hosps
Social Care Mental
Health
ICPs as related to Service Divisions- Horizontal Integration

24. Older
Persons
Children
Women’s
Health
Chronic
Diseases
Patient
Flow
Health &
Wellbeing
Primary
Care
Acute
Hosps
Social Care Mental
Health
Programmes
ICPs – Vertical Integration e.g. EWS

25. Health &
Wellbeing
Primary
Care
AcutesSocial Care Mental
Health
Single Assessment Tool
Integrated Community and Acute Model of
Care
Dementia
Care
Delayed Discharges
Positive Aging
Rehabilitation
Older
Persons

26. Don Berwick's top ten tips
1. Patients first
2. Stop restructuring
3. Strengthen the local health care systems– community care systems–as a
whole
4. To help do that, reinvest in general practice and primary care
5. Don’t put your faith in market forces
6. Avoid supply-driven care like the plague (institutional self interest)
7. Develop an integrated approach to the assessment, assurance, and
improvement of quality
8. Heal the divide among the professions, the managers, and the government
9. Train your health care work force for the future, not the past
10. Aim for health not care

27. Managers and Clinicians
We are stewards together of healthcare
resources

31. The needs of the patient
come first

34. “We must be the change we
wish to see.”
Ghandi

35. Thank you