Do not hold your breath for Sláintecare
Delays encountered in setting up hospital groups in 2013 show how difficult change will be
The Irish Times editorial, Sláintecare appointments: leadership required, of the July 17th, highlighted slow progress in implementing the recommendations of the Sláintecare report, since it was published on May 30th, 2017. The writer welcomes the appointment of Laura Magahy as the executive director of Sláintecare together with Dr Tom Keane as chairman of the Sláintecare Advisory Council.
The writer correctly points out that Magahy’s previous projects involved structural developments whereas Sláintecare will involve a significant cultural change in healthcare delivery in Ireland. Keane’s track record in delivering reform under the National Cancer Strategy was outstanding, but, importantly, at every turn he had the committed and very visible support of then minister for health Mary Harney. Similarly strong ministerial and Government support for Sláintecare will be required if progress is to occur.
Other recent health reform initiatives have had less visible political and ministerial support. For instance, the Higgins Report on The Establishment of Hospital Groups as a Transition to Independent Hospital Trusts. These hospital groups, established in February 2013, were to provide efficient, safe and effective care as close to patients’ homes as possible with a view to improved health outcomes. Interim boards of management were to be appointed as well as executive management teams. Yet it was a full five years after the report was published that the first board meeting of RCSI Hospitals Group – of which I am clinical director – took place, in February 2018.
Without the necessary legislation that empowers the hospital groups, their management teams are an extra layer in a very thick sandwich of management
In the meantime, the group management teams have been in situ and operational since January 2015. Without the necessary legislation that empowers the hospital groups, their management teams are an extra layer in a very thick sandwich of management who do not have autonomy to reorganise clinical activities and services as they see fit. There is tremendous duplication between the Department of Health, HSE and the hospital groups.
Nevertheless, despite not being empowered by the necessary legislation, hospital groups have made some progress. For instance, the RCSI Hospitals Group has used the additional capacity in Connolly and Cavan hospitals to treat patients on long waiting lists for endoscopy and routine, non-complex, surgery. This required senior clinical leadership at local and group level and could not have been developed by a centralised and remote HSE quality system.
These are “small steps” in the change process required to enable the culture of hospital groups or networks. There is potential to achieve so much more and the continued failure to empower hospital groups at management level makes no sense.
Whether small steps will work for the Sláintecare implementation group whose plans were launched this week remains to be seen but a healthy dose of patience and tolerance of slow progress will be required.
Already the lack of costing in the implementation plan has raised major concerns. GPs, even before a new contract is negotiated are adamant that they cannot provide ongoing care of patients with chronic diseases without significant additional resources and continued availability of specialist outpatient services in hospitals. Community care structures will need significant investment, particularly in the area of diagnostics, to help shift the care burden from acute hospitals.
Regrettably the major impediment to progressing these plans is 'parish pump' politics
Taoiseach Leo Varadkar recently indicated that some things in Sláintecare would have to be done “at a slower pace than maybe people would like” and Minister for Health Simon Harris indicated that universal GP access would have to be “introduced on a phased basis”. The Government will, understandably, want to demonstrate some progress with the Sláintecare plan and there’s a strong likelihood that elective hospitals will be developed sooner than the other components of the plan. This, in my view, would be too abrupt unless combined with reconfiguration of existing hospitals, some of which are not fit for purpose.
There are currently 26 hospitals receiving acute and emergency cases throughout the 26 counties. At least nine of these hospitals have no trauma and orthopaedic surgery service. The national clinical programme for trauma and orthopaedics supported by the clinical programme in general surgery has stated that a hospital with no orthopaedic surgeons on staff should not receive trauma patients. There are numerous letters and reports to the Department of Health and HSE expressing serious patient safety concerns in relation to these hospitals continuing to provide acute and emergency care. The quality of resident staff is variable and frequently costs twice as much as other hospitals because of agency staff outlay. If these hospitals were reconfigured or redesignated as elective centres, patient safety concerns in relation to acute surgical care would disappear, the elective care element of the Sláintecare plan could be implemented relatively quickly, with minimal structural costs, and patients would have non-complex elective care delivered close to where they live.
It is acknowledged and understandable that all communities would prefer to be able to access all services in their local hospitals. Loss of acute services, in particular an emergency department, is considered “downgrading” of the hospital, with its potential implications of loss of jobs and ultimate closure. Reconfiguration or redesigning what function the hospital has within a network or group will improve the quality and efficiency of the services provided without loss of jobs. Development of medical assessment units, day treatment centres and minor injury units will boost the morale of the staff by allowing them to function effectively in their local community.
Many of the hospital groups have developed plans to reconfigure hospitals that are unsuitable for acute surgical care. Regrettably the major impediment to progressing these plans is “parish pump” politics as local politicians continue to obstruct such plans for fear of losing their Dáil seats. With the impending elections next year or in 2020 it would require great optimism to expect any change in that attitude in the near future. However, the same politicians are first to claim concern for patient safety. Therefore, before building any new elective hospitals, those same politicians need to be called out on their continued support for an unsafe, inefficient and frankly wasteful system of acute care in some of their local hospitals.
Hospital groups or networks of some variety are here to stay. They will be key to supporting the Sláintecare implementation programme. Harris and the Government should empower the groups with the long awaited legislation to do the work set out in the Higgins Report. Redesign or modification of group boundaries should not be a problem if integration of hospital, community and primary care services can be better achieved. However, if the Sláintecare evolution mirrors the hospital group journey, and in particular allowing for the financial concerns highlighted recently, the public can anticipate very little change or improvement in their health services in the foreseeable future.
Prof Patrick Broe is group clinical director of the RCSI Hospital Group