(
Fully engaging with reforms
October 16, 2012ByDara Gantly
Prof Paddy Broe, RCSI President
In the second part of an exclusive interview, RCSI PresidentProf Paddy Broetells Dara Gantly how vital it is to ‘reconfigure’ our acute hospital services and for the College to ‘re-engage’ with surgeons.
The long-awaited small hospitals review, ‘Securing the Future of Smaller Hospitals: A Framework for Development’, a draft of which has already been seen byIrish Medical Timesand reported on last month (September 7, 2012), focuses on nine hospitals that have been the subject of particular attention from HIQA. They include Navan, Dundalk, Loughlinstown, Mallow, Bantry, Ennis, Nenagh, St John’s, Limerick and Roscommon.
The report outlines how such ‘Model 2’ hospitals would provide emergency medicine services not through traditional emergency departments (EDs), but via a Local Injury Unit (LIU) for patients with non-life threatening or limb-threatening injuries from 8am to 8pm, or 6pm followed by two hours’ clinical work.
And while Model 2 hospitals will provide day surgery and have the capacity to admit some of these patients overnight (up to 20 per cent), these facilities will not have an ICU, which will limit the complexity of surgery provided.
RCSI PresidentProf Paddy Broeis resolute in his opinion that we can’t provide acute care of a safe nature in every hospital in the country — a view he says is recognised by the profession and increasingly by politicians. “As evidenced by the College’s involvement with the HSE in the development of the elective surgery programme and now the acute surgery programme, we support that view, and have done so for years.
“We have hospitals that can do things safely and well and we need just to define those hospitals,” he added in an interview withIrish Medical Times.
“For instance, you don’t need to be in a Model 4 hospital to have a hernia fixed, unless you have medical problems that require back-up. The average patient with a hernia or varicose veins can have them safely treated in Model 2 hospitals. So we want to use the resource… appropriately.”
Within reach?
So is the ‘integrated network’ of acute hospitals proposed by Hanly nearly 10 years ago finally within reach? “Hanly was so long ago, I have forgotten it,” said Prof Broe, behind a wry smile. “It goes back further to the Fitzgerald Report on rationalising our hospital services.
“We are now in a better position to look at the hospital in relation to its place in a community. So you get nowhere — and I think the Government is well aware of this too — if you sweep into town saying ‘we are closing this, or doing that’. We have to accept that this might not be the ideal design if we were to start from square one, so we have to work out a system that allows effective use of the various levels of institution that we have to our best ability, and that is what the network is about. The College — and the discipline of surgery — would be fully supportive of this.
“For instance, already in the North East, DundalkHospital is a wonderful elective hospital day-care centre. The problem is, the minute they have funding issues, they close that down. But that concept of having the more acute and complex work in Our Lady of Lourdes, Drogheda — and having the surgeons travel — that is a model that we as a College would strongly support.”
The President agrees that reform at a ‘micro’ hospital level is just as important as reconfiguration at a ‘macro’ national level, and pointed to The Productive Operating Theatre (TPOT) Programme as one such positive initiative in this regard. However, he believes you cannot solve all the ills of the health service in isolation.
“We have learned that [it is meaningless] unless you have a patient flow of elective workload into the hospital. There is no good studying the efficiency of the theatre if you have nothing to put in it.”
Schemes such as the acute and elective surgery programmes, together with the TPOT initiative and audit programme, in his view, were like “pieces of a jigsaw”, all fitting into each other. “If it all comes off, it will improve the ability of surgeons to deliver a good care package to patients across a wider range of conditions and specialties.”
Surgical audit
Audit of another nature has excited many in the College, and Prof Broe is looking forward to getting the new National Office of Clinical Audit (NOCA) up and running. The Irish Audit of Surgical Mortality (IASM) has commenced user testing and is set to begin actual clinical audit in November.
The objectives of an audit of surgical mortality in Ireland will be to review all deaths that occur following an episode of surgical care and to provide opportunities for improvements in patient outcomes.
The longer-term objectives of the IASM — the first audit stream identified under NOCA — are to provide regular, documented, critical analysis of the outcomes of surgical care. It is being clinically led byMr Ken Mealy— who is also NOCA Clinical Director — andDr David Honanof the College of Anaesthetists.
The first meeting of the NOCA Governance Board took place last month (September 20) and is chaired by Prof Broe, who toldIMTthat such audit programmes have been long overdue. “I have been on the Council since 1991 and I can remember Presidents in the early 1990s going down to the Department of Health to press upon them the need for a national audit programme.”
Having surgeons travel to do complex work is a model the College supports. Photo: Sasko Lazarov/Photocall Ireland
So two decades on, we have the establishment of NOCA, which the RCSI President described as one of the really positive spin-offs from the College’s engagement with the HSE.
“In fairness, the HSE has put the money into developing this audit,” he said. “But if you compare it with Scotland, the same kind of audit has been there for the past 25 years, so we are that far behind.”
While this will see an additional scrutiny of surgeons’ work, Prof Broe does not believe there will be any resistance from the profession. “Every surgeon of any discipline in the country is very tuned into audit and understands its importance,” he explained. “Some may feel threatened and be concerned about the control of the information, but those safeguards are in place.”
Although participation in the audits is voluntary, there have been suggestions that with the accreditation of hospitals by HIQA coming down the road, the system could become a mandatory process. The RCSI President believes sticking to a voluntary scheme would be preferable. “Some countries have a compulsory audit system, which is linked in to their ability to recertify and reregister. We wouldn’t see ourselves as a College promoting that, at least initially,” he stated.
Professional competence
Something that has become mandatory for surgeons is professional competence (PC), and Prof Broe toldIMTthat compliance levels have been “huge” in a “very successful” first year. “There was some feverish activity coming up to the deadline, obviously, but that’s no more than you would expect with any activity.”
While not specifying an exact compliance figure thus far, Prof Broe said the College would want “100 per cent compliance” with the scheme. “It is proposed that there will be random audits, and we would want to ensure that we are not finding a significant number of Fellows who are not fully compliant.”
Other key priorities of Prof Broe’s Presidency include the wish to ensure the College becomes more relevant to the day-to-day lives of surgeons — be they working in Bantry or Beaumont — and that the College continues its programme of Fellowship engagement. He explained the reasoning behind the move: “Many surgeons felt that our College hadn’t a lot of relevance for them. Professional competence has forced a relevance, and we have piggybacked on that a programme of re-engagement with Fellows.
“We had an initial meeting of the group of Fellows in the South-East region, at which a wide range of issues regarding training, consultant appointments, working across a network — all of those issues — were discussed. [It’s about] getting them on a micro level to tell us what they want us as their College to do for them, above and beyond providing them with CPD opportunities, educational opportunities, conferences and access to libraries.”
It seems this ‘re-engagement’ has already delivered results: the electorate for the recent Council elections doubled compared with the previous election, and the number of candidates put forward also grew.
In June,Mr Declan Magee, Consultant General Surgeon at the Blackrock Clinic, was appointed new Vice-President and four new members of Council were elected:Mr Michael E O’Sullivan,Mr David Moore,Prof Kevin ConlonandMr Keith Synnott.
“We have been concerned that the membership of the Council has been largely seen as general surgery,” said Prof Broe. “In this year’s election, we were delighted to see that three orthopaedic surgeons got elected, which brings the total to five orthopaedic surgeons on the Council.”
Governance review
“There are still specialties that unfortunately are not represented, whose candidates did not get elected. But there is an ongoing governance review committee looking at how we can make the Council — in addition to the College — more relevant to its fellows.”
Possible ways of doing that, he suggested, would be to ensure that a representative of every specialty got elected, or a candidate from every region.
On taking up the Presidency, Prof Broe noted that Irish surgeons were living and working in an era of both “unprecedented challenges” as well as “opportunity” within the healthcare system. Given the dire economic times we are in, most might only be able to see the unprecedented challenges. But Prof Broe believes even in these crisis times, there are opportunities for both the College and the health service.
“I think the opportunities are presented by the understanding of the HSE that they have to change things to deliver healthcare in a different manner. Our willingness to get involved and support, on the surgical side, their ideas and programmes has presented opportunities for us as well.”
He accepts that with the continuing recession and the cutbacks in health, the next few years will see “tremendous pressure” on surgeons and other healthcare leaders. “They need to keep the mind focused on all of the changes and, despite the cutbacks, ensure delivery of safe care to their patients, which is what their prime function is,” he stated. And if there ever was a time for surgeons to ‘think outside the box’, then this was it.
One upshot of the recession, perhaps, in the RCSI President’s view, was that surgeons might now be listened to more if they present with innovative, cost-saving remedies to the nation’s ills.