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Hospital groups - where are we now?
Friday, 22 November 2013 13:15
Paul Mulholland reports on a discussion about hospital groups at the RCSI's recent Millin meeting
Speaking at the IHCA AGM last month, RCSI President Mr Paddy Broe reiterated the College’s support for the creation of hospital groups and the recommendations contained in the Higgins report about how the groups should be formed. But Mr Broe said that the progress made in implementing these recommendations and forming the groups has been too slow, and that valuable momentum was being lost.
It was a charge raised again following the presentations on hospital groups as part of the RCSI’s annual Millin Meeting, which took place earlier this month.
One of the views from the floor was that, six months on from the publication of “The Establishment of Hospital Groups as a Transition to Independent Hospital Trusts”, which was produced by an expert group led by Professor John Higgins, setting up the new structures had been “tortuously slow”.
As everyone working in healthcare now knows, the report outlined how hospitals throughout the country will be reorganised into six hospital groups before their eventual transformation into Trusts, recommending the formation of four additional groups to the ones already established in the west and mid-west in January 2012.
Prof Higgins, who made a presentation at the meeting, admitted that progress had proven slower than anticipated, particularly surrounding the appointment of chairpersons for the groups, the process for which had been hoped to be completed by the summer.
But Prof Higgins was adamant that progress now was being achieved.
He said that the terms of reference for the Hospital Groups Steering Group (renamed the Strategic Advisory Board), which is being chaired by Mr Leo Kearns, and of which Prof Higgins is a member, have recently been finalised.
Most importantly he pointed out that recently, the chairpersons of the Dublin East (Mr Thomas Lynch), Dublin Midlands Hospital (Dr Frank Dolphin), the Dublin North East Hospital (Ms Anne Maher) and the South/SouthWest Hospital (Professor Geraldine McCarthy), had now been appointed.
“I hoped this could take place before we went on holidays at the end of July,” Prof Higgins told the meeting.
“It didn’t. It didn’t prove as straightforward as we had anticipated but we are now there.”
He added that, in addition to the chairpersons already appointed in the West (Noel Daly) and the Mid West (Ann Doherty), these are the first people appointed to the new system.
“They are of the future, not of the past,” he said.
“What I’m particularly pleased about is that the six individuals, who in their own domains, can honestly say they have done it.”
Prof Higgins said that the priority now was the appointment of the group CEOs, which he said should take place much quicker than the recruitment process for the CEOs and expected that adverts for the positions would soon be published. Getting the best people for the position of CEOs was absolutely vital, he said, to convince healthcare staff, and indeed the public, that the creation of the groups was about change.
He stated that while the establishment of the groups would not be easy, their creation was necessary.
“There’s a lot of frustration out there, particularly among clinicians,” Prof Higgins said.
“There is a certain hunger for change. There is something gone awry in our hospital and healthcare system and I think we should push on and bring in the new system.”
The Chief Clinical Director in the Mid West Hospital Group (or UL Hospitals are they are now known), Mr Pierce Grace, gave an update on the experience of the Group since it was established. The Group consists of one Model 4 hospital (University Hospital Limerick), two Model 2 hospitals (MidWestern Hospitals Ennis and Nenagh), a Model 2s Hospital (St John’s Hospital, Limerick) and an orthopaedic hospital and a maternity hospital.
Clinical directorates for the group were set up in November 2012 and a single management structure was established in January for the six sites.
“We are the smallest network,” Mr Grace said.
“We have a population of 400,000 people. The average in all the other networks is 850,000. The smallest could be a challenge or an opportunity, we see it as very much an opportunity. What we lack is a Model 3 hospital. We have a standalone maternity hospital, just as there are standalone maternity hospitals in Dublin. We see that as the biggest risk in our group. Also, we have only one emergency department for 400,000 people, and we have a mean of 162 attendances per day, 60,000 per annum.”
The lack of a Model 3 hospital puts a lot of pressure on University Hospital Limerick, though Mr Grace said that the number of people waiting on trolleys has been aided by the intervention of “patient flow” managers, and establishment of an Acute Medical Unit in May.
As a result of the reconfiguration in the MidWest prior to the establishment of the group a unified surgical department was established in October 2009, and the group will have a unified department of radiology before the end of the year. All the Model 2 hospitals are in compliance with the Smaller Hospital Framework, with local injury units, and medical assessment units being established in Ennis and Nenagh.
One innovation in the group, which was taken from the Children’s Hospital, Cincinnati, is a “daily huddle”, which consists of a teleconference across the group every morning.
“People from the four directorates, the six sites, the admissions units and facilities all phone in and have a conference for 30 minutes, which tells us exactly what goes on right across our organisation, and which allows us to highlight risks that may arise,” according to Mr Grace.
“For example, every day we will know how many high risk pregnancies there are in the maternity hospital because some of them may need to come across to the University Hospital.”
Mr Grace said that the group tries to move patients across the system to utilise resources in the best way.
“We are challenged in that, and we average about six patients per day.”
Mr Grace also admitted that there is a challenge to fill Model 2 hospital beds with appropriate patients.
On the positive side, Mr Grace said that the group has a strong governance system in place and the directorate structure is now embedded across the organisation. Activity has risen across the group, and there is evidence of better outcomes for some procedures. On the negative side, Mr Grace said that although St John’s works well within the group, it has its own board and governance structure, which is not ideal. Also, he stated that the group, in a sense, serves two masters – the National Director of Acute Hospital and its own hospital board.
“I know we are in a transition phase and, eventually, we would like the board to take control of the group,” Mr Grace said.
The HSE Director of Acute Hospitals, Mr Ian Carter, also gave a presentation on the groups. Mr Carter did not provide much practical information on the establishment of groups, but focused instead on their significance for the health service.
Hospital groups would provide an opportunity for solving some of the problems currently facing the HSE around access and the distribution of resources, he explained. The function of the Department of Health and the Directorate of Acute Hospitals will be to lead and support, rather than to direct, according to Mr Carter, who added that “top down” management approaches are not the way to proceed. The Irish health service has a lot to learn from the UK’s Mid Staffordshire Hospital report, he said, which found that many of the problems in that hospital were the result of an overt focus on meeting financial targets rather than maintaining the quality of services.
Mr Carter stated that Irish hospitals share some of the risks that were prevalent in Mid Staffordshire as a result of the cuts to finances and staff that have taken place over the last five years. These cuts, particularly regarding the workforce, have been “crude”, according to Mr Carter.
“One of the key problems the system will face is to make sure within the each of the groups that we have the right capability and capacity,” he said.
The Money Follows the Patient funding model, within the group structure, will make the funding of hospitals more nuanced than the current block grant mechanism, and will facilitate a greater emphasis on quality and outcomes, he added.
“Patients can go where they want to go, you’re actually producing some level of instability which is good; the trick will be making sure you don’t create some degree of high level risk.”
In conclusion, Mr Carter said that while the move towards hospital groups is a logical step, it will be complex.
“We need to recognise that, outside of healthcare, most mergers don’t work. What we have to make sure is that it works.”
The last presentation was delivered by RCSI President Mr Cathal Kelly. Mr Kelly highlighted how the College was supportive of the Higgins Report. The strength of the report is its emphasis on governance, he said, and its emphasis on having skills-based boards rather than representative boards. He welcomed how it seeks to build on existing academic relationships, and that the RCSI relishes its role as the academic partner within the Dublin North East Group. Like Mr Carter, he said it was important for the boards of the hospital groups to read the Mid Staffordshire report and that there was a danger that the health system will focus on the wrong metrics.
“The Department, the HSE or somebody needs to tell us what success looks like,” he said.
“Because how as groups can we develop strategic plans if we don’t know the benchmark that we’ll be judged against?”