How the ISAs will work

The new HSE Integrated Care model will deliver services across Integrated Care Areas (ISAs), where one person will be responsible for all hospital and community services, Damien McCallion told the HMI Forum.  Maureen Browne reports.

Damien McCallion
Damien McCallion

The new HSE Integrated Care model will deliver services across Integrated Care Areas (ISAs), where one person will be responsible for all hospital and community services, Mr. Damien McCallion  HSE Director Integrated Services Programme told the HMI Forum in Tullamore, Co. Offaly, when he spelled out details of the current re-organisation plans.

The new HSE service delivery model  put the patient at the centre of the process – with Primary Care Teams (PCTs) at Level 1, Community Health & Social Care Networks at Level 11, Integrated Services Areas (including secondary care hospitals) at Level 111 and Tertiary acute services at level 1V.

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The policy objective  was to transfer non-complex acute services to local hospitals and/or PCTs

The policy objective was to transfer non-complex acute services to local hospitals and/or PCTs.   To support this concept, PCTs and related secondary care acute hospitals should have co-terminous populations.

The design of the ISAs would be based on the catchment area, road network, primary care team design, spatial planning and local authorities’ boundaries.   Each ISA will contain a hospital or a number of hospitals that provide for the secondary care of that population.

While eight of the ISAs were defined, further work was necessary in other regions. Further design work was going on in the HSE South East, the HSE Dublin Mid Leinster and the HSE Dublin North East. He said that work was going on at present between the HSE and some of the Dublin voluntary hospitals to see how this could best be achieved where the ISA contained large non statutory providers.

Stronger voice

In the new model, clinicians have been given a much stronger voice through the development of clinical leadership, PCTs s would serve populations of 7,000 – 10,000, and 531 PCT multidisciplinary teams were mapped out around the country. Health & Social Care Networks will also be established and more specialised services will be delivered through the PCT or network. For example Community Mental Health Teams will work with a number of PCTs at a network level.

What this should mean for staff is that there will be more opportunities to work across boundaries, requirement to work more flexible hours, new roles will develop across settings, flexibility would be required as needs emerged, more multidisciplinary team working and there will be a requirement for increased collaboration between managers and clinicians.

The legacy system of undisciplinary management would change to a full multidisciplinary team approach.

McCallion said that there was a strong case for change in the health services in view of the changing demands on our health and social care system which would increase the burden on services.  Our population was aging, there was an increase in demand from higher-dependency segment of the population, the number of cancer cases was predicted to increase, there was an increasing prevalence of conditions such as diabetes, obesity, heart disease and asthma and there was an increased requirement for prevention and specialist treatment.

The public and patients were also more demanding and had higher expectations. There were stories of people coming into hospital with five pages printed off the internet and a diagnosis already in their head.

Safe and sustainable

In this time of serious economic challenges we needed to ensure that our services were safe and sustainable and that our focus was on patients rather than organisations or professions.  This was a time of continuous change where we were dealing with increasingly complex population health needs  and it was recognised that we needed to bring decision making closer to the front line and to empower the people delivering services on the ground. This is challenging in a stringent economic environment.

What this should mean for staff is that there will be more opportunities to work across boundaries

Research in other areas had shown that structural change, at best, brought about an improvement of a maximum of 10 per cent on services.   He wasn’t sure if that also applied to health, but the evidence suggested that structural change had a much smaller effect than other changes and structural change needed to part of a wider series of changes to achieve benefits for the people using our services. Hence the need for performance systems and clearer process (pathways) for patients and clients.

However, our old structure of the pillars of NHO and PCCC did not support sufficient integration of services at local level and McKinsey had deemed these structures an impediment to the delivery of the type of services we now required.

Based on all this, the HSE Corporate Plan 2008 – 2011 set out a clear vision for implementing an integrated health and social model for Ireland.

The purpose was to re-organise services towards an integrated model of care by building on existing strategies

The HSE was making these changes:

  • To drive and support safe, quality care for patients and clients
  • To bring decision making close to where services are delivered
  • To allow clinicians to shape and assure the services in which they worked
  • To get the best health outcomes for the money spent
  • To plan and organise around what they knew people needed and what they knew worked to give the best results
  • To organise to meet increasingly complex patient and client needs
  • To remove barriers to integrated care

The result of the changes for patients and clients should be:

  • Services which would be more accessible locally, centred around the patient, rather than centred around an institution
  • A shift towards prevention and better self care rather than a focus on acute care and treatment
  • Improved patient outcomes
  • Right balance between inpatient, day case and community based care
  • More efficient use of resources and more transparent accountability

The first set of changes (defining the service delivery model and the national and regional changes) had a national/regional focus and were implemented through a top down approach – with the support of the HSE Board, the Department of Health & Children and the HSE Management Team,    The current stage of defining the Local service delivery model and management arrangements is being implemented from the bottom up by considering how services are and should be organised at the front line.

Corporate re-structuring

Progress made to date included the service delivery model being defined, completion of the corporate re-structuring, the regions were established, the Regional Directors were in place, many ISA catchment areas were agreed and the remainder are being defined, discussions had begun with the trade unions, programmes of care had been defined and teams were being established and the performance management process was being developed.

The two pillars of NHO and PCC had been collapsed and the Integrated Services and Quality and Clinical Care Directorates were established.

National Directors for Care Groups had been put in place and programmes of care for different areas from chronic diseases to EDs were being established by Dr. Barry White. The basic model for each programme of care is clinical expertise leading a team and defining the patient pathways for an area of care.  These programmes are now getting up and running.

A huge amount of energy had gone into the Performance Management process at corporate level to improve reporting to the HSE Board, Department of Health and Children and the public through systems such as Healthstat and the monthly performance report (PR).  It was important that the performance management systems were consistent at the top and bottom and the HSE didn’t want a lot of staff wrapped up producing data.

Currently there was one Clinical Director per hospital and there was agreement to move to Clinical Directorates across hospitals – e g medicine, women and children, peri operative.   Consideration would be given as to whether a similar role was required in primary care.

The next steps were to complete the ISA design and rollout, develop the model for areas with large non statutory providers, approve the ISA Management Team structure, develop and roll out clinical directors, implement the primary care model, develop care pathways, develop and implement a performance management system and implement changes identified in other services such as childcare and mental health. www.hmi.ie