The criteria for success of the new ISAs

HSE Chiefs revealed that a Band 1 hospital (a HSE Regional Hospitals or a Voluntary Teaching Hospital) would not be needed at the core of every new Integrated Services Area (ISA), when they replied to questions from a packed audience at the HMI Forum, writes Maureen Browne.

Maureen Browne
Maureen Browne

HSE Chiefs revealed that a Band 1 hospital (a HSE Regional Hospital or a Voluntary Teaching Hospital) would not be needed at the core of every new Integrated Services Area and that these ISAs  would succeed or fail on their ability to manage chronic diseases in the community, when they replied to questions from a packed audience at the HMI Forum in Tullamore.

They also made it clear that in the reconfiguration now under way surgery should not drag all services with it.

The venue for the Forum had to be changed at the last minute to accommodate the very large attendance.

In the reconfiguration now underway, surgery should not drag all services with it

Ann Marie O’Grady, HMI Council Member and Head of Clinical Services at Beaumont Hospital, Dublin, enquired about the organisational development approach and the support for staff as the reconfiguration developed.

Damien McCallion said that HSE HR had a pool of expertise, but it was relatively small and they were trying to build on it locally.    He said he thought to roll out the changes would require considerable support of people around the country.   In this regard, the HSE had a fair bit to go.

Absolute clarity

Brian Gilroy said that in the reconfiguration they were trying to achieve absolute clarity.  People in most health service grades were among the top quartile people in these jobs around the world.    The evidence was that most effective changes were those which were implemented rapidly rather than those which dragged on for years.

Outgoing HMI President, Denis Doherty said that one of the concerns about which he was hearing was that if reconfiguration followed the cancer template then there would be a dearth of services north of the Dublin to Galway line.

Brian Gilroy said that the HSE was conscious of that.   The evidence was there as far as breast cancer was concerned but there was a tendency to drag all oncology with it.  Surgery should not drag all services with it.  All the international evidence would show that lots of services could be local and so could some oncology.   The clinical call was not up for debate.  We had to bite the bullet there.

Brian Gilroy said the second part of the HSE message that there could be local activity in these hospitals did not seem to be getting out.   Managers should manage and be supported in managing.   The clarity that was needed was that effective management was required.

The venue for the Forum had to be changed at the last  minute to accommodate the very large attendance

Dr. Gerard Crotty, consultant haematologist and clinical director at Midland Regional Hospital, Tullamore said that many people felt there was a need for more defined hospital boards – something on the lines of what existed in the voluntary hospitals.

Linking hospitals with communities

Damian McCallion said it was felt that another layer between the hospital and the RDO would not be a good idea.   The view was that strong Executive Management Teams were needed in hospitals and in communities.  The HSE was working with the Mater and Beaumont Hospitals on ways to link hospitals with communities in the most effective way.

Dr. Crotty asked if consideration had been given to having two non executives for oversight on the management team.

Damian McCallion said that a mechanism had to be found which would ensure the best and most active representation for patients.

Dr. Crotty said he would be thinking of something akin to an NHS Trust Board with a few non executive members and decisions made by a defined group of people.  At present nobody knew the level at which some decisions were made.

Gerard Flynn said he thought there was an opportunity following the Croke Park Agreement.  The HSE needed to move quickly if they were to take advantage of what had been negotiated.

A good window

Brian Gilroy said the length of time of that window would depend on how the HSE implemented reform.  If the vote was in favour and the HSE started random redeployment, the window would close down.  If the work was done sensitively there would be a good window.

Denis Doherty said that the private sector would say that change took forever in the public sector.

Conor Hannaway, MD shrc said that we should not be over critical of the pace of change in the public sector.  Lots of private sector agreements were never fully implemented.  A year to 18 months was generally the available time.

The HSE is working with the Mater and Beaumont Hospitals on ways to link hospitals with communities in the most effective way

Brian Gilroy said that there were elements of the public service in Ireland which was outstripping the private sector and elements that were miles behind.   We had to take the best of both worlds

Damian McCallion said there was a question as to whether staff’s loyalty was to the HSE or whether the HSE was too big for this and loyalty was to the local area. Integrated Service Areas might provide an opportunity for staff to re-connect.

Relationship between ISAs and reconfiguration

Incoming HMI President and HSE South East Hospital Network Manager, Richard Dooley raised the question of the relationship between the ISA and reconfiguration.   He asked if acute hospitals could sit across a couple of ISAs.  What did an ISA need to work?    Was it a 24/7 functioning hospital?  His view was that it did not but it did need access to secondary services.  Managers needed specific guidance on this.

Brian Gilroy said he was right.  You did not need a Band 1 hospital at the core of an ISA.   That still needed some clinical governance work and that was on going.  In the south there would be an ISA for Cork and Kerry but there needed to be links between CUH and Kerry General Hospital.  Ultimately the ISA would stand or fall on its ability to manage chronic illness.  The real issue was if it could work with chronic diseases.

Damien McCallion said that what was needed was to get the local hospital working well with primary care.  There were issues in some areas because of the location of hospitals and this would give rise to challenges to be worked out in some areas including the south east

Brian Gilroy said that the HSE had made quite an investment in primary care, all of which had not yet borne fruit.  There was no major clinical debate on how you should maintain patients with Type 11 diabetes.  If you could do it in the community you would save a considerable amount of resources.  Chronic disease management needed to get into primary care teams.

Geraldine O’Regan, Director of Nursing at Our Lady’s Hospital for Sick Children, Crumlin said there was an enormous process involved in trying to get patients out of acute hospitals and into the community.  At present the amount of negotiations which had to be undertaken with LHOs wasted a lot of time and money and national protocols were required.

Damian McCallion said the care programmes should help with this.  They would start to put in clarity where the receiver couldn’t put the shutters up because of budgetary constraints.  It could also happen the other way around with GPs trying to get people into a hospital being told the patient was not in the hospital’s catchment area.

Asked if there would be extra money for primary care to meet the additional demand if people were to access their services earlier, Brian Gilroy said that the only evidence of financial savings so far was in the management of chronic illness.  The HSE would envisage some savings going back into primary care and some to improve tertiary care.