Department to move on Trusts

The Department of Health will go to public consultation in the next three to six weeks regarding the formation of hospital groups into Trusts, Mr. Tony O’Brien, Chief Operating Officer, Special Delivery Unit (SDU), Department of Health, revealed when he addressed a HMI Dublin Mid Leinster Regional meeting last evening. Maureen Browne reports.

He warned that each acute hospital would be getting a trajectory of its performance each month and in cases where over a period of time there was “a sufficient absence of performance improvement” to the extent that the system no longer had confidence in the hospital management, there would be a discussion with the governing body of the hospital about changing the management involved.

Tony O'Brien
Tony O'Brien

“Another part of our brief is the development of an accountability framework for all services and if a service is consistently failing on access and quality, the logical consequence of that will be a change of the leadership running that service”, he said.

There would be a simplified score card to establish if management was successful – the service provided must be safe, of a high quality and patient centred and equal weight must be given to quality, access and financial balance.

“For example, for several years the HSE service plan committed to six hour patient experience in emergency departments. We will now be holding people to account against these agreed plans.

“There will be a challenge in balancing finances without crushing quality and access. We want to change the thinking form ‘at all costs we must break even’ to ‘at all costs we must break even without crushing our service or our quality and access.’”

Where over a period of time there was “a sufficient absence of performance improvement” to the extent that the system no longer had confidence in the hospital management, there would be a discussion with the governing body of the hospital about changing the management involved.

Turning to the new Trusts, Mr. O’Brien said that in the acute sector, there would be 10 – 13 hospital groups nationally. There would be a big focus on enabling these groups to develop and if that progressed, legislation would be enacted to establish them as fully fledged trusts with their own governance.

“We would be encouraging them to take on a much more commercial view. We won’t be directly replicating what happened in the UK or in any other country but they will inform our thinking. There will not be a single blueprint for how a trust works as we see different blueprints for different locations rather than a once size fits all. Some will be a combination of statutory and voluntary hospitals and we want to see what power can be transferred to CEOs and what powers will be held centrally.

“There is a long term aim that a very real measure of control will be given to senior managers. The present government is determined to bring operations and policy closer together and to have decision making closer to the point of care rather than in Hawkins House, or Dr. Steevens and we are moving towards having hospitals grouped and the same will be true for primary care organisations, but this will only be possible when the Minister and the government believe they have a real grip on the value which they are getting.”

He said that while the country might have sufficient beds nationally there were some hospitals which did not have enough beds and some hospitals which did not have enough money and we must be brutally honest about this.

“There are three different approaches – take money from elsewhere, (some places are overfunded and there are some inequalities in resources), rebalance funding across the sector or we may have to talk to the Troika. But first we must demonstrate that each hospital is operating as efficiently as possible and I don’t accept that we have reached that stage yet.”

There were 27 staff in the SDU – 10 from the health services and 17 from the Department of Health, he told the audience, who packed the large lecture theatre at the Dublin University Dental Hospital.

“There is a long term aim that a very real measure of control will be given to senior managers. The present government is determined to bring operations and policy closer together and to have decision making closer to the point of care rather than in Hawkins House, or Dr. Steevens.”

The SDU had been created as a vehicle for achieving two simple crystal clear objectives which the Minister set a year ago – that by the end of 2011, every elective patient would receive treatment within 12 months (this target would be nine months by the end of September) and never again would there be 570 people on trolleys at 8 a.m. in the morning.

The aim was to interact very directly with the system and with the RDOs in a way that the Department of Health had not done since the establishment of the HSE.  At that time all operational matters were very much for the HSE, but the new government was determined on a different course, based on the Minister accepting direct responsibility and the SDU was the first step in the Minister making himself closer to the detailed work of the health services. Until the new legislation was enacted the HSE remained fully accountable for the services it funded and provided and the SDU had to carry out its interventions in a way that did not overly confuse the lines of accountability.”

New discharge/bed management systems were being put in place. “We have a whole range of systems, not just a single one and many of the solutions lie in our own systems among our own managers.”

“Last winter discharge/bed management networks were established, local capacity plans and escalations plans signed off with the hospitals.  There were resource re-allocations to support at risk sites and we focussed on those hospitals which clearly had challenges with trolley waits in recent years. We visited the sites, met with the leadership teams to ensure they were having the discussions they needed, to have to ensure hospitals would function effectively during Christmas and the New Year. Communications were established with communities where this had not been in place.

“On December 23, green, amber and red monitoring systems were introduced for trolley waits,  giving us the numbers over 24 hours (it’s now 18 hours) so we could see how the system was responding and the trends.

“We can now see national and local hospital wait times, we can see the journey time for each patient and how much of the journey is spent in each process.  This is not for us, we want hospital management teams to have this and make use of it.

“We are working with hospitals now on the basis that everybody listed for treatment on January 1 of this year will have their treatment completed by December 31 this year. We are asking hospitals that once they have dealt with clinically urgent cases that they then treat those on the waiting lists in chronological order. This means that the numbers waiting will go up while the patient waiting time will go down. We are significantly ahead of our targets right now.

“We can drill down and tell by specialty whether they are bang on trajectory. We can see how many patients there are waiting to see each consultant (at this stage we don’t wish to identify consultants. We can drill into each consultant list and see how many are on their list. Perhaps some might have massive waiting lists and others have little or none – this is a tool for hospitals rather than for us.”

There will be no room for ambiguity or debate.  There will be details on the adult elective waiting time, how it breaks down by specialty and consultant and it will enable us to show hospitals’ relative performance against each other and the whole system.”

Mr. O’Brien said that once the legislative arrangements on the HSE were changed they would be moving from the present Healthstat to more flexible CompStat, a much more adaptable system, which each month would allow the acute sector, the RDOs, the Area Manager and the leadership of the hospital in the region to have “an adult intelligent conversation on the challenges”.

There will be no room for ambiguity or debate.  There will be details on the adult elective waiting time, how it breaks down by specialty and consultant and it will enable us to show hospitals’ relative performance against each other and the whole system.”

He said that so far hospitals were ahead of the 12 month target time for elective admissions. They had been broadly met by the end of the year but this was not sustained in January and February and it was decided that in these cases patients would be treated elsewhere and the cost sent back to the originating hospital. It was realised that not every patient could be treated elsewhere so it was decided that in these cases patients would stay in the hospital, but the hospital would be levied €25,000 a month for each month they stayed. “I think this will only happen very rarely, but it changes the discussion.

“Trolley waits are consistently below previous years – cumulatively they are 20 per cent down on last year. We did take some extra money for more staff and for people on the cusp of getting Fair Deal approval. The HSE would see this as a moral hazard, but I think it is a moral hazard to have patents on a trolley for 17 hours.

Mr. O’Brien said that the HSE Board as at present constructed would be abolished in the next few months and the new Directorates created.