Managers and clinicians must put aside distrust

Dr. Aine Carroll, the new HSE National Director of Clinical Strategy & Programmes has called on managers and clinicians to put aside distrust of each other and on hospitals and other institutions to abandon self interest to develop a new and better health service for the country.  Maureen Browne reports.

Dr. Aine Carroll, the new HSE National Director of Clinical Strategy & Programmes has called on managers and clinicians to put aside distrust of each other and on hospitals and other institutions to abandon self interest to develop a new and better health service for the country

Dr. Áine Carroll
Dr. Áine Carroll

“The time for institutional self interest had gone. We need to break down the barriers and start working together properly to develop an integrated approach to the assessment, assurance and improvement of quality and heal the divide among the professions, managers and the government. That is key to much of what we need to achieve,” Dr. Carroll told last week’s HMI Dublin Mid Leinster Regional meeting in the Dublin Dental Hospital.

“We don’t trust each other, we are highly suspicious and we need to think of ways to develop trust and work better together.”

With reference to the insights of Don Berwick, Dr. Carroll said we also needed to train the health care workforce for the future, not the past. “Our structures for education and training are much as they were years back and this applies not just to doctors, but nurses and therapists.  We must aim for health not care.

“We can say we are patient centred, but organise our services so that it suits us rather than the patient.”

Dr. Carroll was a consultant in rehabilitation medicine in the National Rehabilitation Hospital in Dun Laoghaire and National Lead of the HSE Clinical Programme on Rehabilitation Medicine before her new appointment.

She said managers and clinicians were together the stewards of health care resources and together needed to look at better ways and better models of working together to improve patient care.  “We all speak English, but we speak different languages when it comes to healthcare and we need to learn to speak a common language. We need to include patients in that because we might come up with a wonderful language for ourselves as clinicians and managers, but patients might not understand it. There are many ways we can get patients’ views, for example while they are in our outpatients.

“It is key that the need of patients comes first. That is our common aim and common language.  Managers and clinicians want what is best for patients. We must always ask what is best for patients and how will anything we are going to do affect patients.  The needs of patients must come first and that premise should affect every decision we make.

“We can say we are patient centred, but organise our services so that it suits us rather than the patient. We should structure our services to suit our patients. Just because we did things one way for years it does not mean we have to continue doing things that way. We need to change the way we work in order to provide the best service we can for patients and the people we serve and ensure we are getting good value for money.”

Dr. Carroll said that she had done the RCPI Diploma in Leadership and Quality, which was completely different to anything else she had done in management.

Dr. Carroll said Ireland needed to transform its health service because of inequitable access to care, capacity and management deficits, inadequate governance and financial systems, the changing financial and HR environment, significant increases in expectations and demand, decreasing funding, unaffordability and public opinion.

“Every citizen should have the right to access care as and when they needed it. “Why don’t we value our health system.  It is a very good one, it has flaws, but fundamentally you will get looked after when you need it.  In the U.S., if you don’t have health insurance you won’t get access to care. Here you will and most times it is good quality care and there have been significant improvements in recent years.”

She said the rules of transformation were effective leadership and partnership between clinicians and management, good accurate data, honouring the work, engaging clinicians and involving patients and families in a much more meaningful way and having patients and families very closely involved.

The objective of the Clinical Programmes were to improve quality, improve patient care and access, ensure value for money by reducing average length of stay and bed utilisation and ensuring patients were getting a valuable service and one they valued.

The key principles of the Programmes were that they were clinically led, they empowered clinicians to lead change, had a structured programme management approach, nationalised best practice, engaged practitioners and aligned stakeholders  – patients, management and government.

She said that some achievements to date included:

  • Approximately 167,000 bed days saved to date by the Acute Medicine Programme
  • The introduction of the Early Warning Score, which had received a Public Service Excellence Award from the Taoiseach.
  • The Surgery/Anaesthesia had agreed targets with all specialties for the time in relation to AvLOS and day case rates.
  • The National Office for clinical audit for Surgery, Critical Care and Orthopaedics had been established.
  • Epilepsy had been awarded an international nursing ward for its description of the new national epilepsy service in Ireland.
  • Stroke: 24/7 Thrombolysis coverage in the country for the first time. Role of a telemedicine solution
  • COPD:   AvLOS reduction from 8.7 to 7.9 day
  • Heart Failure:  Rate of readmission reduced from 27 per cent to 7.5 per cent at three month readmission
  • Asthma: National Education programme operational in primary and secondary care
  • Acute Coronary Syndrome: Four 24/7 PCI centres operational
  • Mental Health: Three significant programmes being designed in areas such as self harm and eating disorders
  • Diabetes: Pathfinder for developing integrated care model and chronic disease management
  • Emergency Medicine: 28 of 28 continuous improvement implementation teams in place
  • Obstetrics and Gynaecology: Cost savings from centralised procurement and no mis-scanning incidents since early pregnancy guidelines issued
  • Musculo-skeletal (MSK) clinics rolled out which are reducing waitlists
  • Dermatology and Rheumatology: 30 per cent more patients being seen
  • Orthopaedics: Piloting resource allocation/prospective funding successfully
  • Paediatrics: Have visited all paediatric sites and making recommendations to standardise practices
  • Palliative care: New competency framework for all levels and staff involved in palliative care
  • OPAT: New model for delivery of home IV care
  • Older Persons: Integrated geriatric assessment model being rolled out
  • Radiology: New referral guidelines being developed
  • Rehabilitation Medicine: Four new posts pending. Pilot MCRN being established.
  • Retrieval: National model for adult retrieval being developed  and being designed to support smaller hospitals
  • Audiology: National screening of 99 per cent children within four weeks of birth
  • Blood: Reduction in platelet usage across the hospitals by three per cent of 2011 usage.

This had all been achieved in just in excess of two years. “Dr. Barry White’s shoes are very big ones for me to fill.”

Dr. Carroll said that she had done the RCPI Diploma in Leadership and Quality, which was completely different to anything else she had done in management. “It was totally patient focussed and it really did make me, as a clinician and a manager think more about patients, what could I do for them as patients, rather than what can I do for my organisation.

“Often when clinicians go into management positions, colleagues can sometime become a little suspicious and if mangers are seen as too clinically orientated, then their colleagues can see it as a flaw!”

“Often when clinicians go into management positions, colleagues can sometime become a little suspicious and if mangers are seen as too clinically orientated, then their colleagues can see it as a flaw!

Freidson had said there were three aspects to the professionalism of the medical profession and other professions – knowledge, altruism and self-regulation.

However, Don Berwick had said we must look at a new professionalism which looked to complexity, interdependence, pervasive  hazard, a changing distribution of power and control borne on the back of technology and distributed democratised capacities.

“We need to adopt our professionalism to changed times.”

She said that Berwick’s top ten tips were:

  1. Patients first
  2. Stop restructuring
  3. Strengthen the local health care systems– community care systems–as a whole
  4. To help do that, reinvest in general practice and primary care
  5. Don’t put your faith in market forces
  6. Avoid supply-driven care like the plague (institutional self interest)
  7. Develop an integrated approach to the assessment, assurance, and improvement of quality
  8. Heal the divide among the professions, the managers, and the government
  9. Train your health care work force for the future, not the past
  10. Aim for health not care

In reply to questions about the Clinical Programmes and the SDU, she said the Clinical Programmes and the SDU were two sides of the one coin and they were working together very closely. When asked about the proposed hospital groups, she replied that from her experience in the UK she favoured hospital groups and Trusts and had been impressed with what had been achieved by the Galway/Roscommon Group, which had achieved so much in such a short time.

She said it was quite right and appropriate that we looked at commissioning based on good quality data if we were to provide quality services and it would be great for patients and very helpful for clinicians and managers.

She said she hoped to move the Clinical Programmes towards a more integrated model to continue to improve quality, access and value for patients.