We must move to integrated models of care

We could not continue to do things the way we had been, we needed to think about different clinical and financial models and how we planned our workforce within these models, Dr. Aine Carroll, HSE National Director, Clinical Strategy and Programmes Division, told the Conference.

Dr. Aine Carroll
Dr. Aine Carroll

So, it was not business as usual. We needed a radical re-think on how we were providing our services, she said.

Dr. Carroll described the key features and benefits of a connected health strategy and explained why joined-up thinking based on a shared philosophy, with better use of technology and changed practices were necessary for further progress to be made.

There were six “burning platforms” making the case for change – money, restructuring, Portlaoise and other reports, our hospital centric model of care, the recruitment and retention of staff and the fact that increased demand was outstripping capacity.

We seemed to be comfortable with a hierarchical system in management in CHOs and Hospital Groups, yet the evidence was that we needed to flatten the hierarchy.

“We don’t really know how many health related visits there are to pharmacies and while it is not scientific, we guessestimate about 20% of GP consultations could probably have taken place elsewhere and about 40% of those who go to ED could probably have been attended elsewhere.

“There is significant capacity within our system. If we ensure patients are getting the right care in the right place at the right time, then we will have much happier patients and staff because many of the problems that keep coming through centre on lack of integration.”

Dr. Carroll said we seemed to be comfortable with a hierarchical system in management in CHOs and Hospital Groups, yet the evidence was that we needed to flatten the hierarchy. “Why do we feel everything has to be escalated up? This is not a means of properly dealing with an issue. We need to be working together for mutual benefit. All the talk now is of collaborative leadership. Each one of us has a voice in integrated care.

Recruitment and retention of staff was a huge problem at the moment. It had been suggested that in excess of 80% of graduates were going to leave and this applied to nurses and managers. “Other countries are welcoming our graduates and really well trained staff with open arms so we need to find ways to retain our staff.

“We don’t seem to think we have a role in staying fit and healthy. If we don’t think we have a role the demand will rocket exponentially.

Invest in the health of citizens and you will get benefits in terms of increased exchequer funding.

“Money matters but we need to remember we are investing in our citizens when we invest in our health services. If you invest wisely it is a very good investment and will be returned to the exchequer in terms of taxes. Invest in the health of citizens and you will get benefits in terms of increased exchequer funding.

“The Royal College of Physicians in England produced a document called ‘Hospitals On The Edge,’ which looked back over the last decade and found the same issues as we have here, with an ageing population, increasing demands on our service, complex conditions becoming more prevalent although people are surviving better but we need to provide the services they require in a better way.

“Dealing with setting higher standards, the RCP document said we must promote dignity and patient-centred care, redesign services, change the way we organise hospital care, review medical education and training ensure the right mix of medical skills is available, improve the availability of primary care, revolutionise the way we use information, embed quality improvement across the system and show national leadership.

“It also showed that there had been a 37% increase in emergency hospital admissions over the last ten years, a 33% decrease in the number of general and acute beds in the past 25 years, a 65% increase in secondary care episodes for those over 75 in the same period (compared with a 31% increase for those aged 15 – 59) and multiple complex conditions.

She said integrated care programmes might not control costs but it would be money better spent with better outcomes for patients.

“What we mean by integrated care or connected care is very important. It is important that we all work together in making very sure what we are talking about. It is a challenge when managers are talking to clinicians and when clinicians are talking to finance people.

Dr. Carroll said that in developing integrated care we were building on the fantastic work of the Clinical Care Programmes. “We have our models of care and our care pathways through good work done by the Clinical Programmes, which were established to improve quality, improve patient access and provide value for money and value for patients, while valuing value staff.

We have learned important lessons:

  • Supporting integrated services does not mean that everything has to be integrated into one package. In reality, there are many possible permutations.
  • Integration isn’t a cure for inadequate resources.
  • There are more examples of policies in favour of integrated services than examples of actual implementation.
  • Managing change may require action at several levels.
  • It requires engagement of health workers and managers, plus a sustained commitment from senior management and policy-makers.

She said the key principles to make integrated out of hospital care a reality were:

  • Empower patients to have more control over their care and strengthen prevention, self-care and wellbeing
  • Target services – focusing integrated services on those patient groups most likely to derive the most benefit
  • Collective leadership and joint working – health and social care leaders jointly deliver solutions appropriate to their own communities
  • Incentivise integrated care – develop mechanisms to reward organisations and staff to deliver integrated care
  • Ensure openness and transparency – using an open-book approach towards all aspects of integrated care development