Health services need to be reconfigured

One of the country’s most experienced health managers has called for a re-configuration of health services based on patient needs and the introduction of a standardised activity based reimbursement system linked to the location where services are delivered.   Maureen Browne reports.

Liam Duffy
Liam Duffy

Liam Duffy, who has retired as Chief Executive of Beaumont Hospital, Dublin following a 40 year career in the health service says that there is an urgent need to plan for the care of the swiftly aging North Dublin population, which is a huge problem for the catchment area.

He favours specialist training and regulation for health managers and is emphatic about the need for ongoing training and development for all staff who work in the health service.

He has been CEO of Beaumont for 12 years and at the age of 58, he believes the time is right to move on to new challenges and new opportunities.

He favours specialist training and regulation for health managers

Liam Duffy began his career in the old Richmond Hospital, in Dublin, and then worked in Jervis Street before moving to Beaumont as Patients’ Services Manager when it opened.   He subsequently became Hospital Operations Manager, Deputy CEO and CEO.

“I have thoroughly enjoyed my time in the health services.   I have worked with great people and got a real buzz out of helping to introduce new service developments, hearing the stories of patients who had a good hospital experience, seeing staff develop and seeing and availing of opportunities and career advancement as they arose. Recently we were delighted to have been designated as one of the major cancer services and to have St. Luke’s Oncology and Radiotherapy Services opened on our campus.

“I think we need to reform the delivery and the funding of the health services based on patient needs. We need to restructure the services so that the right work is done in the right place. There is a role for every hospital in the country and they need to be clear on what their roles are. Some larger hospitals might lose some services which might be more appropriately delivered in smaller hospitals. St Joseph’s Hospital has proved very valuable to Beaumont. Within reason patients will travel to where the services are.

There is a role for every hospital in the country and they need to be clear on what their roles are.

“We should examine why there is such a dependence on acute hospitals for older people, when what they might need are expanded community services, access to day care physicians and more day care places. The Government’s recent commitment to older people around care packages worked and enabled many to remain in their own homes, but then the money dried up.

“People aged over 65 constitute the highest percentage age group in country and we have a very large number of people over 85, yet we don’t have the infrastructure required to care for them. Community services are developing but there is a lot to do and when the money dries up patients stay in hospitals because they are open and they receive care there.

“Society is changing rapidly, and people may be unable or unwilling to care for older family members at home.   We no longer have the expectation that our children will look after us when we grow old.

“There is planning for education in the north Dublin area with lots of new schools being phased in, but we are not doing the same to meet the needs of older people in their community.

Because we are a tertiary hospital a patient may get a transfer from Galway or some other part of the country faster than somebody who might have to remain in the Emergency Department for 12 hours.

“The ageing population is a huge problem for us in this catchment area.

“If I go to midlands where I come from or to my extended family in Donegal, people talk about great work such as transplants , neurosurgery, cancer care services in Beaumont, but the hospital is not such a good experience for older people in the community. We are not looking after that part of society very well.”

However, Liam Duffy believes the local community benefits from the access to the specialist physicians and surgeons in Beaumont and the wider range of specialties from nephrology to diabetes which might not be available in other hospitals.

“Of course there are two sides to this. Because we are a tertiary hospital a patient may get a transfer from Galway or some other part of the country faster than somebody who might have to remain in the Emergency Department for 12 hours.”

He also thinks that we need to have a conversation about dying with dignity and whether we are meeting the needs of patients in this regard.

He recognises this is a very sensitive and often controversial subject but should not be ignored.

He believes we need a standardised funding reimbursement system which is linked into the location of services. “There has to be some rewards system in place so there is merit in an activity based system, as an insurance based model might result in people only doing lucrative work and the essential services being left out. . . But we need clarity on how an activity based systems would work. It has been tried and failed in different places so we need to look at it realistically.”

He acknowledges that the financial downturn over the last five years has been a huge challenge for everybody, with the recruitment embargo and budget cuts.

The lifetime of a CEO in Ireland can be long – perhaps too long – because one of the problems CEOs face is where is their next career move.

“On the positive side we did more work in that period but it placed a lot of stress on staff. Many staff had internal stresses around work plus external stresses with family members losing jobs and businesses and difficulties in paying mortgages. The hospital suffered from lack of funding and expansion and it was hard to meet the needs and staff were expected to do more work. On the other hand waiting lists increased.

“As a manager there are issues where you put on your problem-solving hat and find solutions but when we can’t recruit staff and people are emigrating it is extremely difficult. Undoubtedly this period has also slowed the growth and development of community services.

“I am proud to say that in Beaumont we kept investing in staff and kept our staff training budgets going despite everything. I am of the view you have to support staff and their development more during a period like this. By doing so you get their commitment and loyalty. We have had good training programmes. We did a Masters programme with RCSI and DCU and had lots of staff development initiatives.”

Liam Duffy says he spent much of his career in Beaumont because that was where the opportunities were. “Why would I move to another place? In Beaumont I had great mentors over the years, in CEOs Chairs and colleagues. I think health service staff have huge potential, but they need to have access to training. AHPs and nursing staff are increasingly moving into management. I think they see the opportunities for developing their skills. They have baseline skills and they speak the language, which gives them comfort in dealing with other clinicians. but they need to get a broader experience in management. I favour initial training and regulation for health managers plus ongoing CME.”

“The King’s Fund in UK did some work on the characteristics of a successful hospital and found that one was around stable leadership and continuity of leadership. The lifetime of a CEO in Ireland can be long – perhaps too long – because one of the problems CEOs face is where is their next career move, what do they do for the remainder of their working life, where are the future opportunities when you get to a hospital CEO.

“As a hospital CEO you have the opportunity to make a difference. You are accountable to a Board from which you get great expertise and support.”

Asked about the big challenges for hospital managers, he said they hinged on the availability of finance, managing risk, recruitment and meeting public expectations and government expectations.

“There are also issues about getting value for the money you get.   We are able to do more work for less money so people have to become more efficient and look at techniques from industry like lean and project management. We also need the skill sets to manage budgets and use the latest IT systems. There is a significant opportunity for innovation from front line staff, but they need to be listened to and included “

On governance he sees the big issue facing us as patient safety. “Sometimes it is not what you know but what you don’t know that is the problem. If you don’t know there is an issue, if you don’t have the mechanism to identify it, that is a problem. You need good systems to identify where things are not going well and interventions to put in place when you identify them.   You also need fit for purpose facilities.

“For example, when Beaumont was opened, hospital wards in the other hospitals would have had 50 beds but Beaumont had 35 beds in rooms of six, four and two beds and single rooms. We are now saying these are not fit for purpose and the majority of rooms should be single. Standards keep changing, infrastructure requirements keep changing, yet we may not be investing fast enough to keep up with them.

“A strong Board is a great support to the management team. If you have a Board with the right skills set it helps to support managers and ensure safer patient safety and accountability. The HSE Board is too far away from the delivery of health care. In our case here and in voluntaries generally, a Board presence is a huge support to the management team. I would like to pay tribute to people with great skills who serve on hospital boards, free of charge.”

Liam Duffy is proud of the fact that Beaumont has developed and implemented A Clinical Directorate structure. “We grew it internally and you need strong CDs to give a voice to clinicians at the table. Co-operation with management is a must and when I say mangers I say management in the broadest since to include AHP, Clinical and Nursing and not just admin management. There must be interconnectivity around the teams.

“I have enjoyed teaching in the RCSI and watching how people can develop with support and encouragement. I would encourage people to go into health management. For me it’s been a great experience and a great challenge and I am looking forward to what the future will bring.”