How do we integrate silos?

Our relatively new model of directorates is now old and we need to replace it with an integrated care model. The question is how we do that, given that different directorates have different areas of responsibility, funding, resources and control, writes Derek Greene.

Derek Greene
Derek Greene

When the HSE was established it struggled to find its identity and more importantly a robust organisational structure which enabled it to fulfil its role.

After a number of iterations the HSE settled on ‘Directorate Model’ which at the time it believed to be best suited for purpose. The Directorate model appointed National Directors who each took responsibility for key areas of service delivery and the service delivery system. So we had directorates for acute hospitals, primary care, social care and mental health etc. etc.

Each directorate built a management structure and supporting protocols and procedures were produced to underpin their raison d’être. From there, defined areas of responsibility were established and delineated and this is how the directorate engaged with providers and service users. The ‘rules of engagement’ were determined from the defined areas of responsibility, authority and range of services to be provided, using the established legislative framework as its backup.

In retrospect we created a perfectly designed system for what the health service believed was needed, to organise, manage and control our public health system. What in fact we created was the perfect silo system which broke up our health service into particular discreet chunks (directorates) which were to be managed and interacted with, independent of each other, (silos).

How do we begin to unpick the lock we’ve just put in place and replace our model with a more fluid one which transcends traditional, established boundaries, intersects across directorates and gets better outcomes for patients by lessening artificial barriers across our continuum of care?

All went well, until we realised that our holy grail for effective health care delivery should be the provision of end to end, integrated care. Care pathways, bundles and systems which were meant to flow effortlessly around clinical/diagnostic groups and which if they worked right, would seamlessly transcend and outpass the current points of interdependence or hand offs in our system which created bottlenecks and ineffectiveness. So using our new model, care pathways transcended hospital care, primary care, mental health, social care etc. in order to make the patient or service user experience integrated or whole, seamless and flowing logically, following patient need.

So our relatively new model of directorates is now old and we need to replace it with an integrated care model. So how do we do that, given that different directorates have different areas of responsibility, funding, resources and control? How do we begin to unpick the lock we’ve just put in place and replace our model with a more fluid one which transcends traditional, established boundaries, intersects across directorates and gets better outcomes for patients by lessening artificial barriers across our continuum of care? How do we create seamless movement across care boundaries, manage our resources prudently, have proper accountability and yet still improve the quality of outcomes?

Of course we need to be careful how we proceed, we need to use small evidence based tests of change, which can be scaled up. But most importantly we must understand in detail the continuum of care that we provide and more importantly what we seek to provide in the future. Changing for change sake is not the answer. If the evidence in this case points us to integrated care models, and it does, than this is what we must commit to in an open, evidence based way, in which service providers are actively engaged with, not just engaged with to ‘tick a box’. We must then start about breaking the barriers we have established to ensure that our system is re-engineered to support our new objectives. Using the New Integrated Care Programme under the National Clinical Programmes is an excellent start. Using champions or those who know the system best to effect the change on a pragmatic learn as you go basis is the way forward.

Using the New Integrated Care Programme under the National Clinical Programmes is an excellent start.

Difficult to do, but nonetheless achievable over a realistic timeframe. When we as managers in the health service all really feel part of the solution, and are actively engaged with and supported than the full power and ingenuity of our system can be experienced and maximised.

Thankfully we know what needs to be done, but while we have to have a robust evidence based approach, it is the practicalities of changes, and the willingness of all those who participate that deliveries its success. Committing to the process fully is vital as well as seeing it through.

So let’s get started and make sure that the direction of travel is clear, the destination is known and the commitment to engagement with is open and fulsome. People moving together with a clear objective in mind, a common purpose, can achieve great things.