Health investment and reform must go hand in hand

Capital investment in the Irish health services would be needed to enhance service provision and to drive reform, but investment should go hand in hand with reform, as the current configuration of the system was not optimal, a HMI meeting in St. James’s Hospital, Dublin, was told. Maureen Browne reports.

Laura Casey, Tony Flynn and Adam Monaghan, of the Health Systems and Structures Unit of the Policy and Strategy Division, Department of Health and members of the Department project team for the Health Service Capacity Review 2018, made a presentation on the Capacity Review, which was published in January 2018.

They said high-level recommendations from the report made it clear that:

  • Reform was needed to drive more appropriate models of care and to protect the sustainability of the system and investment must act as a catalyst.
  • There was a need for investment in capacity across all sectors, particularly in out-of-hospital care.
  • There was a need for short-term increases in bed capacity to address potentially unsafe bed occupancy levels.
  • Further work was needed on workforce requirements, on other services such as disabilities or mental health, on the implementation of Sláintecare, on the development of evaluation frameworks to monitor and assess reform initiatives along with the development of robust and comprehensive data systems.

Laura Casey, Head of the Health Systems and Structures Unit, Policy and Strategy Division, Department of Health and project manager for the Capacity Review said the Review fulfilled a commitment in the Programme for a Partnership Government.

Without reform, there would be a 39 per cent increase required in long term residential care, a 70 per cent increase in Home Care Packages and a 69 per cent increase in Home Help Hours

At the outset, it was agreed to extend the scope of the Review beyond acute hospital bed capacity and to include key components of primary care and services for older persons, in acknowledgement of the interdependencies of capacity across the system and the need to consider reform proposals as part of the analysis.

The aims of the Review were to provide analysis and assessment of future demand and capacity requirements, to provide quantitative data on the impacts of reform (on both future demand and capacity requirements) to support changes in the model of care, and to provide an evidence base for additional resources.

The terms of reference were:

  • To determine and review current capacity, both current and private, in the health system and benchmark with international comparators.
  • To determine drivers of future demand and estimate the impact on capacity requirements to 2031.
  • To consider and analyse how key reforms to the model of care will impact on future capacity requirements across the system.
  • To provide an overall assessment, including prioritisation and sequencing of future capacity requirements on a phased basis for the period 2017-2031 at a national and regional level, cognisant of resource availability.

“We saw it as an opportunity to determine the drivers of future demand, to see how key reforms to the model of care would affect capacity and to provide an overall assessment of capacity requirements across the acute and non-acute sectors.

“We only looked at additional capacity required, not replacement. For the acute and older persons’ areas we did not look at the workforce required to deliver increased capacity and for all areas we did not look at cost. Our primary aim was to assess infrastructure requirements..

The majority of the Review’s work was delivered over four months. The baseline year was 2016. Activity data was used from a variety of sources and in most cases waiting lists were used as a proxy for unmet demand. CSO demographic projections were used to forecast future demand. The modelling included assumptions around improved bed occupancy levels, namely 85 per cent acute bed occupancy for inpatient activity and 80 per cent for critical care beds,

She said given the time constraints, the following were not considered:

  • Mental Health Services
  • Disability Services
  • Some aspects of Primary Care, Palliative and Ambulance Care
  • Workforce Capacity (except primary care)
  • Costing of additional capacity requirements
  • Costing of replacing/upgrading existing capacity.

Ms Casey said the review was guided by a Steering Group representative of the DoH, DTAO, HSE and clinical and academic experts.

The Department of Health Project Team had input from an international peer review group and technical expertise from PA Consulting.

PA met with a range of key stakeholders including the HSE Leadership, insurers, the private hospital sector, Hospital Groups, the Department of Health and HSE units.

With reform the increase in long term residential care would remain roughly the same, there would be a 122 per cent increase in Home Care Package and a 118 per cent increase in Home Help hours

With reform the increase in long term residential care would remain roughly the same, there would be a 122 per cent increase in Home Care Package and a 118 per cent increase in Home Help hours.Ms. Casey said they looked at baseline demand – 2016 activity plus unmet need, projected forward on the basis of demographic and non-demographic factors and waiting list reduction. A number of scenarios were modelled to project the impact of an improvement in occupancy rates for acute beds and considering a range of reform scenarios. Trends for up to five years (2012 – 2016) were used where data was available and robust, e.g. acute hospital data.

Three reform scenarios were identified – Reform 1 (Improved Health and Wellbeing), Reform 2 (An improved model of care centred around comprehensive community based services) and Reform 3 (Hospital Productivity Improvements).

Reform 2 focussed on developing a comprehensive primary and community care service through raising CHO capacity, more proactive management of chronic diseases in the community, increases in primary and social care activity, a 15 per cent reduction in ED admissions and Medical NEL (over 65s) and cohorted wards within hospitals and reduced LOS for the 65 plus population.

The Reform 3A Scenario focussed on more efficient use of acute HG resources, such as 10 per cent of day case surgery moving to OPD and primary care, IP LOS reduction due to better patient flow from better separating IP EL and NEL, and (as a result) IP EL operating at a higher safe occupancy rate of 90 per cent.

The Reform 3B scenario focussed on improved patient flow and productivity/throughput through ALOS reduced to national median LOS (maximum reduction 20 per cent per HG), 30 per cent day case average throughput improvement from 2 to 2.6 cases, a 40 per cent increase in AMU throughput, a reduction in the ratio of OPFA to OPFU, and moving 20 per cent medical day case to OPD.

The drivers of demand growth were the projected 12 per cent increase in total population between 2016 and 2031, the 59 per cent increase in the 65 plus population and the 95 per cent increase in the 85 plus population.

Non-demographic growth factors included epidemiological trends, lifestyle risk factors, (smoking, alcohol etc) technological developments, (new drugs etc) socio economic changes and changes in expectations of services, population with private health insurance and supply induced demand (e.g. additional funding for services unlocking demand).
Demand increases across all sectors – primary care, social care and acute care – were expected.

Ms. Casey said that the report outlined two scenarios. The first assumed no change in the system as it currently operated, with no change in configuration, productivity or utilisation. The second examined the potential of a range of reform scenarios that would align with current national policies and reflect a desired future state for our health services.

Without reform, a 39 per cent increase in the GP workforce and a 40 per cent increase in Practice Nurses was projected. With reform this would be 29 per cent for GPs, and 89 per cent for Practice Nurses, reflecting the increased role for Practice Nurse in chronic disease management and the shift in tasks to reflect a better skill mix in general practice.

There was a need for increases in bed capacity in the short term to address potentially unsafe bed occupancy level and for detailed planning for elective hospitals, acute capacity planning and the nursing home programme

Without reform, there would be a 46 per cent increase in Public Health Nurses, a 38 per cent increase in physiotherapists, 32 per cent in Occupational Therapists and a six per cent reduction in Speech & Language Therapists. With reform, the increase in Public Health Nurses would be 67 per cent, 58 per cent for Physiotherapists, 50 per cent for OTs and an 11 per cent reduction for SLTs. (The figure for SLTs was based on current (2016) use which was mainly for young people, but they knew there were current and projected increases in demand for SLTs for older people and future planning would have to take that into account).

Ms. Casey said that without reform, there would be a 39 per cent increase required in long term residential care, a 70 per cent increase in Home Care Packages and a 69 per cent increase in Home Help Hours.

With reform the increase in long term residential care would remain roughly the same, there would be a 122 per cent increase in Home Care Package and a 118 per cent increase in Home Help hours.

Without reform, a 37 per cent increase in AMU beds would be required, as would a 47 per cent increase in day case beds and a 56 per cent increase in inpatient beds.

With reform, there would be no increase in AMU beds, a 14 per cent increase in day case beds and a 20 per cent increase in inpatient beds.

She said the Capacity Review findings and recommendations informed the development of the National Development Plan 2018 – 2027, which had committed €10.9 billion in capital funding for health over the next ten years. This included 2,600 acute hospital beds, including three new elective hospitals in Cork, Galway and Dublin and 4,500 residential care beds (a mix of long-term and short-term in public community nursing homes).

The Capacity Review and the NDP provided the starting point for capital development. There was a need for increases in bed capacity in the short term to address potentially unsafe bed occupancy level and for detailed planning for elective hospitals, acute capacity planning and the nursing home programme.

The presentation slides are available at
https://www.hmi.ie/2018/10/hmi-dml-regional-meeting-8-october-2018/