Ireland is moving towards Academic Medical Centres

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John O'Brien
John O'Brien

The current provisions around relationships between universities and the health system in Ireland are unlikely to be sustainable into the future and Ireland is likely to be compelled to move towards establishment of Academic Medical Centres or Academic Health Science Centres, Mr. John O’Brien told a recent HMI Forum organised by the Dublin Mid Leinster Regional Committee.

The current provisions around relationships between universities and the health system in Ireland are unlikely to be sustainable into the future. In this respect, Ireland is likely to be compelled to move towards establishment of Academic Medical Centres or Academic Health Science Centres, Mr. John O’Brien told a recent HMI Forum organised by the Dublin Mid Leinster Regional Committee.

John O'Brien
John O'Brien

Maintenance of contemporary health service, academic and organisational standards, our international reputation and peer status will demand an ultimate shift in this direction.  Ireland is poised to potentially significantly advance AMCs/AHSCs. They are consistent with the new government intent for the health system, and fit strongly with HSE integration, ISA, and Clinical Care Programmes. There would also seem to be good support for such developments across the system.

Where AMCs/AHSCs have been  successful in Europe, they have been underpinned by strong Government/ Health Ministry policy and legislative support and this requires urgent attention in Ireland

However, some essential facilitative support is necessary if the AMC/AHSC objective is to be achieved. Two fundamental pre-requisites in this regard are as follows:

Development of enabling policy and legislation. Where AMCs/AHSCs have been     successful in Europe, they have been underpinned by strong Government/ Health Ministry policy and legislative support. This requires urgent attention in Ireland.

Initiatives in the area are on a strong timelined project footing. Where work has commenced in Ireland on AMCs, it has been slow to progress.

O’Brien said there were four groupings in the country already at varying stages of AMC evolution.  The most advanced were UCD/the Mater and St. Vincent’s University Hospitals and TCD/St. James’s Hospital and AMNCH.

He defined an AMC/AHSC as a partnership of one or more universities and healthcare providers focused on achieving excellence in and integrating the joint mission areas of service, research and education

The UCD initiative is centred around an incorporated company, co-owned by UCD, the Mater, St. Vincent’s – the Dublin Academic Medical Centre. All participants remain corporately independent with provision for some delegation of authority by each to DAMC in specified small areas. They are currently moving to corporately unify the health system.

The TCD initiative provides for joint governance by an unincorporated committee in the first instance. This is enabled through a formal agreement between TCD, St. James’s and AMNCH, which again makes some small provision for joint authority delegation in specified areas. They are at present driving significant expansion of the health system through incorporation of further hospitals and creation of a comprehensive ISA within the framework of the AMC.

He defined an AMC/AHSC as a partnership of one or more universities and healthcare providers focused on achieving excellence in and integrating the joint mission areas of service, research and education.  Latterly, there had been an added emphasis on enterprise and innovation.

These partnerships can be established at differing levels of intensity, each of which is likely to support achievement of the impact and value of AMCs to varying degrees:

  • An informal partnership with loose, unstructured, inter-mission recognition –  minimal/no impact
  • A memorandum of understanding with formal inter-mission commitment – patchy impact
  • A collaborative agreement which provides for joint corporate oversight, delegated authority, full joint mission commitment – high impact.
  • Full integration comprising a singly incorporated entity with full joint mission ownership – high impact.

The rationale and benefits of these types of partnerships include:

  • Interdependence considerations. Health education and research cannot function without service linkages. Conversely, the health service is dependant on health academia for education/training of professionals, new knowledge, standards and quality. AMCs consolidate interdependence.
  • Economic development/knowledge economy considerations – The knowledge economy in Health is centred around AMCs. A higher level AMC/AHSC is more likely to deliver on knowledge economy objectives.
  • Scale issues – Stand alone health service entities of contemporary Irish size are not sustainable. They require horizontal and vertical integration. Health academia requires increasing scale for research/education purposes and to achieve economic development potential of research. AMCs facilitate this.
  • Translational issues – Discovery to care timelines are shown to be radically shortened in AMC/AHSC environments. The larger and broader the scope of a centre or system the more successful it was likely to be in rapidly delivering discovery to patients.
  • AMCs/AHSCs are likely to allow for improved development of new models of health professional education and training and to create an environment which attracts and retains the highest level service and research health and health sciences professionals and executives.

International models of AMCs and AHCs

AMCs and AHSCs are well established internationally, John O’Brien told the Forum.

He said the longest established are in the USA,  where some examples are Johns Hopkins in Baltimore, Partners/Harvard in Boston, Duke in Raleigh/Durham, the University of Pennsylvania in Philadelphia and New York/Presbytherian/Columbia in New York. While models in the US differ they all display some critical underlying characteristics for success including

  • A single overarching corporate governance with full devolved authority
  • A single corporate executive head for the AMC
  • Strong underpinning health system and academic heads
  • Centralisation of corporate services and functions
  • Full participant commitment
  • Strong personal relationships at leadership level

In England, a formal government initiative in 2009 set to establish and support AHSCs, with selection based on competition.  Successful bidders were Cambridge University Health Partners, Imperial College, Kings Health Partners, Manchester AHSC and UCL Partners.

The Netherlands has established eight AMCs around academic hospitals and universities on foot of a formal and legislatively based government initiative.

Scotland has developed an interesting hybrid by creating University/NHS partnerships around four health boards and four universities at Edinburgh, Glasgow, Aberdeen and Dundee. The initiative was governed by a strategic oversight board, chaired by the Chief Medical Officer, reporting to the Head of the NHS in Scotland. Its primary focus was to target public investment in research.

John O’Brien is a former CEO of St. James’s Hospital, Dublin. He was also National Director of the National Hospitals Office and Adviser to the then CEO Brendan Drumm at the HSE

1 COMMENT

  1. The report in HMI on John O’Brien’s address to the recent Dublin Mid-Leinster Regional Committee Forum was a useful and timely summary of where we currently are in relation to the Academic Health Centre (AHC) agenda. In a phrase, we are talking about bringing together health education, research and delivery into a coherent organisational framework with a common vision and strategy. This first arose as a concept in the US but has been, and is being, successfully developed in forward looking health services across the world. Countries closest to home would include the Netherlands, Sweden, France and the UK.

    Ireland currently has a single centralised health service with strong regional divisions. It also has a strong voluntary sector, the inheritor of earlier days when hospitals were founded as private charitable institutions. Voluntary hospitals are now funded largely by the state though they have their own boards. This facilitates the Dublin based Voluntaries and universities in their negotiations.

    In Cork, there is strong interest in developing an academic health system for Cork and Kerry that would include voluntary hospitals and HSE hospitals and in which the integration and governance of acute clinical services would be a principal driver. This is set out in the Reconfiguration Roadmap for Cork and Kerry published last November and representing the joint vision of the HSE, the Mercy University Hospital, the South Infirmary and Victoria University Hospital and University College Cork. The Roadmap sets out the organisation of clinical services that would underpin an academic health system. Consultants would work in regional specialty teams reporting to regional clinical directors of medicine, perioperative care, diagnostics, mental health and women and children’s health. There would be strong links with a number of Primary Care Centres and a strong pre-hospital care element that would bring together hospital A&E departments, urgent care centres and Acute Medical Units with GPs, Southdoc and the Ambulance service.

    The AHC model provides a goal that is worth striving for. In the Netherlands, the eight AHCs are all clinically led, bureaucracy is minimised and the achievement of outcomes is maximised. A joint committee, representative of all AHCs, manages competition between them and jointly represents them in their interface with government. Each has an identity that is recognisable to its local catchment population so that adverse publicity in one does not affect the others. Conversely, good publicity is maximised instead of being spread over the whole country.

    In Ireland, where local is so important and where our Celtic temperament seems to find more freedom to reach its potential in small innovative organisations, the AHC model may just possibly provide an answer.

    Michael Hanna

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