John Connaghan, Deputy Director General and Chief Operations Officer of the HSE participated in the HMI Forum in Merlin Park Hospital Galway in February 2018. Maureen Browne reports.
HMI President, Lucy Nugent, welcomed Mr. Connaghan and the large attendance at the Forum. She extended a particular welcome to Tony Canavan, Chief Officer, Community Health Office 2, Maurice Power, Chief Executive of the Saolta Group, Breda Crehan-Roche, the Chief Executive of Ability West, Liam Cullen, Director of External Affairs and Public Policy, GSK, Helen O’Dwyer, Healthcare Partnership Manager, GSK, and Seamus Gallagher and his organising committee.
Mr. Connaghan opened his discussion with the Forum by thanking Seamus and the organising team for the excellent work carried out to support HMI in the West. Mr. Connaghan said he was 150 days in the job on the day of the Forum, and answered questions suggested by the audience.
1. Winter Planning
Asked about the difficulties of providing services in the Winter months, Mr. Connaghan said that we needed to do a number of things to improve the position for next winter. Firstly, we needed to shift the timetable for integrated planning back by three to four months. Completing winter plans in October and deploying funds in November was far too late.
Mr. Connaghan said, “Sometime after the end of Easter and before summer we should conclude the lessons we have learned from the previous year and put together the plan for the following winter.” We need to draw up an integrated and unified Winter care plan across social, community and acute care and agree any resources (within HSE/DOH) well before the end of the Summer.”
Mr. Connaghan welcomed Sláintecare. His view was that this was relatively unique in healthcare systems (in the sense that we had a unified political view of the future). We had an opportunity in Ireland to really change the way in which we delivered healthcare services, however there was a risk around implementation of any national change programme.
“In implementing the various aspects of Sláintecare, let us not underestimate how difficult a task that might be. We need to ensure that in doing so, we do not take our minds off the day to day task of managing the health service.”
3. Commissioning and Payment by Results
Mr. Connaghan’s view was that there were good and bad aspects of commissioning.
“I prefer to work with a system which is based on mutual support through a value programme and which has quality at the centre of everything we do. However, we also need to demonstrate that we can get as much as possible out of the public purse in terms of value.”
Mr. Connaghan gave some examples from the UK system, and his experience in the Western General in Edinburgh where services were changed in line with a market driven competitive NHS which did not always make (in Mr. Connaghan’s terms) a strategically coherent healthcare solution.
“We need to get the balance right between top down overall vision and bottom up innovation and service delivery. In that respect we also need to include voluntary organisations. We need to consider these are absolutely important in Ireland in terms of delivery of local healthcare services, but again we need to ensure that we get the best value for the public purse and that they are strategically aligned with our service delivery intentions.”
4. Management at Local Level
Mr. Connaghan’s view is that we should be trying to get decision making much nearer patients and at local level (using the example of it being difficult to manage a hospital if you were 25 miles away from the site). He said he was an enthusiastic supporter of devolving accountability and budget responsibility through to clinical director teams, given his experience in Scotland as a Trust Chief Executive.
However, he cautioned that “Chief Executives need to be able to wrap sufficient support around the Clinical Directors and their team, with recognition of what is going well and with establishment of a set of checks and balances to ensure that delivery of local services is in line with regional and national strategic direction.”
He recognised that we are at a relatively early stage in the full development of the Clinical Director concept in Ireland and mused that he needed to develop a dialogue with the Chief Executives/Chief Officers over the next year. He was also aware of some excellent work that was focussing on this area (he mentioned Saolta as an example).
5. What Makes Him Angry
Mr. Connaghan’s reply to this question was that he thought we should all be angry about the human indignity of patients waiting for extended periods of time on trollies. This was not a problem to be laid at the door of staff, but a problem that needed to be addressed on a system basis. He welcomed the recent announcement that additional capacity will be made available over the next 10 years.
6. What About Opportunities?
Mr. Connaghan said he thought that we were at the start of a new journey as a number of national and local programmes were now aligning. “But what a marvellous opportunity we have – a politically agreed vision of healthcare and the benefits of the capacity review. We just need to use these wisely. We cannot just invest in beds. We need to invest in the community and some of the system deficiencies.”
7. Health Funding
Mr. Connaghan advised that his previous experience was where there was alignment of hospital based and community-based services (geo-alignment) where services were delivered through health boards and where resources were provided for care of that population took account (through a specific formula) of population demographics, social factors, deprivation and tertiary service provision. He welcomed a thought process on money being applied on an integrated basis (which would drive integrated care) and speculated that this was where Ireland might eventually be heading in relation to the concept of geo-alignment.
8. Comparative Health Funding
Mr. Connaghan’s view was that when he looked at metrics on Ireland’s healthcare spending being above the average of OECD countries, he wondered if we were truly comparing like with like.
For example, in other jurisdictions, we did not have social care included in the spend, whereas in Ireland we did and there are of course variances which were fairly dramatic across European countries in terms of how much provision was made through the private sector. For example, the French healthcare service spent around 8.7% of GDP on publicly funded healthcare and 2.3% on a private basis, compared with 7.7% and 2% in the UK.
He would like to learn a lot more about how the Irish healthcare spend compared to other countries, and through that this dis-aggregating the spend such that we could truly understand acute, community, social care and primary care might be the best way forward.
He said he would like to sit down with a group of health economists to do that piece of work and advised that “When I look at expenditure in Ireland, my gut feeling is that there is a significant amount of resource which is locked up in fixed infrastructure costs. The more you lock up in fixed costs, the less you have to deploy in direct patient costs.”
9. Patient Safety
Mr. Connaghan challenged the audience to tell him what they thought the top two categories were in relation to serious reportable events in Ireland. Mr. Connaghan advised that these were firstly Falls and secondly Pressure Sores. Together they made up over 50% of all serious reportable events.
“We should ask why we have such variation across the country in relation to the reported number of falls and pressure ulcers. We need to seriously look at developing a programme for prevention and to support those excellent programmes that are already beginning to make some traction in parts of the country.”
Mr. Connaghan welcomed the recent announcement that short term capacity could be made available over the course of the next year or two to alleviate the trolley situation in hospitals. However, he cautioned on the prospects of purely investing inside the acute system, and proposed a wider range investment, also including community and primary care services such that we utilised community resources as a first response to avoid hospitalisation.
In terms of efficiency in the system, he advised, “We must consider whether or not we are providing services in the right place at the right time. If we consider the hospital system as an example, we should only optimise and drive value and efficiency in a hospital system for work that only needs to be done in the hospitals. There are excellent examples of where we can move some activity outside of hospitals which is better for patients and which increases value in the system.”
“We have excellent examples of where much more can be done in the community – reference Sligo Eyecare project – patients can be seen more quickly, and this will create space within the hospital system to concentrate on those patients who have more acute issues.”
11. The Next Year
Mr. Connaghan looked ahead to the next year, and outlined a number of personal and organisational challenges as follows:
- We need to have meaningful performance agreements signed and delivered during 2018.
- We need to further develop CHO and local networks to drive integrated care delivery.
- We need to drive value for money within the system and maintain financial control.
- We need to support the Value Improvement Programme in line with the National Service Plan commitment.
- We need to recognise that improvement methodology needs to be supported at a local level and on a sustainable basis as we seek to deliver new services in new ways.
- We need to deliver on time and on budget the major capital projects (such as the new Children’s Hospital).
- We need to highlight that patient safety is front and centre in all that we do in delivering services for patients.
- We need to tackle the very longest waiters for elective care and introduce the concept of a three-year improvement plan for unscheduled care performance.
- We need to move decision making closer to the front line, through the development of Clinical Directorates.
- We need to recognise and support the spread of best practice. There is so much in the Irish healthcare system which is very good and excellent, and we should recognise that.