HSE to appoint Director of Public Health for Children

The HSE is to appoint a new Director for Public Health for Children and a National Clinical Advisor and Group Lead (NCAGL) for Children, Dr Siobháin Ní Bhriain, National Lead, Integrated Care (NLIC), HSE told the Conference.

Siobhan
Dr Siobháin Ní Bhriain, National Lead, Integrated Care (NLIC)

She said the pandemic had highlighted the critical role of schools in meeting a wide range of children’s needs, particularly for marginalised groups and the gap between disadvantaged children and others had been widened by the pandemic. The NCAGL for Children was a new role to bring all the elements of children’s programmes together and would work closely with the Director for Public Health for Children.

She said the National Lead for Integrated Care leads the National Clinical Programmes that fall under each of the National Clinical  Advisors and Group Leads (NAGLs). “The NLIC ensures the work of the team on the National Clinical Programmes develops an integrated care approach in the design, planning and delivery of the health services and ensures alignment of the Programmes and Sláintecare.”

Speaking on “COVID: Looking Back and Moving On,” Dr Ní Bhriain, said a very wide range of personal and workplace problems had been found among healthcare staff as a result of the COVID pandemic.

The following themes had been observed from data collected for the period March to June 2020 following HSE EAP interactions with staff, calls to the HCW Helpline and referrals for support to Occupational Health.

Personal problems included anxiety regarding COVID and panic attacks, bereavement, depression (high rates reported in HCWs involved in COVID response), addiction and substance misuse, financial stress, relationship issues, pregnancy concerns, stigma and COVID, negative perceptions of being contagious and domestic conflict.

Workplace and work environment problems included support on ‘return to work’ phase for workers coming back to the health system, work-related stress, communication, fear of exposure to COVID at work, response to a workplace incident, work-life balance affected due to COVID crisis, working from home issues (feelings of guilt and being isolated), role change due to COVID redeployment issues, anger towards management and moral injury.

Additional research highlighted fractured/damaged working relationships, bereavement and complicated grief in the healthcare setting, burnout in HCWs,  family responsibilities being superseded by additional COVID related work demands, fatigue and sleep disruption, issues around staff who have underlying health issues, the impact of COVID on managers, moral injury and PTS/PTSD.

She said the Psychological Layered Care Framework model, recognised the need for support across the entire population for personal, family, work and societal stressors associated with COVID as well as highlighting services for those who would require different levels of support to help them cope effectively.   There had been over 21,000 calls to date to the dedicated HSE phone line.

The framework covered Societal Wellbeing, Resilience & Safety, Self Help, People to People support, Primary Care and Voluntary Care Services, Specialist Mental Health Services and Severe and Enduring Needs.

“I would like us to capitalise on the capacity of HCWs to lead and change in their areas of expertise, the ability to innovate, the powerful impact of ‘coming together’ had on staff and how staff were enabled to work flexibly and fast, maintain close working relationships with Colleges, patient advocacy groups, HSCPs.   Also, we would all like to capitalise on digital learning/other platforms for healthcare delivery.

They were aware of Post Acute Sequelae of COVID and planned to continue to monitor the outcome of the pandemic on health services and respond to this. There was emerging evidence of prolonged and debilitating symptoms of post COVID affecting up to 10% of those infected, irrespective of initial severity.

Long COVID, when signs and symptoms that developed during or after an infection consistent with COVID continued for more than 12 weeks and were not explained by an alternative diagnosis, had to be considered. Symptoms could fluctuate and change over time and could affect any system in the body.  There was emerging evidence of prolonged and debilitating symptoms of post COVID affecting up to 10% of those infected (irrespective of initial severity).

Dr. Ní Bhriain said her focus was integrated care and care delivered closer to home.

This involved accelerating the Enhanced Community Care (ECC) and addressing historical waiting lists and delays in service access through the Scheduled Care Transformation Programme.

She said there would be a significant uplift in staffing for chronic disease/older person specialist teams under the Enhanced Community Care Programme.  These teams would be based in the community (Ambulatory Care Hub).  Access to diagnostics in a community setting and some critical acute hospital staffing gaps would be filled to enable the implementation of the Chronic Disease Model of Care.

The Consultants Application Advisory Committee (CAAC) had approved a considerable number of consultant posts to support this initiative.

Phase 1 had started in Winter 2020.  Eleven hospitals were linked with 18 Ambulatory Care Hubs which covered approximately 49 Community Care Networks.  The second phase would see Hubs introduced for the remaining 14 acute hospitals and 48 Community Healthcare Networks.

She said the Scheduled Care Transformation Programme (SCTP) was a Strategic initiative to deliver access targets for scheduled care as per Sláintecare. “We have 13 targeted initiatives including advanced clinical prioritisation (ACP) reform of scheduled care pathways and 15 target specialities, that make up over 92% of our current waiting list, including ENT, Ophthalmology and Rheumatology.”

Dr Ní Bhriain said her appointment as NCLI coincided with COVID and her immediate tasks in the new role were to develop HSE Operational Pathways of Care for COVID-19, which was published in March 2020. It provided for COVID and Non-COVID Pathways.   “Our immediate response was with older people and the acute hospital’s response, but I also worked with other colleagues to deliver primary care.  To date, we have published 154 Guidance documents, 41 Summaries of Evidence.

There had been considerable learning from the effects of the pandemic on a number of client and patient groups.

A very wide range of personal and workplace problems had been found among healthcare staff as a result of the COVID pandemic.

COVID had resulted in more severe illness in those with cardiology, respiratory disease and diabetes and there was a need to accelerate the chronic disease programme and the management of chronic disease outside of the hospital.

For older people there had been an immediate and severe impact in the residential care sector and they were now implementing the  COVID Nursing Homes Expert Panel Report.  “We have learned that cocooning means loneliness and social isolation and we have seen other problems such as  Sarcopenia and risk of fracture from lack of exercise and we are now looking at a fracture liaison service.  We also need to accelerate the Integrated Care Programme for Older Persons.

In the acute hospitals, engagement with the private sector had enabled the continuation of urgent elective care,  NOCA and HSE partnership had ensured real-time data was available nationally and ICU capacity had been increased permanently by 39% and many people had been managed outside the ICD, which had resulted in lower mortality for those admitted to ICU by comparison with other countries.  An early understanding of the vulnerability to COVID of patients on dialysis enhanced the application of IPC and resulted in 50% less mortality than in England or Spain.

We have learned that cocooning means loneliness and social isolation and we have seen other problems such as  Sarcopenia and risk of fracture from lack of exercise.

In the Mental Health Services, there was a reduction in referrals in the first six months of 2020 vs 2019  to CAMHS, the adult service and the domiciliary service for older people. Referrals to CAMHS were down 14% and to the adult services by 16%. However, we had seen an increase in the severity of illness.  Involuntary admissions were up by 2%, there was a  480% increase in traffic to HSE yourmentalhealth.ie from March to July 2020, a continued increase in online counselling services and, worryingly, an increase in the severity of self-harm presentations from the end of 2020 to date. One of the most dramatic changes had been in eating disorders, where there had been a 60% increase in admissions of children under the age of 16 to acute hospitals and a large increase in referrals to the public and private mental health sectors for eating disorders. Longer-term to manage this there had been a significant investment across all the mental health National Clinical Programmes from 2021 onwards.

In primary care there was extensive use of remote consultation, GPs had taken public roles in leadership, giving trusted advice to public media and other social platforms, continued to engage with developing ECCs and enhanced and closer working relationships with clinical colleagues.

In the disability services, there had been a loss of day services and outbreaks in residential settings-CRTs.  Many of those with disabilities had many other co-morbidities and were very vulnerable to COVID.  On the positive side, there was widespread use of technology with improved digital literacy for service users.

Questions

Conference Moderator, Sharon Morrow, HMI Council Member and Director, All-Island Congenital Heart Disease Network Ireland said she was particularly delighted with the news of the two new roles within children’s health.

She said there were a number of questions from the floor.

    1. Was there was a plan at the national level for developing eating disorder units, since the current capacity doesn’t meet current needs?
      Dr Ní Bhriain said the aim of the eating disorder programme was to try and identify cases earlier rather than later, as the earlier cases were identified the less need there was for residential care.  They were expanding the programme for children this year and focusing on early intervention.  There was not a specific plan for eating disorder units at the present, but they had various ways of managing that, including sometimes referral to the private sector.
    2. There is a tendency for large institutional players to dominate resource    To what extent is resourcing both in terms of staffing and budgets being aligned to the integration programmes?
      Dr Ní Bhriain said they were really keen to enable people on the ground to deliver so she would hope that they would be aligning resources in that way.  Part of the plan was to ensure greater equity of resources nationally, so people got the same care wherever they were in the country.  They were very keen to ensure resourcing was in line with patient need.
    3. What access would there be to diagnostics in the Enhanced Community Care service?
      Dr. Ní Bhriain said one of the big developments this year was the approved access to diagnostics for GPs in the community.   They were planning to have diagnostics available to specialist care teams in the ambulatory hubs to avoid referral to the hospital setting.  That would dovetail very nicely with increased access to diagnostics for GPs over recent times.  There was an allocation of €25 million for GPs this year to improve their access to community diagnostics.
    4. Eilish Hardiman, Chief Executive, Children’s Health Ireland said it was great to see a national focus on children and adolescents and early integration with plans for the new children’s hospital.
    5. Are there enough buildings to accommodate the new Enhanced Community Care programme in the community?
      Dr Ní Bhriain said that the ECC very much part and parcel of how we moved on.  We had to physically move out of the hospital settings.  The job descriptions for the new consultants who would be working as part of the specialist teams looked at 50% of their work being delivered outside hospital settings.

Dr Siobháin Ní Bhriain.

Dr Siobhán Ní Bhriain is a graduate of UCD and trained in Medicine and Psychiatry in the UK and Ireland. She worked as a Research Fellow in the Mercer’s Institute for Research on Ageing before completing her Higher Specialist Training in Old Age and General Adult Psychiatry. She has worked in Tallaght University Hospital/CHO 7 as Consultant in Psychiatry of Later Life since 2006 and was appointed Clinical Director for the Tallaght and St. James’s Mental Health Services in 2012, finishing up in 2018. During that time, she also served as Chair of the TUH Medical Board for four years and represented the MB at the Hospital Board.

She took up the post of NCAGL for Mental Health in January 2019 and moved to the role of National Clinical Lead for Integrated Care, Clinical Design and Innovation in February 2020. The move coincided with the onset of the Covid-19 pandemic and Siobhán led the development of the ‘HSE Operational Pathways of Care for Covid-19’ for the Chief Clinical Officer. She chairs the Covid Clinical Advisory Group to the CCO, as well as participating in many other Covid and non-Covid related working groups, including the National Public Health Emergency Team. She is currently leading the HSE Consent for Vaccination Working Group and is supporting two transformational programmes in the HSE, the Scheduled Care Transformation Programme and the Enhanced Community Care Programme.

Her clinical interests include the diagnosis and management of dementia and delirium with an emphasis on the management of the psychiatric sequelae of those conditions. She also does complex capacity and consent assessments, as well as having an interest in the psychiatric complications of Parkinson’s and related diseases.

She is particularly interested in the development of integrated care pathways across the continuum of care for patients and has worked closely with colleagues in various settings to develop care pathways.

Siobhan is a Member of the Royal College Physicians of London, the Royal College of Psychiatrists, the College of Psychiatry of Ireland and has recently completed an MSc in Leadership in RCSI in 2019, which was funded by the Meath Foundation.