Presentation and Outcomes - hse.ie · electoral ‘transformational stability’ > 10 year plan • “ Severe pressures on the Irish health service, unacceptable waiting times that

Professor Paul StantonCEO Southminster Consultancy Associates Ltd

Fit for the future? –The Irish health and social care system

in the 21st Century“If things are going to stay the same, they are going to have to

change” Lampedusa, The Leopard.

Clinical Directors Seminar15th September 2017

A turbulent context

• The pressures of clinical practice• A context characterised by urgency and

contradiction• A (rare) chance to focus collectively and

exclusively on the important • “We do not learn from experience; we learn

from reflecting upon experience” John Dewey, 1939

Focus• The 21st Century global context• The Irish health & social care system: political, financial, societal and operational context

• Fitness for current and future purpose? • The Oireachteas ‘Slaintecare’ Report

– A national health service for the 21st C “triple aim’ -­ improving care, improving health and reducing costs”

• Pivotal role of CDs & clinical leaders shaping radically new landscape

• Reference to prior reading and questions posed

The 21st Century global context• Unprecedented social, economic, military and political volatility– ‘Future Shock’ Tofler 1964– “What we’re experiencing is not simply the acceleration of the pace of change, but the acceleration of acceleration itself. In other words, change growing at an exponential rate” Kurzweil 2006

Upsides• Technological ‘quantum leaps’

– ‘the 21st century as a whole will experience almost one thousand times more technological change than did the 20th century’ Grossman et al 2005

• “The challenge of harnessing the potential of new technologies to the positivist/humanist value base of medicine & extracting optimal benefit for patients and taxpayers” Stanton, UKDH, 2007

• Prioritised in Oireachtas report• “Last developed country without a functioning

eHealth system – just behind Botswana” eHealth Ireland, 2016

• A fundamental & irreversible shift in world’s economic centre of gravity

• The ‘Sino century’• A trend not an aberration• India, Indonesia, Singapore, RSA• EU wide public resource constraint: demand escalation

• “The Irish system faces major challenges;; greater demand, long waiting lists;; complex chronic illnesses growth in a context of a much reduced health budget” EDoH2012

Sensitivity to global and parochial realities

THE HEALTH & CARE

Conversation 1 OutcomesQuestion 1: How much pressure is your part of the health care system under at the present time?

None at all Moderate Severe0 1 2 3 4 5 6 7 8 9 10

Question 2.1 a To what extent do patients and their families now have higher expectations about the care they will receive from your organisation?

Not at all Moderately Significantly0 1 2 3 4 5 6 7 8 9 10

Question 2.1 b To what extent to patients have higher expectations about the care they will receive in your own clinical specialism?

Not at all Moderately Significantly0 1 2 3 4 5 6 7 8 9 10

Group Range Mean

a 8:9 8.5

b 8:10 9.4

c 8:10 8.7

Group Range Mean

a 9 9

b 8 8

c 4:10 8.3

Group Range Mean

a 9 9

b 8 8

c 4:10 8.3

Conversation 1 OutcomesQuestion 2.2 To what extent have you experienced a rise in antibiotic resistance in your organisation’s patient population?

Not at all Moderately Significantly0 1 2 3 4 5 6 7 8 9 10

Question 2.3 a To what extent have increased social mobility and changes in the care provided by extended families impacted on your own organisation?

Not at all Moderately Significantly0 1 2 3 4 5 6 7 8 9 10

Question 2.3 b To what extent have increased social mobility and changes in care provided by extended families impacted on your own clinical specialism? ?

Not at all Moderately Significantly0 1 2 3 4 5 6 7 8 9 10

Group Range Mean

a 1:9 7.4

b 8 8

c 9 9

Group Range Mean

a 0:10 7.2

b 7`:10 9.6

c 6:10 8.5

Group Range Mean

a 0:10 7.2

b 5:10 7.6

c 5:10 8.3

Conversation 1 OutcomesQuestion 2.4.1 To what extent, over the last decades, have Irish governments invested wisely in health education and illness prevention & used taxation to penalise unhealthy life choices?

Not at all Moderately Significantly0 1 2 3 4 5 6 7 8 9 10

Question 2.4.2 To what extent does obesity impact upon the health status of your local patient population ?Not at all Moderately Significantly

0 1 2 3 4 5 6 7 8 9 10

Question 2.4.3 To what extent does drug and alcohol misuse impact upon the health status of your local patient population?

Not at all Moderately Significantly0 1 2 3 4 5 6 7 8 9 10

Group Range Mean

a 3:8 5

b 4:6 4.8

c 1:4 2.5

Group Range Mean

a 7 7

b 6:10 7.6

c 4:9 7.6

Group Range Mean

a 6:10 8

b 8:10 8.6

c 8:10 9.3

Conversation 1 OutcomesQuestion 2.5 To what extent does social disadvantage complicate and compromise the health status of some sub-­groups within your organisation’s patient population?

Not at all Moderately Significantly0 1 2 3 4 5 6 7 8 9 10

With the exception of demographic pressures what seem to you to be the two major drivers of increasing demand?

Group A Group B Group C

Group Range Mean

a 10 10

b 8:10 8.6

c 9:10 9.5

1. Heightened public expectation inflating demand2. Information revolution > more ‘informed’ (or misinformed) patients

1. Unrealistic expectations that health system can solve life problems 2. Social media driven ‘health’ fads

1. Life style risk factors (drugs etc.) compounded by social disadvantage2. Increased expectations & awareness (fuelled by information/misinformation)

Health & Social Care Need

• Irish Demography– Post WWII spike in birth rate– ”Twilight of the ‘baby boomers’– Pension/health/social care/carer/impact

> 270% increase people 80+ to 2046• Accelerative growth in acuity, LTCs

and co-morbidity– “The number of people with dementia in Ireland

is expected to almost double over the next 20 years from current estimate of around 57,000 people to an estimated 112,000 by 2036 and to reach 150,000 plus by 2046” Prevalence and Projections of Dementia in Ireland, Trinity College Dublin, 2014

Health & Social Care Need

Ageing Ireland

12

Commensurate with the ageing of the population, Table 5 shows estimates of the projected

growth in the number of people with dementia by age group in Ireland at five yearly intervals

from 2011 to 2046. These estimates were calculated by mapping the EuroCoDe prevalence

rates onto the most recent CSO population projections (CSO, 2013). The projections show

that the number of people with dementia in Ireland is expected to double over the next 20

years from the current estimate of around 47,000 people to an estimated 94,000 in 2031.

Figure 2: Actual and Projected Population of Older People by Age

Group in Ireland, 2011-2046 (M2F1)

0

200

400

600

800

1000

1200

1400

1600

2011 2016 2021 2026 2031 2036 2041 2046

Source: CSO (2013)

No. of persons

by (thousands)

85+80-8475-7970-7465-69

The impact of ageing• Newcastle longitudinal study 2006 <– Assess the spectrum of health in the oldest old– advance understanding of the biological nature of human ageing– identify factors which contribute to or work against the

maintenance of health and independence• 1042 people born in 1921: 18 chronic diseases -

hypertension to dementia• “The average number of diseases was four for men and five for

women....• How we care for older people in our society needs a radical

rethink” Holden, 2014• “Managing frailty and complex LTC co-morbidity will present the

distinctive 21st Century challenge to clinicians, carers & overall systems of care” Stanton, 2004

‘Easily neglected’ allies• 200,000 carers provide €10 billion worth of care p.a. to older,

chronically ill and disabled adults and to children• ‘Share the Care’ asked Government to make three

commitments in 2018 Budget– greater investment in homecare– improved financial support for carers– allocation of additional funding for a new national carers strategy.

• Carers feel “undersupported and find it very difficult to access vital services, such as respite care”

• “The disproportionate numbers of women who may in the future develop dementia highlights the importance of using a gendered analysis to look at dementia and to explore the impact of dementia on women and men, both from the point of view of their being caregivers as well as care recipients”. Keogh et al Op Cit

•“Too long a sacrifice, will make a stone of the heart” Yeats

Conversation 2The three groups then discussed and recorded their answers to questions 2.6.2 to 2.6.4 (set out in the attached pre-­reading) – see Slide 23. They also recorded their individual answers to question 2.6.3 – Slide 24.The groups then agreed what they saw as the primary weaknesses in current models, patterns and locations of care for frail older people and those with co-­morbid LTCs – Slide 24.

Question 2.6.1 a To what extent does your organisation currently experience demand and resource pressures?Not at all Moderately Significantly

0 1 2 3 4 5 6 7 8 9 10

Question 2.6.1 b To what extent does your clinical specialism currently experience demand/resource pressuresNot at all Moderately Significantly

0 1 2 3 4 5 6 7 8 9 10

Question 2.6.2 How appropriate to needs of older patients are models patterns and locations of health/social careNot at all Moderately Significantly

0 1 2 3 4 5 6 7 8 9 10

Question 2.6.4 How much additional capacity currently exists within your own organisation to deal with the projected surge in demand, over the next decades, from older patients and those with complex LTCs?

Non at all Moderate Significant0 1 2 3 4 5 6 7 8 9 10

Group Range Mean

a 9 9

b 10 10

c 9:10 9.6

Group Range Mean

a 9 9

b 10 10

c 5:10 9

Group Range Mean

a 5 5

b 2:5 3

c 1:8 2.8

Group Range Mean

a 0 0

b 0:1 0.6

c 0:1 0.2

Conversation 2 OutcomesQuestion 2.6.3 approximately what % of local acute elective and other beds that are currently occupied by people who are 65 and above ?

20 to 45% 46 to 65% 66% and aboveIndividuals Group aIndividuals Group bIndividuals Group c

What do you see as the primary weaknesses in current models, patterns and locations of care for frail older people and those with co-­morbid LTCs??

Group A Group B Group C

1. Lack of co-ordination between health care providers2. Lack of co-ordination between health and social care

1. Ignoring inevitability of decline in later life 2. No public debate on impact of ageing on health services3. Inappropriate acute hospital focus4. Poor primary/secondary integration5. Pathways only exist during office hours

1. We are avoiding facing up to scale of challenge2. We do not manage frail elderly or LTCs effectively3. Staff and the system stuck in habitual ways of providing ‘care’

Two decades of attempts to initiate reform

• European Observatory on Health Systems and Policies lists 14 statutory & policy reform initiatives over last 2 decades

• Incremental, poorly aligned and only partially implemented change > no radical overall transformation in funding or in models of service provision:– Profoundly complex

• Entitlement & payment inter and intra public and private systems

• Bureaucratic and expensive to administer• Poor integration of physical and mental health• Structurally uncoordinated & opaque

• “Weaknesses, in any system of care, express themselves most forcefully, from the perspective of service users, at points of ‘transition’ -• intra-organisational interfaces;• organisational boundaries;• and sectoral frontiers -

• in an escalating hierarchy of risk and disruption.• Such ‘transitions’ and their consequences are mostly

invisible to clinicians many of who operate within defined and hermetic spheres” Stanton, UK DH, 2004

• “The extent to which the patient ‘journey of care’ is co-ordinated and managed is as important a contributor to safety and overall cost effectiveness as is the quality of the constituent and discrete ‘episodes’ of care” Kramer, UK CGST, 2006

• “The current range of services is costly, fragmented, episodic and difficult to negotiate” Slaintecare Report, 2017

A complex and fragmented system

A new way forward?• A commitment to cross party consensus > trans

electoral ‘transformational stability’ > 10 year plan• “Severe pressures on the Irish health service, unacceptable

waiting times that arise for public patients, and poor outcomes relative to cost mean that doing more of the same is no longer an option …integrated and co-ordinated health & social care is needed to respond to an ageing population with complex needs”

• Key elements (291 pages):• New funding model – primarily based on general taxation &

responsive to population health needs • universal single tier service with patients treated on basis of

health need rather than on ability to pay • Timely access to all health and social care based on need• Patients access care at most appropriate, cost effective

service level – strengthened prevention and public health

A new way forward?• Underpinning principles:

– best health outcomes and value for money achieved by re-orientating model of care towards primary and community with majority of people’s health needs met locally

– Services integrated; care planned and provided so that patient is paramount > appropriate & managed care pathways > seamless transition > full patient record

– Key enablers (1) Resource:• Adequate and secure funding• Significant and ongoing investment, circa €2.8bn phased

over 10 years (over & above medical inflation + additional demand - projected 6 years €380-465Mn p.a. tapering as savings achieved

• Transitional fund > €3bn investment across system on. infrastructure, e-health, expansion of training capacity

A new way forward?• Key enablers (2): Increased capacity > accessibility

• Reduction and removal of charges • Cárta Sláinte, entitling all residents to access

comprehensive range of services based on need - 5 year phase in]

• Adequate resourcing of child health and wellbeing services• Expansion of primary care, social care, mental healthcare,

dentistry > significant expansion of diagnostic services outside hospitals > vast majority of care delivered and accessible in primary and social care settings

• Expansion of public hospital activity– removal of private care from public hospitals - 5 year phase in

– replace €649m income - independent impact analysis of the separation

– specific waiting time guarantees (12 weeks in patient; 10 weeks Out Patient) & moving towards 4hr ED

A new way forward?• Key enablers (3): Simplified structures

• International evidence negative impact of system reorganisation > minimal structural change

• New ‘strategic’ role for HSE – “care groups”• System characterized by accountability, effective organisational alignment and good governance

• WHO ‘building blocks’ >Workforce > Leadership and Governance > Safety (?‘clinical governance’)

• Key enablers (4): Workforce expansion & investment• “A health service workforce appropriate, flexible, accountable, well-­resourced, supported & valued”

• New contractual arrangements > flexibility• Improvements and investment in training• Addressing historic staffing shortages across the system – additional consultant numbers

I think we could be a little more explicit here at step two

Conversation 3The groups then discussed and recorded their answers to the following questions:To what extent have you and other CDs/senior clinical colleagues been involved with the formulation of the Slaintecare report? – Slide 34What do you see as the major strengths in the recommendations? – Slide 34What do you see as the major flaws or omissions from the report? – Slide 35What do you see as major obstacles that will need to be overcome if the reports key recommendations are to be implemented? – Slide 35

Conversation 3 OutcomesTo what extent have you and other CDs/senior clinical colleagues been involved with the formulation of the Slaintecare report?

What do you see as the major strengths in the recommendations in the Oireachtas SlaintecareReport?

No involvement at all Minimal involvementNot at all

1. Political agreement on need for change

2. Agreement on need for one tier system

3. Recognition of need to move to primary care led model

Universal access to healthcare free at point of delivery

1. Principle of free universal provision

2. Priority given to community based provision of care

3. Longer term perspective and cross party consensus

Conversation 3 OutcomesWhat do you see as the major flaws or omissions in the Slaintecare report?

What do you see as major obstacles that will need to be overcome if the reports key recommendations are to be implemented?

1. Central command and control implementation model

2. Failure to recognise or address demographic time bomb

1. Absence of detail on the how, when and by whom of implementation

2. Expecting/relying upon a miracle to turn recommendations into new reality

1.Naïve account of how structures will be ‘simplified’2. No clarity re who decides if particular ’needs’ are a priority3. Magical and wishful thinking re scale of implementationchallenge

1. Level of financial investment needed:

2. Risk averse political & professional cultures

3. Resistance to shift to primary care led provision

1. Robust and credible financial plan with costed tax Implications2. Separation of public/private provision3. Funding implications of that separation

1. Politics – ‘pork barrel v parish pump’

2. Unions and workforce agreement

3. Deep seated cultural resistance to change

Implementation?• Caveats (1)

• “One of the strongest concerns of the Oireachtas Committee is to ensure that this is not just another report on the health sector which is not implemented –resistance from vested interests”

• Political will – necessary but not sufficient• Support from Boards of constituent hospitals etc.• Report shifts between strategic aims and detailed operational prescription

• Implementation mechanisms are predominantly ‘top down’ and driven from and by the centre –“We need to bring decision-­making closer to the point of care delivery, & provide counterweight to the unnecessary over-­centralisation… Recommend the early establishment of an Implementation Office under the auspices of An Taoiseach, reporting directly to the Minister for Health“

Implementing transformation?• Political caution/realism – MOH Response 23.06.17

– “It is only a first step…It is appropriate that we now allow time to reflect and deliberate on the findings and consider how best the vision and spirit of the Committee’s report can be realised

– The first obvious challenge …is that of current capacity. To be blunt, our starting point is not good. A review is underway …

– I understand the desire of many to move quickly on the recommendations and to demonstrate real momentum but we need to balance this with the potential consequences of rushed or incomplete implementation plans..”

• “Despite the priority given to the Report by the new Taoiseach in June, there is neither sight nor sound of the proposed Implementation Office or of the MOH’s’ detailed response’ to the Report.” Health Reform Alliance, August 2017

Implementation?• “Moving to a universal integrated single tier public health service

presents major workforce planning challenges [&] must put in place conditions of employment that will make our health system the employer of choice for the most talented staff.” Irish Congress of Trade Unions

• Professional groups as well as Trade Union group highlighted current staff morale issues across healthcare system - at both primary and secondary level and in social care

• Widespread “reform fatigue” > staff buy-in to any change will be a challenge.

• “The current public health service, in particular the Hospital sector, is increasingly difficult to work in. We have never seen morale as low.” Dr. M. O’Mahony, Galway University Hospital

• “Changes in contracts will not be easily achieved and this cannot be at any price to the taxpayer. It would be naive to consider that there will not be resistance to change in these and other areas”. Minister of Health, June 2017

Welcoming a new setof challenges

Clinical involvement & leadership• “For too long, policy has been developed by politicians and by civil

servants who are detached from the reality of care provision. Senior clinicians, alongside front line professional colleagues must, in the future, shape policies that they, and they alone will need to implement” Stanton, UK DH, 2007

• “Leadership must be visible, receptive, insightful and outward looking at all levels in an organisation, from board to ward…

• In particular, the gulf between clinicians & management needs to be closed....

• Clinicians must be engaged to a far greater extent in senior leadership & managerial roles” Francis Mid Staffs Public Inquiry, 2010

• “Although senior leaders set the tone, line managers are the people who really make the difference to staff engagement…

• Neglected by reform initiatives, they became the ice in the heart of the Met – stifling attempts to change its culture” Lawrence Inquiry

Maximising your individual contribution to whole system transformation

Learning is a process – not an ‘event’.Horizontal contextual as well as vertical clinical understanding is vital if senior clinicians are to optimise their contribution to system reform.Reflect on your own leadership and change management learning needs.Keep these under periodic review through appraisal and seek imaginative ways to address these needs.

Conversation 4Finally the three groups addressed and recorded their answers to the following questions:How can CDs and senior clinicians most effectively influence and shape the service transformation debate? – Slide 43How might the ‘gap’ between clinicians and Executives and Senior Managers be closed? – Slide 43Identify 3 constructive ‘next steps’ – Slide 44

Conversation 4 OutcomesHow can CDs and senior clinicians most effectively influence and shape the service transformation debate?

How might the ‘gap’ between clinicians and Executives and Senior Managers be closed?

1. Make persistent and constructive contributions to the debate2, Keep faith in need for & possibility of reform3. Use ‘coal face’ new forms of care examples4. Promoting well-being for all grades and types of staff & foster greater two

way understanding

1. Generate ways to be actively involved in reform debate – at present we are not invited to attend or contribute2. Increase constructive local interactions with non clinical managers and executives

1. Proactively develop links and relationships with executives and colleagues across the organisation

2. Persist in promoting and advocating improvement and reform

1. Empower CDs:2. Include management

component in clinician roles

3. Build real time data systems that support clinical practice and system management

4. Provide training in management for Drs & medical students

1. Formation of formal matrices to facilitate clinical/managerial connections and linkages2. Promote reciprocal education and learning opportunities across the clinical/managerial divide

1. Build personal relationships with management colleagues

2. Create opportuntiesto develop understanding of each others roles and pressures

Conversation 4 OutcomesIdentify 3 constructive ‘next steps’

1. Focus on management of points of ‘transition’2. Develop KPIs on integration of care common to different organisations along care pathway3. Raise profile of long term planning

future proof strategy

1. Clinicians foster links to managers

2. Promote shared learning forums to promote reciprocal understanding

3. Develop medical management faculties in medical colleges

1. Keep chipping away at resistance to changes that will improve care

2. Develop local strategies to make provision fit for the future.

3. Look for early wins

Constructive ways forward

• Maintaining focus on the important: “If you have more than six priorities you don’t have any priorities” Berwick, IHI

• Pro-active involvement > powerful & constructive consensual voices • “Change is the one 21st Century constant.

• If you don’t shape a new landscape of care, it will shape and may well distort you and your colleagues and end up harming patients and failing those in our communities who are most vulnerable”

• It requires courage, vision, energy and above all persistence to lead profound value based transformation” Kings Fund, 2017

• “Illness is neither an indulgence for which people should have to pay...

• nor an offence for which they should be penalised...

• but a misfortune the cost of which should be shared by the community” Aneurin Bevan, 1948

• A challenging, but honourable pursuit

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