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A new dawn for elective care?

Details of a plan for three new elective-only hospitals were revealed during the recent RCSI Charter Week, writes David Lynch

Three new dedicated ambulatory, elective-only hospital facilities will have 10 specialties represented and work six days a week for 50 weeks of the year, the annual conference of the National Clinical Programme in Surgery (NCPS) heard. The virtual conference was held on 3 February as part of the RCSI Charter Week.

Mr Kenneth Mealy, immediate past-President of the RCSI and NCPS joint Clinical Lead, laid out the main aspects of the elective hospitals oversight group’s (EHOG) preliminary business case for the separation of acute and elective care.

Mr Kenneth Mealy

This was the beginning of the consultation process and the EHOG was eager to obtain feedback on the plan, outlined Mr Mealy, a Consultant General Surgeon.

Single event procedures

The EHOG preliminary business case recommends that 10 specialties be represented in the new hospitals as these specialties “lend themselves to single event procedures.”

These 10 specialties are orthopaedics, general surgery, ophthalmology, urology, gynaecology, ENT, plastic surgery, gastroenterology, pain medicine and vascular. Radiology facilities will also be included in the new centres.
Other specialties were excluded because of the complexity of patient needs (for example, cardiology), or because they have their own care programmes (paediatric and cancer services).

It is estimated that 250,000 to 300,000 procedures could be carried out on a combined annual basis

“We are talking about these hospitals providing work six days a week, operating for 50 weeks of the year,” said Mr Mealy. It is estimated that 250,000 to 300,000 procedures could be carried out on a combined annual basis in these hospitals.

The most recent National Development Plan stated that “new dedicated ambulatory elective-only hospital facilities will be introduced in Dublin, Galway, and Cork”. These facilities “will provide high volume, low complexity procedures on a day and outpatient basis, together with a range of ambulatory diagnostic services”. The introduction of these dedicated elective/ambulatory sites is also in line with the recommendations of the 2018 Health Service Capacity Review and the Sláintecare Implementation Strategy.

In 2019 the Sláintecare Programme Implementation Office established the EHOG to guide the development of the site.

E-health

During his presentation Mr Mealy emphasised the importance of a significant e-health infrastructure for these new hospitals and the care pathways within them.

“It really is imperative that these care pathways have attached to them a sophisticated IT platform that allows integration with primary care,” he said.

“The purpose of these pathways is that GPs can refer in, electronically, patient requirements.”

He said a successful IT platform would mean “patients only need to turn up to these facilities on one occasion”. Pre-operation assessments could be carried out virtually.

“This has to be integrated into the greater Sláintecare vision, it is really important that they are integrated into primary care and this allows an electronic platform to happen in a seamless fashion,” he said.

“And it is important that this electronic platform is developed in tandem with this hospital planning. Locally we need consultation with the current Hospital Groups, and the regional health areas if they come about.”

Mr Mealy described the plan for the three hospitals as “the most significant investment in scheduled care that has ever taken place in this country”.
No figures for the cost of the hospitals have been provided as yet.

The surgeon warned that without the introduction of these new elective ambulatory care centres, there will be unsustainable pressure placed on current hospitals in the coming years.

Mr Mealy said that the separation is needed “because every time there is surge in activity in the acute sector, the elective sector suffers”. Other reasons for the move include demographic challenges and current long waiting lists.

He noted that the Sláintecare Implementation Plan indicated that three elective care hospitals be built in Dublin, Cork, and Galway, however, he said no decision was made in the business case on the locations for the hospitals.

The “preliminary business case is in the process of being finalised as we go out for consultation”.

Mr Mealy added: “I think it is important to say that there is no standardised day case surgical model… anywhere around the world.”

Following “a review of international data” Mr Mealy said the EHOG had chosen a day case ambulatory case model for the centres.

“Partly because it is effective for dealing with such a high proportion of the patients that we currently know who are on waiting lists, and it’s economical and practical and easier to integrate into our current system,” he said.

He added that this model encourages one-stop type treatment when patients have low acuity needs.

“It is absolutely clear, though, that complex cases cannot be treated in these centres and it is also a given that if complications were to arise in patients they would need a very clearly defined protocol for transfer,” he said.

Mr Mealy said the new hospitals should cut waiting lists and free up capacity in the acute sector when it comes to theatre space, although this may be less likely in respect of bed capacity. He noted that “ambulatory care centres are also cheaper to build and cheaper to run”.

“With the development of this model, one could also hope in years to come that we could also suck in other services as we become more proficient.”
Mr Mealy noted that some hospitals currently have plans in place to develop their own ambulatory care centres and that “we really need to work with them to see what their needs are”.

He added that the three new hospitals would “offer wonderful opportunities for postgraduate and undergraduate training”.

“One of the advantages of these centres I think will be the standardisation of processes across the country.”

‘Open mind’

Speaking to the surgeons and other delegates in attendance at the virtual meeting, Mr Mealy said: “I would ask you to enter this process with an open mind, it will pose challenges for many of us in the sense that we will all have to work, perhaps, in a different way, but I would ask everyone to focus on the central issue here – what do patients want and need?”

He said the aim is to provide patients with the best access to surgical services. Over 2,000 surgeons from across the world joined the RCSI for its Charter Week. The virtual programme involved 120 speakers from five continents.

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