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A question of capacity

International health experts engaged by the Department of Health (DoH) strongly challenged its decision to exclude acute hospital workforce planning from the Health Service Capacity Review, according to documents obtained by the Medical Independent (MI) following a Freedom of Information request.

As part of the process of developing the Review, which was a commitment in the 2016 Programme for Government, the Department convened an International Peer Review Group (IPRG). It comprised of Mr Steve Wright, a Luxemburg-based international consultant in health policy and finance; Prof Niek Klazinga, Professor of Social Medicine, University of Amsterdam, The Netherlands; and Ms Carolyn Gullery, General Manager, Planning, Funding and Decision Support, Canterbury District Health Board, New Zealand.

Last September, the IPRG members gathered at Hawkins House to meet Department officials and representatives of PA Consulting, who were engaged to provide “technical, analytical and engagement expertise”.

Meeting minutes obtained from the Department show that the IPRG advised against excluding workforce planning in acute hospitals.

On the scope and purpose of the Review, the IPRG members “noted that there is no mention of staff resourcing of acute hospitals or of any costings in the material circulated. DoH confirmed that the Review will not address workforce planning, except to the extent necessary in primary care or full costing, as these would be very time-consuming and will be happening elsewhere outside of the project.”

The IPRG sought to confirm that the Review was “not just about number-crunching but also to be policy-focused”. This was confirmed to them, according to the minutes.

There was also significant concern about the level of focus on beds as a measure of capacity. “The IPRG’s question regarding the Review’s intended outcome is, what is the DoH going to do with this report, and what other work will it lead to? They suggested not to dress it up just to secure more beds. A modernising health service should not look to beds as the answer, and should move away from the bed focus.  The Review must take account of current hospital processes and underpin a modernisation of hospital processes and related primary and social care services.”

The minutes added: “Notwithstanding previous comments around the scope of the Review, the IPRG members stated that workforce planning is the key future issue, and Ireland must try to reverse the migration trends of its health staff. For example, NZ [New Zealand] had a similar migration problem with GPs and nurses, which was solved by re-orienting the health system around the GP, with appropriate staffing and infrastructural support. It allowed the GP to deliver more complex care while the practice nurse was able to deal with management of people with multimorbidities. Improvement in GP access to diagnostic/test results (at same speed as hospital) was also a factor.”

Mr Wright expressed the opinion that the Review was effectively an analysis of demand and infrastructure capacity and not a “full capacity-planning exercise”.

The minutes continued: “To be a broader capacity review, it needs to also include an acute workforce element, which is the biggest constraint in hospitals, as without it, bed capacity is an almost meaningless measure of capacity. It was also suggested that the Review needed to examine costs to determine cost-benefits — for example, the costs of running the system and the costs of managing change.”

The IPRG stated that beds were “the least important measure of acute capacity, particularly in the long-term. What is important is how you transform the acute sector and link it to primary care and home care/long-term care. Beds are irrelevant to making a hospital work. They fulfil two main roles: (i) transitioning patients between care services; and (ii) a buffer when the system slows down. There is a latency in the system while decisions are being made (about patients). Patients need to be moved on. Don’t look to use more beds as a buffer to keep patients in a holding pattern. Adding capacity won’t help if the issue is the inability to process patients fast enough.”

The experience of Canterbury, New Zealand, was discussed. It has “only 30 acute beds more than it used to have, but it has reduced ED attendances and admissions, reduced ALOS [Average Length of Stay] (0.5 days), reduced bed days, while improving primary and social care and coping with an ageing population. They ‘spun’ the system. In NZ, the health boards have 97 per cent accuracy on predicting ED levels three months ahead. The Canterbury acute system focuses on ‘pulling people through and out of the hospital’. The amount of work you can do, rather than the number of beds you have, is the main constraint on your ability to achieve the potential quantity and quality of healthcare which can be delivered.

“You need people to change the way doctors (GPs, consultants, NCHDs) and nurses function and redesign processes accordingly. You could grease the wheels by offering a ‘bribe’, such as new facilities, new functions, investment.”

There was reference to 30 per cent of activity by hospital specialists in New Zealand being remote/virtual, eg, tele/video contact with GPs and patients and other consultants.

The IPRG also strongly suggested that analysing information on theatre capacity and usage was “very important” to the Review.

In comments on the Government’s capital review, the IPRG members advised that many countries were reducing acute bed numbers.  “While it was noted that acute capacity will become degraded over time, the trend internationally is to build replacement hospitals and not do refurbishments or expansions of existing hospitals. You could also rationalise by agreeing to replace two old hospitals with one new one.”

‘Wide consensus’

The Health Service Capacity Review, which was published by the Department in January, echoed the themes of the Sláintecare Report, released in 2017 by the Oireachtas Committee on the Future of Healthcare.

It referred to a “wide consensus” that the current health service was not fit for purpose and needed to “evolve considerably in the coming years”.

The system was overly hospital-centric, community-based services were fragmented and there was lack of integration within and across services.

There were various views among stakeholders on capacity levels in the current system, noted the Review. “Two contrasting views are often cited. The first focuses on access issues such as long waiting times and potential high levels of unmet need to suggest that there is significant under-capacity in most parts of the health system. High bed occupancy levels of the order of 95-to-100 per cent in the acute sector further support this position.

“By contrast, a second view is expressed that high levels of funding, combined with suboptimal outcomes and patient experiences, suggests there are fundamental issues with our model of care and significant performance and productivity issues across the health system. The argument is made that the problem is not with the level of capacity, but how that capacity is being used. Both views are valid, but offer only partial explanations of the problems being currently experienced.”

Two forecasts

In the Review, two sets of forecasts were provided. The first was based on no major change to the current system, and the second on the basis of “significant reform and productivity improvements happening over the next decade”.

Without reform, the following capacity increases were projected to meet increasing demand up to 2031: Over 7,000 extra acute hospital beds, 37 per cent increase in primary care workforce, 12,000 extra residential care beds, and 70 per cent increase in homecare.

However, if reforms were implemented, the following capacity increases were required: Nearly 2,600 extra acute hospital beds, 50 per cent increase in primary care workforce (including approximately 1,000 extra GPs, 1,200 extra practice nurses and 1,100 extra public health nurses), 13,000 extra residential care beds, and 120 per cent increase in home care (home care packages and home help hours). The Review said the two scenarios provided “the extremes for a range of possibilities for the capacity needed within the system”.

It also highlighted that Ireland’s acute hospital occupancy levels were around 95 per cent, far in excess of the “international norm” of 85 per cent. The acute hospital system would need “an immediate injection of the equivalent of an additional 1,260 beds” to meet international norms of bed occupancy.

The National Development Plan 2018-2027, published in February, has committed to a number of “major investment projects and programmes, along with significant reform initiatives” with funding of €10.9 billion, although a breakdown of costs was not included in the Plan.

According to the Plan, 2,600 additional acute hospital beds will be delivered across all Hospital Groups, including in “new, dedicated elective-only hospitals in Dublin, Cork and Galway to tackle waiting lists and provide access to diagnostic services”. The NDP also commits to 4,500 additional long-term and short-term residential beds in community nursing homes in the public system, additional primary care centres and community diagnostic facilities, as well as more facilities for mental health services and for people with disabilities.

“As recommended in the Sláintecare Report, investment in ICT infrastructure will enable the integration of services and flow of information across and within various care settings. This includes the National Electronic Health Record Programme, vital to make patient information available through technology to support improved patient care, safety and efficiency.”

But many question marks remain over funding levels and regarding the Government’s commitment to Sláintecare, with an implementation plan yet to be published by press time.

On 15 January last, in response to the draft National Development Plan, Minister for Health Simon Harris wrote to Minister for Finance, Public Expenditure and Reform Paschal Donohoe to express concerns in relation to health funding needs. The total amount of funding required, as identified by the Department of Health, was redacted from this released letter.

Minister Harris wrote that “greater certainty” was required on funding than was contained in the draft of the NDP. Among his concerns was “the need to take account of the current review of health sector capacity and the implementation of the Sláintecare Report, both of which will be published in the near future. This relates to the early years of the Plan in addition to later years, in particular the Capacity Review and Sláintecare Report will both call for a front-loading of new acute capacity and eHealth investments.”

Minister Harris wrote that he was “extremely anxious” that the NDP give careful recognition of his Department’s work on the Capacity Review, Sláintecare implementation plan, eHealth and other health strategies, along with health commitments in the Programme for Government.

Before it was published, the Health Service Capacity Review was consistently referenced by Government as the means by which system deficits would be identified and addressed. But it has generated further questions since its publication in January. This was most apparent in April, when representatives of PA Consulting met with the Oireachtas Health Committee.

In response to questioning at the Committee, Mr Chris Nightingale of PA Consulting said that “within the scope of the report, the workforce was explicitly ruled out by the Department. We were explicitly told not to do a workforce review because one was already ongoing with the HSE.”

Mr Nightingale also said it was “challenging” getting data from the HSE. “We undertook a 16-week project, with a four-week time scale for collecting data. We were still looking for stuff in week 12. That was something we encountered. However, we did get good information from the Hospital Inpatient Enquiry data system.”

He further stated that “initially, the plan was to include theatres [operating hours] and diagnostics as key resources in the acute sector. It was not possible to get the associated data in the time available. We explicitly asked for it on several occasions. One reason was that we would have had to go to individual hospitals to get the data, as there was no centralised dataset that we were given access to, despite requesting it.”

Sinn Féin Health Spokesperson Deputy Louise O’Reilly told MI she felt the PA Consulting representatives were “dissatisfied” with the terms of reference.

“The thing I was pushing for [at the meeting] was the fact they didn’t look at the staff… it was a relatively simple exercise, I felt, that they [the Department] were paid a lot of money for, to really not get a massive amount of information that we wouldn’t have already.

“And the fact there was no manpower plan put into place at all — I found that outrageous. I mean, identifying that we have a deficit in our bed capacity, sure, the INMO do that for us every single day. Looking at yesterday, we had 380 too few beds — 380 people on trolleys. The fact that we have a deficit and an issue — that is already an established fact. It wasn’t a review in that case, it didn’t say ‘we need X number of beds and X number of nurses’. But when I probed them on it, what they said — and they were very clear about this — was they were explicitly precluded from looking at the staffing implications.”

””

Deputy Louise O’Reilly, Sinn Fein Health Spokesperson

On the fact that the HSE is working on workforce planning, Deputy O’Reilly says these processes should have been married together.

However, on the absence of a workforce planning element, Prof Colette Cowan, CEO of UL Hospitals Group, says National HSE HR has done a lot of work in that area. She believes the figure of 2,600 additional hospital beds by 2031, dependent on reform measures, is “well measured”.

“There was a steering committee set up for that Capacity Review and in fact, my chief nurse was a member of it and she used to feed back, and we would put our opinions in about it. I think the main thing is that we don’t just keep building beds in the system if we don’t have reform attached to it… ”

She said University Hospital Limerick has an immediate deficit of 100 beds just to stand still (see panel).

Meanwhile, the Department of Health said the Government “has committed to fully funding the findings of the Review”. The spokesperson said that a draft submission has been received from the HSE on beds that can be opened in 2018 and 2019 to “alleviate” overcrowding.

The spokesperson said the Review was “never intended” to include workforce planning.

UL Chief: ‘My utopia would be no patients on trolleys ever’

University Hospital Limerick (UHL) regularly has the highest number of patients on trolleys in any of Ireland’s public acute hospitals.

On 26 June, this was again the case, with 23 patients on trolleys in wards and another 23 patients on trolleys in the emergency department, according to figures from the Irish Nurses and Midwives Organisation (INMO).

“Around capacity, we are unique, as we have only one emergency department in the region. And our activity continues to grow,” UL Hospitals Group CEO Prof Colette Cowan tells the Medical Independent (MI).

 “Last year, we saw 68,000 people come through the department, and even this year, we can tell you it is up 7 per cent already… We know already from our own analysis of our bed capacity that we are short of capacity to the tune of over 100 beds, just to come in line with other model 4 hospitals in the country.”

UHL has approval for the design phase of a 96-bed unit. However, it is a three-year project, while the capacity demands are immediate. As such, the hospital has drawn-up a plan for a 60-bed modular unit that could be constructed over a 12-month period.

Prof Cowan met with Minister for Health Simon Harris and his officials to examine the proposal. “The meeting was very positive. My sense was, they understood the capacity need for the region.”

However, while there is approval to proceed to the planning phase for this modular unit, full approval is awaited. Prof Cowan says funding is required as soon as possible.

UHL is in ‘full capacity protocol’ mode on most days. This means elective work is reviewed but Prof Cowan insists cancellations are “minimal”. She also says that “on any weekend, you could have between five and 10 beds closed for 12 hours [at UHL] to allow us to deep-clean them” for infection prevention and control purposes. However, she says that generally, no other beds are closed.

One of the changes instigated over the last year was limiting the number of patients placed on wards in response to the concerns of staff. Previously, up to three patients could be placed on trolleys on a ward for 24 hours, but it was agreed that only two patients would be placed on trolleys at ward level, one at 7am and one at 9am, with ward managers responsible for finding the patients a bed.

There is also an ongoing patient flow project called LEAF, which was adapted from LEAN methodology and kaizen events, where staff are brought together to identify areas of improvement. 

“Our recent LEAF event was the acute surgical assessment unit, which we refurbished and opened about two months ago and they did a LEAF on it and allowed us to have very streamlined processes. And the benefit I note… is they are taking five or six patients a day directly out of the emergency department, whereas before, those patients would have to wait there to be looked after, so it is all about efficiencies and LEAN management.”

Diagnostics is an issue for UHL at weekends, confirms Prof Cowan. It has one magnet (MRI) and requires a second one.

“The fact we only have one and it is an extremely busy service, we have to outsource patients… At one time, we had insourced a company to assist us out-of-hours around the scanner… in the recent 12 months, we have been successful in hiring additional radiologists and radiographers into the service, which will help, but we are at a point at the moment where we don’t have enough skilled staff to run the current magnet that we have, and on top of that, it is actually so busy that we would need a second magnet and the staff.”

She also believes the salary scale of consultants must to addressed to aid recruitment and retention.

 “In my view, we really do have to address the salary scale of consultants, particularly new consultants post-2012, because I know there has been an agreement in recent weeks for pre-2012… There is a window of time when you can attract them home, when their children are young mainly, before they put them into the schools in America. But the salary offered to them is just too low a base for the work they do, and we are all in agreement that there has to be a negotiation of the contract because the cuts to their salary scale definitely did us damage on retaining or recruiting top consultants into the health system in Ireland.

 “I have hired 15 consultants, believe it or not, in the past four years, and it is great to have all that new energy. But we have 10 posts we are currently trying to recruit.”

Dr Gerry Burke, a Clinical Director at UL Hospitals, has stated that the Group is operating at a deficit of 560 frontline staff. But Prof Cowan takes issue with this figure.

“Dr Burke is a great colleague of mine; he is Clinical Director for Child and Maternal Health and he analysed data he received from the system and there are different views on how data is mined, as you know. So 560 would be… fantastic. But we have had a lot of staff growth; we have 4,000 WTE in the Group. When I arrived here, there were 3,600, so we have grown staff but what has happened is, we have opened a lot of new facilities and staffed them and our focus now would be to turn and look at areas that might have deficits… in my view, we need another 100 WTEs to keep the service maintained and running at all times across the Group.”

MI asked Prof Cowan her thoughts on commentary that focused on inefficiencies and bad management in the acute hospital service. 

“We could listen to that but we actually work in the service so we know how difficult it is, and we try to be efficient, and of course there are inefficiencies in certain areas. So it is a continuous cycle of trying to reinvent and change and make it more streamlined. But public expectation is high. It is very difficult for patients when they have to wait on a trolley — it is very difficult for us to even see a patient waiting on a trolley — so we work on that behind the scenes all of the time and unless you are in the system working it is very hard to understand. So the perception would be there that we are bad managers, or that we are inept, but the fact is, we do understand that people don’t understand the complexity of what we are trying to do.

“My utopia would be no patients on trolleys ever and that’s where we need to end up with it — zero tolerance. It is a long road.”

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