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Leading from the front to get Sláintecare up and running

Sláintecare is a long-term plan to fix the health service.  It is the product of an all-party Oireachtas committee, with a commendable level of input from stakeholders, including patient advocacy groups.   From a service design perspective, it makes a lot of sense, even though there are some important omissions, including the need to embed clinical research into practice at all levels and a commitment to support academic clinical practice.

But over one year from its launch, we remain in the same  ‘crisis fire-fighting mode’ that led to the formation of Doctors Alliance in 2006/2007.  We were an advocacy group that came together to argue against privatisation of Irish healthcare. The financial crisis intervened, with the ensuing consequences for all services.

Eleven years on, strategic planning of the public health system  seems a luxury that is continuously deferred. Sláintecare is already behind target and there are real concerns that the necessary funds may not be available  to implement the required changes.    Cross-party collaboration appears to have fragmented and partisan politics seems to have re-emerged. 

This is a great shame. Without political will, the prospect of multi-annual budgeting with investment in the necessary changes is remote and Sláintecare is at risk of being relegated to the shelves containing all of the previous blueprints for reform.  

Staged implementation

But perhaps we should try to be more optimistic. Not all aspects of Sláintecare need to be implemented at the same time. Notwithstanding all of the crises, small changes that we make can positively impact on the lives of our patients. We must continue to advocate for the vision of a responsive healthcare system that is free at the point of entry, accessible and based on need and not on ability to pay. But it is possible, indeed imperative, to try to build upon what is good within our system. We should recognise the  initiatives that reflect the broad principles of Sláintecare, advocate on their behalf, and ensure that they are formally embedded within the system and replicated where possible. 

Patient groups

In this context, there is much that can be achieved with grass-roots support. There is a major and under-used role for patient groups here. In Ireland, many patient organisations already provide services that are part of standard healthcare systems in other countries. Harnessing this patient-oriented expertise, and embedding it within the existing delivery of care, can help to integrate services that are otherwise fragmented. There is considerable appetite within the voluntary sector in this regard. 

Examples of how this operates include the specialist nursing service provided by the Irish Motor Neurone Disease Association (IMNDA). These nurses, funded entirely from philanthropic donations to the Association, work closely with the National MND clinic in Beaumont Hospital, and ensure care is fully integrated between hospital and community-based services. The IMNDA also maintains an equipment bank that is available to patients based on clinical need rather than ability to pay. This is Sláintecare in action.  And the IMNDA is not alone.  Many other voluntary organisations provide similar types of clinical services. 

Mainstreaming funding for these services through well-governed patient advocacy groups could provide targeted and sustainable care for patients, fully aligned with the aspirations of Sláintecare. 

Community setting

One of the fundamental planks of Sláintecare is to provide appropriate care for patients close to their home, preferably within a community-setting. This requires that we value, promote and enhance the work performed by those working within primary care and that we seek to  enhance the co-ordination between specialist teams and primary care teams. 

There are many excellent primary care teams across the country. Clearly, the essential role of the GP must be recognised and valued. This is essential for Sláintecare to work.  In the meantime, we can seek to provide better integration between hospital services and professionals working within a community setting. This could  be achieved with some planning and modest additional investment of liaison services. 

It is also possible to think laterally about how we might address the long waiting lists for some of our specialist clinics in Ireland.  In many instances (including neurological care), Irish clinics  have a much  lower new-to-return ratio than in other countries. The reasons for this are multifactorial, including the perverse incentive that drives those without medical cards to hospital clinics (free) rather than GP services (payment required). Notwithstanding this, there remains considerable scope for referral of patients with stable conditions to community-based services. This could be achieved at modest cost by providing supportive outreach services, including specialist nurses and dedicated phone lines. Such a model has already been successfully developed for some conditions (eg, diabetes, epilepsy, etc) and could be replicated.

Moreover, audit of outpatient referrals to specialist services indicates that the most common referrals of new patients can be categorised into groups of common symptoms. For example, in neurology, the majority of referrals  include requests for assessment of headache, dizziness, seizures, falls, and non-specific neurological symptoms. A high percentage of these patients receive return visits, which would not be the case in other healthcare systems.  Return visits could be reduced if systems were in place for review of investigations and structured management plans implemented. This would require a modest investment in IT infrastructure, and a system of reliable communication between hospital services and primary care.

Standardising clinical practice

And with respect to hospital-based inpatient care, there is considerable variance in the utilisation of resources both within and  across hospitals. To date, there has been limited appetite for examining this variance to understand the underlying factors.  While clinical independence is highly valued by Irish clinicians, it is also important that wide variances in clinical practice are captured, evaluated, and where necessary, modified to ensure both  good clinical practice and responsible use of resources. 

A national audit of resource utilisation would be difficult to implement at present. However, a pilot study within a small number of teaching hospitals through the Clinical Leads programme could be feasible. Designated individuals could be trained in methodologies to measure variance. This in turn would provide an early indicator of the likely variance within and across centres in bed utilisation, resource utilisation and diagnostic complexity.

Sláintecare is the best chance that we have to develop a properly-functioning and integrated system of health. The roadmap to improve our healthcare system has been drawn. There is no doubt that we must hold our politicians and policy-makers to account to ensure the provision of  long-term, multi-annual funding to facilitate this.      

But at the same time, as healthcare practitioners, we also have a considerable opportunity to lead from the front. Anybody for  Doctors Alliance, Version 2?

A plan for implementation

More than a year after Sláintecare was released, the Government published an implementation plan for the strategy in August. This followed the appointment of Dr Tom Keane as Chairperson of the Sláintecare Advisory Council and Ms Laura Magahy as Director of the Sláintecare Programme Office.

Key actions in the first three years of reform include:

Establish HSE Board and reconfigure the HSE to improve accountability and support integrated care.

Deliver a new model of healthcare through the development of a Citizen Care Masterplan for the health service and new models of care that are population-health centred.

Launch a programme of public engagement on Health Outcomes and a nationwide series of events in 2019/2020 to promote health and wellbeing.

Enhance community care, including the expansion of community-based diagnostics facilities, a new community nursing service and a continued programme of investment in primary care centres.

Reform the GP contract, including providing for a greater role in chronic disease management.

Continue investment in community mental health services.

Introduce a new statutory scheme for homecare services.

Review the eligibility framework to develop a roadmap to achieve universal entitlement.

Increase bed capacity in public hospitals.

Choose locations and commence the planning process for new elective hospitals in Cork, Dublin and Galway.

Tackle long waiting times for acute hospitals by continued investment in the National Treatment Purchase Fund (NTPF) and the development of an integrated waiting list management system.

Develop a national clinical strategy and Hospital Group strategic plans to guide organisation of hospital services.

Roll out eHealth systems and infrastructure.

Source: Department of Health

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