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The HSE’s report on Community Healthcare Organisations (CHOs) was published in October 2014, providing a blueprint for an integrated approach nationally to non-acute healthcare.
The complex integrated model of care that was proposed included many facets under the umbrella of nine CHOs, each covering a population of around 500,000.
In the two-plus years since the report was published, developments have been taking place but at a slow place, as predicted by the HSE itself.
“The introduction of integrated care takes a significant period of time to implement. Even countries recognised as having made significant advances in the area have been working on the concept for two decades or longer,” the report noted.
Much has been written internationally about the benefits of integrated healthcare. It seems all healthcare professionals are in agreement on the principle of integrated care and its potential patient advantages within a busy and often fraught healthcare service.
What is yet to emerge, however, is whether the HSE will succeed in its practical plan for integrated care, a plan that some believe may not be the right one for Ireland.
Furthermore, more than 100 GPs are to be hired to fully implement the CHO structure. Will the HSE be able to fill these posts?
Achievements to date
The new structure is currently being embedded, along with the staff needed to implement it, according to the HSE.
A spokesperson told the Medical Independent (MI) that the Chief Officer posts for each of the nine CHOs have been filled.
“Each CHO has a Chief Officer and all nine positions are filled. Each CHO has a Head of Service for each of the four Divisions (Mental Heath, Primary Care, Social Care, Health and Wellbeing) and all 36 positions are filled. Each CHO has a Head of Finance and a Head of Human Resources and all 18 positions are filled,” the HSE spokesperson told MI.
“The majority of CHO management posts were filled from within the Health Service group (HSE, TUSLA, Department of Health, Funded Agencies, Section 38).”
Each CHO is responsible for all care outside of hospitals, including the four divisions, major emergency management and inter-agency integration.
The HSE advised that the CHO sub-structure is currently designed “in draft” as the changeover to the new structure occurs.
“Many of the previous structures are outdated and, while these new details are being finalised and negotiated, there is a need to maintain some elements of the older governance systems,” the spokesperson noted.
“In this regard, a number of those appointed as Heads of Service were previously general managers and they are being backfilled by Specified Purpose Contracts, pending the finalisation of the detail of the sub-structure across each of the four divisions of the CHO. Twenty-one temporary general manager posts were recently filled, again from within the health service group.”
Within each CHO, between eight and 14 primary care networks are to be established, with the country now mapped into 96 primary care networks in total.
Each network will have a GP Lead and serve an average population of 50,000. Each of the nine CHOs will have a GP Lead and another overall GP Lead will also be appointed, bringing the total number of GPs required to 106.
According to the HSE, work completed to date includes the development of an operating model for the networks, while new role definition and clarity have been designed and are now subject to negotiation.
“The development and growth of a quality and patient safety focus in each local area is also taking place,” the HSE spokesperson advised.
Some 14 workshops were held with GPs nationwide last autumn, with 257 GPs and trainees in attendance to help inform the recruitment process, stated the Executive.
“The workshop process was tested with members of the ICGP and the actual workshops that took place were supported by the IMO and the NAGP without prejudice to the outcome.
“The feedback is now being considered in formulating a draft job description for each of the two roles. It is envisaged, subject to agreement and approval, that these roles will be negotiated and then submitted to the Department of Health for final approval from the Department of Public Expenditure and Reform (DPER).”
But there are a number of obstacles that will have to be overcome before any GPs are recruited, potentially delaying full implementation of the plan and in a worst-case scenario, completely stalling it.
An IMO spokesperson told MI that CHOs, and how GPs will interact with them, is an item for discussion under the new GP contract.
“The job description and terms and conditions for GP Lead posts will have to be negotiated with the IMO in advance of any recruitment to these posts,” the spokesperson stated.
GP contract negotiations are at an embryonic stage currently and the entire contract may not be in place by the end of the year, with contractual changes due to occur on a phased basis, according to the IMO.
Mr Chris Goodey, NAGP CEO, said GPs are willing to develop structured business meetings with their local hospital and associated CHOs, but that the process must be resourced and structured.
“All meetings should be accessible, accountable and productive. It is essential that we find new ways to work together to drive agreed change that is patient-centred. Our current hospital-centric model of care is past its sell-by date,” Mr Goodey stated.
“An integrated approach, such as Local Integrated Care Committees (LICCs), are the best option for the future. General practice has a central role to play in this process, if properly resourced. The role of GPs is not yet defined within the CHO structure. The role of GPs has to be reflective of the needs of patients and general practice.”
The ICGP failed to issue a response to MI at time of going to press, but a statement by the College on its website last August urged members to attend GP workshops.
“The ICGP is supportive of this development and it is in everyone’s interest, particularly patients, that CHOs are effective and that GPs are well integrated and involved at the outset,” the statement noted.
“The next steps will be the recruitment of a significant number of local sessional inputs from the GP community to take up part-time roles within CHOs, with a view to improving the integration of care at a local level.”
Dr Eamonn Shanahan, Co Kerry GP, said he believed the HSE would find it very difficult to fill the posts.
“Given the very significant difficulties in recruiting locums, I believe that trying to fill CHO posts is going to be difficult,” Dr Shanahan said.
Co Kerry GP Dr Eamonn Shanahan
He added that existing GP GMS vacancies in the South and the fact that further vacancies will arise due to retirements will also affect the CHO recruitment process.
The right model?
More widely, concern has been expressed about the new structure and whether it is the right model for Ireland.
A separate integrated care model has been in operation in Carlow and Kilkenny for many years and is actively illustrating how greater co-operation between healthcare professionals and management can enhance patient care.
Kilkenny GP Dr Ronan Fawsitt spoke to MI about how the LICC has helped to bring about major patient improvements through an enhanced working relationship between primary and secondary care stakeholders in the two counties.
Kilkenny GP Dr Ronan Fawsitt
The model of integrated care, formed from the ground up, involves monthly meetings with consultants, GPs, mental health professionals, primary care staff and public health personnel, among others, in attendance.
It is a way for clinicians and management to do business locally to help improve services for patients, explained Dr Fawsitt.
Dr Fawsitt, who is Chair of the LICC, said the model had helped to deliver much positive change in the region, including providing direct GP access to the Acute Medical Assessment Unit (AMAU), Acute Surgical Assessment Unit (ASAU), Acute Gynaecology Assessment Unit and the Acute Paediatric Assessment Unit.
‘We would like to see the roll-out of LICCs nationally, supported by the CHOs and Hospital Groups’
Dr Fawsitt advised that through a process he called streaming, Ireland’s first purpose-built Integrated Ambulatory Care Centre with an acute floor was now operational at St Luke’s Hospital, Kilkenny, and that 48,000 attendances had occurred in 2016.
He said direct GP access to the AMAU had reduced length of stay (LoS) by 1.6 days.
“In November, we opened direct access to the Minor Injuries Unit at the emergency department,” he added.
“In the last year, we brought in a new gynaecology clinic in St Luke’s, a virtual clinic for heart failure, and a rapid-access acute arthritis clinic.”
Due to the success of the LICC, which is supported by the local CHO and ICGP, Dr Fawsitt revealed that other LICCs were now being established, sponsored by the Ireland East Hospital Group and the primary care division of the CHO.
New LICCs are active in Loughlinstown, Wexford, Mullingar, Tallaght, Navan and at the Mater Hospital, Dublin, and others are currently being established, with an LICC in Cork in development.
Dr Fawsitt described the new CHOs as a “parallel structure” to be aligned to LICCs. “We would like to see the rollout of LICCs nationally, supported by the CHOs and Hospital Groups.
“I think GPs would like to see a better relationship between primary and secondary care and a ‘bottom-up’ approach supported by the top is more likely to get buy-in from GPs.
“We need to engage constructively with the CHOs and Hospital Groups. The idea to allow GPs to have leadership roles in the CHOs is very welcome.”