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Special no more?

The establishment of targets is a necessary part of running any organisation. Within the health service, however, these targets frequently end up embarrassing their creators in Hawkins House and Dr Steevens’ Hospital, serving as an inescapable reminder of the habitually obstinate problems of the sector. Earlier in the year, Minister for Health Leo Varadkar announced that no patient would be on a waiting list for over 18 months by the summer. The target was a modest one, given that similar targets had been set under the Minister’s predecessor Dr James Reilly for those waiting over 12 and nine months. While significant progress was made, this target was not fully achieved, and the end-of-year 12-month target is no longer being discussed.

Not only that, the number of people waiting over 18 months on inpatient and outpatient waiting lists is actually increasing. Latest data from the National Treatment Purchase Fund (NTPF) reveals that 2,244 patients were waiting over 18 months for inpatient and day case procedures at the end of September, compared with 1,368 at the end of August. For outpatients, 13,176 were waiting over 18 months at the end of September, in comparison to 11,235 at the end of August. Likewise, emergency department (ED) overcrowding is worsening, despite the establishment of the Emergency Department Taskforce by the Minister last December to help solve the problem. The Irish Nurses and Midwives Organisation (INMO) recently announced that 7,630 hospital patients were on trolleys during September, which represents a 17 per cent increase when compared to September 2014. The Organisation also stated that 71,486 patients admitted to hospitals were on trolleys in the first nine months of 2015, which is a 28 per cent increase when compared with the same period in 2014.

The dawn of the SDU

It wasn’t supposed to be like this. Before the last general election, Fine Gael promised an initiative to tackle waiting lists and ED overcrowding — the Special Delivery Unit (SDU). Although the Unit was overshadowed by the party’s plans to introduce a system of universal health insurance (UHI), it was a fundamental part of their health reform platform. Like Fine Gael’s plans for UHI, which were based on the Dutch health system, the proposal for the SDU was also inspired by healthcare reforms in another jurisdiction, this one closer to home.

In April 2005, the Northern Ireland Department of Health, Social Services and Public Safety (DHSSPS) established a strategic alliance with the Greater Manchester Strategic Health Authority to reform elective care in Northern Ireland. This approach proved very successful and, at the end of March 2006, only three patients were waiting longer than 12 months for inpatient or day case treatment, compared with almost 4,000 at the end of March 2005.

By the end of December 2012, the number of adults having to wait more than nine months for inpatient and day case surgery was down to 86 from 3,706 in December 2011, a 98 per cent decrease

The potential that this approach showed for delivering improvements in performance through system reform and associated changes in behaviour prompted the DHSSPS to establish a special delivery unit in April 2006 to enact a programme of reform and modernisation across a wider range of healthcare activity. The process impressed Fine Gael so much that the promise to establish a unit based on the Northern Ireland model within the first 100 days of Government was contained in its health policy document FairCare, published in April 2009. The same pledge was made two years later within the Programme for Government when Fine Gael formed a coalition government with Labour.

The SDU was launched in June 2011 within the stated time period, although it was really just in nominal form, as the Unit did not become fully operational until that September.

Northern influence

The influence of the Northern Ireland model was made even clearer when Dr Martin Connor, who led the reforms there, was recruited as special advisor to the Minister on the SDU initiative. Yet conversely, after the appointment was announced, the Government was seeking to distance itself from the unit in the North, where waiting lists were already starting to increase. When questioned on this development by Fianna Fáil Health Spokesperson Deputy Billy Kelleher, (then) Minister Reilly said there were a series of reasons the initial, impressive effect of the Unit was not sustained in Northern Ireland.

“The Government here is engaged in thorough reform of our health service,” commented Minister Reilly. “As such, what occurred in Northern Ireland will not pertain here. Underlying reforms that did not take place in other jurisdictions will happen here.”

The reform programme

One of the key aims behind the SDU was to introduce ministerial accountability. According to the FairCare document, one of the key drivers of change in Northern Ireland was direct ministerial involvement.

The Northern Ireland Minister for Health was involved at every step of the reform process, with weekly and sometimes daily briefings on individual hospitals and departments, supplied by a real-time IT system. In the Republic, by contrast, Fine Gael said the establishment of the HSE had isolated and insulated the Minister for Health from what was happening to hospitals on a daily basis.

The SDU was also to be the key driver behind updating the health service’s antiquated IT systems. One element of the original conception of the SDU that was quickly dropped was the plan to make it responsible for improving mental health services. In FairCare, it was stated that the SDU would be asked to identify hospitals where conditions of care are unacceptable and to draw-up plans for their orderly wind-down and the transfer of staff to more appropriate settings in the community. This development, however, never materialised and it remained the responsibility of the Mental Health Commission.

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Mr Tony O’Brien

Originally, the SDU was located within the Department of Health, although 11 staff members were seconded from the HSE and some other organisations. The current HSE Director General Mr Tony O’Brien was appointed as the inaugural Chief Operating Officer (COO) of the SDU. The number of Department of Health staff providing administrative support varied over the period of time between 2011 and 2013.

The attractiveness of the SDU model for the Government was its focus on process. At a time when the Government was under severe financial pressure due to its obligations to the Troika, the mantra of ‘working smarter and more efficiently’ was frequently repeated. Statistical process control techniques were employed to establish patterns and trends in EDs over the previous years in order to facilitate better planning and avoid re-occurrence. This process led hospitals to produce winter capacity plans and the SDU issued technical guidance to the system in relation to management of EDs over the Christmas period in 2011/12.

The SDU established a liaison protocol to assist with hospitals that were experiencing particular difficulties.

This involved setting up conference calls between key decision-makers to review the situation and agree actions, as well as regular site visits to work with clinical staff and management on process improvement. According to the Department of Health, the system resulted in a better ability to manage surges of ED activity and to mitigate their impact.

But process improvements were not enough to make an impact on their own, as funding was also required in many cases. The SDU invited hospitals that had significant numbers waiting on trolleys to make costed proposals that would reduce the numbers waiting over the holiday period. Following these proposals, the Unit made approximately €4.8 million available to 16 hospitals for targeted measures.

Allocations made to the SDU in 2011 totalled €3,708,449 and in 2012 increased to €9,997,666. But the overall funding that the Unit was responsible for was much greater due to the changed role of the NTPF, which was no longer to focus its attention on treating public patients in private hospitals and came under the remit of the new SDU agenda. Funding of €70.857 million was allocated to the NTPF/SDU in 2012 from the Department of Health. Of this total, €30 million was surrendered to meet overall budgetary health pressures, resulting in a total spend of €40.857 million by the SDU/NTPF in 2012. A total of €8.8 million was incurred by the SDU in support of public hospitals reducing ED wait times. Some €27.487 million was incurred by the NTPF in support of public hospitals reducing waiting times for inpatient and day case elective surgery. Also, €4.3 million supported provision and maintenance of the national patient treatment register, the development of systems and initiatives in support of the overall health reform programme, responsibilities under the Nursing Homes Support Scheme (Fair Deal) and the facilitation of patient treatments.

Results

Targets were set for hospitals across a range of areas (12 months and then nine month cut-offs for inpatient and day case waiting lists) and many improvements were made over the first year-and-a-half. According to the Department of Health, there were 20,352 fewer patients on trolleys in 2012 compared to 2011, which amounted to a reduction of almost 24 per cent.

According to INMO figures, there was a 33 per cent reduction in the national trolley count in the period 2011 to 2013.

By the end of December 2012, the number of adults having to wait more than nine months for inpatient and day case surgery was down to 86 from 3,706 in December 2011, a 98 per cent decrease. Also, the number of children waiting over 20 weeks for inpatient or day case surgery was down to 89 from 1,759 in December 2011, a 95 per cent decrease, while the number of patients waiting over 13 weeks for a routine endoscopy procedure went down from 4,590 in December 2011 to 36 at the end of December 2012, a 99 per cent decrease. The gains were even more impressive considering the severe cuts to the healthcare budget during the recession.

The SDU also led the project to collect data on outpatient waiting lists for the first time, and implement the target that no patient should wait for a first-time outpatient appointment for over 12 months.

Despite these improvements, the SDU was not without controversy during this period. One high-profile issue centred around the consultancy fees charged by Dr Martin Connor, who was not based in Ireland, and others for their contribution to the Unit (see panel). Also, Mr O’Brien left the position of SDU COO to become Director General Designate of the HSE in July 2012.

Public patients who were ‘long waiters’ also continued to be treated in private hospitals, even though one of the reasons behind the SDU was to end this practice. As reported previously by the Medical Independent (MI), the SDU/NTPF spent €14.5 million on procedures in private hospitals in 2012.

Upheaval

Operational responsibility for the SDU transferred to the HSE on 1 January 2013. When asked about the decision, the Department of Health stated it was considered that this was a more appropriate governance structure, bringing the SDU into a direct reporting and support relationship with the HSE’s then recently-established Acute Hospitals Directorate. The fact that the move contradicted the original intention to make the Minister more accountable for waiting lists was not mentioned.

The move mirrored what occurred in Northern Ireland, when its unit left the Department in April 2009 and was integrated into the Health and Social Care Board as the Performance Management and Service Improvement Directorate.

This was a time of great upheaval for the SDU, as in May 2013, it was revealed that Dr Connor would be leaving his position after the summer, 15 months before his contract was due to end. Other high-profile appointees — the Director of Scheduled Care Dr Alan Smith and, at a later date, Director of Unscheduled Care Ms Lis Nixon — also left their posts. In June 2013, the HSE announced that the then National Director Designate of Acute Hospitals Mr Ian Carter was to take over responsibility for the SDU. It was around this time that the gains the SDU had made in waiting lists and times appeared to reverse. Figures published by the NTPF showed the number of patients waiting longer than six months for hospital treatment had nearly doubled between December 2012 and April 2013, from 6,039 to 11,348, while there was a significant increase in the numbers waiting more than 12 months over this period going from 36 to 563.

The focus by the Minister and the SDU on long waiters meant that patients lower down the priority list were starting to wait longer for treatment. ED overcrowding, which still persisted in many hospitals, started to become a major problem again in 2014, with the INMO figures revealing that the number of trolley waits was 6.5 per cent worse than it was in 2013. According to the recent Emergency Department Taskforce Report, reasons for this deterioration included: Fair Deal delays; an increase in the number of delayed discharges; and staffing shortages.

Changing role

There is little doubt that the visibility and influence of the SDU has waned since its incorporation into the HSE. Gone are the media update briefings about new initiatives to reduce waiting times. The establishment of the Emergency Medicine Clinical Programme, the Emergency Department Taskforce and the Office of the HSE Chief Information Officer have taken away a lot of its responsibility regarding EDs and IT.

The Unit also no longer has the power to direct funds, as it once did.

A Freedom of Information request to the HSE from MI sought to ascertain the level of funding approved by the SDU, or the list of recommendations made by the Unit in respect to funding, between October 2014 and April 2015. This publication has previously shown how funding from the Unit halved between 2012 and 2013. According to the HSE, during 2013 the SDU allocated €18 million in funding to “maintain ED-related access and progress the reduction in waiting lists”. In 2012, €36 million was spent trying to drive-down wait times. While most of this, €27.7 million, was spent on inpatient and day case wait times, €8.8 million went towards improvements to EDs.

Unfortunately, despite the money that has been spent by the HSE and the Department of Health on this initiative, things haven’t gotten better; they have gotten worse

In response to current funding decisions or initiatives, the HSE stated that no such records existed relating to the SDU. According to the HSE’s statement, the SDU has been operating as the “key facilitator” of service improvement in the areas of scheduled and unscheduled care. This has primarily involved senior staff continuing to monitor individual hospitals and engaging with their management teams in respect to performance on both scheduled and unscheduled care targets. These visits generally involve a review of key processes relating to these areas.

“The National Director [of Acute Hospitals] was generally advised of progress, but this did not involve any recommendations in respect of funding or not funding particular sites or services,” according to the HSE.

EDs

In October 2014, the HSE requested that the SDU co-ordinate the implementation of the Irish Hospital Redesign Programme, commencing in Tallaght Hospital. The programme is yet another attempt to improve efficiency of patient flow through hospitals, an aim that continues to prove elusive for healthcare management.

“While this has involved expenditure, the project was the initiative of the National Director rather than the SDU,” according to the Executive.

A lot of the work done by the SDU (including its own report on unscheduled care, published in 2013) was drawn on in the recent report from the Emergency Department Taskforce, which was convened at the end of last year as a result of the spiralling problem of ED overcrowding. The recommendations of the Taskforce, which contains a representative from the SDU, have thus far failed to control the problem. When Mr O’Brien recently assumed leadership of the Taskforce, he cited his experience with the SDU, which he feels could help the Taskforce to overcome its challenges.

“The Taskforce was the latest thing that was meant to end overcrowding, where we are expecting great improvement,” according to Dr James Gray, Emergency Medicine Consultant, Tallaght Hospital, Dublin.

“Unfortunately, despite the money that has been spent by the HSE and the Department of Health on this initiative, things haven’t gotten better; they have gotten worse. If you compare August 2014 to August 2015, there is a 40 per cent increase in the number of trolleys nationally, which is a damning indictment in the middle of summer. We have got winter approaching and I dread to think how bad it will get.”

Legacy

Despite its ongoing work, the SDU has stopped being the defining part of the conversation regarding waiting lists and hospital overcrowding for some time. It is far from the dynamic, innovative spearhead of reform that Minister Reilly once spoke so passionately about. Since moving into the HSE, its existence is very much cloaked in the shadows of the Executive’s bureaucracy.

Dr Brian Turner, a health economist from University College Cork, always felt that the operations of the Unit lacked transparency, even when it was part of the Department of Health.

“At least with the NTPF you knew what was going on, whereas with the SDU, even the definition of it, ‘we will reduce waiting lists by setting these targets’ — it was never quite clear how this was going to work,” Dr Turner told MI.

Dr Turner also contended that the concept of the SDU never came close to penetrating the mind of the public, so its marginalisation should come as no surprise.

Dr Peadar Gilligan, Emergency Medicine Consultant, Beaumont Hospital, Dublin, said that the gains initially made by Unit were not sustained because of the ultimate lack of investment in EDs and hospitals.

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Dr Peader Gilligan

“The SDU was set up to try to address process issues and to see what internal things could be done to improve the flow of patients requiring acute hospitalisation and indeed just requiring assessment in EDs as well,” Dr Gilligan told MI.

“We met many of the members of the original SDU when they were going around the acute hospitals and particularly those hospitals that are particularly challenged with prolonged waits for hospital beds. They very quickly realised that most of the internal processes that they were looking for within the EDs themselves were already in place, such as advanced triage, streaming of patients to minor injuries, and ambulant emergency care. So there wasn’t much low-hanging fruit in that regard to actually improve processes. The main issue, which was pointed out to them by every emergency medicine doctor in the country, is not the process so much within the ED, but the fact that we have an access block to the hospital and as you know, that means when we get a patient that actually requires hospitalisation, there is no bed available for that patient to go to.

 “Has the SDU made an impact?” asked Dr Gilligan.

“The answer is, it certainly highlighted some of the areas that needed to be addressed. Were all those areas being addressed beforehand? Certainly a lot of them were. Some of them needed more attention than they were being given. But the reality was that what the SDU brought was resources to bear on the areas that they were concentrating on. For example, they brought resources around home care packages for patients requiring discharge to home with increased support, they brought increased nursing home beds availability to the public system through the private sector and made those available as well. So it wasn’t that it was all about terrific organisation, it was about aligning resources to provide them where they were most needed.”

Future

The funding element that was originally part of the SDU’s remit appears to have vanished, leaving question marks about the relevance of the Unit at present.

Getting information on what exactly the SDU is doing now is not easy. Detailed queries sent to the HSE from MI about the staffing, funding, work, and future of the Unit have so far not received a response, despite repeated requests. Yet the SDU, even though its form has diminished, is still continuing on and there appear to be no plans to wind it down.

Last month, the HSE advertised for a new head of the SDU. The new head, who will be graded at Assistant National Director level, will be responsible for both scheduled and unscheduled care. The salary scale for the post is between €90,514 and €94,448; €98,382 and €102,314; or €106,250 and €110,183.

According to the job description, the SDU head will also take the lead on behalf of the HSE’s National Division in relation to the implementation of the recommendations of the Emergency Department Taskforce and to drive general improvements, including accountability in all areas of ED performance, which may have an impact on the efficient and effective delivery of activity targets.

“There will be a particular focus on delivering sustainable improvement solutions and projects, as part of the Acute Hospital Services National Division strategy and approach in this area,” according to the HSE’s job specification.

Whether the new post-holder will imbue the SDU with a renewed sense of distinction and purpose will be worth observing, though the Unit’s incorporation within the Acute Hospital Directorate makes the likelihood that it will regain its former standing highly unlikely. Potential solutions to the ever-present reality of growing waiting lists and overcrowding will have to be a collaborative effort and as the journey of the SDU has shown to date, there are no easy solutions to this persistent and chronic problem.

The SDU’s consultancy fees

The consultancy fees paid to senior advisors to the SDU was a continual source of controversy throughout the Unit’s time in the Department of Health.

The first contract to Dr Martin Connor in his role as Special Advisor covered a period of six months from June 2011 to November 2011 and was for a fixed price of €250,000. Following the completion of this work, Dr Connor’s company, Value Based Solutions, was engaged for a further three-year period, commencing in December 2011 and ending in December 2014. The total value of this contract was €480,000. However, Dr Connor, who was also a member of the HSE’s Interim Board, left his role in 2013, more than a year before his contract ended.

””
Dr Martin Connor

The latest data from the Department of Health shows that Dr Connor was paid €199,925 in 2012 and €98,420 in 2013. Much of the controversy surrounding the fees centred on the fact that Dr Connor was not based in Ireland and was completing a research fellowship in Stanford University, US. According to the Department of Health, he was only based in Ireland for an average of two days a month and conducted much of his work through teleconference. After leaving his role, Dr Connor became Executive Director at the Centre for Health Innovation at Griffith University in Queensland, Australia.

Another SDU consultant, Ms Lis Nixon, was employed to the role of Director of Unscheduled Care after an earlier open recruitment process failed to secure a candidate of sufficient calibre. Ms Nixon had carried out consultancy work for the Department in 2011 and early 2012 to the value of €82,000.

””
Dr James Reilly

The then Minister for Health Dr James Reilly said at the time that her three-year contract, which was entered into in March 2012, was for an all-in price of €492,000 over the full duration of the contract, or €164,000 per annum. However, recent figures provided by the Department of Health shows Liz Nixon Associates received €202,726 in 2012 and the same amount in 2013. Ms Nixon has since left the role.

Correspondence between the Department of Health and HSE in 2013 stated that the cost of running the Unit was approximately €2 million a year, much of which related to consultancy costs.

Special Delivery Unit timeline

April 2006             A Special Delivery Unit (SDU) is established in Northern Ireland to reduce waiting lists.

April 2009             Fine Gael publishes its health policy document FairCare, which promises to establish an SDU in the Republic, along the lines of the Northern model, within the first 100 days of Government.

June 2011             The SDU is established by the Fine Gael/Labour Coalition. It is announced that Dr Martin Connor will be Special Advisor to the Unit.

October 2011     The SDU visits the Mid Western Regional Hospital in Limerick to conduct a “performance diagnostic analysis” of unscheduled care and publishes 13 recommendations on how the hospital can improve its management of patient flow.

October/November/December 2011     
The SDU makes over 24.8 million available to 16 hospitals which are experiencing high trolley numbers.

January 2012      Then Minister for Health Dr James Reilly announces that no-one will wait more than nine months for inpatient and day case treatments.

March 2012          Ms Liz Nixon is employed as the SDU’s Director of Unscheduled Care.

July 2012               Mr Tony O’Brien leaves the Unit to become Director General Designate of the HSE.

December 2012            The number of adults having to wait more than nine months for inpatient and day case surgery was down to 86 from 3,706 in December 2011, a 98 per cent decrease. The number of patients waiting on trolleys is also significantly below the equivalent figure in 2011.

January 2013      The SDU leaves the Department of Health and is incorporated into the HSE’s Acute Hospital Directorate.

May 2013               It is revealed that Dr Connor and the Director of Scheduled Care Dr Alan Smith are leaving the Unit. Waiting lists worsen, with figures published by the NTPF showing the number of patients waiting longer than six months for hospital treatment had nearly doubled since between December 2012 and April 2013.

June 2013             The HSE announces that the then National Director Designate of Acute Hospitals Mr Ian Carter is to take over responsibility for the Unit.

December 2014                  The INMO calls the increasing number of people on trolleys a “national emergency”. In response to the crisis, the Minister for Health establishes the Emergency Department Taskforce.

September 2015           The HSE advertises for a new head of the SDU.

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