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The value of experience

These are just a few heralded healthcare plans of recent years that either never materialised, or else are taking a long time coming. Another one is hospital licensing. It is a decade since the Report of the Commission on Patient Safety and Quality Assurance, which recommended licensing of the acute sector as a fundamental foundation for safer treatment and care. Since then, as with much in the health service, progress has been slow to the point of glacial. The Government only approved the drafting of the Patient Safety (Licensing) Bill last December. The legislation is currently being drafted by the Office of the Parliamentary Counsel to the Government and will only be introduced to the Dáil by the Minister for Health once this has been completed.

The pace of legislative reform was clearly a source of frustration for HIQA CEO Mr Phelim Quinn during a recent interview with the Medical Independent. The Authority has been primed to start a hospital licensing regime for some time, but has had to wait for the go ahead from the Oireachtas.

One possible advantage of the delay in introducing licensing, however, is the regulatory experience HIQA has acquired since the Commission’s report in 2008. That year the Authority was only a year old. Now, HIQA has years of experience inspecting and registering nursing homes, and disability centres, as well as undertaking major hospital investigations following patient safety incidents. This experience will certainly inform how a hospital licensing regime will operate.

As revealed in this issue, HIQA produced a scenario testing paper for hospital licensing in October 2016, which it submitted to the Department of Health. The draft general scheme stipulated that licences are valid for a period of three years. However, research conducted by HIQA found that such a cycle is not commonly found in other jurisdictions. Requiring licence renewal would be a time-consuming exercise and increase the regulatory burden on providers, particularly those with a good track record of compliance with regulations. HIQA said the experience in adult social care, where there is a three-year registration cycle, is that the administrative process of renewing registrations distracts from the core work of monitoring compliance, fostering improvement in services and reacting to serious risks. As a result, the Authority was of the view that there should be no time limit on a licence. It recommended the licence should be issued once and would only be removed at the request of the provider or in circumstances where HIQA has cause to revoke the licence. HIQA also suggested requiring a hospital to submit an improvement plan when non-compliance is identified, which is similar to what is already in place in the adult social care sector and, to a lesser extent, HIQA’s healthcare monitoring programmes. If HIQA was of the view that the plan was insufficient or was not being satisfactorily implemented, it could issue an improvement notice. However, this represents a challenge as hospitals may not be in a position to comply, as many of the measures will be dependent on significant additional resources and/or capital expenditure.

The paper also noted that the power to revoke a licence is a power rarely used in other jurisdictions. According to HIQA’s own research, where revocation of a licence is deployed, it tends to be directed more at smaller providers and clinic-type settings, rather than acute hospitals. There would need to be serious and sustained concerns regarding the quality and safety of the totality of services being provided for a public hospital to have its licence revoked. According to HIQA, it is conceivable that licences of private providers would be revoked on a more regular basis, particularly in terms of small, non-hospital surgical settings that are currently unregulated or unable to produce evidence of financial viability. 

Although the paper was produced over a year and a half ago, these are interesting questions to consider. The hospital licensing regime will be a radical change for the health service and will require the combined efforts of management, providers and regulators for it to operate effectively.

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