Aim is to move all acute services into University College Hospital Galway
Major changes are underway as the HSE West struggles to control a mounting deficit. Talks are at an advanced stage with the Irish Nurses & Midwives Organisation (IMNO), the IMO, IMPACT and SIPTU through the Labour Relations Commission.
Proposals have been discussed at local level and Dr David O’Keeffe, the Clinical Director of acute services and continuing care for Galway/Roscommon, was hopeful there would be agreement with the unions at a scheduled LRC meeting in Dublin on August 31.
Speaking to Irish Medical Times before the talks, Dr O’Keeffe claimed services were being maintained in the region. Although the region faces a deficit, costs have been reduced significantly over recent months. There has been a rolling programme of theatre closures and non-pay costs are being addressed. Stores and requisitioning policies across the hospitals are being examined.
Dr O’Keeffe stressed that activity levels for elective and emergency work remained high. “We have a service plan which we will fulfill,” he said. “We are ahead of planned activity for the first six months of the year by between 10 and 15 per cent. We will come in on target with our Service Plan in all areas, but my role is to ensure that the quality of patient care is not compromised.
Front-line staff
“It is a very fine balance, particularly in regard to temporary, locum and agency staff. We have been hit by the moratorium, but we have been resisting closing or cutting back services. All of the front-line staff in acute hospitals are there for a reason, in my view.”
Last month, a new report urged making no more consultant appointments to new posts in the HSE West and “no further service developments” until 2011. Radical solutions “need to be identified and supported”, concludes the Mott MacDonald Review of operational controls and an assessment of cost-containment measures for HSE West.
The measures outlined included reducing day-case provision from five to four days a week and amalgamating beds across specialties. Terminating 1,000 temporary contracts for six months to save €15-20 million was also mooted.
At the end of April 2010, the financial deficit for HSE West was €46 million. Forecasting for year-end, this suggests a deficit of over €107 million. “It will be extremely difficult for HSE West to achieve breakeven at year end and still achieve its service plan targets,” the review stated.
The reduction in public sector pay, employment controls and the continued recruitment moratorium was leading to “unintended consequences”, in that there was evidence of increased cost due to expensive rates for agency, overtime working and part-time staff working additional hours. The achievability of a 9 per cent reduction in inpatients and significant improvements in wait times for elective patients, outlined in the HSE National Plan, was also questionable.
The review focused on six HSE West sites with the highest estimated financial deficits: University College Hospital, Galway; Mayo General; Sligo General; Letterkenny General; Portiuncula Hospital; and the Galway Local Health Office.
Dr O’Keeffe told IMT that the HSE hoped to be in a position to provide an outline plan for reconfiguration by the fourth quarter of this year. One exploratory meeting has been held with senior clinicians and managers in Roscommon and Portiuncula, as well as clinicians in Galway University Hospitals. A further series of meetings is planned for late August and early September. There was no question of any of the hospitals closing, insisted Dr O’Keeffe.
Long-term savings
The HSE, he added, “needs time” to implement the reconfiguration plan — which will show longer-term cost-savings.
Initially, two gastrointestinal surgery appointments will be made at Portiuncula within the next couple of months. Each post has been designated as having 10 hours at Galway University Hospital. To complement that, some of the existing general and gastrointestinal surgical staff, would seek to move surgical and OPD work from Galway to Roscommon or Portiuncula. There is availability of theatre time there, Dr O’Keeffe told IMT.
“That would lead to a much more sensible utilisation of time. People are showing that level of flexibility,” said Dr O’Keeffe. “We are looking at developing a plan that will allow for the safe implementation of appropriate levels of acute medicine and surgery in all of the hospitals in Galway and Roscommon.”
Dr O’Keeffe’s responsibilities encompass the acute services in Galway University Hospitals, Portiuncula Hospital and Roscommon County Hospital. He has been assigned the duties of General Manager of Galway Regional Hospital.
A strategic development plan, which was drawn up with Prospectus in 2005, is about 60 per cent implemented, Dr O’Keeffe said. This blueprint dealt with the operational and strategic management of Galway University Hospitals – two hospitals with different skills and talent sets. The aim is to move all acute services into University College Hospital in Galway. Merlin Park University Hospital is to be developed predominantly as a centre for elective surgery. It will also cater for outpatients and rehabilitation and operate as a step-down facility, which will treat stroke patients.
The objective is that people would stay in the large acute hospital for the shortest period possible. Any residual disability would be subject to aggressive rehabilitation elsewhere. The objective, according to the HSE, is timely discharges.
An Emergency Department ‘avoidance plan’ is also in place, with the aim of greatly reducing such ED treatments as acute rehydration, dressing changes or treatment for ulcers. The Prospectus plan also envisaged having day care facilities, particularly for geriatric patients.
Integrated Service Area
The HSE plans that funding should go to an Integrated Service Area (ISA) – where the PCCC, acute services and mental health have a common management structure.
The third stage of the HSE’s Integrated Services Programme (ISP), which is now underway, will see approxiamtely 17 or 18 ISA catchment areas set up across the country, which will be responsible for the delivery of both primary and acute hospital care to their defined populations. Each ISA will have a lead clinician and a lead manager who will manage a budget right across the hospital and community system.
The HSE West will be one of the earliest areas for development of these ISAs, with the Galway/Roscommon area to the fore in this.
Dr O’Keeffe’s said his job was to “concentrate the minds” of the operational management team and the existing Clinical Directors, to progress the plans in place. “We need to take a more co-operative approach between acute services and the PCCC,” he suggested.
He believes that the experience with reconfiguration in other areas has shown that in order to cope with change, there needs to be a very mature out-of-hospital care system, investment in ambulance services and advanced paramedics for pre-hospital care. “There also needs to be consultation with the primary care sector, particularly GPs who will have established referral patterns to hospitals. There needs to be buy-in by the clinicians in all of the hospitals,” Dr O’Keeffe explained.
Hospital licensing
The HSE West plan will also ddress the probable changes that will accompany the hospital licensing legislation. It is likely that with their licences, hospitals will be designated for certain levels of activity. “The disaster would be that if we don’t prepare for this, it may be thrust upon us. Roscommon and Portiuncula have to be prepared for that,” said Dr O’Keeffe. “This will also affect Merlin Park and Galway University Hospitals to a great degree as well, in terms of critical care, cancer, surgery and so on. Rather than closing hospitals, the reconfiguration plan is the main way that hospitals can invest in their own survival.”
Emergency activity
He added that the region has already shown flexibility. “In the clinical staff so far, there has been an increased recognition that delivery of elective care — particularly in surgery — is compromised by the emergency activity in the large acute hospitals,” said Dr O’Keeffe.
Doctors have already started to vote with their feet by taking elective surgical lists outside the acute hospital setting. Elective plastic and maxillofacial surgery as well as work in urology and in other areas is already moving to Portiuncula, Roscommon and other hospitals. This is because it has become so difficult to get planned elective work done in acute hospitals – due to the effects of the recruitment moratorium, particularly on theatre nursing staff.
NCHD overtime
Increased emergency activity is also a factor, as is the complexity of work – which leads to people spending more time in ICU and HDU beds. OPD work is also migrating out of Galway to the smaller hospitals.
“At UCHG, we will come very close to breakeven this year,” Dr O’Keeffe predicted. “NCHD overtime has been pared back almost to the absolute limit. We are compliant to the EWTD in virtually all areas. We do not have significant NCHD vacancies,” Dr O’Keeffe concluded.
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