Dr Barry White
The HSE’s Quality and Clinical Care Directorate has been established to help improve patient care throughout the health system. The Directorate, led by Dr Barry White, is charged with defining how health services are delivered, measured and resourced.
Twenty programmes have now been established under the leadership of a multi-disciplinary team of clinical experts. These programmes, which are joint initiatives with the academic colleges, are charged with defining the ideal care for patients so that it can be implemented across the country.
The HSE says it will start this implementation in 2011 and that the programmes will improve patient care, remove waiting lists and save money.
At the launch at Dr Steevens’ Hospital, Dr White stressed that the key principles of the Directorate included having clinicians from all healthcare groups leading change.
Clinical leads
Most of the national clinical leads have been appointed for the programmes, established over the past six months. They include: Primary Care, Dr Joe Clarke; Care of the Elderly, Dr Diarmuid O’Shea; Palliative Care, Dr Karen Ryan; Radiology, Dr Risteard O’Laoide; Obstetrics and Gynaecology, Prof Michael Turner; Obstetrics and Gynaecology (Deputy), Dr Mike Robson; Joint Stroke (Geriatrician), Dr Joe Harbison; Joint Stroke (Neurology), Prof Peter Kelly; Acute Coronary Syndrome, Prof Kieran Daly; Heart Failure, Prof Ken McDonald; Diabetes, Prof Richard Firth; COPD, Dr Tim McDonnell; Asthma, Dr Pat Manning; Epilepsy, Dr Colin Doherty; Dermatology, Prof Louise Barnes; Neurology Outpatients, Dr Brian Sweeney; Rheumatology, Prof Oliver Fitzgerald; Joint Acute Medicine, Prof Shane O’Neill; Emergency Medicine, Dr Una Geary; Critical Care, Dr Michael Power; and Surgery, Prof Frank Keane. The clinical lead for Mental Health has yet to be appointed.
The programmes have been established to cover a range of clinical services. Multi-disciplinary teams include GPs, nurses, consultants and allied healthcare professionals working with local management. They operate similarly to the National Cancer Control Programme in that experts define how care should be delivered, so this can be done nationally. Unlike the cancer programme, however, in these areas there is good evidence for enhancing local services.
Waiting lists
Dr White pledged that the HSE was “going to remove the longest outpatient waiting lists”. There are particular concerns around neurology, dermatology and rheumatology. Removing the waiting lists will involve looking at mechanisms whereby existing consultants can see more patients. Dr White accepts that “clearly there is a need for a limited number of additional posts”.
The programmes are focused on “improving care, significantly reducing waiting times and cutting out inefficiencies”, he added. They have been jointly established with the various professional colleges (ICGP, RCPI, RCSI) and other training bodies.
In asthma, for example, there is significant evidence that people do not take their preventive medicine. That results in a significant increase in asthma episodes and even deaths.
Solutions implemented in Finland resulted in almost all patients there achieving the correct inhaled steroid technique. This has brought asthma deaths down from 100 per year to practically zero, over the past 10 years. Hundreds of millions of euro was also saved in the process. The HSE’s asthma programme, together with the ICGP, is now implementing a model of care similar to Finland’s.
Stroke care
There are substantial opportunities to improve outcomes in stroke too, which would also be cost-effective, Dr White said. Stroke units and thrombolysis services will be made available on a 24/7 basis across the country. Together with transient ischaemic attack (TIA) clinics, a life a day can be saved, Dr White believes.
“Not only can you improve patient outcomes, but you can cut back on the use of resources,” he said.
In some cases, healthcare can improve with minimal additional resources. Some initiatives may simply require standardising of care across the system. Initiatives that realise a saving are easier to implement. Other elements will require a more substantial reallocation of resources – for example, additional consultant posts.
However, having out-patients wait longer than three months does not make any sense, he added. “It is no good for the patient. It is also probably very costly and ineffective. An example is back pain. The longer somebody waits to get seen, the less likely it is that the back pain will resolve,” said Dr White.
The aim of the clinical programmes is to decrease mortality and disease complications. Access issues – particularly waiting lists and trolleys – will be addressed. Simultaneously, removal of inefficiencies is also an objective. Many of the patient organisations will be embedded within the programmes, and there will be autonomy for local services. In almost every area, there is existing good practice, which needs to be “nationalised”, Dr White pointed out.
Chronic diseases
Chronic diseases cause 70 per cent of deaths internationally and 70 per cent of Western healthcare spending is on those chronic diseases. A good deal of expenditure is on people with multiple chronic diseases.
Only 50 per cent of people internationally take the correct treatment for their conditions. In the US, 25 per cent of health spending results from preventable complications arising from chronic diseases.
Primary care and self-management will be key, added Dr White, and clearly the availability of community intervention teams is an issue.
Clinical governance
As part of its quality and safety remit, the Quality and Clinical Care Directorate is also introducing clinical governance to ensure that patients can get the right treatment. It is establishing a national clinical audit programme and developing guidelines to support service-use involvement in the health services. These standards will be measured and audited to ensure that they are delivered across the system.
“Clinical governance is about local controls to ensure patients get the right treatment. There is still a substantial amount of work to be done in this area: we definitely need to focus on this,” added Dr White.
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