PA Consulting, which carried out the Health Service Capacity Review 2017, enquired from the Department of Health whether its assessment should include workforce requirements, it told the Oireachtas Joint Committee on Health recently.
The scope of the Health Service Capacity Review 2017 did not extend to a comprehensive workforce capacity assessment, and one will be needed to assess the rate at which capacity can be brought into service, the PA Consulting group that carried out the review has said.
Four members of the PA Consulting group attended as witnesses at the latest meeting of the Oireachtas Joint Committee on Health last week to discuss the Review. The Review quantified future demand for capacity across primary care, acute hospitals and social care services for older people — the three domains most affected by an ageing population and the rising prevalence of long-term conditions.
Ireland was facing a dramatic and rapid increase in the number of older people. The number of people older than 65 was forecast to rise by 60 per cent, and the number of over 85s was set to double over the next 15 years with an impact on the number of people with chronic conditions. Other Western economies were not seeing as extreme a growth in the number of elderly.
Exclusion of workforce capacity planning from the scope of the review was roundly criticised by Health Committee members. In the Chair, Sinn Féin’s Deputy Louise O’Reilly said many of the difficulties of the health services centred around recruitment and retention, and it seemed that the report had sidestepped that. Labour’s Deputy Alan Kelly described the report as “hamstrung” by the exclusion of workforce planning. He acknowledged it was not the consultants’ fault, but should have been part of the process.
PA Consulting responded to the Committee members and said they had raised the question of whether they would look at workforce assessment and include it in the scope of the review. However, it was explicitly ruled out by the Department of Health, because a review was already ongoing within the Health Service Executive.
Looking at the scale of things, the authors of the Review felt workforce reform was really a matter for the professions getting together and agreeing what the suitable roles were. What they were looking at were the demands on the system and what the capacity was, added Tim Daly of PA Consulting. “You talked about staffing questions, about workforce reforms; we didn’t do a comprehensive workforce assessment and there are quite significant workforce implications around the capacity within hospitals in other areas,” he said.
A few building blocks needed to be put in place. “I think doing an overview of the capacity needs is the right first step, and sets out a landscape for where you are going,” PA Consulting’s George MacGinnis told the Committee. “We have set out very clearly that a comprehensive workforce assessment is needed.”
Reasonable assessment Given where Ireland was, the team thought it was a broad reasonable capacity assessment, but it had posed profound questions on the mechanisms for doing that. “The next stage would be to look at that in detail. If we contrast the 2007 review with this review, what this review does is it poses many more revenue financial questions than were ever posed in the 2007 review,” MacGinnis added.
There was still a long journey in Ireland around resourcing healthcare. The system of budgeting did not encourage an output, let alone an outcome review of what was being achieved. It was very much an input-based way of putting in resources.
Combined reform scenarios
They quantified where key changes, aligned with the Sláintecare plan, could impact on demand. The key changes were based on the need to shift care from an acute-led model and assume a more integrated model of care, particularly for the management of chronic conditions and the care of older people. Members heard the direction in health systems was towards population health management, and it required a comprehensive view in planning outcome and resource-based decisions to achieve the desired effect.
As part of the work for the Review, PA Consulting identified three drivers for future change and their impact on demand — demographics, non-demographics and unmet need. The report set out the landscape; continuing with the current model of care as a baseline scenario, would see demand exceed capacity by more than 7,000 hospital beds by 2031.
The combined reforms scenarios were ambitious and, noting the complexity of bringing a new hospital into service, they believed the reform scenarios more feasible. The three main reform scenarios envisaged were the impact of Healthy Ireland strategy on that demand, secondly, an improved model of care centred around comprehensive community- based services and thirdly, hospital productivity improvements through improved patient flows through hospitals.
Health Committee members heard there was insufficient data available within the timescale to forecast beds to include specific hospital facilities such as operating theatres, or computed tomography scanners and these would need to be picked up in more detail at the design stage.
The analysis established two extremes to define the order of magnitude of the range of potential capacity needs, and associated level of changes in the model of care.
Fianna Fáil’s Stephen Donnelly also raised the exclusion of mental health and palliative care services from the Review, and added that the Primary Community Care Review was quite limited as it focused on the elderly. However, PA Consulting said they did not expect that bringing in mental health would have had a big impact, and they would not expect the number of extra beds would vary.
The Committee members heard the main reason for the exclusion of mental health was the lack of data and the timescales required. There was relatively good data available for general practitioners (GPs) and the activity they undertook. PA Consulting’s Chris Nightingale agreed that it was challenging to get data from the HSE. They had a 16-week project with a four-week timescale for collecting data, and still looking for data in week 12, “was something they did encounter”. However, they got good data from their main data source, the Hospital In-Patient Enquiry (HIPE) data in hospital activity.
It was important to talk about the immediate injection of capacity to get occupancy levels down to an acceptable norm. “We make the point that although we quantified it in practical terms, the measures that you would use are similar to what you would be familiar with in the winter pressure planning,” MacGinnis told the Committee members.
It was a combination of things that would improve patient flow. “In other industries it would be called ‘productivity’, so looking at blockages and systems.”
It was important to look at capacity outside of the hospitals as well as inside the hospital because, from his experience of working in the system here, that was a key driver of extended lengths of stay, particularly with older people.
He highlighted the work that they did with the national clinical programmes at Tallaght Hospital in Dublin, saying they could see there were improvements in patient flow within the main wards in the hospital, even within the acute floors, the Emergency Department (ED), and the Acute Medical Unit.
Joint Committee members took issue with the suggestion that the decisions hospital consultants took every day not to discharge someone from a ward, condemned someone in an ED to another night on a trolley, or that doctors under pressure held on to beds so that their patients could get into those beds. Fine Gael Deputy Kate O’Connell described this as “unhelpful”.
“All we were saying was the average length of stay appeared to be higher than we would have seen in other systems,” MacGinnis responded. “What I was trying to do was to understand that.”
They looked at how many different organisations or coordinators patients were discharged to and stressed that the more fragmented and complex this was, the more difficult it was for the system to achieve the level of patient care aspired to.
The equivalent of a new 550-bed hospital, on the lines of Tallaght Hospital, would need to be opened every year, starting this year, to meet hospital bed capacity requirements unless the combined reform scenarios were implemented across the health services.
The PA Consulting group identified a need for more than 7,150 hospital beds up to 2031 on top of the current 13,310, if the health services continued on the current baseline — and that was added to a range of increases, such as a 30 per cent increase in the primary care workforce, a 40 per cent increase in residential care, and more detailed planning would be required on this number at the implementation stage, and a 70 per cent increase in home care was also required.
However, full implementation of a comprehensive three-point package of reforms would reduce the capacity needed to 2,590 extra hospital beds — 300 day case, 190 adult day critical care beds and 2,100 inpatient beds. This equated to opening a new 550-bed unit every third year.
They described their analysis as sensitive to the specific context in Ireland in respect of the mix of public and private healthcare, the role of GPs, and the nature of the social care services available.
The Review was asked to inform the development of a national development plan for the next decade, in particular for the scale of capital infrastructure needed.
The findings had been accepted by the Government and the provision for proposals included in the recently published National Development Plan. The Department of Health also had their model, and they were using it to do more evidence-based planning.
They had modelled the capacity on how hospital groups worked together and with their catchment areas, their community health organisations (CHOs).
Four key areas
Daly highlighted four particular areas which the PA Consulting group felt were important to make progress on reform for the provision of capacity.
The first was about securing and maintaining clinical leadership and, the second about how hospital groups were supported, effectively operating as a network with legal and regulatory aspects to make sure the incentives were there for people to work and deliver more in an integrated way.
The third aspect they wanted to highlight was about aligning the hospital groups with their CHOs, “So that you can start to move to population health planning.”
The final aspect was detailed control and management, and planning of the provision of extra capacity. “You can quite easily provide the extra capacity and not get the reform that was supposed to go with that unless you monitor it quite closely,” Daly concluded.