Health Report eolas Magazine issue 49 by bmf business services

Removing Barriers of Digital Transformation in Healthcare

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Removing Barriers of Digital Transformation in Healthcare

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Removing barriers of digital transformation in healthcare Providers are challenged to keep their staff safe, provide non-urgent clinical services and prepare for resurgent needs, all whilst supporting a remote and sometimes disparate workforce, not to mention the continuing impact of the pandemic. Given the focus on short-term operational challenges over recent times, many healthcare organisations have yet to address the new ways of working required to satisfy the ever-evolving needs and demands of patients into the future. When I was asked to lead the healthcare business for Dell Technologies a year and a half ago, I was both apprehensive and excited about the opportunity that digital change could bring to our health system.

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The pandemic has changed the face of every organisation for good, and none more so than those within healthcare. As healthcare organisations focus on the road ahead, they face changing patient expectations for virtual care, along with new clinical and business realities, writes Ryan Heynes, Healthcare Lead, Dell Technologies. 32

However, I was reassured to join a wellestablished, dedicated healthcare team in Dell Technologies, brimming with experience from around the world in various healthcare disciplines and very much aware of the great responsibility that comes with our role. I recall one of my now colleagues explaining to me that “technology in health is similar to other industries but having the right solutions can actually be a matter of life or death”. Needless to say, this was a little daunting. Dell Technologies has a long history of supporting healthcare organisations in Ireland and beyond to realise the potential of technology in delivering patient care, as well as helping clinical providers to optimise their applications for use in healthcare environments. We currently support over 10,000 hospitals worldwide with digital transformation programs and with our team of over 200 healthcare specialists we are well positioned to understand the unique and demanding requirements that healthcare providers have.

Removing Barriers of Digital Transformation in Healthcare

health report Advances in technology are helping healthcare organisations to treat these diseases more effectively, but they are also helping patients to self-manage their own care more effectively, or to “stay left” by taking responsibility for administering treatment on time and recording changes in their condition. This in turn has led to a richer set of data being captured by health care providers, who are utilising advanced analytical programs to determine optimised treatment pathways and new drug combinations to improve a patient’s outcome.

However, as we live longer and see an increasing number living with chronic conditions, Ireland’s population will require additional healthcare supports. Globally, on average one-in-three of all adults suffer from multiple chronic conditions (MCCs). In Ireland, the situation is even more pronounced with over 50 per cent of adults suffering from at least one chronic condition, and 40 per cent suffering from two or more. The most common conditions include coronary heart disease, arthritis, cancer, stroke, dementia, hyper-tension and high cholesterol, diabetes, and chronic obstructive pulmonary disease (COPD).

In addition to “staying left” and managing your treatment from home, technology is supporting the “shift left” movement focused on moving patients out of the acute hospital settings which are invasive and expensive, into a community or home setting to be treated. These initiatives underpin the Sláintecare strategy for modern healthcare, but also align with a proactive health model or what’s known as the “wellness model” of keeping people healthy and preventing illness, which is the opposite approach to our current “sickness model”, whereby you become ill and look for treatment.

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As we look ahead, it’s clear that healthcare providers will have to contend with an ageing population. More than 700 million people on the earth today are aged 65 or over, approximately 9 per cent of the entire global population. The United Nations (UN) predicts that one out of every six people will be over the age of 65 by 2050. In Ireland, it's expected to be more than one-in-four with the number of people aged 75-84 set to jump by 76 per cent by 2031. With advances in medicine and technology helping people live longer, this trend is only set to continue.

Removing Barriers of Digital Transformation in Healthcare

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“We currently support over 10,000 hospitals worldwide with digital transformation programs and with our team of over 200 healthcare specialists we are well positioned to understand the unique and demanding requirements that healthcare providers have.” Speaking of treatments, the speed at which new treatments and drugs are being developed and released into the market seems to be a major cause for concern amongst some individuals. The Covid-19 vaccine is an example in point, whereby there is still a level of mistrust and fear amongst communities about the vaccine due to misinformation that has spread about the speed at which the vaccine was developed and released, fuelling concerns about safety and potential side effects. But what isn’t so well understood is how the use of new technologies such as artificial intelligence and machine learning have helped to dramatically speed up the analysis of the research data that previously would have taken months and potentially years to understand, enabling it to be analysed in a matter of minutes or hours. Similarly, the use of technology to automate the manufacture and distribution of these drugs reduced the time it took to mass produce and deliver the vaccine to healthcare organisations around the world.

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This is another area with which Dell Technologies have been supporting industry leaders within the pharmaceuticals sector: utilising these complex technologies to bring drugs to market quicker, enable patients to benefit from them earlier and receive improved treatments that will lead to a better quality of life.

Technology can sometimes be perceived as complex and a little scary to some. This is often a major barrier to digital transformation across any industry. One of our goals in the Dell Technologies healthcare group is to help more people who work in healthcare roles better understand the basics of technology in health and de-mystify some of the more emerging technology trends. One of the initiatives we started to discuss after a short time in the role was an open briefing programme, which in partnership with the HSE quickly evolved into a six-month, recognised diploma programme. We wanted to make the initiative free, flexible, and engaging for anyone working in healthcare. The diploma, now entitled Digital Futures in Healthcare, helps to highlight several key healthcare technologies and inform healthcare staff of their benefits, how the technologies have developed and continue to develop and the potential use cases in improving care for patients. We marry industry expertise from our global healthcare team to local expertise from leaders across our health system to highlight key digital health technologies in a short two hour fully produced webinar format. The course is set across six separate modules, each focusing on a different type of technology used in the treatment of patients.

The Digital Futures programme has been designed to be accessed by staff at any level working across any discipline in healthcare. So, whether you’re a Chief Executive or in a clinical role or IT role, it doesn’t matter. Everyone working in healthcare has a role to play in driving digital transformation which, in turn, will deliver better patient and clinician experiences and, ultimately, better outcomes. The numbers registering for the programme has been simply incredible, with over 1,500 people taking part in the program. Numbers are still rising as we continue to accept registrations, with content available on demand after each broadcast. We are now in the fourth month of the course and feedback has been really positive from across the board, with lots of suggestions and requests for additional topics to be covered in follow-up initiatives. Why should people sign up? Quite often new technologies can be implemented in complete isolation from the other teams across a hospital or healthcare organisation, with very few understanding the reason for its implementation or the benefits it can bring. We have seen new innovations in the use of these technologies come from staff who are not involved in its primary use, but who understand the capability of these technologies and apply it to their own work environment. Through sharing and helping people to understand the benefits of these technologies, we hope to empower staff to come up with their own innovations and identify new capabilities for using technology to improve patient care, along with improving adoption rates. This will result in better outcomes for all and help remove the barriers to digital change.

E: Ryan_Heynes@dell.com W: www.dell.com

If you would like to register for the Digital Futures in Healthcare program and access the On-Demand content from previous sessions, you can find all the information on this website: www.delltechnologies.com/enie/industry/healthcare-it/ digital-futures-in-healthcare.htm

Removing Barriers of Digital Transformation in Healthcare

Budget 2022: Key health ﬁgures

€10.5 million to provide 19 additional critical care beds in 2022

€31 million

€250 million

to advance the Sláintecare objective of accessible and affordable care for the most vulnerable

€62 million

€36.5 million for measures to deliver safe, quality, and patient centred care

€30 million

€65 million

in new funding for health services for older people

in new funding for disability services

€10 million in additional funding for Healthy Ireland

€45 million

(€200 million to the HSE and €50 million to the National Treatment Purchased Fund) in additional funding to reduce acute hospital and community waiting lists

in new funding for specific women’s health measures to underpin Action Plan in Women’s Health for 2022

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Budget 2022 incorporated a record-breaking investment in Ireland’s health and social care services, increasing core spending by approximately €1 billion. In 2022, health expenditure will total €22.4 billion (including €0.2 billion held in reserve).

in new funding for national clinical strategies

€24 million in new funding for mental health services, including provision for 350 additional mental health services posts

€9 million

€8 million

to fund accessible contraception for women aged between 17 and 25

to modernise and increase capacity of the National Ambulance Service

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Removing Barriers of Digital Transformation in Healthcare

A system under pressure With the pandemic now stretching into its third calendar year in Ireland and waiting list numbers reaching all-time highs in 2021, the Irish health system has come under significant pressure of late, at a time when efforts were to be focused on the implementation of the Sláintecare reforms. Covid-19 Yet again, the health system has come under pressure due to a spike in the number of Covid-19 cases. Having been as low as 200-300 new cases per day in June 2021, case numbers steadily rose from October onwards, peaking at 5,959 new cases on 21 November, with between 3,000 and 5,000 new cases recorded each day for most of November and into December. While these numbers do not make for good reading, there is solace to be drawn from both testing numbers and hospitalisation rates that show a health system that has gotten to grips with the virus much more than in previous waves. The effectiveness of the vaccination campaign rolled out by the health system during 2021 is borne out in hospitalisation figures: on 5

December, a seven-day average of 4,885 new cases was recorded, with a seven-day average of 543 hospitalisations (11.1 per cent) and 115 (2.3 per cent) people in intensive care. In comparison, a seven-day average of 4,381 new cases per day was recorded on 15 January 2021, with a seven-day average of 1,623 hospitalisations (37 per cent) and 156 people in intensive care (3.6 per cent). Testing capacity has also been greatly increased, with November and December consistently recording seven-day average records for tests taken. The average now exceeds 30,000 per day. This, of course, has led to an increase in the rate of positive tests, with positive rates over 10 per cent recorded in October for the first time since January, reaching as high as 15 per cent in November, though still

not as high as the 25 per cent seen in January, when 5,000 less tests per day were being taken. However, despite the relative success of the vaccination programme in keeping people out of hospitals and in the increased testing capacity in detecting cases, the health system has still been put under significant pressure due to a lack of capacity. HSE figures released in mid-November showed 288 ICU beds open and staffed in Ireland, with 279 of them (97 per cent) occupied, 119 by Covid patients. Projections for numbers of ICU beds needed for Covid cases alone during this current wave range from 300 to 500; while Budget 2022 committed to the delivery of 340 ICU beds in the State by the end of 2022. ICU capacity is an issue that has affected the health system well before Covid, with the

Removing Barriers of Digital Transformation in Healthcare

Covid-19 in the Republic of Ireland, 2021 90%

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OECD reporting in 2019 that Ireland had 5.2 ICU beds per 100,000 of population, as compared to an average of 14.1. Capacity in testing has also been put under great stress due to the increase, specifically in the Greater Dublin Area, with three new centres opened in November in an attempt to alleviate some of this pressure. The Health in Ireland: Key Trends 2021 report stated that an expenditure increase of €3 billion had occurred between 2019 and 2020, with staffing increases due to the pandemic a major contributing factor. Separate HSE data published in November showed one-in-25 HSE staff to be off work at the time due to either being infected with Covid-19 or being deemed a close contact. 5,800 employees were absent at the time, a total of 4 per cent of the workforce, as compared to 1,800 a month previous.

Waiting lists Unsurprisingly, the pressure placed on the health system by the pandemic has seen problems elsewhere in the system worsen since March 2020. National Treatment Purchase Fund data published in August 2021 showed a record 908,519 patients on some form of public hospital waiting list for assessment by a consultant or treatment at the end of July. 268,500 of these were waiting for over a year for assessment, a 15 per cent increase on July 2020 and a seven times increase over seven years. 20,513 patients were waiting over a year for hospital care, an increase at a rate of 88 times since 2012. The Key Trends 2021 report, which was prepared by the Department of Health, found that there has been a 25 per cent increase in the number of people who have spent more than six months on

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9,000

inpatient waiting lists since the pandemic began. Over 28,000 adults and almost 4,000 children were found to be waiting more than six months for inpatient treatment in October 2021. The Government had sought to reduce waiting list numbers by 18,300 between August and the end of October, but the final figure recorded was 10,700, or 60 per cent of the target. The Irish Hospital Consultants Association has said that it expects the target of 36,600 reduction by the end of 2021 to be missed.

Sláintecare Sláintecare implementation has been thrown into doubt of late with the resignation of three members from the Sláintecare Implementation Advisory Council (SIAC), but progress towards the goals in the reform programme continues with the Winter Plan and 2021 National Service Plan placing pronounced emphasis on the building of capacity for healthcare to be delivered within local communities. However, the Irish Fiscal Advisory Council has recently warned that basic financial information around the reforms is “severely lacking”, stating that no budgeting is available beyond one year, updated costing have not been produced since 2017; “little clarity on progress made is publicly available”; and public spending on health, pay and other cost issues “do not appear to have been factored into the original costings”. With this likely to have driven up the final cost of the implementation of Sláintecare, the IFAC has warned that factoring in these pressures “should be carried out as a matter of urgency”. 37

Immunising the nation

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Since the World Health Organization declared that Covid-19 was a pandemic on 11 March 2020, a lot has changed in our personal and professional lives but one thing that hasn’t changed is my team’s dedication to preventing vaccine preventable diseases, writes Lucy Jessop, Director of Public Health, National Immunisation Office within the HSE. I lead a small but dedicated multidisciplinary team in the HSE National Immunisation Office; we manage vaccine procurement and distribution and developing training and communication materials for the public and health professionals to allow safe and high-quality vaccination programmes to be delivered in line with Department of Health Immunisation Policy. During the Covid-19 pandemic we have also supported the implementation of the Covid-19 vaccination programme and its many changes. The first Covid-19 vaccine was administered in the Republic of Ireland on the 29 December 2020 to Annie Lynch and up to the end of November 2021 over 7.4 million doses have been administered. It’s important to remember that as millions of doses of Covid-19 vaccines were administered in Ireland during 2021, our routine vaccination programmes continued thanks to dedicated health professionals who know the value of preventing vaccine preventable diseases.

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In Ireland, our vaccination programme offers protection against 13 diseases including influenza, rotavirus, meningococcal disease and measles. We offer vaccines throughout the life course; the primary childhood immunisation programme at two, four, six, 12 and 13 months of age through GP practices, our schools programmes to Junior Infants in primary schools and first year in second level schools delivered by HSE school immunisation teams, vaccines in pregnancy and to those in risk groups through GP practices and pharmacies and our vaccines for health professionals delivered through peer vaccination

programmes in our CHOs and Hospital Groups across the country. In lots of cases the professionals who are delivering the Covid-19 vaccines also deliver our routine programmes.

reflecting the amount of clinical changes to the programme since it began; •

dealt with over 6,000 queries covering topics like intervals between Covid-19 vaccines, cold chain and clinical questions about vaccines;

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provided up to date e-learning training which has so far been completed by 20,000 learners across the country;

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worked with HSE communications to ensure information provided to people before and at the time of vaccination is clinically accurate;

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we worked with colleagues in HSE Social Inclusion to provide information in over 26 languages using print, audio and visual materials; and

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worked with the HSE Office of the Chief Information Officer (OoCIO) to test software releases and sanity testing before updates are made to the CoVax system being used to record Covid-19 vaccination records across the country.

Reflecting on 2021 My multi-disciplinary team have a wealth of experience in public health, medicine, pharmacy, procurement, ICT, communications and project management. With these skills we have supported our colleagues across the HSE working across different work streams to safely implement a population wide Covid-19 vaccination programme and maintain our support for the routine programmes. The National Immunisation Office has taken the lead on the training of vaccinators for the Covid-19 vaccination programme and in providing clinical information on the vaccine programmes. Frequent updates from the European Medicines Agency (EMA) and the National Immunisation Advisory Committee (NIAC) have meant that we have had to respond quickly to ensure all our clinical and public facing materials always contained the most up to date advice which has been by no means easy. For example, so far this year we have: •

developed over 40 different clinical materials to support our vaccinators across the country and updated them as needed for example our Clinical Guidelines are currently on Version 29,

I have attended Department of Health NPHET briefings on four occasions and presented at Joint Health Select Committees, HSE press briefings, the European Congress of Clinical Microbiology, BIPA Committee B along with multiple TV and radio appearances to provide updates and answer questions about the Covid-19 vaccination programme. It hasn’t been all smooth sailing; the cyberattack in May meant we had to rethink the work processes we had put in place to run an efficient team. Our email, education, shared files and all

“It’s important to remember that as millions of doses of Covid-19 vaccines were administered in Ireland during 2021, our routine vaccination programmes continued thanks to dedicated health professionals who know the value of preventing vaccine preventable diseases.”

other HSE IT systems went off line overnight but our vaccination programmes continued, so we needed to adapt to continue to support them.

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My team developed a solution that allowed health professionals to contact us if they had clinical queries and they developed a bespoke training and education programme similar to that provided by the HSE HSELand platform to ensure vaccinators and vaccine advocates could continue to access up to date clinical training materials for the Covid-19 vaccination programme. This was up and running within days of the HSE systems going offline. During the time of the cyberattack we dealt with over 2,000 clinical queries and over 6,000 people completed the Covid19 Vaccination Training Programmes. Throughout 2021, we also continued to work on our routine immunisation programmes and adapt our messaging in line with Covid-19 measures. We encouraged people to avail of vaccines for their babies, school children and themselves to not only protect them from vaccine preventable disease now but when they are older too using traditional and digital channels.

Planning ahead As we approach the end of 2021, we are reflecting on the work we have completed so far this year and putting plans in place for our routine work in 2022. We are also very aware that we will need to continue to adapt to support the Covid-19 vaccination programme and whatever changes are required in line with Department of Health policy.

the position of Director of Public Health, National Immunisation Office. She was previously the Northern Ireland member of the Joint Committee for Vaccinations and Immunisations in the UK and is now a member of the National Immunisation Advisory Committee.

W: www.immunisation.ie Lucy Jessop worked in paediatrics before training in Public Health Medicine in London. She worked as a consultant in both England and Northern Ireland. In 2019 she took up

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Although Covid-19 public health measures like social distancing and reduced foreign travel have supressed the number of vaccine preventable disease being reported in Ireland temporarily, they have not gone away. Some people have not taken the opportunity to complete the recommended vaccination schedule for themselves or their children. It is never too late to catch-up on vaccinations so I would encourage people to contact their GP or other healthcare professional to arrange any vaccines they have missed.

The mission of the National Immunisation Office has not changed through the pandemic and beyond. We will continue to work with key stakeholders and support healthcare providers to maximise the uptake of all national immunisation programmes and provide strategic direction in support of a best practice based, equitable and standardised delivery of publicly funded immunisation programmes.

Social: @hseimm on Twitter and Instagram and National Immunisation Office on YouTube.

Removing Barriers of Digital Transformation in Healthcare

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Digital transformation for resilience and better healthcare Gar Mac Críosta, Product Manager for the Health Service Executive (HSE) and Product Lead for the Covid Tracker Ireland app, reflects on the experience of digital transformation during the pandemic and how it has informed a future vision of a more resilient health system.

“It has been a really interesting experience over the last year-and-a-half to see what we could do in the time we were given,” Mac Críosta begins. “We are now in a moment of reflection, figuring out what we bring forward, what we leave behind, and what are the constraints.” Capacity in the HSE has been severely tested during the pandemic, and Mac Críosta says that high demand is something the health system understands it must learn to live with. Furthermore, the HSE must use the opportunity to not just change technologically, but psychologically: “In healthcare, we have experienced massive demand that we know is not changing and we must determine how to avoid being overwhelmed. It is a fact that we are going to have to deal with the demand and in order to do that we have got finite capacity in our physical structures, so how do we rethink the delivery of healthcare in a sustainable way? “Before Covid, I felt like I had spent 25 years adding technology to existing processes and not really making too much progress. We were stuck, not in terms of the technology we were deploying, but in terms of the way we were thinking about this. “After Covid, we have a choice to go back to the status quo, and there are a lot of people who would feel comfortable with that because we

were safe there. However, if we move into this new world of continuous change, that brings with it a lot of other things. One of the common framings of digital transformation is changing from A to B. That is a poor framing. Digital transformation is changing the way we think, not changing the thing we are in any given moment. That is one of the big steps we need to take.” Problems emerge, Mac Críosta says, when technologies that were considered significant changes 20 years ago are now complicating modernisation attempts. A need to be more brutal with regard to these issues is one that the Product Manager touches on. “It all becomes intertwined and difficult to remove,” he says. “Even now as we deploy new technologies, you add time to it, and you get instant legacy issues and things go on life support. Technologies are livestock, you kill them when it is time and you move on, but we treat them like pets and nurse them, look after them, keep them alive for way too long and that causes stress and despair.”

Removing Barriers of Digital Transformation in Healthcare

From their experiences with the pandemic, Mac Críosta and his colleagues have developed three laws of operation: 1. Hardware will fail: “Stuff could fall over; heating units, servers, anything.”

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2. Software has bugs: “You pay for the software and the bugs come for free. Then it is up to us to fix them. It is part and parcel of this process, and we need to get away from thinking that it is awful and move towards a systemic way of fixing these issues when we find them, because we will find them.” 3. People will be people: “People are the greatest source of variance and failure in any system. That is the reality of it. Our job is not to engineer people out of it, but to recognise that this is a frailty in the system and figure out a way to deal with it and how do we support people through that.”

“One of the common framings of digital transformation is changing from A to B. That is a poor framing. Digital transformation is changing the way we think, not changing the thing we are in any given moment. That is one of the big steps we need to take.” A common theme identified by those implementing digital transformation amid Covid is the speed at which change has happened. Mac Críosta is no different, remarking upon how the pandemic has changed perceptions of both how and when to act, he asserts: “There is such a thing as being too late, there is no time for apathy or complacency. This is a time for vigorous and positive action. As a result of Covid Tracker Ireland, we have had lots of conversations that span many government departments and there is consensus there is an opportunity now that we have never had before. “We never had it but, both from a technological and an urgency point of view, there is a feeling that we need to do something now. One of the big things is energy. The problem with our thinking is that we have spent the past 30 years figuring out how to do complicated things, from an order perspective all we have done is plan, treat the future as predictable, and work through it. Over the past 18 months, we have proved that does not work. I am not saying it does not work for everything, but in certain situations, particularly where there are people involved, you have to employ different techniques. We cannot do the same things as before.” Energy, Mac Críosta reflects, can be key in such transformations. Too many transformations are often stopped in their tracks due to too much energy demand. As such, the transformations targeted are too big in scope. “If you look at any change or transformation, the reason it does not stick is because the energy gradient is too high, what you are trying to do requires too much effort and unless you lower the energy gradient, you cannot make that move,” he says. “Over and over again, we see these grand programmes of change failing because the energy gradient is too high. Energy gradients within a system constrain what you can do.”

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Removing Barriers of Digital Transformation in Healthcare

Significant amounts of energy may be expended by Mac Críosta and his colleagues in dealing with older technologies, but a blanket perception of old as bad is one that he warns against, stating that fragility is the main issue of the day with technology. Age, in the case of resilient technologies, appears to be just a number, and understanding this requires a change in the way we learn. “There is nothing wrong with old technology; old fragile technology is the problem,” he says, adding: “We keep mischaracterising things, applying one label to everything else, saying old is bad and then rationalising and getting rid of everything. It is not that simple. “In a complex domain, I have got to probe, experiment, and learn, so it is a learning environment, whereas an ordered environment is a knowing environment. These are two opposing philosophies: One where I know everything and another where I am learning what I need to learn to create some coherence and begin to develop some knowledge. We are stuck in that, and this thinking goes back to school. We are taught to know things, not learn things. We talk about learning, but we do not examine things and that drives a particular perspective on things.” Reflecting on this lack of critical thinking, Mac Críosta concludes with what he believes to be the crucial aspect to digital transformation: “Imagination is the key in this. Nobody thinks about imagination in terms of decision-making but if I have no imagination, I have no options. Imagination is thinking about what could happen. What would it be like, in terms of delivery of healthcare in Ireland, if we could deliver it anywhere in the country at any point of time to anyone in collaboration with any other department that is out there? What would that look like? That’s totally reimagining how we deliver public services.”

“There is nothing wrong with old technology; old fragile technology is the problem. We keep mischaracterising things, applying one label to everything else, saying old is bad and then rationalising and getting rid of everything. It is not that simple.”

Major milestone on Ireland’s paediatric healthcare journey emergency care units – with the same staff and standards, as well as easier access – are embedded in communities first, people will stay there and feel that they do not have to go the principle hospital. That is our chief objective.”

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Breaking from a tradition whereby referrals are often made directly to specialists, this investment seeks to consolidate a cohort of general paediatricians who can become a first point of contact, liaising with GPs, community services, and families, to manage most paediatric conditions and assess what must go to specialist services. “By enabling healthcare professionals Eilísh Hardiman, Chief Executive of Children’s Health Ireland (CHI) and Minister for Health Stephen Donnelly TD at the opening of the new Paediatric Outpatient and Emergency Care Unit (ECU) at CHI at Tallaght.

Eilísh Hardiman, Chief Executive of Children’s Health Ireland (CHI) speaks with eolas Magazine about her organisation’s realisation of a major milestone on the journey towards modernising children’s healthcare in the State.

such as consultants and doctors, as well as nurse specialists, psychologists, physiotherapists, and phlebotomists, to establish multidisciplinary teams, the new facility at CHI at Tallaght will ensure more efficient, child-centred, family focused care, which treats children at the earliest opportunity,” the Chief Executive asserts. Indeed, a similar facility in CHI at Connolly Hospital, Blanchardstown opened in July 2019 and its services

It has been a challenging year for CHI. In fact, ‘challenging’ is an understatement. Alongside the busiest emergency department attendances in the history of its hospitals, CHI’s priority has been to recover from both the Covid-19 pandemic and the May 2021 ransomware attack on the HSE.

In this context, in 2021, CHI successfully met several objectives on its journey towards better health outcomes for children and young people throughout Ireland. Most decisively, Hardiman outlines: “We have opened a new paediatric outpatient and

contributed to a 65 per cent reduction in

Primarily, the model for paediatric care in Ireland is defined by keeping care in the home where possible or as close to the home as clinically appropriate and Children’s Health Ireland’s catchment area incorporates the entirety of Dublin city and county, alongside Meath, part of Louth, Kildare, and Wicklow.

Chief Executive of Children’s Health

“As such, we have to ensure that we have a paediatric outpatient and urgent care centre on both the northside CHI at Connolly and the southside CHI at Tallaght. This ensures that families can be supported locally without traveling to attend the New Children’s Hospital,” Hardiman explains.

waiting lists for general paediatric services. “One-quarter of the citizens of Ireland are aged under 18 and my purpose as Ireland is to advocate hard on behalf of children’s services. Our objective is to have healthier children and young people, ultimately ensuring a healthier, wealthier, and happier nation,” Hardiman concludes.

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Simultaneously, remarking on “long waiting lists and significant numbers of people waiting”, the Chief Executive identifies access to care as the single greatest operational risk facing her organisation. With the delivery of the New Children’s Hospital moved out until 2024, therefore, improving access to care in existing facilities has become a necessity.

emergency care unit at CHI at Tallaght. That is a very important milestone in the plan for the new children’s hospital. The rationale is to keep paediatric services local and convenient.”

W: www.childrenshealthireland.ie

“International experience indicates that if a hospital is established first, people will gravitate to it. However, if outpatient and 43

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Removing Barriers of Digital Transformation in Healthcare

Sláintecare Implementation Plan 2021–2023 Budget 2022 detailed the spending of €1.5 billion in additional government funding to “progress critical strategic reform measures at pace across the health system”. These reforms are “underpinned by the principles set out in the Sláintecare Implementation Strategy and Action Plan 2021–2023”. Along with the €1.5 billion outlined within the Budget that would progress the aims of Sláintecare as illustrated in the implementation strategy and action plan, the record €21 billion investment in health and social services delivered by Budget 2022 also includes €45 million specifically to “advance the Sláintecare objective that care is accessible and affordable for the most vulnerable”. Speaking upon the publication of the Budget, Minister for Health Stephen Donnelly TD said that the funding delivered would “address health inequalities and substantially ramp up the resources allocated” in a fashion “embodying the Sláintecare principles of delivering the right care, in the right place at the right time”. Under the “three key dimensions” of Sláintecare (access, quality, and affordability), the Budget delivered various commitments. Under access, €10.5 million will be provided for an additional 19 critical care beds in 2022, bringing the total to 340; €8 million will be provided to increase the capacity of the National Ambulance Service; and €22 million be provided for additional Winter Plan measures in 2022. 44

In terms of quality measures, €36.5

million is to be provided for “a range of measures” including progression of the Safe Staffing Framework, which seeks to reduce patient time in emergency care settings and “better outcomes for patients and staff”, and expansion of the advanced nursing and midwifery workforce. Lastly, the €45 million pledged to affordability measures will enable the expansion of access to free GP care to children aged seven, the reduction of the monthly threshold for the Drug Payment Scheme from €114 to €100 and “moving on a phased basis to reduce the financial burden of hospital charges for children under 18”. The Sláintecare Implementation Strategy and Action Plan 2021–2023 outlines the eight fundamental principles of Sláintecare: patient is paramount; timely access; prevention and public health; free at the point of delivery; workforce; public money and interest; engagement; and accountability. To begin on the path to delivering on these principles, the document sets out the two reform programmes to be prioritised from 2021 to 2023: improving safe, timely access to care and promoting health and wellbeing; and addressing health inequalities – towards universal healthcare.

Removing Barriers of Digital Transformation in Healthcare

Reform Programme 1: Improving safe, timely access to care, and promoting health and wellbeing The first of the Sláintecare reform programmes scheduled for the period 2021-2023 is to be focused on integration, safety, prevention, shift of care to the right location, productivity, extra capacity and reduction of waiting lists. Seven projects make up Reform Programme 1: 1. Implement the Health Service Capacity Review including healthy living, enhanced community care and hospital productivity.

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2. Scale and mainstream integration innovation. 3. Streamline care pathways, from prevention to discharge. 4. Develop elective centres in Dublin, Cork, and Galway. 5. Implement a multiannual waiting list reduction plan. 6. Implement the eHealth Programme. 7. Remove private care from public hospitals and implement the Sláintecare Consultant Contract. Four targets set out under this programme are that nobody should wait longer than 12 weeks for an inpatient procedure, 10 weeks for an outpatient appointment, 10 days for a diagnostics test, or four hours in an emergency department. Of particular interest to the public among these goals will be the implementation of a multiannual waiting list reduction plan, with Ireland’s waiting times, already bad and worsening before Covid-19, now exacerbated to record levels by the pressures placed on the health system by the pandemic. Steps taken to establish the plan will include: identifying and reporting on all waiting lists for all locations by discipline including community, social care, hospital, diagnostic, and palliative care; arranging a programmatic and accountable approach to delivering the plan; establishing clinical groups to agree pathways from prevention to discharge; and implementing supporting eHealth projects such as waiting list management system and agreed care pathways.

Reform Programme 2: Addressing health inequalities — towards universal healthcare Reform Programme 2 is focused on moving Ireland towards the goal of universal healthcare. Four projects make up Reform Programme 2: 1. Develop a citizen care masterplan. 2. Rollout Sláintecare Healthy Communities Programme. 3. Develop regional health areas. 4. Implement Obesity Policy and Action Plan 2016–2025. The concurrent aims of rolling out the Sláintecare Healthy Communities Programme and developing regional health areas will be key to the achievement of Sláintecare’s goal of relocating health in Ireland within communities. The Healthy Communities Programme aims “to improve the long-term health and wellbeing of the most disadvantaged communities in Ireland, objectively selected based on the Social Inclusion and Community Activation Programme (SICAP) areas”. 18 of 51 SICAP areas will receive additional investment in 2021 and “health-specific interventions will be offered by the Department of Health and the HSE, while non-health government departments, their agencies and delivery partners, will offer their wider determinants of health supports”. The six regional health areas were approved by the Government in 2019, with the development of the areas designed to improve clinical governance, corporate governance and accountability, population-based approach to service planning, and integration of community and acute services. A business plan and change management programme will be developed in 2021 to further progress the implementation of the regional health areas. 45

How new Health Impact Assessment Guidance can help to build healthier communities

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Incorporating the latest international and European developments and best practice in the field, the Minister for Health in Northern Ireland, Robin Swann MLA, and the Minister of State for Public Health, Well Being, and National Drugs Strategy in Ireland, Frank Feighan TD, both welcomed the suite of updated guidance documents launched in November 2021. At its core, HIA seeks to inform and enhance the decision-making process in favour of health and health equity while underpinning a whole-of-government ‘Health in All Policies’ approach to improving population health.

Dr Joanna Purdy, Public Health Development Officer, Institute of Public Health

Public Health Development Officer with the Institute of Public Health, Joanna Purdy, shares some insights into new Health Impact Assessment Guidance and how it can help policy- and decision-makers to ‘health proof’ new laws, policies, or programmes. As the world emerges from the Covid-19 pandemic and responds to the many challenges posed by climate change, there is an opportunity to build healthier communities. One tool that can help to do that is Health Impact Assessment (HIA), a process that can ensure that proposals are more inclusive, more equitable, and more sustainable for everyone.

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The Institute of Public Health recently published the fourth edition of HIA Guidance for Ireland and Northern Ireland, the first major update of this allisland guidance since 2009. The work of the Institute centres on promoting health and wellbeing, improving health equity, and reducing health inequalities throughout the life

course and this is a central theme of the suite of updated HIA Guidance documents. A HIA can be conducted on a new law, policy, plan, or programme, otherwise known as a strategic level HIA but can also be conducted at project level. This new HIA Guidance can assist policy- and decision-makers to assess the potential impact of a new proposal and how it might affect the health of the community or population before it is implemented. It is designed to help community organisations, local authorities, and other policy- and decision-makers at national, regional, or local level to build healthier communities and reduce health inequalities.

Healthy Ireland, the public health framework in Ireland, acknowledges that health is influenced by factors outside the health sector, such as housing, transport, social protection, employment, and environment. HIA can play a central role in national and local decision-making to help ensure that policies and planning in these sectors have a positive impact on health and mitigate any potential negative health outcomes. Based on the guiding principles of equity and equality, participation, sustainability, a comprehensive approach to health and ethical use of evidence, HIA also provides a unique opportunity to give communities a voice and say on proposed laws, plans, policies, or programmes that may affect their health. Whilst the guidance has been developed specifically within the policy and legislative contexts of Ireland and Northern Ireland, it is also transferable to the UK and Europe. HIA is not conducted in isolation and the new guidance sets out how HIA interfaces with both statutory and non-statutory impact assessments. When a new piece of legislation, policy, or programme is being developed, it is often subject to a number of statutory impact assessments, such as human rights and equality impact assessment. HIA practitioners and those working in a

CASE STUDY: Sugar Sweetened Drinks Tax The Institute of Public Health carried out a HIA on a proposed tax to support a reduction in the consumption of high sugar drinks as part of Ireland’s obesity policy and action plan. This is an example of a policy level HIA. The tax, introduced in 2018, prompted drinks companies to reduce the sugar content of products to offer consumers healthier choices. 46

What is Health Impact Assessment? Health Impact Assessment (HIA) can be used to help understand how a new law, policy, programme, or project might affect the health of the population or local communities before being implemented.

•

HIA ensures that new proposals are more inclusive, more equitable, and more sustainable for everyone. For example, it can assess how people with less money, children, older people, or people with a disability might be affected by a new law or policy.

•

HIA can be carried out by a wide range of policy- and decision-makers in sectors such as health, transport, environment, housing, planning, education, and employment. Examples of organisations that can use HIA include central government departments and their statutory agencies, local councils, health and social care services, community and voluntary sector organisations, planning authorities and private developers.

This graphic outlines the seven stages involved in the HIA process.

range of sectors can conduct a standalone HIA or include health within environmental assessment, such as Environmental Impact Assessment (EIA) or Strategic Environmental Assessment (SEA), which follow the same principles, process and approach. There can be statutory, policy, and voluntary drivers for HIA, which will determine how the health impacts of a proposal are reported, either in a standalone HIA or as health within environmental assessment. There is no legal requirement to conduct a HIA in Ireland or Northern Ireland, but this tool has the capacity to ‘health proof’ new laws, policies, programmes, or projects and support better integration of health and health equity in decision-making. The HIA process underpins the United Nations Sustainable Development Goals to reduce health inequalities and improve health equity. At a time when climate, health, and sustainability are in the spotlight, there is now a unique opportunity within our grasp to use the HIA process and this new Guidance to build healthier and more sustainable communities.

A suite of updated HIA Guidance documents has been developed for different audiences, including the general public, commissioners, policymakers and impact assessment practitioners. The Technical Guidance document provides practical tools for each stage of the HIA process. The HIA Guidance has been endorsed by the European Public Health Association and the International Association for Impact Assessment. For more information about this new HIA Guidance please visit www.publichealth.ie/hia. To discuss HIA or the Guidance documents, you can contact the Institute of Public Health by emailing hia@publichealth.ie.

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•

What are the benefits? •

HIA aims to ensure potential positive health impacts and prevent potential negative health impacts of a proposal;

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HIA can support people from different backgrounds to work together to ensure that decision-making for health is fairer and more inclusive;

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HIA can be used at strategic or policy level as well a national, regional and local level to ‘health proof’ new and future programmes or projects;

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HIA provides evidence-based conclusions and recommendations; and

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HIA can complement or inform other impact assessments such as poverty, human rights, or equality impact assessments.

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HIA underpins a whole-of-government ‘Health in All Policies’ approach to improving population health. 47

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Removing Barriers of Digital Transformation in Healthcare

Health measures in Budget 2022 Budget 2022 identifies “immediate actions to address waiting lists” as the most urgent health priority for next year, before implementing a long-term multiannual plan for waiting lists in both hospitals and community health services. While Budget 2022 provided more than €1.1 billion for the expansion and modernisation of the health service, delivery was impeded by the Covid-19 surge last winter and the subsequent HSE cyberattack in May 2021. Consequently, not all the measures planned for 2021 will be delivered by the end of the year. Regardless, the additional funding provided during 2021 has been again made available for 2022. Indeed, an additional allocation of €1 billion, including over €300 million for new measures, has been added for 2022, increasing overall core funding allocation for current expenditure to over €20.4 billion. Referencing the pandemic as “the greatest challenge that has ever faced our health system”, Minister Donnelly asserts that Budget 2022 is a demonstration of the Government’s

commitment to deliver universal healthcare. Identifying his most urgent priority in 2022 as “taking immediate action to address waiting lists which are unacceptably high at present”. As such, the Department of Health, the HSE, and the National Treatment Purchase Fund are collaborating on a multiannual waiting list plan which will seek to resolve the backlog associated with the Covid-19 pandemic and align waiting lists with Sláintecare objectives. Another priority he emphasises is investment in women’s health, which will be boosted by an additional €31 million in 2022. This will fund the phased introduction of free contraception, beginning with women aged from 17 to 25, as well as measures to address period poverty and expand clinics for endometriosis and menopause.

Credit: Merrion Street

Removing Barriers of Digital Transformation in Healthcare

Disability

BUDGET 2022:

Advancing Sláintecare AC C E S S A N D C A PAC I T Y

➤ €8 million to modernise and build capacity of the National Ambulance Service.

With a total allocation of €1.15 billion in Budget 2022, mental health will receive an additional €47 million (€24 million for new developments, €13 million for existing services and €10 million for once-off Covid funding) next year.

➤ €22 million for additional Winter Plan measures.

Mental health and older people

QUALITY ➤ €36.5 million for clinical governance system measures. ➤ Implementation of phases two and three of the Safe Staffing Framework. ➤ Funding to expand the advanced nursing and midwifery workforce to a target of 2.3 per cent of the total nursing and midwifery workforce in 2022. ➤ Implementation of the Nursing Home Expert Panel recommendations. A F F O R DA B I L I T Y ➤ €45 million provided into 2022 to advance the Sláintecare objective of health services moving to free at the point of delivery provision, based entirely on clinical need. ➤ Expansion of access to free GP care to children aged six and seven years. ➤ Expansion of dental access to medical card patients.

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➤ €10.5 million for 19 additional critical care beds in 2022.

Meanwhile, Minister of State with responsibility for Disability, Anne Rabbitte TD outlines that Budget 2022 allocated a further €65 million to the €2.2 billion disability budget, inclusive of €10 million for one-off Covid measures. This, the Minister of State noted, would enhance the delivery of supports and services for disabled people, including the recruitment of therapists and administrative staff in support of the 91 Children’s Disability Network Teams, alongside increases in digital health technologies, respite houses, personal assistant hours, and residential places for disabled people.

Minister of State with responsibility for Mental Health and Older People, Mary Butler TD remarks: “This investment will ensure significant developments in mental health services next year… New mental health services for older people will also be developed, in line with the model of care for specialist mental health services for older people and will be piloted next year.” Detailing the Budget’s €2.33 billion allocation to older people services, which includes €30 million for new developments, Butler explains that this will specifically facilitate: •

funding totalling €150 million for five million additional hours of home support in 2022;

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an increase in the new home support hours that are ringfenced for people with dementia from 5 per cent into 2021 to 11 per cent in 2022;

•

further improvement in dementia services, as well as the implementation of the dementia registry and dementia audit within acute hospitals and the national intellectual disability memory service; and

•

the implementation of the Covid-19 Nursing Homes Expert Panel Report recommendations.

“This budget falls far short of what is needed to tackle waiting lists, invest in public hospitals, and bolster community healthcare.”

➤ Reducing the monthly threshold for the Drug Payment Scheme from €114 to €100.

Sinn Féin spokesperson David Cullinane TD

➤ Moving on a phased basis to reducing hospital charges for those aged under 18 years.

Public health, wellbeing, and the National Drugs Strategy Announcing a €16 million investment in new measures to in support of Healthy Ireland and the National Drugs Strategy and €13 million of Covid funding, Minister of State with responsibility for Public Health, Wellbeing and the National Drugs Strategy Frank Feighan TD outlines specific initiatives for 2022 which include “a healthy weight campaign, an innovative coordinated approach to encourage physical activity through Sport Ireland and the HSE, and funding for the expansion of the HSE’s pilot online STI 4 testing programme”. 49

Removing Barriers of Digital Transformation in Healthcare

Reaction Welcoming the health allocation in Budget 2022, the Irish Nurses and Midwives Organisation (INMO) praises proposed spending on women’s health, “including the long-underfunded National Maternity Strategy”, as well as Sexual Assault Treatment Units, and mental health, disability, and hospice services.

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However, the INMO indicates that it would seek greater clarity on several areas including the number of nurses and midwives to be recruited by the end of 2022, the Safe Staffing Framework in Nursing, and the number of additional CAO places that will be allocated to nursing and midwifery. Meanwhile, having acknowledged the additional funding for health in Budget 2022, the Irish Medical Organisation (IMO) asserts that it will not be

Resource allocation for the health vote group in 2022

Gross Voted Current Expenditure (€m)

Gross Voted Capital Expenditure (€m)

Total Gross Voted Expenditure (€m)

CORE

COVID

NRRP

TOTA L

20,384

750

21,134

993

1,060

21,377

800

22,194

sufficient given that around one million patients were on a waiting list at the end of 2021, one-in-five consultant posts are vacant, and there are only three hospital beds per 1,000 of the population. Equally critical, Sinn Féin spokesperson on health, David Cullinane TD remarks: “It is clear that the Government does not realise the scale of the challenge in health, and this budget falls far short of what is needed to tackle waiting lists, invest in public hospitals, and bolster community healthcare.” Likewise, Labour health spokesperson Duncan Smith TD suggests: “Budget 2022 will be a disappointment for many people in Ireland, particularly those with additional care needs. It’s clear that this government will do nothing to tackle the huge systems failures within the health service… There is no vision for community based primary care and moving treatment outside the acute hospital setting.”

Keeping track of the Covid-19 vaccine TrackVax is now running in nearly all 43 Centralised Vaccination Clinics. A barcode scan of each vaccine records the critical data, including its batch and the exact time a vial is to be discarded. Prior to the introduction of TrackVax, the discard time was handwritten on the vials, a time-consuming process that also posed a medication safety risk.

GS1 standards are helping to ensure that Covid-19 vaccines get efficiently and safely to patients at Central Vaccination Clinics, writes Siobhain Duggan, Director of Innovation and Healthcare, GS1 Ireland. Almost immediately after the world learned that Covid-19 vaccines existed, a question arose: what is the best way to ensure their efficient and safe distribution? This is the sort of challenge where GS1 standards can, and do, play a critical role. GS1 barcodes can be used globally to identify Covid-19 vaccines uniquely and securely as they move from manufacturing sites through complex distribution networks to points of administration. During the last year, the team at GS1 Ireland worked closely with the Health Service Executive (HSE) to help ensure the safety of Covid-19 vaccines.

barcode on each of the vaccine boxes,

It was important for the National Immunisation Office (NIO) that no dose was wasted and that batches of vaccine could be tracked to the point of vaccination. Following an intensive design phase with the HSE project team, two software applications were developed: ScanVax and TrackVax. ScanVax was installed on over 1,000 PCs across the country to allow for the receipt of vaccines. By scanning the

High Level Taskforce has been really

vaccine information is then uploaded to the national vaccine administration system. This means that vaccinators can select the correct batch when administering the vaccine. TrackVax has

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“Traceability is a key part of managing the vaccine process. The use of barcodes has been very beneficial, and it is evident that while it has saved time and resources, more importantly it is giving time back to clinicians while providing accurate information for decisions. Patient safety is key and TrackVax has been a real enabler in this case,” says John Swords, National Director of Procurement, HSE. The excellent data quality from TrackVax provides the NIO with oversight of vaccine usage, logs accurate stock level data, and keeps waste to a minimum. Looking forward TrackVax has been operational since 3 March 2021. The software has enabled the tracking and management of nearly four million vaccine doses, as of December 2021, or nearly 50 per cent of Ireland’s vaccination programme. TrackVax has been widely accepted across CVCs and has delivered value to the HSE through medicine safety, vaccine tracking, operational efficiency, and programme integrity. The next step is to provide ongoing traceability support for the rollout of the Covid-19 vaccine in Ireland and, in time, for other vaccines.

been installed in all CVCs across the country. This allows the CVC teams to identify, label, track, and report on the vaccines in their centres, allowing a much easier vaccine reconciliation process locally and nationally. Both solutions are provided by GS1 Ireland.

Senior Management Teams and the positive in terms of enabling visibility

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“The feedback on TrackVax from the

GS1 licences the most widely used system of supply chain standards, serving more than two million public and private sector organisations worldwide. T: 01 208 0660 E: healthcare@gs1ie.org W: www.gs1ie.org/healthcare Siobhain Duggan, Director of Innovation and Healthcare, GS1 Ireland

of vaccine usage and it has been recognised that TrackVax has made a significant contribution to the efficient rollout of the Covid-19 vaccinations across Ireland,” says Lucy Jessop, Director of Public Health, HSE National Immunisation Office. 51

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Time for a medical workforce strategy

A comprehensive and coordinated approach to the medical workforce is needed to secure the future of our health service writes Leo Kearns, Medical Council CEO.

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For the past two years, healthcare providers and institutions in Ireland have had a tumultuous time, navigating the uncharted waters of the Covid-19 pandemic. While there have been many steep learning curves, the dedication of tens of thousands of healthcare staff to meet the challenge of delivering care to their patients and the wider community in such difficult circumstances has been truly outstanding. This experience has once again reminded us that our health service is fundamentally dependent on the people who work in it. Quite simply, without high-quality healthcare staff, at all levels and in all disciplines, it is not possible to have a high-quality healthcare service. While the pandemic may have 52

refocused attention on the challenges faced by healthcare staff, the reality is that issues relating to workforce and staffing long predate the arrival of Covid-19. The primary role of the Medical Council, as the regulatory body for the medical profession, is to protect the public. While there is perhaps a general perception that this only refers to the Council’s responsibility to investigate complaints against doctors, the Council’s actual role is much broader and relates also to registration, education and training, maintenance of professional competence and ethical and professional guidance; all of which play a very significant role in protecting the public.

In the context of this broader role, the Medical Workforce Intelligence Report, published by the Medical Council, provides essential information regarding the make-up of the Irish medical workforce. The 2019/2020 Report highlighted issues that affect Ireland’s doctors including excessive working hours, resourcing issues, workplace bullying, consultant vacancies, doctor training numbers and the need for a greater focus on doctor wellbeing. 24,720 doctors retained their place on the Medical Council’s register as of June 2020, while 1,135 doctors withdrew voluntarily from the register in 2019, of whom 382 doctors were graduates of Irish medical schools. The main reasons cited for voluntary

withdrawal were resourcing, excessive working hours, lack of respect, personal and family reasons, retirement, costs of professional indemnity and registration, inflexibility of the registration model and in 2020, reasons associated with the impact of the Covid-19 pandemic.

The Medical Council’s annual Your Training Counts survey provides insights into the experiences of trainee doctors and interns in the Irish healthcare system and examines working conditions, experiences of bullying, retention and career plans, and the health and wellbeing of doctors on training schemes. Overall, the results of the latest Your Training Counts survey have been broadly positive, and in some areas, we have seen improvements on recent years. The latest survey was carried out in 2019 and 2020, so although it captures the timeframe of the outbreak of the Covid-19 pandemic, interns and trainees largely reported feeling safe in their workplace, having good general and mental health, and their selfreported quality of life is similarly positive and improving year on year.

Long working hours are associated with burnout and stress and increase the likelihood of involvement in adverse

“The latest survey was carried out in 2019 and 2020, so although it captures the timeframe of the outbreak of the Covid-19 pandemic, interns and trainees largely reported feeling safe in their workplace, having good general and mental health, and their self-reported quality of life is similarly positive and improving year on year.” events, thereby negatively impacting patient safety. It is therefore necessary to ensure that the European Working Time Directive (EWTD) is followed in all clinical settings. Furthermore, compliance with EWTD is necessary in addressing retention and attrition rates and ensuring the wellbeing of doctors and high-quality, sustainable patientcentred care. These are challenges that must be addressed as they impact directly on patient and professional safety. Patterns highlighted in previous reports are repeated in 2019 and 2020 and will continue to do so in the future unless there is a commitment to collective, coordinated and planned action across stakeholders. There is no simple or single solution to the problems faced by the medical workforce. We must address the systemic issues impacting our doctors, so we can truly protect patients, and support our medical workforce. What is clear is that we need a comprehensive medical workforce strategy for our country, one which addresses critical immediate issues and also plans for the next 10 to 20 years. This needs to be part of a broader healthcare staffing strategy to meet the needs of an integrated, multi-disciplinary model of care for patients. It is only by working collectively with all stakeholders

that we as a country can make real positive changes in healthcare delivery in Ireland and ensure continued highquality care for our patients. Leo Kearns is Chief Executive Officer of the Medical Council, appointed in May 2021. Previously, Kearns was Chief Operating Officer of VHI Health and Wellbeing DAC from 2019 to 2021. He was Chief Executive of the Royal College of Physicians of Ireland (RCPI) from 2006 to 2018 and National Lead for Transformation and Change for the Health Service Executive (HSE) from 2013 to 2015. Kearns was heavily involved in the development of the National Clinical Programmes and played a key role in the development of Clinical Directors within the Irish health sector. He played a major part in the introduction of Professional Competence Schemes for doctors and was instrumental in founding the Forum of Irish Postgraduate Medical Training Bodies. Kearns holds a master’s degree in organisational behaviour from Trinity College, Dublin.

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However, significant issues do remain, including bullying and harassment, and working excessive hours. While the percentage of trainees who reported experiencing bullying has decreased since the previous survey, it remains far too high. An environment where bullying or intimidation is tolerated creates conditions where an adverse event is more likely, with the consequent implications for patient safety.

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There has long been a positive history of Irish doctors moving to work abroad for a period and returning to work in the Irish healthcare system, which then benefits from that enhanced experience. However, it is concerning that despite having a relatively high number of medical school graduates by international standards, the Irish healthcare system is still significantly dependant on recruiting doctors from around the world to fill staffing gaps and who in the main are not in a training programme. Recent changes to legislation to remove the barrier to access training for non-EEA qualified doctors are very welcome, but more needs to be done in this regard.

E: info@mcirl.ie W: www.medicalcouncil.ie

Removing Barriers of Digital Transformation in Healthcare

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€77 million Winter Plan unveiled The Health Service Executive’s Winter Preparedness Plan was belatedly published in early November 2021, pledging over €77 million to deliver on Winter Plan funded initiatives, as well as the implementation of 2021 Service Plan aims such as the delivery of 205 acute beds over the winter.

Of the €77 million dedicated to Winter Plan specific measures, the two initiatives receiving the most funding will be the increasing of acute services purchased from private capacity (€20.16 million) and the funding of transitional care for older persons (€20 million). Most notable among the supports to be implemented during the winter of 2021/2022 from the 2021 Service Plan are the addition of 205 acute beds, 1,100 private bed days per week, 275 community beds and 100 additional private community beds.

Aside from the additional beds to implemented as part of the 2021 Service Plan, the winter of 2021/22 will also see the expansion of the ECC Programme, circa 4,000 GP diagnostics per week and the addition of 2.7 million home support hours available “in the context of pressures caused by unfunded price increases” as part of the Service Plan. The five priorities for the winter, as outlined in the plan, are: building capacity; pathways of care; testing and contact tracing; population health; and vaccinations.

The full year 2022 cost of the Winter Plan will be €77,051,157 overall, with the costs broken down into four basic categories. In line with government priorities under continuing efforts to progress Sláintecare reforms, community services are the most wellfunded of these categories, receiving €41,654,978, 54.1 per cent of the total. Acute services will receive €29,345,777 (38.1 per cent); the National Ambulance Service will receive €5,700,402 (7.4 per cent); and €350,000 (0.45 per cent) will be pledged towards communications.

New initiatives to be rolled out to ensure the meeting of these priorities include the implementation of new community based models of care; the introduction of new roles such as ED phlebotomists; the expansions of the Pathfinder Frailty model; additional emergency Placement, Respite and Complex Packages of Care; and the identification and targeting of those who have not yet been vaccinated with a communications campaign addressing hesitancy.

Removing Barriers of Digital Transformation in Healthcare

Between 119 and 313 general acute care beds will be needed in the conservative scenario, with between 513 and 615 needed in the pessimistic scenario. Before the announcement of Budget 2022 and the recent uptick of Covid-19 cases, the Irish Medical Organisation (IMO) had stated that the number of critical care beds in hospitals would need to be doubled. “The fragility of our health services was exposed during the pandemic and had it not been for exceptional efforts of doctors, and other professionals across the country and huge temporary financial support, the services may have collapsed entirely,” IMO President Ina Kelly said in September 2021. “As it is, the services have been severely weakened and patients are being forced on to ever-lengthening waiting lists which should shame a leading EU state.” Upon publication of the plan, Minister for Health Stephen Donnelly TD said: “I

2 0 2 1 S E RV I C E P L A N

particularly welcome the enhanced focus on service restoration in disability services, mental health, services for older people and social inclusion care groups. I fully support the HSE’s commitment to improve Patient Experience Times, particularly in terms of keeping everyone safe while we respond to Covid-19.” However, the IMO has labelled the plan “inadequate”, pointing to the pressure that the healthcare system was under at the time of its launch in terms of both bed capacity and staffing. Kelly said: “This plan was launched at a time when we have only 21 ICU beds available in the country. Every doctor and healthcare worker is working beyond capacity right now and it is untenable that they are being asked to face into a winter with insufficient support.

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With the number of beds in both critical care and general acute care a major talking point and point of criticism of the Government’s recent Budget 2022 due to its addition of just 19 additional ICU beds, the plan includes Covid-19 demand and capacity modelling. Broken down into conservative and pessimistic scenarios, the modelling predicts the need for between 43 and 89 or between 152 and 164 critical care beds in conservative and pessimistic scenarios respectively. The 19 additional beds will bring the total to 340; in January 2021, when there was a capacity of 348 due to the leasing of private beds, occupancy peaked at 330.

“We have 700 vacant consultant posts meaning huge extra pressure on those consultants we do have. We have NCHDs working excessive and illegal hours putting them under enormous strain, and we have GP services facing unprecedented demand from patients. The capacity is simply not there to meet demand and it is not all Covid-related.” An additional 16,000 hours whole-time equivalent was approved in the 2021 Service Plan “for a comprehensive range of new initiatives”, but just 10,716 were taken on, with an additional 3,200 staff recruited for vaccination and contact tracing. Further criticism has surrounded an apparent lack of clarity as to how the staffing increases still needed given the failure to meet this target will be met, with no details offered in the Winter Plan.

S E RV I C E P L A N S U P P O RT S TO B E I M P L E M E N T E D DURING WINTER 2021–2022

• 1,152 acute beds (795 open) • 73 sub-acute beds (all open) • Circa 1,100 private bed days per week • 551 community beds planned (276 open) • Access to 572 private community beds (472 currently contracted)

• 205 acute beds • 1,100 private bed days per week • 275 community beds • 100 additional private community beds • ECC programme expansion

• 96 EEC networks planned (15 networks in place YTD)

• Circa 4,000 GP diagnostics per week

• 85,315 diagnostics accessed by GPs

• 2.7 million additional home support hours available in the context of pressures caused by unfunded price increases

• 5 million additional home support hours (2 .3 milion used YTD) • Full population coverage for CIT services

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The future of the Irish Blood Transfusion Service hospitals to start cancelling elective surgery that may require blood support. “Despite the Covid-19 crisis I was keen that we finalise our strategic plan and Connections That Count was approved by the Department of Health in May 2021,” says O’Brien. “This Strategy is an exciting development with a vision for the IBTS in five years time that will transform the organisation. Work commenced on implementing strategic initiatives in early 2021 and we will continue to deliver on our strategic objectives over the coming years.

The Irish Blood Transfusion Service’s (IBTS) Chief Executive, Orla O’Brien talks to eolas about the ongoing challenges posed by the pandemic, the organisation’s strategy, Connections That Count, published in 2021, and Research and Development Lead Allison Waters outlines the key elements of the first ever R&D strategy Advertorial

devised by the IBTS. As the pandemic rolls on, the IBTS has continued to provide blood and blood products to the Irish healthcare system. This has been incredibly challenging, and we have been in real difficulty meeting hospital demand on occasion. We imported RhD blood from the NHSBT in June as ongoing restrictions and social distancing requirements on donation clinics made it increasingly harder to meet our collection targets. 56

Many venues previously used to run clinics were too small to allow for adequate social distancing and some venues were no longer available to us because the hospitality industry was effectively dormant. This meant we were relying on the same cohort of donors to keep the blood supply going. In October, we initiated a targeted appeal to replenish the blood supply as we were in very real danger of having to advise

“It has a strong emphasis on initiatives that will strengthen innovation and people development. One of the services the IBTS is focusing on is the re-establishment of the Irish Eye Bank, the project plan for this complex project was developed in consultation with healthcare partners and approved in Q3 2021. Delivering a project of this scale will take some time, however it is expected within the lifetime of this strategy, the IBTS will be in a position to launch the national eye bank for Ireland, facilitating a safe and sustainable supply of corneas procured in Ireland for use in cornea transplants.” The National Donor Screening Laboratory in the IBTS undertook a benchmarking exercise with My Green Lab, an organisation that aims to introduce sustainability to the communities responsible for the world's life-changing medical and technical innovations. The IBTS is committed to introducing sustainable best practice throughout the organisation and utilised the services of My Green Lab to commence work on this. On the basis of the benchmarking exercise, the NDSL introduced a pilot project to improve some of the practices in this area with the aim of rolling it out to other departments in 2022. In developing Connections That Count, the majority of feedback from our donors

The IBTS is undergoing somewhat of a transformation, there is an emphasis on innovation, agility and improving the experience of our people and our customers. In 2021, an innovation working group was established in the IBTS and in 2022 it will be progressing an action plan with a series of initiatives aimed at embedding innovation in the organisation. The action plan is very much aligned to the Public Service Innovation Strategy, and we look forward to implementing innovation initiatives and building capacity for innovation, research, and development in the IBTS. There is also a renewed focus on R&D so that the IBTS “can do its own research and development providing an Irish context on transfusion medicine,” according to Allison Waters.

The research and development strategy is underpinned by three core objectives:

1. To gain a deeper understanding into the dynamics of the donation process. Insights into the factors motivating and preventing people donating blood will drive improvements to blood collection policies, testing algorithms and clinical guidelines. 2. To future-proof the service in relation to changing technologies, blood demands and blood component usage, thereby optimally serving all transfusion and transplant recipients. Specifically, the development of novel cellular solutions to disease management requires translation from the research benches to large-scale production using good manufacturing processes. 3. To position the organisation as a key research leader in the field of transfusion medicine through participation in national and international networks, and through collaboration with clinical colleagues, international blood services and commercial partners for research endeavours and clinical trials. The effective implementation of research best-practice, a clear research governance structure and a supportive research culture has begun the creation of a positive and innovative environment for all personnel engaging in research. Over the course of 2021, the IBTS have contributed to 10 peer-reviewed publications and presented their research findings at numerous international and national conferences. The newly formed R&D department also further developed its research profile through collaboration on six different

international studies alongside international blood establishment partners. In 2021, research investment was directed to supporting public health monitoring by investigating the progression of the SARS-CoV-2 epidemic in healthy donors. The SARSCoV-2 antibody profile was investigated through each infectious wave and following the rollout of the vaccination programme. Furthermore, European funding supported the production high titre Covid convalescent plasma, which successfully enabled the production of plasma from Irish donors for the firsttime in over two decades. Other research focused on profiling the red cell antigens in the Irish donor population providing baseline Irish blood group data. Investigations on blood components gained insights into the mechanisms impacting the function and activation of cold-stored platelets, as well as red blood cell oxygen saturation. The focus for the immediate future is on effective research communication and building on the innovative research culture foundations laid throughout the past year. The team aims to design and launch a research, learning, and development website, targeted at clinical, scientific, and academic professionals. In addition, the IBTS will lead on a future-focused blood donation and haematology research symposium. Lastly, they will continue to build on their research publication strengths in epidemiology and component production.

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“In April 2021, the IBTS published its first-ever dedicated research and development strategy outlining the role of research in maximising the ability of blood and tissue donation to improve the health of patients,” she explains. “The organisation is committed to providing the evidence-base from which to build future improvements to its blood and tissue services. Research engagement will be supported at all levels throughout the organisation, thereby capitalising on previously untapped expertise of personnel, and clinical and academic colleagues, and ultimately positioning the IBTS as a key research leader in the field of blood donation and transfusion.”

“Research engagement will be supported at all levels throughout the organisation, thereby capitalising on previously untapped expertise of personnel, and clinical and academic colleagues, and ultimately positioning the IBTS as a key research leader in the field of blood donation and transfusion.”

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was that they would like to have an online appointment system. Our donors donate not just their blood but also their time and so it's important to us to make the donor experience as efficient as possible. We are tying this in with our sustainable objectives as we work towards a digitalised environment. We are aiming to remove the need for paper forms on our clinics by Q2 2022, donors will be able to use a tablet to complete the health and lifestyle questionnaire before progressing with their appointment. In addition, we aim to have an online appointment system available before the end of 2022, this will mean donors will be able to make appointments themselves either on their laptop or phone without the need to speak to one of our customer service agents. Of course, that option will still be available for those donors who prefer to use the telephone.

W: www.giveblood.ie

Removing Barriers of Digital Transformation in Healthcare

Next decade care costs will require billions health report

The Government will need to substantially increase its expenditure on primary, community, and longterm care by 2035 to meet rising costs and population growth and ageing, an ESRI report has found.

Projected nominal expenditure growth by health and social care service, 2019–2035 General practice

2019 2035

Public health nursing* Occupational therapy* Physiotherapy* Speech and language therapy* GMS/DP/LTI HT LTRC Home support

500

1,000

1,500

2,000 2,500 Expenditure (€m)

3,000

3,500

4,000

4,500

Projected nominal expenditure growth under the central scenario. *Provided through HSE Primary Care services. Source: ESRI

The need for increased expenditure will be largely driven by the cost of delivering care, specifically pay-related costs, the report, which projects expenditure in health and social care from 2019 levels out to 2035, found. Designed to help inform policymakers on which parts of the health and social care system should be prioritised for investment and where policies should be focused to contain cost pressures, the report suggests that up to €12 billion could be needed to fund primary, community, and long-term health services over the next 14 years.

A range of factors and pressures including population changes, healthy ageing, government policy measures and pays costs will affect the scale of the increase needed, with overall projections ranging between a low of €4.4 billon to a potential high of €12 billion. Analysing four services, it estimated the largest cost increases will be: public and private GP services and public health nursing and community care; high tech-medicines dispensed in the community; long-term residential care; and home support services. The report’s authors find that “continuing current trends will lead to expenditure

growth on high-tech medicines and long-term residential care that far exceeds that of general practice and home support in the medium term”. The increased cost of providing care is identified as the largest driver of projected expenditure growth of between €1.6 billion and €2 billion in public and private general practice by 2035. The report implies a 2.9 per cent to 4.5 per cent average expenditure increase. A 6.1 per cent to 10.5 per cent average annual increase in high-tech medicines reflects a continuation of high recent growth in demand and comes at an estimated expenditure increase of between €2.3 billion and €4.4 billion in 2035. Population ageing is the key driver of projected expenditure increase in public and private long-term residential care of between €3.8 billion and €5.7 billion in 2035. The costs imply a 4.3 to 6.9 per cent average annual expenditure increase. Finally, the ESRI follows the Sláintecare recommendation that a statutory home support scheme be established and predicts a 4.4 per cent to 10.4 per cent average annual increase requirement to meet a projected public and private home support requirement of between €1.2 billion and €3 billion in 2035. “Changes in the cost of delivering care, particularly pay-related costs, is the main driver of expenditure growth. In addition, population ageing, and additional modelled demand for hightech medicines and the assumed introduction of the statutory home support scheme, are key drivers of expenditure growth. Identifying approaches to address the projected increases in the unit cost of care delivery should be an important consideration of policymakers,” the report states.

A modern and dynamic nursing and midwifery regulator

Development of our new strategy will begin in 2022 and we are more aware now than ever of the need to provide leadership to registered nurses and registered midwives.

Modernisation at NMBI

Essene Cassidy, President of the Nursing and Midwifery Board of Ireland (NMBI) talks about the role of the regulator, modernisation and adapting during the global pandemic.

As we enter the final year of our Statement of Strategy 2020-2022, we will continue to ensure we can adapt to the evolving global healthcare environment and regulate effectively, while upholding the highest standards.

As well as streamlining the process for registrants the new online portal MyNMBI also allows for the collection of data which assists us in our work to maintain standards and associated public safety and contribute to workforce planning. This is more relevant than ever with the rollout of Sláintecare in the years ahead. Since the start of the pandemic NMBI has moved speedily and dynamically to embrace new technology. As a board we showed agility, as our meetings continued without disruption. Our complaint management process also moved online or to hybrid format to ensure hearings could continue. Witnesses can give testimony from anywhere in the world now without having to get on a plane or into a car.

Pride in my colleagues On behalf of the board, I would like to acknowledge the challenges faced by nurses and midwives since the Covid19 pandemic began and express our appreciation for the valuable contribution they have made in treating patients and maintaining ongoing healthcare services. Nursing and midwifery professionals in all their roles have always been able to adapt to change. For generations, new ideas have been embraced and welcomed, all with the sole aim of improving outcomes for our patients. When the Covid-19 pandemic struck, once again we saw our nurses and midwives adapting to change in all care settings. It has been a difficult time for many, but the dedication and compassion of our professions shone through and continues to do so. It fills me with enormous pride to witness this incredible commitment to care.

T: 01 639 8500 W: www.nmbi.ie

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As the regulator for more than 80,000 nurses and midwives in Ireland, NMBI’s mission is to protect the public and the integrity of the professions through the promotion of high standards of education, training, and professional conduct. We maintain a Register of Nurses and Midwives and a Candidate Register for students.

NMBI is dedicated to the implementation of our digitisation agenda. Every nurse and midwife practising in Ireland must be registered with NMBI and the annual process of renewing registration is taking place online for the second year running.

nurses and midwives. A key example I recall is the removal of the requirements for collaborative practice agreements (CPAs) for nurse prescribers. This change has allowed our nurse prescribers to become autonomous practitioners. We also worked with the Department of Health on the advanced practice policy and revised the Advanced Nurse Practitioner pathways.

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Our focus remains on professional development and competence, engaging more with registrants and stakeholders, and the continued digitisation of the organisation. We also remain committed to building trust and to ensuring our role as a regulator is understood.

Embracing change for all stakeholders Engagement with stakeholders, and in particular our professions, has never been better. NMBI does a huge amount of work in collaboration with key stakeholders around setting standards, supporting practice initiatives, and promoting quality care provision by

health report

Removing Barriers of Digital Transformation in Healthcare

Capital spending Capital spending on health accounted for 10.4 per cent, or €1.084 billion, of the €75 billion allocated under the National Development Plan in 2021. Capital spending on health will amount to €5.7 billion in the first five years of the renewed NDP. Of the 10 national strategic outcomes included in the renewed NDP, released in October 2021, number 10 pledges the Government’s commitment to “access to quality childcare, education and health services”. Under this heading, the expansion of primary and community care in line with Sláintecare reform goals is the key health goal mentioned, a goal that will require sustained capital spending on health around the State in order to localise health infrastructure. In its sectoral strategy section for health, the NDP states that the Sláintecare Implementation Strategy “identifies capital investment as a critical enabler of the reform proposed” and that “capital investment has a key role to play in enhancing service provision, ensuring the delivery of high quality and safe health and social care” such as the delivery of the

recommendations of the Health Capacity Review, the eHealth Strategy for Ireland, the National Maternity Strategy 2016-2026 and a host of other government plans. Over the full course of the NDP, 20212030, the plan says health capital investment will be “based on needs to enhance service provision, enable reform in the sector and the ongoing need to address patient safety and regulatory requirements”; from 20212025, the investment will be focused on “patient safety, regulatory requirements” and will “provide the foundations for reform in the sector”. Projects outlined as priorities in health spending from 2021 to 2025 include: eHealth and ICT investment programmes (estimated between €50 million and €100 million); the new Children’s Hospital campus at St

Removing Barriers of Digital Transformation in Healthcare

Strategic investment priorities in health, 2021-2025 Status

Estimated cost

Cybersecurity enhancement

Not given

€250 million-€500 million

CHI, EHR and ICT improvements

In progress

€50 million-€100 million

Integrated Financial Management System

In progress

€50 million-€100 million

Children's Hospital and Tallaght Hospital

Construction stage with commissioning completion in 2024

Over €1 billion

Oncology units in Galway

Construction completion in 2024

€50 million-€100 million

Dublin Beaumont Phase Two

Construction completion in 2025

€50 million-€100 million

St James's

Preliminary design

€50 million-€100 million

Acute bed capacity projects

In progress

€500 million-€1 billion

Primary care centre construction

In progress

€100 million-€500 million

Enhanced Community Care Programme

In progress

€100 million-€500 million

Replacement and refurbishment of Community Nursing Units

In progress

€500 million-€1 billion

Equipment Replacement Programme

In progress

€100 million-€500 million

Infrastructural Risk Programme

In progress

€100 million-€500 million

Ambulance Replacement Programme

In progress

€50 million-€100 million

Ambulance Base investment

In progress

€50 million-€100 million

Mental Health Capital Programme

In progress

€100 million-€500 million

James’s and the second outpatient department and urgent care centre at Tallaght Hospital (over €1 billion); radiation oncology units in Galway, phase two of Dublin Beaumont construction and St James’s redevelopment (all €50 million-€100 million); acute bed capacity projects (estimated €500 million-€1 billion); and the construction of primary care centres (estimated €100 million-€500 million). Health service capacity will, given the context of the Covid-19 pandemic, be the most high profile of the reforms funded through the NDP, but it is an area of the plan where details are light. The plan states that the building of dedicated elective centres in Dublin, Cork and Galway is currently being progressed for consideration through the Public Spending Code and that “these facilities will provide high volume, low complexity procedures on a day and outpatient basis, together with a range of ambulatory diagnostic services”. The plan also states that additional capacity has been delivered since the publication of the Health Service Capacity Review in 2018, but that “further beds in line with overall requirements and informed by regional requirements will be required to be

provided in the period to 2030”. In 2018, before the pressures of the pandemic, the Health Service Capacity Review stated that an additional 2,590 hospital beds would be required between 2018 and 2031; the plans within the NDP do not seem to address this need.

The National Maternity Hospital project, which will add capacity to the health system, is estimated under the plan as costing €20 million-€50 million, which indicates that its construction will likely not commence until after 2030, with the majority of the capital spending related to the project happening then.

Indeed, amongst the most costly and common of the health priorities for the period 2021-2025, many appear to be refurbishment and replacement schemes that while providing necessary updates to Irish health and its technologies, will not increase capacity. It has been well documented that the National Children’s Hospital will not add significant capacity to the health system, but other projects such as the replacement and refurbishment of 88 community nursing units to regulatory compliance are estimated to cost €500 million-€1 billion. Continued maintenance of the current ambulance fleet is set to cost €50 million-€100 million with no added capacity. Both the Equipment Replacement Programme, which will update diagnostic equipment, and the Infrastructural Risk Programme, which focuses on fire and electrical safety as well as emergency supply, carry estimated costs of €100 million to €250 million.

While the capital spending on modernisation efforts within the health system are no doubt worthwhile and necessary, aside from the Children’s Hospital, the plan shows a bias towards replacement buildings, equipment, ambulances and investments in eHealth, which raises the question of the amount being spent. The €5.7 billion of capital spending allocated to health from 2021-2025 account for approximately 5 per cent of the total health spend in that period. When the capacity issues facing the health system are taken into account, the lack of projects similar to the Children’s Hospital in scale, but with the key provision of enhancing capacity, seems a glaring omission.

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Project

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A modern hospital with medieval foundations the destitute in Limerick by creating the first ‘fever hospital’ in Ireland (or Great Britain for that matter), fitting out the old ‘guard house’ with beds and whatever essentials she could get to help the helpless. As epidemics evolved, so too did the hospital; the take-over of it by the Little Company of Mary sisters in 1888 enhancing care and operational standards. The raison d’être of the order, physically caring for the poor, sick, suffering and dying people in our midst, was an imperative for the time.

There’s a remarkable yet reassuring dichotomy story writ large in the annals of St John’s Hospital in the heart of Limerick city today. It is of an old hospital, Limerick’s oldest, that dates to darker days of even more deathly epidemics, Advertorial

such as cholera, typhus, and typhoid. A creaking and capacity strained 99 bed hospital of narrow corridors and constricted rooms, its 20th century constructs mixing with old limestone remnants of the original 15th century Walls of Limerick. Yet, for all its reminders and challenges of past, it’s a hospital very much of the present and with a definite focus on the future, and it’s a hospital that still puts the patient at the centre of everything. It may be wrapped by medieval city 62

walls, but the remarkable thing is that, in contrast with those ancient surrounds, it’s a hospital of innovation. A hospital breaking new boundaries, meeting new needs with new approaches and practices and all with a ‘patient first’ approach. Then again, St John’s has always been about meeting the greatest medical demands of the day, right from its very foundations in 1780 when Lady Hartstonge responded to the needs of

Through the decades it met, struggled with, and saw off pretty much everything that was thrown at it, not without pain and loss but always with courage and resilience. Much of the 500-year-old city defence walls may have gone but St John’s remains at the frontline of health responses, finding new ways for innovation. It was such last year when Covid hit, turning the clock back to origins of the ‘fever hospital’. The words of its CEO Emer Martin in a short video documentary titled House of Courage synopsises this latest heroic frontline siege of the Limerick hospital: “There's a lot of history behind these walls, but so much of it is about the courage of St John’s and the people who come to work here every day. It was that way in 1780 and it's still that way today.” It’s a hospital, the only acute voluntary hospital still standing in the city centre, that’s always served the people of Limerick well, has always put them first in return, St John’s has a special place in the heart of Limerick people, as borne out by patient feedback to this day. As is often said locally, “everyone has a St John’s story”. It’s the proverbial underdog that never gives in, using whatever resources it can

to succeed and today that’s very much about innovation. In fact, it’s flourishing in a classroom in the Old Medical School, otherwise the ground-breaking Rapid Innovation Unit (RIU). The Science Foundation Ireland sponsored unit uses 3D printing and other engineering pathways to find live patient-centric solutions, as explained by the unit’s Director, Leonard O’Sullivan, who works on the project with Kevin O’Sullivan, Research Lead and Aidan O’Sullivan, Technical Lead.

One of the many examples of this ‘living lab’ at work is resolving catheter issues for a teenager who had cystic fibrosis. “The child had a feeding tube into the stomach that had a problem. It resulted in the child being unable to feed successfully. It just took 24 hours to design a solution, get it made on-site and put it on the patient. The child would not have been a good candidate for surgery because of the medical condition so that was a really good outcome.” He adds: “We’re throwing away shackles of old-fashioned manufacturing methods. What we have in St John’s is a pilot to demonstrate this. It’s a ‘factory in a box’. The digital element is important. We identify the opportunity with front line staff and then digital manufacturing kicks in.”

“The first day I walked on the ward I thought the beds are so close, the rooms are so tight but what it does is it makes us sharper. It’s managed so well by our staff that infection rates here are very, very good. For example, CPE bug rates are high in the Mid-West, yet our infection rates are so low. We work hard

“There's a lot of history behind these walls, but so much of it is about the courage of St John’s and the people who come to work here every day. It was that way in 1780 and it's still that way today.” Emer Martin, CEO, St John’s Hospital at it. That’s the way it is here. When things are hard, people get on with it. No matter what we do, patient care is at the centre of it.”

“Internationally this is now recognised as

Andrew Scott’s contribution in setting up a regional service in respiratory care is another example of how St John’s is a patient-first hospital. “My goals since I have started in July 2020 are to develop a Respiratory and General Internal Medicine centre of excellence. I have from the beginning had excellent support from the senior management in St John’s Hospital. Everyone here is enthusiastic to develop St John’s into something we can all be proud of,” he says.

train family members to look after

“Recently we have initiated a lung function lab in St John’s which will provide basic respiratory tests to the patients of the region which is something that was greatly missing over the years for patients in St John’s. We’ve also introduced the indwelling pleural catheter (IPC) service for managing malignant pleural effusions, which is another first for patients in the region.

ways to care for them.

a first line option for the management of malignant pleural effusions. The patient can normally go home the next day. We patients at home following this very simple procedure, allowing patients to have more control over the management of their own care in the later stages of their diagnosis and to have more time with their loved ones.” Some 240 years after Lady Hartstonge’s

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The old hospital’s ability to meet today’s needs is also reflected in how it is dealing with one of the biggest threats to patient care everywhere today: infection control. The appointment last year of a new Director of Nursing, Michelle Burke, to also take on the role of Director of Infection Control, the only hospital in the country to twin these roles, reflects just how seriously St John’s is taking on the threat.

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“We just saw potential benefit from having a natural innovation unit between a hospital and university, working with clinical stakeholders in University of Limerick Hospital’s Group to identify unmet needs from patient quality of life perspective,” he says. “It was really important to move out of the university and embed this into the hospital setting and St John’s has been a great partner in this. We are using 3D printing to be able to innovate and create the novel medical devices of the future and get them onto patients as quick as possible.”

intervention, St John’s is still putting patients first and finding innovative new

St John’s Hospital St John’s Square, Limerick, V94H272 T: (061) 462 222 W: www.stjohnshospital.ie

Removing Barriers of Digital Transformation in Healthcare

Irish health statistics Main results of Irish Health Survey 2019 health report

Of those aged 15 years and over (self-reported):

56%

In the last 12 months

82%

are overweight or obese

of females visited the GP

compared with

68%

males

21%

Almost

50%

of 15–24-yearolds drink six or more units of

of unemployed people have some form of depression

alcohol in one sitting at least once a month

82%

of employed people have some form of depression

people have no limitations in everyday activities due to a health problem

41%

of 25-34-year-olds perform muscle strengthening exercises

16% of 55-64-year-olds perform muscle strengthening exercises 64

Source: CSO, Irish Health Survey 2019

Over

25% have a longlasting health condition

92% of ‘very affluent’ people feel their health status is ‘very good or good’

78% of ‘very disadvantaged’ people feel their health status is ‘very good or good’

Removing Barriers of Digital Transformation in Healthcare

Persons with disabilities Of those aged 15 years and over (self-reported):

43% 25% have some form of depression

Source: CSO, Irish Health Survey 2019

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25%

Around

have a health status of ‘bad or very bad’

have unmet health needs due to waiting times

Of those aged 55 years and over (self-reported):

37%

Of those

69%

have difficulties with personal care activities

with personal care difficulties get help with these activities.

Source: CSO, Irish Health Survey 2019

Carers and social supports Of those aged 15 years and over:

13%

19% of carers suffer from some form of depression

of non-carers suffer from some form of depression

11% 14%

of males are carers

of females are carers

Source: CSO, Irish Health Survey 2019

1/8 of persons aged 15 years and over provide care 65

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DASSL: A technical infrastructure to support access, sharing, storage and linkage of health data the RCSI, HSE, and TCD, was awarded funding from the HRB to develop the proof-of-concept (PoC) technical infrastructure for DASSL. Hosted by NUI Galway and supported by DFHERIS, ICHEC is Ireland’s national centre for high-performance computing (HPC), providing e-infrastructure, services and expertise to higher education institutions, industry, and the public sector.

Objectives

Simon Wong

Orna Fennelly

Covid-19 has highlighted the importance of and accelerated the demand for high-quality health data for policymaking, practice, and research. Ireland has a poor track record in this regard and in a recent OECD report1 ranked last for secondary use and availability of health datasets. Ireland is also one of only two countries not regularly linking datasets for research, statistics, and monitoring.

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Across the Irish health services, barriers to data sharing and linking datasets have included siloed datasets, inconsistent application of existing legislation, the need for new enabling legislation, concerns, and different interpretations over data protection. Added to these barriers, minimal use of unique identifiers and the lack of a formal and secure infrastructure to integrate, link and support remote access to data for secondary purposes, including for research, has led to valuable projects being inordinately delayed or in some cases abandoned. Internationally, similar barriers have been 66

overcome. To protect individuals’ privacy while driving benefits from routinely collected, statistical and survey data, national Health Data Platforms have been developed, most notably in the UK, Australia, Canada, and Finland. A similar model has been proposed for Ireland by the Health Research Board (HRB2); DASSL, or, data access, storage, sharing, linkage. The DASSL model aims to provide a single point-of-access to researchers and data controllers to facilitate linking of health data in a safe and trusted manner, with patient anonymity secured at all times. The Irish Centre for High-End Computing (ICHEC), along with collaborators from

A key objective of the work ICHEC is undertaking with the PoC is to develop a prototype technical infrastructure for DASSL and test it using synthetic health data. The final report will provide recommendations gathered during the PoC and from key stakeholders which will inform the development, technical infrastructure requirements, operations, and governance of Ireland’s future Health Information Systems. The overall objective of which is to improve healthcare and public health and wellbeing.

The proposed model Overall, the DASSL model includes several components to facilitate safe and secure access, sharing, storage and linkage of health and related datasets as outlined in Figure 1.

Governance Access, sharing, storage and linkage of national health data requires a lawful basis, clear security and data protection policies and procedures, and governance boards. While this PoC will only use synthetic data, the national roll out of a solution that processes real health and related datasets will necessitate legislation, significant investment, public consultation, appropriate governance structures and various project approval boards (e.g., Research Ethics Committee

Figure 1: DASSL Model

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approval, declarations from the Health Research Consent Declaration Committee, access requests via a Research Data Governance Board). These processes are under review by the Department of Health as part of a reform of Ireland’s Health Information System.

Stakeholder involvement and engagement

By linking GP care data, emergency hospital admissions, prescriptions and asthma deaths together with geographical and socioeconomic deprivation areas from 2013 to 2017, an asthma study found that people from deprived areas in Wales have worse outcomes and increased risk of death. This was then used to inform new policies to combat inequity.

Research Support Unit

Technical operation

The Research Support Unit (RSU) plays a pivotal role in facilitating researchers from the conception of a project idea, support in conducting the research and managing any research output. As the point-of-contact for researchers, the RSU staff require in-depth knowledge of the datasets to assess whether a research project is feasible, prepare linked pseudonymised datasets for researchers (with the data minimisation GDPR principle in mind) and assess any research outputs to ensure privacy is preserved prior to export. The RSU role also includes managing a catalogue of datasets.

A key principle that underpins the operation of the DASSL model is that only the data custodians store (a) personally identifiable information such as names, addresses and (b) the

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In addition to close engagement with the HRB (the commissioners of this project), other key stakeholders have contributed to the planning and development of the DASSL PoC, including the formulation of use cases. This includes representatives from the Department of Health, the HSE, public and patient representatives, HIQA, researchers, and data controllers. It is clear that ongoing public consultation including a Public Advisory Board will be critical to the success of any model taken forward. Openly sharing of the results of research projects using national data will also be crucial to promoting use of these findings for public trust and enhancing public benefit.

SAIL Databank (Wales) Use Case2

1. https://www.oecd-ilibrary.org/docserver/55d24b5d-en.pdf?expires=1632828042&id=id&accname=guest&checksum=17313F06FC4DAB502633A51CBDF16130 2. https://saildatabank.com/wp-content/uploads/Annual_Report_2020_21.pdf 3. https://www.hrb.ie/fileadmin/publications_files/Proposals_for_an_Enabling_Data_Environment_for_Health_and_Related_Research_in_Ireland.pdf

and outgoing internet access is disabled. The researcher is provided with the required analytical software to process the requested datasets. Once the researchers have completed their analyses, any output that needs to be exported (e.g., for publication) is placed in a folder for output checking before being released.

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Output checking

“Research is a crucial component of healthcare practice and innovation that improves life for everyone. DASSL is an important step towards supporting the secure and safe use of health data and more importantly the ability to share and link that data for better research outputs” Loretto Grogan, Office of the Nursing and Midwifery Services Director, HSE.

corresponding medical/clinical/health data. They are split at source into Dataset A and Dataset B and sent to the Trusted Third Party (TTP) and the Health Research Data Hub, respectively. Datasets can then be linked, prepared, analysed and any research output vetted by the following components of the system.

Trusted Third Party: where records are linked

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The TTP is a trusted team of people or an organisational unit who conduct record linkage using personal data (Dataset A) received from data custodians. Linking individual records between datasets is critical for reassociating a person across their healthcare pathway to produce useful insights, and the establishment of a TTP for this purpose is common practice internationally. Again, the explicit separation of personally identifiable information from corresponding health data ensures that only the data controllers have both sets of information and thus helps ensure privacy. The TTP then shares encrypted linkage keys with the Data Hub. 68

Health Research Data Hub: where data is prepared This is a tightly controlled data storage and processing platform to prepare datasets for researchers. It receives the variables of interest to the researcher (Dataset B) that are already pseudonymised (i.e., personally identifiable information is stripped and replaced with a random identifier). Using linkage keys from the TTP, the same individual can be linked across the different pseudonymised datasets. These datasets never store any personally identifiable information and are stored for only as long as required in line with GDPR. Access is highly restricted to operations staff (e.g., the RSU) who need to prepare datasets for researchers.

Safe Haven: where data is analysed A locked down, secure research environment supports virtual access to the pseudonymised project data by approved researchers. Once a researcher is securely connected to this environment (following a stringent access request and approval process), data is prevented from being imported/exported

The research findings that the researchers want to export from the Safe Haven are assessed for statistical disclosure control by the RSU. This ensures that the data released does not contain any information that could reidentify individuals.

Outlook There is a huge demand for a national technical infrastructure to support safe and secure analysis of linked datasets both in Ireland and internationally. Increased momentum of initiatives such as the European Health Data Space and associated EU legislation to support the coordination of international data sharing will also require Ireland to be able to facilitate secondary use of data for public benefit. The DASSL PoC, commissioned by the HRB and delivered by ICHEC will report its findings at a critical time to inform actions to shape a fit-for-purpose Irish health information ecosystem, with a clear policy intent to optimise the use of health and social care data for secondary purposes, and informing the associated governance, legislation and investments required. The ultimate aim is to enable a better, evidence-informed health system and stimulate research and innovation to improve healthcare outcomes and the wellbeing of the population.

T: 01 529 1042 E: info@ichec.ie W: www.ichec.ie

IACP celebrates 40th anniversary

In 2021, the Irish Association for Counselling and Psychotherapy (IACP) celebrated its 40th anniversary. For 40 years, the IACP has been promoting safe and effective counselling and psychotherapy in Ireland. From auspicious beginnings, when the inaugural meeting was held in a basement in Dún Laoghaire in 1981, the IACP has become the most prominent and leading body of counsellors and psychotherapists in Ireland. We now have over 4,700 members, and our membership continues to grow. The years 2020/2021 were challenging; our organisation, no different to any other, was significantly affected by the pandemic and had to move its operations online. Like countless others, we had to rapidly adapt to this shifting paradigm, and we took advantage of the available technology.

Continuing with our public awareness raising and lobbying work to increase accessibility to counselling and psychotherapy, we launched our PreBudget Submission (PBS). This is a vital tool for an organisation to communicate their wants to government ahead of the publication of the following year’s budget and we publish one yearly. This year, in keeping with our move to embrace technological advances, we also called on our members to engage via a digital advocacy platform where they could send emails directly to their Oireachtas representatives.

From our modest beginnings in Dún Laoghaire 40 years ago, we have seen a remarkable change in public attitudes towards counselling and psychotherapy. We have been instrumental in changing these views. Inevitably, there is more work to be done, and persistent campaigning is one such means of achieving our goal. The firm belief that all people should have access to regulated, high quality and professional counselling and psychotherapy services continues to propel us forward. The IACP believes that counselling and psychotherapy must be an integral part of healthcare provision, and we will continue to lobby and advocate for the realisation of this vision.

T: 01 230 3536 E: ceo@iacp.ie W: www.iacp.ie

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To celebrate this momentous year, we hosted our 40th anniversary campaign. This consisted of a public awareness campaign and an online public event. The awareness-raising campaign aimed to promote our excellent Find a Therapist function on iacp.ie. This tool facilitates potential clients to connect with accredited IACP members. Our first online public event, Essential Conversations with IACP, was a resounding success. Essential

Conversations featured host Blindboy Boatclub, and moderated discussions in featured panels on body positivity, parenting, sports and mental wellbeing, and inclusion and diversity. Each forum featured panellists such as Colman Noctor, Dublin football’s Shane Carthy, and Síle Seoige. The IACP and our PR company, Fuzion Communications, were nominated for Best Technology Innovation for this event at the recent Digital Media Awards 2021.

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expansion and evolution of our profession and the increased discourse around mental health, particularly during this pandemic period. These are very positive developments and our requests to the government in our PBS are reflective of this trend. We are simply seeking parity of esteem with other health professionals. The implementation of our requests would have multiple benefits. Tax relief, if fully extended to counselling and psychotherapy, would not only make therapy more affordable, it would also further endorse the profession and solidify the view that good mental health is of the utmost importance to us all. Further details of our submission are available on our website.

In our 40 years, we have witnessed the

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