20 minute read
Gar Mac Críosta reflects on HSE digital transformation during
health report 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.”
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.”
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.”
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.” 4
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.”
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.
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.
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.
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 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.”
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.
“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.
“International experience indicates that if a hospital is established first, people will gravitate to it. However, if outpatient and 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.”
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 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 contributed to a 65 per cent reduction in waiting lists for general paediatric services.
“One-quarter of the citizens of Ireland are aged under 18 and my purpose as Chief Executive of Children’s Health 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.
W: www.childrenshealthireland.ie
health report 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. 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.
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.
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 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.
How new Health Impact Assessment Guidance can help to build healthier communities
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.
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. 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.
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.
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.
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.
What are the benefits?
• HIA aims to ensure potential positive health impacts and prevent potential negative health impacts of a proposal; • HIA can support people from different backgrounds to work together to ensure that decision-making for health is fairer and more inclusive; • 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; • HIA provides evidence-based conclusions and recommendations; and • HIA can complement or inform other impact assessments such as poverty, human rights, or equality impact assessments.
