Community Healthcare Organisations report

Community Healthcare Organisations Report & Recommendations of the Integrated Service Area Review Group

Community Healthcare Organisations Report & Recommendations of the Integrated Service Area Review Group

ISA Review Project Team Project Lead: Pat Healy, National Director Social Care Project Team: Geraldine Crowley, Head of Performance, Planning & Programme Management – Social Care Michael Fitzgerald, Head of Operations & Service Improvement – Services for Older People Bernard Gloster, Area Manager – Mid West PCCC Brian Murphy, Head of Performance, Planning & Programme Management – Primary Care Imelda O’Regan, Project Support – Social Care Division Seamus Woods, Head of Portfolio Management – HSE System Reform Group

Forewords

DIRECTOR GENERAL FOREWORD The Health Service provides a wide range of care and social supports to people in every community in Ireland. The range of services delivered at community health level includes a complex mix of primary care, social care for older people and services for people with disabilities or mental health concerns. In 2014, more than half of our total health spend on operational services is in this community sector. These services are delivered by the Health Service Executive directly and in partnership with a strong voluntary sector.

The review of the HSE’s Integrated Service Areas was undertaken to ensure that we have a manageable system of Community Healthcare, oriented around people’s needs. This extract from the report explains why this review was necessary:

“People today experience many parts of the service as being very good. However, they experience difficulties in ‘navigating the system’ due to both complexity and scale of present arrangements. What must be improved is how these parts fit together so that the services are integrated and people can move smoothly through the system. Staff must be organised in a way that enables joined-up teamwork, responsive to the assessed needs of the local people.”

When this review is placed alongside the 2013 report on the Establishment of Hospital Groups, we have the basis for new structures for the most important part of our health services, the operational delivery system that interacts with the public every day.

In relation to service reform, the structures detailed in this report will facilitate a further move towards a real integrated system which treats and responds to people’s needs at the lowest level of complexity possible. Placing primary care at its centre, there is a focus on units of the population in local areas.

Strong leadership and ownership at local level in primary care will bring the relationship of specialist social care and mental health services into a much more focused and integrated approach in each local area.

The changes which will now be implemented provide the basis for improved ways of working and of meeting people’s care needs in a joined-up way, with the emphasis on care at the community level. The reorganisation of the frontline resources already in the system into multidisciplinary teams and networks, serving clear catchment populations, is a central element of the proposals and one which I look forward to seeing in operation. Such arrangements can positively improve the range and quality of care available to people at community level and support integrated care delivery in conjunction with the acute hospitals.

Each of the nine Community Healthcare Organisations will have the required focus on the individual aspects of service, which will help drive standards and improvement. For the first time we have clarity on the management and leadership required in the collection of services we call primary care. In addition, we have clarity on how specialist community services in disability, older persons, mental health and health and wellbeing will interface with primary care.

I would like to acknowledge the excellent work undertaken by the review team, led by Mr Pat Healy, HSE National Director for Social Care, on the Community Healthcare Organisations Report. The review involved a careful, evidence-based examination of options, taking into account appropriate care pathways between primary care and acute services, hospital groups, and other key public services such as the Child and Family Agency and local authorities. The review was also informed by detailed consultation with those who provide the services such as GP’s, Nurses & allied health professionals, service users and advocacy groups. I wish to express my appreciation to all who participated in this most important part of the review process.

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The nine Community Healthcare Organisations which will be put in place in 2015 will be driven by a combination of national leadership and local ownership. When we reect on the reform agenda there is no doubt the creation of nine Community Healthcare Organisations will be key to our short, medium and long-term future. The many instances of good and innovative work done in recent years, in the most challenging of times, are the cornerstone which will make this report a real basis for change and improvement. Such improvements can only be positive for those who work in, and deliver, services and is of central importance for the people who use and need health services.

This report provides the structure and system where health professionals can improve services for the public in their own local areas by providing; better access, services that are close to where people live without reducing quality, local decision making and services in which communities have conďŹ dence.

Tony O’Brien Director General Health Service

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PROJECT LEAD FOREWORD The Report “Community Healthcare Organisations - Report & Recommendations of the Integrated Service Area Review Group”, was commissioned by the Director General, Mr. Tony O’Brien in May 2013. In producing this report we drew extensively from a wide consultation process, took account of learning from the changes in the Health Services since 2005, along with national & international experience.

Working with the dedicated project team, I had the opportunity to visit each of the current 17 Integrated Service Areas (ISAs) across the country and to hear first hand from over 600 staff and 40 groups involved in representing voluntary and statutory organisations. These included GPs, nurses, therapists and support staff as well as service users and advocacy groups with a role in Community Healthcare who all gave willingly of their time in contributing to this review.

Many of those views form the basis of the recommendations in this report. Moreover I was struck by the commitment of our dedicated staff and the representatives of the service user and voluntary groups we met and their appetite to embrace and implement the change programme upon which we now embark. It is important to thank everyone who participated in and contributed to this review.

The full implementation of the Community Healthcare Organisations and all of the recommendations will take time, and as the international experience outlined in the report indicates, delivering fully integrated care will be challenging. However, I am confident that the development of Community Healthcare Organisations, placing primary care at the centre of service delivery, along with the development of networks of services, will provide the framework to deliver integrated care to individuals in their local communities. Our approach will be to deliver “the right service, at the right time, in the right place, by the right team”.

I would like to acknowledge in particular the work of the project team, including the administrative support. I am also grateful for the support and advice provided by my colleagues on the HSE’s Leadership Team & Health Service Directorate, as well as in the Department of Health in finalising the report.

Pat Healy National Director Social Care Project Lead

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TABLE OF CONTENTS 1. Executive Summary ............................................................................................................1 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8

Introduction ................................................................................................................................... 1 Delivering Future Health ............................................................................................................... 2 Primary Care Networks................................................................................................................. 2 Reforming Social Care, Mental Health and Health & Wellbeing .................................................. 3 Integrated Care ............................................................................................................................. 4 Recommendations for Community Healthcare Organisations – Number, Scale and Geographical Boundaries ............................................................................................................. 6 Recommendations for Community Healthcare Organisations – Governance & Management Arrangements ............................................................................................................................... 9 Transitioning Arrangements........................................................................................................ 12

2. ISA Review - Context ........................................................................................................14 2.1 2.2 2.3 2.4 2.4.1 2.4.2 2.4.3

2.5

Introduction ................................................................................................................................. 14 Policy Context ............................................................................................................................. 15 Importance of Community........................................................................................................... 17 ISA Review – Approach .............................................................................................................. 17 Consultation ........................................................................................................................................18 Literature Review & Research.............................................................................................................18 Questionnaire......................................................................................................................................18

Summary..................................................................................................................................... 18

3. Evolution of Recent Structures ........................................................................................19 3.1 3.2 3.3 3.4 3.5

Introduction ................................................................................................................................. 19 Health Boards 1971 - 2005......................................................................................................... 19 HSE 2005 – 2009........................................................................................................................ 20 HSE 2009 – 2013........................................................................................................................ 21 Primary Care Strategy Approach................................................................................................ 21

4. Consultation ......................................................................................................................24 4.1 4.2 4.3 4.4 4.5

Introduction ................................................................................................................................. 24 Phase 1 – Consultation Workshops ISA Teams......................................................................... 24 Phase 2 – Consultation with Internal & External Stakeholders .................................................. 28 Importance of Community........................................................................................................... 29 Summary – Chapters 3 & 4 ........................................................................................................ 30

5. Integrated Care – Research and Learning.......................................................................31 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8

Introduction ................................................................................................................................. 31 What is Integrated Care .............................................................................................................. 31 Enabling Integrated Care – Irish Context ................................................................................... 32 Summary of Key Themes and Learning from International Experience of Integrated Care....... 33 Guiding Principles for Delivery of Integrated Care ..................................................................... 35 Guiding Principles of Good Governance .................................................................................... 36 Linking Learning from Research, Consultation & Experience of Change to Date...................... 36 Summary..................................................................................................................................... 39

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6. Options for Community Healthcare Organisations.........................................................41 6.1 6.2

Introduction ................................................................................................................................. 41 Current Situation ......................................................................................................................... 42

6.3

Options Identified ........................................................................................................................ 48

6.2.1 6.2.2 6.2.3 6.2.4 6.3.1

6.4

6.4.1 6.4.2

6.4.3 6.4.4

6.5 6.5.1 6.5.2 6.5.3 6.5.4

6.6

Community Services ...........................................................................................................................42 Proposed Hospital Groups ..................................................................................................................44 Issues with Hospital Catchment Overlap.............................................................................................45 Mental Health Services .......................................................................................................................47 Design Criteria ....................................................................................................................................48

Proposals .................................................................................................................................... 50

Option 1 - Based on Hospital Groups..................................................................................................51 Option 2 - Based on Maximising Primary and Secondary Care Activity, Pathways and Relationships.......................................................................................................................................54 Option 3 - Based on Alignment with Local Authorities and Proposed Regional Assemblies ...............60 Option 4 - An Alternative Approach to Dublin......................................................................................64

Options Appraisal Process ......................................................................................................... 70 PHASE 1.............................................................................................................................................70 PHASE 2.............................................................................................................................................71 Discussion on Options ........................................................................................................................73 Evaluation of Options against Decision Criteria ..................................................................................75

Outcome of Option Appraisal and Recommended Option ......................................................... 76

7. Governance & Management Arrangements for Community Healthcare Service Delivery Organisations .....................................................................................................77 7.1

Introduction and Context............................................................................................................. 77

7.2 7.3 7.4

Clinical and Corporate Governance............................................................................................ 81 Transition Arrangements ............................................................................................................ 81 Recommendations for Governance and Management Arrangements for Community Healthcare Organisations ........................................................................................................... 81

7.1.1 7.1.2 7.1.3 7.1.4

7.4.1 7.4.2 7.4.3 7.4.4 7.4.5 7.4.6 7.4.7

7.5 7.6

Future Health Structural Reform – A Phased Transition .....................................................................77 Delivery of Phase 1 - Future Health Structural Reform .......................................................................77 Planning Phase 2 – Future Health ......................................................................................................79 Implications for Governance and Management Arrangements for Community Healthcare Organisations ......................................................................................................................................80

Management Team of Community Healthcare Organisations Replacing Existing ISAs......................81 Central Role of Primary Care ..............................................................................................................82 Primary Care Management Arrangements..........................................................................................84 Primary Care Clinical Governance and Supervision ...........................................................................88 Mental Health Management Arrangements.........................................................................................89 Social Care Management Arrangements ............................................................................................91 Health & Wellbeing Management Arrangements ................................................................................92

Clinical Leadership...................................................................................................................... 94 Summary..................................................................................................................................... 95

8. Appendices........................................................................................................................97

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1. Executive Summary 1.1

Introduction

The context for this review is provided by the setting out of national government policy in relation to health and social care services in Future Health - A Strategic Framework for Reform of the Health Service 2012 – 2015. This required a process to ensure that health delivery structures were appropriate to achieve national policy objectives. The fundamental requirement is to deliver better, more integrated and responsive services to people in the most appropriate setting. In February 2013, “The Establishment of Hospital Groups as a transition to Independent Hospital Trusts” report dealt with the arrangements for acute hospital services.

In this context, the Director General Tony O’Brien commissioned Pat Healy, National Director Social Care, to lead a review of the organisation of community based services. A project team was appointed to undertake this review (terms of reference and project scope are provided in Appendix A).

In summary, the key deliverables were to recommend: x The number, scale and geographical boundaries of Community Healthcare Organisations as successors to Integrated Service Areas (ISAs) and the transitioning arrangements. x The appropriate governance and management arrangements to apply.

The project team’s approach included: x Consultation with consumers of services, representative organisations and interest groups, clinicians and service providers. x A review of evolving historical arrangements. x A review of international experience in developing integrated care.

This report recommends the establishment of nine Community Healthcare Organisations and the associated governance and management arrangements. While acknowledging the large range of variables which are unresolved, the report recommends that the nine Organisational Areas are fit for purpose regardless of the finalised detailed approach in regard to commissioning, etc. The report highlights the importance of the transitional arrangements that are required to maintain the safety and integrity of the service delivery system. The establishment of the Directorate and the Divisional structures provide the framework for this transitional phase.

This approach will position primary care at the centre of delivering services through around 90 local Primary Care Networks with average populations of 50,000 with better, more integrated access to specialised services in social care, mental health and health and wellbeing.

Arising from the entire process there is a clear consensus that future Community Healthcare Organisations must: x Enable and support integrated care o within community services o between the community and hospital services o with wider public service organisations – local authorities, Child & Family Agency, education, local voluntary organisations, etc. x

Deliver the model of service envisaged in Future Health operating in a Universal Health Insurance environment with a Healthcare Commissioning Agency.

The foundation steps to achieve this will be to: x Position primary care in a central role of providing care to local communities. x Develop identifiable “local community scale” networks averaging 50,000 to: o support groups of Primary Care Teams and o enable integration of all services for a local population. x Reform social care, mental health and health and wellbeing to better serve local communities; o through standardising models and pathways of care while delivering equitable, high quality services o supporting primary care through delivery of rapid access to secondary care and specialised services.

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1.2

Delivering Future Health

The need for organisational change to deliver on Future Health is evident. In this context, a phased approach to the necessary organisational change is appropriate. In the first year, the focus will concentrate on developing primary care services, while at the same time developing and implementing standardised pathways and models of care within each of the specialised community services i.e. social care and mental health. Key to this will be a stronger emphasis on prevention, early detection and health promotion and improvement. This will also enable more effective integration within the networks; between primary care and the acute hospital system generally, and deliver a continuum of care consistently across geographic areas.

Each subsequent year a further phase of the change programme will be progressed, building on the learning from the previous phase. This phased approach will achieve significant benefits for patients and service users, not only in primary care, but in accessing specialised community based services and will lay the foundation for the delivery of fully integrated care over a number of years. Significant collaboration is already taking place across all Divisions i.e. acute services, primary care, social care, mental health, etc. to support implementation of the fully integrated model of care envisaged in Future Health. The completion of this report is a further step in progressing this programme of change.

1.3

Primary Care Networks

Ownership and responsibility for the provision of health and social care services, through the life cycle is best placed within the communities that people live. In future, it is recommended that the fundamental unit of organisation for the delivery of services will be the Primary Care Network, serving an average population of 50,000 people. The network will support and resource the primary care teams with an identifiable responsible manager in each network. A GP Lead will also be identified to support the network and to act as a GP leader. Consequently every large town and its hinterland, and district of a city, will have a network with an identifiable manager. These positions will be developed through the reorganisation / reassignment of existing resources. x x x x x x x x x x x

90 primary care networks of 50,000 average population will be developed across the country.

Leadership of the network will be provided by re-assigning existing senior professional and clinical staff to the new leadership roles as the identifiable and responsible manager of the primary care networks, working with a GP Lead.

The role of the Heads of Discipline will be redesigned to provide the necessary clinical governance and supervision across all primary care networks.

Greater participation by GPs at primary care network level, with the establishment of the GP Lead for each network, supporting the Network Manager in developing professional relationships, innovative solutions and multi-disciplinary approaches to challenges within the network.

The role of Team Leader with protected time will be established for each Primary Care Team.

A Key Worker will be assigned to support people with complex needs.

The network will support the maximum provision of primary care services locally, and will ensure appropriate access to specialised services e.g. social care and mental health, etc. for the people living within the network.

A national process will be put in place to oversee the establishment of the primary care networks as envisaged in this report and to maximise co-terminosity between primary care and specialised services at network level.

Re-align clerical and administrative supports to ensure effective frontline administrative resource for all primary care networks, to the benefit of primary care teams locally.

The success of the network over time will depend on how people experience joined-up, integrated care.

The reorganisation of governance and management arrangements will be delivered from within existing resources.

As outlined in Future Health, and echoed in this consultation, people should receive the majority of their services, accessed through primary care, within their local community.

People today experience many parts of the service as being very good. However, they experience difficulties in “navigating the system� due to both the complexity and scale of present arrangements.

What must be improved is how these parts fit together so that the services are integrated and people can move smoothly through the system.

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Staff must be organised in a way that enables joined-up teamwork, responsive to the assessed needs of local people.

In response to these challenges, the creation of accountable networks will pull all of the primary care services together for its population of 50,000, while driving the integration with other specialised services.

This new structure will, for the first time, place an identified, accountable person as responsible for actual service delivery to a defined local population averaging 50,000. This person, working with the GP Lead, will prioritise and manage the delivery of primary care services, while ensuring effective integration of other specialised services e.g. social care, mental health and access to acute hospital provision.

Sample of Community Healthcare Organisation in Mid-West with 8 Networks supporting 41 Primary Care Teams:

1.4

Reforming Social Care, Mental Health and Health & Wellbeing

From the analysis of the project team and the feedback from the consultation and research it is clear that significant work remains to be done to develop standardised models and pathways of care within each of the individual care groups that make up “community services” i.e. primary care, mental health, social care and health and wellbeing. These models and pathways of care must encompass the necessary clinical procedures and protocols, business processes and performance measures necessary to deliver comprehensive and effective outcomes to their service users and patients.

Only when this work has been sufficiently developed can the services encompassed by each of these “care groups” effectively integrate with each other in a way which maximises the experience and outcomes for service users. Similarly, the development of such standardised processes will support effective integration between all aspects of community services with the hospital system and external partners, e.g. local authority, education, etc.

Healthy Ireland highlights the importance of intersectoral relationships in promoting the health agenda. At a national level and at a policy level the Health and Wellbeing Division will support the Health and Wellbeing Programme in the Department of Health in the co-ordination of the ‘development of models and supports to promote and foster advocates for health and wellbeing in all sectors of society and develop key partnerships with voluntary and other organisations, which can favourably influence health and wellbeing.’

Healthy Ireland also refers to the importance of local operational intersectoral engagement as follows: ‘Local health partners will engage with local authorities in their work to address local and community development, with the aim of co-ordinating actions and improving information-sharing for improved

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health and wellbeing.’ And ‘It is important to identify local structures for implementation and how these can be supported through this Framework to work on common agendas. It is at this level that individuals, community and voluntary groups and projects, sporting partnerships, local schools, businesses, primary care teams, community Gardai, etc can interact to work together.

While the Health and Wellbeing Division will lead on intersectoral collaboration at national level enhancing, developing and supporting effective intersectoral linkages as a key support to all Divisions and CHOs, at the CHO level intersectoral collaboration will be led by the local operational health services – Primary Care and Community Services. This will ensure effective intersectoral engagement both nationally and locally While it will take time to fully standardise and integrate the specialised services i.e. social care and mental health, the intention is that each year we will progressively increase the levels of standardisation and consistency achieved. These annual improvements will be demonstrated by the achievement of identified and measurable targets and outcomes, delivering significant benefits to patients and service users, as services proceed through a journey to fully integrated care.

Community healthcare organisations are committed to the implementation of the clinical effectiveness agenda as a key component of patient safety and quality. Clinical effectiveness underpins the proposed standardised models of care for each care group. Quality assured national clinical guidelines and national clinical audit linked to key performance indicators are quality improvement processes which are critical elements of the clinical effectiveness agenda. A clinical effectiveness approach incorporating national and international best available evidence will promote the delivery of integrated care in the community that is current, effective and consistent.

This process of reform will also prepare the way for the implementation of a commissioning model and the purchaser / provider split envisaged in Future Health which are currently under development.

The programme of care group reform must be guided by the objective of fuller integration and responsive delivery to people locally at primary care network level.

1.5

Integrated Care

The delivery of integrated care, treating people and service users at the lowest level of complexity that is safe, timely, efficient and as close to home as possible, is a fundamental objective of the Irish health service.

In the context of the international experience, and informed by the consultation process, a phased approach will be taken to the development of a comprehensive integrated care system as diagrammatically represented below:

Integrated Care - Phased Development

Integrated Development 2014Care – Phased 2015 2016 2014

Standardized pathways / models of care - roll out early implementers

2015

Development of additional standardized pathways / models of care each care group

Commissioning Framework

2016

Integrated Care

UHI Model

Commissioning Framework

UHI Model

The overall objective of Future Health is the provision of an integrated model of care. The phased approach recommended in this report is based on an appreciation of the complexity involved in achieving this.

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The Irish and international experience to date shows that the implementation of comprehensive integrated care takes time and must be implemented in a phased manner with clear milestones and goals which enables safe transition (ref. Chapter 5).

International research on integrated care shows a number of things very clearly: x

It can make a real difference to the quality of care received by patients and service users: The danger of a fragmented delivery system is that individuals’ needs will not be fully met, substantially reducing patient outcomes.

x

The introduction of integrated care takes a significant period of time to implement. Even countries recognised as having made significant advances in the area have been working on the concept for two decades or longer.

x

One size and approach to integrated care does not fit all circumstances and it is important to be cognisant of the local challenges in any approach. More importantly, it is neither possible nor advisable to attempt to introduce integrated care across all areas in one step, and a number of countries have adopted a pilot type approach introducing integrated care in pockets of service with a view to expansion

x

It is very difficult to turn the concept of integrated care into a cost effective operational reality. One of the main challenges is to target the right individuals and conditions. For instance, it is clear that case management must be a crucial part of integrated care. However, because case management is a labour intensive activity it is unlikely to be cost effective unless it is targeted effectively.

x

There are many ways to implement integrated care: Crucially organisational integration is not necessarily required. The key requirement is clinical and service level integration, supported by an appropriate incentives system.

Achieving integrated care means that services must be planned and delivered with the patients’ needs and wishes as the organising principle.

It will be necessary to identify early successes where it will be possible to roll out “early implementers” of this integrated care model and new ways of working. This will require a body of work by each care group to bring their services to a level where integrated care is achieved.

Examples of the type of practical benefits that will be delivered from this approach are: x Home Care and Community Support Services – Realignment of the model of care to enable older persons to live independently in their own homes for as long as possible, with a service improvement programme to ensure standardised delivery of home help and home care packages and supporting self-care. x Disability Services for Children and Young People (0 - 18s) – A national unified approach to delivering a clear pathway to services regardless of where a child lives, the school attended or the nature of the disability or delay. x Diabetes – Integrated management of diabetes, alignment of existing primary diabetes care initiatives to nationally agreed model of care. x Chronic Obstructive Pulmonary Disease (COPD) - A model of care including guidelines for the management of COPD including spirometry in the primary care setting. x An over-arching model of care in Mental Health Services to provide a relatively standard level of basic services regardless of location, focused on recovery and enhancing clinical excellence. x

Integrated community services management of healthcare associated infections with processes for access to specialist expertise as required.

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The end phase of a fully integrated Health and Social Care model would contain all of the elements in the diagram below:

Social Care

Social Care Local Communities 50,000

Health & Wellbeing Health & Wellbeing

Primary Care Network - GP Lead - Manager Responsible for population Integrator

Primary Care Team

Supporting them to improve health & wellbeing

Support Change Build Leadership System Reform Unit

Mental Health

- Team Leader - Key Worker

Integrated Care

Unique client Identifier Standard Business Processes / Pathways / Models of care

Clinical Programmes Programmes of Care

Clear Clinical & Corporate Governance

Acute Hospitals

Mental Health

1.6

Acute Hospitals

Recommendations for Community Healthcare Organisations – Number, Scale and Geographical Boundaries

Organisational arrangements are required to support and enable the delivery of services. In order to best support the ultimate objective of fully integrated services, and the foundation steps of development of primary care networks, together with the reform of specialised services and enable the ultimate objective of fully integrated services, it is necessary to develop a number of community organisations to replace the existing ISAs and to outline appropriate transitioning arrangements.

These community organisations will be known as “Community Healthcare Organisations”.

The project team developed key criteria to guide the decision making process on the number, scale and geography of these organisations. The criteria and process are outlined in Chapter 6 of this report. Informed by the literature and research, and from experience, an important consideration centred on striking the right balance between two considerations: x sufficiently small scale to provide the local responsiveness required to deliver effective integrated care and x sufficiently large scale to justify the necessary organisational architecture, business and service capability In determining the appropriate geographical configurations for the community organisations a range of criteria were developed and applied. These criteria take account of the output from the consultation process, representative organisations and interest groups, clinicians and service providers and the previous spatial mapping exercise.

The main criteria used are outlined below in summary form: Internal Integration Criteria x Maximise co-terminosity with new six hospital groups; x Recognition of the clear relationship between primary and secondary care; x The primary care teams must be the building blocks for any new spatial units as their determination followed a robust decision process which took cognisance of a wide range of relevant criteria to form areas which maintained natural community integrity, captured GP populations and followed patient flows; x Cognisance needs to be taken of the establishment of mental health areas in the context of “Vision for Change” and that any new areas should minimise the impact on the work already established;

x

x

Take consideration of existing and historical linkage across former Local Health Offices (LHOs) and ISAs, where service relationships and arrangements have built up; Minimise change for change sake, given the extent of change still happening following previous transformation initiatives e.g. ISAs.

Demographics/Deprivation Populations are not evenly distributed and a balance must be found between spatial factors, community integrity, deprivation levels and a justifiable population size to support service levels.

Key considerations include: x Population size and density; x Deprivation levels; x Demographics; x Cultural diversity.

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Self Sustaining / Manageability Factors x Viability i.e. each area identified must have a critical mass of population which is sufficient for an area to be self-sustaining in terms of service delivery; x Manageability i.e. the area should be of a size that its senior manager can balance focus on both integration matters and managing accountability; x Facilitate clustering of services without too many tiers of management; x The new organisations must be capable of facilitating strategic direction as articulated in Future Health.

x

those on lower income but also connects to natural tendencies and directions of communities and populations and local cultural links; Geography needs to be seen to have relevance beyond size to what can be described by people as “making sense” and deciding what forms “natural communities”.

External Integration Issues There is a requirement on the wider public services environment to develop new ways of tackling complex societal goals.

In many reports the adoption of county boundaries or groupings of them is recommended as a key initiative.

Geographical/Physical/Cultural x Relatability i.e. there must be a simplicity of service arrangements where people can relate to the community organisations and there is an ability to drive integrated responses with local communities and agencies; x Area contiguity i.e. the whole catchment area must be physically joined (The law of contiguity states that things which occur in proximity to each other are readily associated); x Issues such as road infrastructure and avoidance of traffic congestion are important in terms of equitable access. This includes an area being well served by public transport for

There are a number of key external boundaries that the project considered to maximise co-terminosity but the team recognised the fact that some natural community affiliations and historical client flow sometimes work across such boundaries and would work against the benefits for integration with clients.

The following were considered: x Local authority boundaries; x Existing and proposed local authority Regional Assemblies; x Gardaí catchment areas; x Cross border connectivity with Northern Health Authorities

In applying the criteria, a total of seven options were identified for consideration and all of these options are outlined in detail in Chapter 6. These options were then subjected to further appraisal based not only on the above criteria, but also having regard to the prioritised considerations which are summarised below:

Emphasis on Community and Integration

Local Authorities

Child Care Services

Efficiency of Scale

Design of Governance and Management Structures at Area and Sub-area Level

Supporting UHI Environment

The project team also gave particular regard to the issue of connectivity with the Hospital Groups, particularly the primary / secondary care interface.

The recommended option below meets more fully the broad range of criteria referred to and the development of nine community organisations, with each responsible for the geographic areas as outlined in the recommended option.

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Area 8

DN

Meath

Area 9

Area 1 - Population 389,048 Donegal LHO, Sligo/Leitrim/West Cavan LHO and Cavan/Monaghan LHO.

Legend Option 2A v2 Option_2A

DNW

DW

Area 7

DSW

Kildare/W Wicklow

DNC

Area 1 - pop 389,048 Area 2 - pop 445,356

DNC

Area 3 - pop 379,327 Area 4 - pop 664,533 Area 5 - pop 497,578

Donegal

DSC DSE

Area 6 - pop 364,464

DL

Area 7 - pop 674,071

Area 6

Area 8 - pop 592,388 Area 9 - pop 581,486

Wicklow

Area 1

Louth

Cavan/Monaghan

Roscommon

Area 2

Meath Longford/Westmeath

DN

Area 9

Area 8

Galway

DNWDNC

DW DSE DSC DSW DL

Area 7

Kildare/W Wicklow

Laois/Offaly

Area 6 Wicklow

Clare

Area 3

North Tipp/East Limerick Carlow/Kilkenny

Limerick

Tipperary SR

North Cork

Kerry

Area 4

Area 5

Area 5 - Population 497,578 South Tipperary LHO, Carlow/Kilkenny LHO, Waterford LHO and Wexford LHO Area 6- Population 364,464 Wicklow LHO, Dun Laoghaire LHO and Dublin South East LHO Area 7 - Population 674,071 Kildare/West Wicklow LHO, Dublin West LHO, Dublin South City LHO and Dublin South West LHO Area 8 - Population 592,388 Laois/Offaly LHO, Longford/Westmeath LHO, Louth LHO and Meath LHO

Wexford

Waterford

North Lee

South Lee West Cork

Area 3 - Population 379,327 Clare LHO, Limerick LHO and North Tipperary/East Limerick LHO Area 4 - Population 664,533 Kerry LHO, North Cork LHO, North Lee LHO, South Lee LHO and West Cork LHO

Sligo/Leitrim

Mayo

Area 2 - Population 445,356 Galway, Roscommon and Mayo LHOs

SRG Projects Office, Limerick Produced Under OSI License HSE 030601

Area 9 - Population 581,486 Dublin North LHO, Dublin North Central LHO and Dublin North West LHO

This option is considered the most appropriate proposal to recommend as: o it met a broad range of the criteria; o met a key requirement of linking the Primary Care Networks and PCTs and secondary care; o while also providing a very strong basis for linkage with local authority boundaries, both in the context of county councils and the proposed Regional Assemblies in the future; o provides the best fit in striking the right balance between an organisation of sufficiently large scale to justify the necessary organisation and business capability, while at the same time being sufficiently small scale to provide the local community connectivity and responsiveness required to deliver integrated care. o The grouping of Donegal, Sligo/Leitrim/West Cavan and Cavan/Monaghan in Area 1 provides a unique opportunity to build cohesively on the existing cross border linkages and connections. o This option will not require the development of significant sub-structures, unlike a number of the other options. x It would be advisable to develop a mechanism to support an approach for planning, social inclusion and related purposes across Dublin as a whole. This could be developed as part of the Regional Assembly arrangements, through which a Dublin wide group could be developed to engage with the health sector.

In the future consideration might also be given to reorganisation of the Regional Fora within the health service along these lines to develop collaboration at a regional level between local authorities and the health service which hasn’t been sufficiently evident to date. This approach may offer significant potential to build on existing partnership arrangements and to help to progress the implementation of ‘Healthy Ireland’. x

This option of nine community organisations is recommended.

8

1.7

Recommendations for Community Healthcare Organisations – Governance & Management Arrangements

National Context The approach to the governance and management arrangements must be informed by the structural reform which has already occurred involving the establishment of the Health Service Directorate. The Directorate is responsible for implementing the strategic policy direction of Future Health and the development of standard national service frameworks. The Directorate will also provide leadership and direction on shared service platforms, new financial systems, the development of a commissioning framework, procurement and other business supports which are currently underway.

It is the intention of the Health Service to gradually transition to a commissioning model on an administrative basis, as both provider and commissioner capabilities strengthen, with the clear aim of achieving the greatest progress possible on a commissioner / provider split prior to the introduction of the statutory functions. This will reduce the risk at the point of statutory transition.

During 2014 progress will be made on the development of a phased implementation of the commissioning function and the development of a robust commissioning and provider framework, which allows for the purchasing of services and which provides assurance that the services are provided at the level and quality required. This important work will commence on the design and development of the formal contractual arrangements to support the commissioning framework.

An important outcome from this reorganisation of service is to devolve greater autonomy and decision making to frontline services at local level through the establishment of the Hospital Groups on the one hand, and the new Community Healthcare Organisations on the other. This earned autonomy, will support the development of leadership capacity and innovation locally. However, there is a critical balance to be achieved with this independence on the one hand and the necessity for clear accountability and the standardisation and delivery of services locally in a consistent and equitable manner in line with national frameworks. Striking the right balance in this regard will be an important consideration for the management and governance arrangements to be put in place in respect of the Community Healthcare Organisations to replace the existing ISAs. Other important outcomes from this service reorganisation will include an improved focus on quality and patient safety, an enhanced focus on health and wellbeing and an enhanced ability to plan and deliver integrated care.

Consultation with Stakeholders Throughout the consultation process it was also fully recognised and communicated that any proposals would need to be considered by the DoH and Government within the overall context of health service reform, including the requirement to ensure a cohesive and integrated structure for the whole health system. Similarly, it was recognised that any reorganisation at local level would need to have regard for the emerging commissioning type model and the associated purchaser/provider spilt appropriate to the Irish context.

It is fair to say that the expectation of the majority of stakeholders was that the Community Healthcare Organisations to replace the ISAs would become the local service provider of Primary Care and Community Services, working within national frameworks and direction, and accountable to the national system through the Healthcare Commissioning Agency or other national entity, through a performance contract type arrangement.

In the context of reorganisation of acute services into hospital groups, there emerged an inferred expectation within the system that any revised structures of Community Healthcare Organisations would also see them established as legal entities in due course, similar to the potential that exists for the hospital groups.

Following consultation with DoH it is important to note in designing a new organisational structure for the health services we need to be conscious of the number of agencies required. In developing proposals for new organisational structures, a strong emphasis will be placed on streamlining functions, avoiding duplication and having full regard to the Programme for Government and Future Health.

In this context, consideration should be given to options which range from the nine successor ISAs progressing to individual agency status or being operational divisions within a single national delivery organisation.

9

“Best Fit” Community Structures The considered view of this report is that the nine boundaries and the associated management and governance arrangements for these structures at local level are the most appropriate to deliver the type of significant reform and responsive service delivery envisaged in Future Health and the Programme for Government. These structures are sufficiently robust to deliver the current requirements for service management, while being flexible enough to support the system from the current state through a number of transition phases to the UHI environment. They provide the “best fit” structure to dovetail with whatever final national organisational arrangements emerge.

The primary emphasis of the future Community Healthcare Organisations as outlined in this report is on service delivery within the context of nationally prescribed frameworks. They will concentrate on implementation of the nationally agreed standardised models of care for each care group, bringing a local community focus to service delivery, and ensuring integrated services are provided to their primary care networks serving average populations of 50,000. The primary focus has been to establish the appropriate leadership and management team arrangements that need to be put in place to ensure the new structures are fit for purpose in implementing the challenging reform agenda ahead.

The Community Healthcare Organisations will be responsible for the delivery of primary and community based services within national frameworks responsive to the needs of local communities.

It is essential, to ensure the continued effective management and organisation of the service and to progress implementation of the reform programme, that we move rapidly with the implementation of the recommended nine Community Healthcare Organisations on an administrative basis.

Transition Arrangements The clear intention is that the reform programme will be implemented on a phased basis as outlined in Future Health.

In this first phase, the intention is that from March 2014 the current ISAs will report directly to the National Directors of Primary Care, Social Care, Mental Health and Health & Wellbeing. It is essential, to ensure the continued effective management and organisation of the service and to progress implementation of the reform programme, that we move rapidly with the implementation of the recommended nine Community Healthcare Organisations on an administrative basis. This reorganisation can take place smoothly within the existing governance arrangements of the Health Service Directorate. This approach will allow the new arrangements to bed down at local level while work is continuing in finalising the overall national approach to be taken with regard to the commissioning model and other issues referred to at 7.1.3.

During transition, the appropriate governance at national level will be provided through the National Directors, the Leadership Team and the Health Service Directorate. During this period arrangements will also be put in place to ensure effective integration and performance management across the system.

Community Healthcare Organisations - Organisational Arrangements

The management arrangements for the Community Healthcare Organisations are illustrated below in summary form: Chief Officer

Lead Quality & Professional Development

GP Lead

Head of Primary Care

Head of Social Care

Head of Health & Wellbeing

Head of Mental Health

Business Management Head of Finance Head of Human Resources

Quality & Safety, Standards & Professional Development

Primary Care Networks (Between 8-14 networks per CHO) 90 Networks Nationally 50,000 avg. per network

Leadership Team: - Medical Lead - Nursing Lead - Allied Health Professionals Lead

Network Manager GP Lead Primary Care Teams – Average 5 per network Multi-disciplinary working Heads of Discipline

Head of Corporate Support Services

CLINICAL LEADERSHIP PROFESSIONAL DEVELOPMENT PROGRAMMES OF CARE

10

(ICT, Estates, Comms, Legal)

Chief Officer of Community Healthcare Services The Chief Officer, working in line with nationally agreed frameworks and reporting arrangements, will have full responsibility and accountability for the delivery of all primary, community, social and continuing care services within the catchment area, ensuring the appropriate integration with secondary care services and with all appropriate stakeholders. The Chief Officer will: x deliver the multi-year strategic plan and the annual service plans x lead the Management Team in reforming services of care to ensure integrated care for patients and service users x be accountable for the quality and safety of care provided and support clinical leadership in the management and delivery of services x represent the future Community Healthcare Organisation in public and representational engagements and ensure motivated staff x ensure appropriate engagement with communities and public representatives to develop the necessary public confidence in the Health and Social Care services.

Management / Leadership Team x

Head of Primary Care The Head of Primary Care will have full responsibility and accountability for service provision across Primary Care Networks and Primary Care Teams. The Head of Primary Care will carry particular responsibilities for developing an effective relationship with General Practitioners, driving the implementation of the primary care approach envisaged in Future Health. Similar to the Network Manager role, the Head of Primary Care will be responsible for driving effective integration at Community Healthcare Organisation level. Their relationship with the Head of Health and Wellbeing will be key to ensuring a stronger emphasis on prevention, early detection, health promotion and improvement.

x

Head of Social Care The Head of Social Care will have full responsibility and accountability for service provision for older people and people with a disability, implementing standardised models and pathways of care to support integration. In line with the reform programme, the intention is to introduce a standardised framework to commission services from both public and non-public providers; individualised budgeting to bring about a closer alignment between funding and the outcomes for individuals; and a robust regulatory regime to ensure quality and safety. The Head of Social Care will lead the implementation of these reforms at Community Healthcare Organisation level.

x

Head of Mental Health The Head of Mental Health will have full responsibility and accountability for mental health service provision. The reform programme reaffirms the move from the traditional institutional model of mental health care, towards a recovery focussed, clinically excellent model that involves service users in all aspects of the design and delivery of the service in line with Vision for Change policy.

The Head of Mental Health will lead the implementation of these reforms at Community Healthcare Organisation Level.

x

Head of Health and Wellbeing Given the criticality of health and well-being services to the health of the population and its status as a pillar within the Future Health document, the review proposes that a Head of Health and Wellbeing be appointed to the Leadership team of the new Community Healthcare Organisations.

As part of the continued development of the Health and Wellbeing Division at national level, a significant programme of work is underway to align, and where relevant, more fully integrate its operational service components. The specification for the role of Head of Health and Wellbeing at CHO level, potentially encompassing responsibility for a range of services hitherto managed discretely will be informed by the output from this programme. Clarity around governance, the ‘best-fit’ for such a post relative to the current delivery models (spread of national, regional and departmental resources) and its role within a commissioning environment are key here. The pace at which this process can be meaningfully completed, relative to the timeline for the creation of Community Healthcare Organisations, may mean that the role specification, accountabilities and competencies of a Head of Health and Wellbeing will be interim.

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x

Lead Quality and Professional Development The Lead for Quality and Professional Development will provide assurance that the appropriate clinical governance and related assurance frameworks are in place in respect of all services throughout the Community Healthcare Organisation area.

The post holder will lead a multi-disciplinary team of clinicians to steer and monitor the day to day development of clinical governance, providing staff with the necessary support and leadership.

The post holder will also provide advice to the management team and review progress against specified objectives. The Lead Quality and Professional Development will be a non-executive member of the Management Team.

x

GP Lead – Management Team Level The General Practice Lead will be a key influencer on decision making at management team level. In particular, this position will support the development of the Primary Care Networks and the service delivery arrangements in order to ensure responsiveness to the needs at Primary Care Team level.

x

Business Management The Heads of the Business Support functions will operate within the context of the national shared services arrangements. These positions will lead their respective functions in support of efficient and effective service delivery. In particular, they will be responsible for achieving the benefits of scale arising from national frameworks in areas such as procurement within the Community Healthcare Organisation area.

The detail of these new arrangements will be implemented in consultation with staff associations and representative bodies in line with the Public Service Stability Agreement (Haddington Road). The development of the GP Lead role and its specifications will be undertaken in collaboration with the ICGP and relevant representative bodies.

1.8

Transitioning Arrangements

The implementation approach and process must be grounded in the objectives of the Health Reform Programme and measured against the objectives of this programme.

Challenges In embarking on this programme of change, ensuring that integrated care is experienced by people and their families, involving the establishment of Community Healthcare Organisations it is imperative to take on board the learning and experience of other countries to ensure that change is implemented in a timely manner but not at the cost of sustainability.

Both international and Irish experience demonstrates that structural and organisational reform by itself is limited in effecting significant change and impacting positively on the experience of service users.

Fundamental cultural and attitudinal change must complement the changed organisational arrangements:

The values and leadership approach engendered in each Community Healthcare Organisation will be critical to success.

Direct service providers must work across all traditional boundaries and outside of historical service settings with the service user as the focus of all activity.

People in senior clinical and management positions must provide the necessary leadership to give effect to the implementation of the fundamental changes that are now required.

All staff, including those in positions of leadership such as Heads of Discipline and heads of clinical services must combine responsibility for safety and stability of existing services, while transforming their services and their own ways of operating.

The challenges of working in a comprehensive and integrated way are significant and will need to be supported through a comprehensive human resource strategy which will include an appropriate investment in education and training with appropriate mentoring, and development of leadership and management skills.

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Enablers A number of critical enablers are necessary and these include for example the development of comprehensive ICT systems and a unique patient identifier which will facilitate greater linkages between electronic health record systems and thus ensure better, safer care.

A number of key enablers are already in place which will support the necessary change management process: x

The new Health Service Directorate will bring a national leadership focus in respect of each Division (care group) i.e. primary care, mental health, social care, acute services and health and wellbeing.

x

The National Clinical Programmes, developed in collaboration between the health service, the Royal Colleges and with the support of HIQA and the DoH, provides a strong platform to develop and implement the standardised models of care and processes referred to above. The National Clinical Programmes will support the development of a national, strategic and coordinated approach to the design of clinical service improvement, to deliver improved patient care, access and better use of resources. A National Clinical Group Lead is being appointed for each of the Divisions, which will embed clinical and professional leadership within the management structures of the new Divisions, providing the necessary support and advice at national and local level.

x

The System Reform Unit will play a key leadership role to support the work of the Divisions in the implementation of their significant change programmes. It will be responsible for the necessary programme and project management.

x

The Quality and Patient Safety Division provides strong patient safety and quality improvement support and assurance to each of the service Divisions and throughout the system. This programme of support will be further enhanced with the establishment of the Patient Safety Authority which will be formed and located initially within the Health Service.

x

Communications and Stakeholder Engagement is an essential enabler of change. Key stakeholders such as staff, patients and service users, representative and professional bodies and others should feel part of the change, and that their views are listened to. This approach will inform a comprehensive communication effort throughout the change programme.

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2. ISA Review - Context 2.1

Introduction

In order to achieve the overarching objectives of the reform programme Future Health – A Strategic Framework for Reform of the Health Services 2012 - 2015, significant changes are required in the organisational arrangements of the health and social care services, both from a governance and service delivery perspective. Structural reform is not an end in itself but is a key enabler that will facilitate the achievement of the vision for Community Healthcare Organisations. It will support the development of a stable environment for delivering integrated care in a measured and coordinated way, throughout the reform process as we move towards the phased implementation of a Universal Health Insurance (UHI) environment.

The Reform Programme, as set out in Future Health envisages a move from the current centralised management model for health services to a model that will see greater autonomy for frontline services. This will be achieved by establishing Hospital Groups and similar structures for the organisation and management of Community Healthcare Organisations within identified geographic areas. The changes to be introduced will; x

Ensure that primary care, social care, mental health and health and wellbeing services will be delivered and managed in a single structure that maximises integration within geographic areas, which will be identified in this review. This will include HSE funded agencies in these service areas.

x

Provide direct line accountability to and between the individual National Directors for services and the managers responsible for hospitals and Community Healthcare Organisations as a precursor to moving to a purchaser / provider split commissioning model.

x

Ensure the foundation for greater autonomy at service level is in place within agreed national frameworks, and provide a greater capacity to support the innovative and responsive service delivery model envisaged in Future Health.

x

Outline the future governance mechanism of Community Healthcare Organisations. These will be similar in approach to the development of hospital trusts, ensuring robust management structures and ‘parity of esteem’ with the acute hospital sector.

The following points were useful in focussing the work of the review: x

Commitment in Future Health to reforming the way services are provided in the areas of primary care, social care, mental health & health and wellbeing services. Future Health also provides for a review of the Integrated Service Area (ISA) structure.

x

The output and findings from this review will inform decisions on achieving a stable environment for delivering integrated care during the course of and beyond the health reform process and into the UHI environment.

x

There is a move from emphasis on acute care towards preventative, planned and well coordinated community based care.

x

Primary Care Teams and Networks provide the foundation for a new model of integrated care in Ireland.

The announcement of the establishment of the new Hospital Groups on an administrative basis in May, 2013, with Group Chief Executives having budgetary and staff responsibility for both the HSE and voluntary hospitals in their group, represented the end of the structural basis for existing Integrated Service Areas (ISAs). This necessitated a review of the ISAs to recommend the best successor body. This review will: x

ensure maximum alignment between all service providers at local level,

x

review executive management and governance arrangements and

x

inform new structures for the delivery of primary care and community services.

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2.2

Policy Context

The Programme for Government outlines fundamental reform of the health service over the coming years in order to develop a more sustainable model for the future. The current system is facing major challenges including significantly reducing budgets; long waiting lists; capacity deficits, an ageing population and a significant growth in the incidence of chronic illness.

Future Health provides the overarching policy framework and high level actions to deliver this fundamental reform programme. Future Health makes a commitment to ensuring a new focus on moving away from simply treating ill people, to a new concentration on keeping people healthy. This concentration needs to be seen across all levels of reform from structural, to service and financial. As part of the structural reform set out in Future Health, following the enactment of the HSE (Governance) Act, the Health Service Executive (HSE) Directorate was established on the 25th of July, 2013. The Directorate has strengthened accountability arrangements, is headed by the Director General and is accountable to the Minister for the performance of the HSE’s functions as well as its own. In addition to the Director General, the Directorate consists of other appointed Directors who are responsible at national level for the delivery of services in the relevant service domain and also lead the development of national service strategies associated with their areas. The Directorate is comprised of the Director General, Chief Operations Officer and Deputy Director General, Chief Financial Officer, National Director Primary Care, National Director Acute Hospitals, National Director Social Care, National Director Mental Health and National Director Health and Wellbeing. Within this overarching policy and delivery framework, a number of key policy objectives can be delivered as part of the reform programme: x Primary Care Future Health sets out a vision for primary care where GPs work in teams with other primary care professionals. The focus is on the prevention of illness and structured care for people with chronic conditions; Primary Care Teams working from dedicated facilities; and staffing and resourcing primary care appropriately to meet regularly assessed needs.

Primary care teams and networks will provide the foundation for medical and non-medical care that people need, whether it is for health or social needs, maintaining at all times the community ethos of primary care. Patients will be referred from primary to secondary care only when their needs for care are sufficiently complex. Otherwise they will be managed through primary care. Registration with a Primary care team will become compulsory once the Universal Health Insurance system is fully implemented. x Social Care Future Health commits to the development of a social and continuing care system for older people and people with disabilities that maximises independence and achieves value for the resources invested. The intention is to introduce: a standardised framework to commission services from both public and non-public providers; individualised budgeting to bring about a closer alignment between funding and the outcomes of individuals and a robust regulatory regimen to ensure quality and safety. x Mental Health Future Health reaffirms the move from the traditional institutional based model of mental health care towards a patient centred, flexible community based service as set out in Vision for Change. Services are focused on delivering a modern, recovery focused, clinically excellent service built around the needs and wishes of service users, carers and family members and on implementing the reform programme in a way that ensures they are properly integrated with other health and social services. x Acute Hospitals Three main areas of reform are identified in respect of the hospital system. These are: i. More responsive and equitable access to scheduled and unscheduled care. ii. Reorganisation of hospitals into more efficient and accountable Hospital Groups – harnessing the benefits of increased independence and greater control at local level. iii. Implementation of a Framework for the Development of Smaller Hospitals which will ensure that smaller hospitals play a vital role in service delivery.

15

x Health and Wellbeing Future Health reaffirms the core purpose of the health system, which is to help improve the overall health and wellbeing (one of the four pillars of Future Health) of the population. A Health and Wellbeing Framework, providing a structured mechanism to mandate other sectors to support the health system, has been developed with the publication of the Healthy Ireland Framework in March 2013. An effective health service plays a critical role in driving this agenda. Improved patient and population health outcomes will only be achieved by ensuring all new reforms and governance arrangements in health are underpinned by a commitment to deliver on the four goals of Healthy Ireland; Increase the proportion of people who are healthy at all stages of life; reduce health inequalities; protect the public from threats to health and wellbeing; create an environment where every individual and sector of society can play their part in achieving a healthy Ireland. This will assist policy makers to integrate considerations of health, wellbeing and equity in the development, implementation and evaluation of policies and services. x Child & Family Agency Consistent with the Programme for Government the Child & Family Agency Bill 2013 is the foundation for the transfer of a range of Child & Family services to a separate statutory Agency. The Community Healthcare Organisations will continue to play a significant role in the lives of children in areas such as child health, development and screening and in specialised service provision (e.g. children with disabilities). Robust integration between the Child and Family Agency and the Community Healthcare Organisations at local level, supported by national decisions and direction, will be necessary. x Healthcare Commissioning Agency The Directorate Divisional Management Teams involved in performance, contracting and financing of services will be subsumed into a new commissioning body the Healthcare Commissioning Agency. It will be responsible for driving performance improvement through value-based purchasing. A formal purchaser/provider split will be established within the health sector, though the system will remain entirely tax funded during this phase.

In advance of this, a Money Follows the Patient (MFTP) funding model will be introduced in order to create incentives that encourage treatment at the lowest level of complexity that is safe, timely, efficient, and is delivered as close to home as possible. This will facilitate the movement of money to where the service can best be delivered. This, along with other initiatives such as the introduction of integrated payment systems, will help to support integration between primary, community and hospital care.

A rigorous performance management process will be put in place with defined national outcomes for all of the care groups. Providers will be measured regularly against the achievement of these outcomes and the results published. Performance against outcomes will be used, in turn, to inform the commissioning process. x Universal Health Insurance Future Health identifies that the final phase of structural reform will see the move to a combination of Universal Health Insurance funding for acute hospital and certain primary care services, with general taxation funding for other services including the social care services such as disability and long-term care. While funded separately, these services will still be delivered in an integrated manner around the needs of the person. The Healthcare Commissioning Agency will also continue to finance certain health and social care costs directly via the other funds. As such, it will retain a central strategic role in terms of managing the flow of funds between different arms of the health system and in working with health insurers to support the delivery of high quality, integrated care. x Model of Integrated Care Future Health identifies a new model of integrated care that treats patients and service users at the lowest level of complexity that is safe, timely, efficient and as close to home as possible. This aim of increasing integration is consistent with initiatives in other countries that seek to shift the emphasis from episodic reactive care to care based on need which is evaluated on its impact on outcomes. The aim is to build service delivery around the full cycle of care for the major conditions/diseases which a patient may have, i.e. from prevention to self-care to primary care to acute care. Integrated care can be defined as care that improves the quality and outcomes of care for patients and their immediate families and carers by ensuring that needs are measured and understood and that services are well co-ordinated around these assessed needs.

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2.3

Importance of Community

A consistent theme throughout Future Health is that services should be delivered as close to or if possible in a person’s home. In considering the organisational arrangements required to give effect to the objectives of delivering care as near to the person as possible, and having regard to the experience of change programmes to date, together with feedback from the consultation process as part of this review, the project team was cognisant of local communities, particularly the importance in Ireland of enabling local communities to support their own people through the life cycle. Community in this sense is related to the wider network of organisations and supports which are at the heart of local communities, ranging from local voluntary organisations of all kinds, not just in the health sector, but across all sectors including farming organisations as well as groups such as the ICA or the GAA and other sporting bodies which span both rural and urban communities.

It is in the engagement between these informal networks and the more formal state provided services, through agencies such as the health service, local authorities, community Gardaí, local schools and educational institutions, community welfare and other support services, where a real partnership approach is developed and sustained, through which people come together in a way that supports and enables communities to meet the needs of their people. In addition, working with local communities in this way maximises the opportunities of promoting health and wellbeing in the broader sense envisaged in Healthy Ireland.

2.4

ISA Review – Approach

In advance of the publication of the report on the Hospital Groups, Mr. Tony O’Brien, Director General, established a review of ISAs led by Pat Healy incoming National Director Social Care. The terms of reference and project scope statement are outlined in Appendix A The project team was asked specifically to delineate and map out appropriate successor bodies and related geographic areas for Community Healthcare Organisations and design appropriate governance models at area and sub-area levels that would: x x x x x x x x

clarify the lines of governance and the operational management structure including frontline management arrangements to support effective service delivery and policy implementation drive and support safe, quality care for patients and clients bring decision making close to where services are delivered allow clinicians to shape and assure the services in which they work get the best health outcomes for the money spent that would be planned and organised around peoples’ needs and what works to give the best results facilitate meeting increasingly complex patient and client needs remove any barriers to integrated care.

The methodology adopted in undertaking the review focused on an extensive consultation process together with an overview of the literature and learning in respect of the delivery of integrated care and an analysis of existing governance structures and their stage of implementation. An important element of the overall approach to this review was to undertake a comprehensive process of consultation and dialogue with a wide range of stakeholders to: x Map out appropriate successor bodies and related geographic areas for x Bring forward proposals for appropriate governance models at area and sub-area levels. x Ensure the recommendations support the UHI environment.

In undertaking the review of the ISAs the project team have been cognisant of the reform programme, specifically the evolving commissioning model, introduction of UHI and the importance of ensuring that the Community Healthcare Organisations and associated governance and management structures are robust and flexible enough to support each phase of the transition from the current service delivery model to the final end state of the reformed system. It is also important that services are delivered safely while the system is changing.

This work involved consideration of the potential appropriate successor bodies to ISAs. This included recommendations on the appropriate number of geographical areas and the resource requirements for management structures for the Community Healthcare Organisations.

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2.4.1

Consultation

Consultation with each of the current 17 ISAs took place between the 3rd and 17th of July, 2013. The project team met with over 600 staff, encompassing a broad range of multidisciplinary professionals, support services, management and care staff reflective of the services provided in the ISA. Representatives from the acute services, general practice, etc. were included in the consultation process. In addition, professional associations and representatives of the voluntary sector were engaged with (Appendix B). A number of the groups made formal submissions, the output of which was incorporated in the process of consideration of the options and recommendations.

All members of the team were available to individuals and stakeholders to submit feedback and a dedicated email address, isareview@hse.ie was established to facilitate ease of access and to ensure that feedback was captured appropriately. In addition, a number of focused sessions with senior representatives from a number of ISAs – the Mid West, Kerry, Carlow/ Kilkenny / South Tipperary and Waterford / Wexford and Dublin were held to “road test” emerging thinking and proposals.

2.4.2

Literature Review & Research

The project team reviewed a range of current documentation and thinking in respect of the organisation of Community Healthcare Organisations and the delivery of integrated care. This included considerable work previously undertaken in mapping PCTs and Health & Social Care Networks (HSCNs) and primary and secondary care referral pathways. To complement this process, a Review of International Experience from the Literature was carried out under the auspices of the Institute of Public Administration on behalf of the project team. The work was undertaken by Dr. Katherine Gavin, Healthcare Management Consultant and IPA Associate. The Department of Health also provided the project team with insight into the research undertaken by the Health Research Board on integrated care and related issues and advice on emerging thinking with regard to the implementation of a UHI model in Ireland.

2.4.3

Questionnaire

A critical part of the work undertaken by the project team was to review the existing management and governance structures in the 17 Integrated Service Areas (ISAs). In order to assist the project team with this task a survey questionnaire, comprising of 6 sections with 12 questions was issued to all 17 ISAs. The returns from the questionnaire coupled with the consultation process that involved each ISA management team assisted in an analysis of the existing management and governance structures.

2.5

Summary

Having considered all of the inputs as outlined above, the options and associated recommendations put forward in this report represent the judgement of the project team on the most suitable approach to developing a health and social care services model in Ireland. The recommendations take into account the phased transition from the current system to a full UHI model in line with the policy direction outlined in Future Health.

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3. Evolution of Recent Structures 3.1

Introduction

The organisational structure and management of the health service remained fairly static over 35 years following the establishment of the Health Boards in 1971 arising from the enactment of the 1970 Health Act. The establishment of the HSE in 2005 marked the commencement of a significant period of change for the health system in Ireland during which the organisational management structures have changed on a number of occasions. The organisation is now moving into the post HSE era in line with Government Policy as outlined in Future Health. This is characterised through the establishment of the Health Service Directorate, the move towards a Purchaser / Provider Split and a commissioning model, and with the establishment of Hospital Groups requiring proposals to be developed for Community Healthcare Organisations.

In this context of changing structures over recent years, the project team felt it would be useful to outline briefly how the structures being reviewed have evolved and to reference a number of the core constructs, which have emerged within the health service structures, such as Community Care Areas, Local Health Offices, ISAs and the care group approach to service organisation and delivery to populations within geographic boundaries.

3.2

Health Boards 1971 - 2005

In 1971, responsibility for healthcare moved from the former Local Health Authorities to the Health Boards. They established a basis of provision for largely medicine/surgery and institutional care (acute hospitals and mental health hospitals and elderly hospitals). These were called the Hospitals and Special Hospitals programmes. The Health Boards developed the basis of a fledgling community service through a Community Care programme, comprised of 32 community care areas, which represented defined geographical areas of service delivery. It is this latter programme that became the basis and framework for the provision of a number of frontline services provided by the State to people in their homes and communities.

The European Observatory in their 2009 report referenced how the Irish healthcare system, in its initial phase of development, had been characterised by a high degree of decentralisation with the delegation of service delivery to the Health Boards (and prior to this to the counties). Delegation of planning, management and delivery functions for some specific services were also under the remit of the Health Boards.

As new responsibilities were conferred on the Health Boards in aspects of provision such as disability, child protection, child health, etc. the Community Care programme became larger in its resource structure and increasingly complex in nature. This was accelerated by the introduction of a succession of legislation and Government Policy initiatives in the latter part of the 1980s and throughout the 1990s. With each legislative introduction/amendment or policy direction, came a focus on resource and the three programmes were largely replaced by what was referred to in more recent years as the Care Group approach. The following examples reflect this.

The mental health services began to implement significant change in line with the policy document “Planning for the Future”.

The disability sector saw a number of policy initiatives focused on improving the delivery of services to this care group i.e. the “Needs and Abilities” policy. The Government established a commission in 1993 which reported in 1996 on “The Status of People with Disabilities – A Strategy for Equality”. The report underpinned significant reform and equality legislation, etc. which resulted in a significant refocusing of the models of service delivery to people with a disability.

Since 1988 the Child and Family Services have seen the progression of the Child Care Act 1991 as amended and a resource and policy focus underpinned in part by crisis response articulated in a number of 'inquiries'.

Since the publication of the Primary Care Strategy in 2001, Government policy has placed a strong emphasis on the development of primary care as the cornerstone of the health system, operating as the first point of contact for the public in terms of accessing appropriate and responsive services.

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Many of these and other changes such as in child health were increasingly underscored by a emerging regulatory compliance requirement set out on a statute basis, bringing not only regulation but standards by which the regulatory compliance was measured.

The care group emphasis, as it has evolved, has challenged the structural approaches to service delivery which have sought to ensure the 'rights' and ' needs' of the care group on the one hand, and the necessity for integration both as a means of responding to whole populations and geographic areas on the other.

In terms of reorganising the management and structures to deal with the changing nature of service delivery the Health Boards introduced a model of general management in 1998, which moved away from the Director of Community Care model and established for the first time a general manager, with delegated responsibility for all primary and community services in the “Community Care Area”. It is important to recognise that these Community Care Areas (in many cases) were co-terminous with counties. They were an important building block for the health service in terms of finance, workforce management and service planning. This period also saw the introduction of the Eastern Regional Health Authority (ERHA) in the Dublin region which sought to bring a more co-ordinated approach to the strategic planning and management of services.

The European Observatory noted following publication of the National Health Strategy 2001, that there was a growing perception that the Health Boards had developed services in very different ways, and thus there was a lack of consistency across the country. There was increasing levels of criticism and a growing demand for a national framework and approach to be put in place, to reduce fragmentation and to ensure a coherent and consistent implementation of national policy and resource management. Important in all of this was the sense that the Health Board members were politically appointed, principally made up of local authority councillors. As a result, loyalty to county priorities had a tendency to undermine the implementation of national strategies and priorities, particularly in relation to cancer care and the re-organisation of hospital and other services.

In the course of the implementation of the Health Strategy in 2001 a number of other influencing factors came to bear on the necessity for change including the Hanley report on the reorganisation of the hospital service, the Brennan report on financing of the health service, the Action Plan for People Management to address human resource issues, as well as the Prospectus report on organisation reform. The necessity for statutory regulation and the plan for a Health Information and Quality Authority, as well as a Mental Health Commission were also important influences. The Government of the time decided in 2003, to establish the HSE as a single body responsible for the provision of health care and personal social services in Ireland. The Health Boards were abolished with the majority of their responsibilities and functions transferred to the HSE.

3.3

HSE 2005 – 2009

Within the HSE structure, primary and community services were organised at a national level under a National Director, with responsibility for Primary, Community and Continuing Care (PCCC) Services.

They were divided into thirty-two LHOs within four regions – the LHOs equated to the Community Care Areas in the Health Board system. A local manager was responsible for the delivery of all community services within the geographic area reporting to a regional manager. The four PCCC regions consisted of the West, South, Dublin Mid Leinster and Dublin North East. At national level there were also seven care group managers who focused on policy and operational implementation in respect of primary care, children and families, mental health, disability services, older people, palliative care and social inclusion. These managers together with the four regional managers worked under the national director on a national management team for PCCC. The Local Health Offices were the unit of management and delivery for all services outside of acute hospitals.

An important aspect in the development of the HSE was the intention to secure benefits of scale and effectiveness by standardising business processes in shared services, procurement, etc. Significant work was undertaken in this respect. Management, finance and HR resources were also restructured to enable the implementation of the strategic priorities set by the Government of the time.

While it was recognised as necessary to centralise authority and decision making in order to achieve these objectives, as time progressed there was an increasing sense that the process may have become overly centralised in the sense of a “command and control” model, to the detriment of innovation and responsiveness at local level. A high proportion of decision-making and issues needed escalation to national level for determination. Concurrently there was a growing emphasis on the necessity to develop an integrated model of care, in response to the demand for consistent and standardised delivery of services.

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3.4

HSE 2009 – 2013

In this overall context, a decision was made in 2009 to simplify the organisational structures, to build stronger links between services and more connected team working. The reorganisation was also to commence a process for devolving responsibility for delivering services from national level to the four geographic PCCC regions. This was intended to shorten the distance between the public and those making decisions.

This restructuring involved the establishment of the Integrated Services Directorate, combining the National Hospitals Office and the Primary, Community and Continuing Care Directorate. In addition, four Regional Management Teams, led by a Regional Director of Operations and operating under the direction of the National Director for Performance and Financial Management and the National Director of Reconfiguration were established. The four Regional Directors of Operations were fully accountable and responsible for all local health and social care services.

In 2010 ISAs were created to form a governance structure which encompassed the services of both the Acute Hospitals and the Local Health Offices under one system. These were designed as the response to the need for a structure of integration where Local Health Offices were largely grouped around patient flows to local Acute Hospital in all 17 possible ISAs. The ISA placed the management of all of these services at local level under one structure. The plan envisaged for the full completion of the ISA structure, was impeded by the changed economic circumstances and not fully put into effect.

3.5

Primary Care Strategy Approach

Throughout this change process, since 2001, significant efforts have been made to implement the concept of Primary Care Teams and Health and Social Care Networks envisaged in the Primary Care Strategy 2001 (A New Direction). The intention has been that these teams and networks would form the cornerstone of the system supporting the move away from an over reliance on acute hospital services to a more community based model of service delivery. The strategy defined primary care as being “an approach to care that includes a range of services designed to keep people well, from promotion of health and screening for disease to assessment, diagnosis, treatment and rehabilitation as well as personal social services. The services provide first-level contact that is fully accessible by self-referral and a strong emphasis on working with communities and individuals to improve their health and social well-being�.

The general principles underpinning primary care services include: x a single point of entry with clear joined up integrated pathways of health and social care; x universal services, locally available, community focused and easily accessible; x a holistic approach that follows the individual/family/community over the whole life cycle; x a whole population approach - organising and delivering services around the changing needs of individuals/families/communities and a focus on identified needs of the local defined population.

The objective of primary care services is to improve the health of the population by providing local access to multi-disciplinary Primary Care Teams and collaborating with specialised services to provide responsive and integrated care, achieved through: x health and personal social care personnel working collaboratively in a multidisciplinary environment; x working collaboratively with local communities; x identifying and addressing local needs based on local needs assessment; x identifying and working towards removing health inequalities; x improving access to services; x improving performance through national care standards and development of good quality information systems.

Primary Care Teams and Health and Social Care Networks were envisaged as the vehicles through which the strategy would be implemented and set out below are the details in relation to same:

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Primary Care Teams (PCTs) Primary care was to be centred on the needs of individuals and groups of people to match their needs with the competencies required to meet them. A group of primary care providers would come together to form an inter-disciplinary team known as the Primary Care Team. The teams would serve small population groups of approximately 3,000 – 7,000 people depending on whether a team was in a rural or urban setting.

Health & Social Care Networks (HSCNs) It was envisaged that a wider network of health and social care professionals would be formed who would work with a number of primary care teams. Members of the network would work with more than one primary care team.

Fundamental to each change which has taken place since 2005 has been the intention to put primary care and the related network of services at the centre of health service provision. This is to ensure that these are linked effectively to the specialised services in mental health and social care, while at the same time ensuring streamlined and appropriate access to, and early discharge from, acute hospital services. The clear intention has been to develop a model which would move the Irish system away from an overly hospital centric focus, to one which is centred around the individual, their families and local communities.

With the development of LHOs and subsequently ISAs, serious efforts were made to develop an integrated approach to service delivery which sought to deliver as many services as possible through PCTs and HSCNs. Consultation and discussion took place with HSE professionals at local level, as well as GPs and their representatives to develop and agree a framework for the management and governance of the primary care teams and networks within the system. Notwithstanding the efforts of all involved, we have not been successful over the intervening twelve years in systematically implementing the model in a comprehensive and consistent way across the country.

Report to HSE Board 2011 Given the challenges involved, the matter was considered by the HSE Board in 2011 and the following challenges identified as barriers to implementation; x x x x x x x x x x x x x

Competing demands on existing staff with many teams indicating that they are not adequately resourced and trained Staff difficulty moving from a traditional hierarchy to a more collaborative style Lack of co-located team members Issues with engagement and participation by GPs and HSE staff Organisation and governance/management structures in primary care are weak and much less developed than those in hospitals Lack of administration support, ICT infrastructure, and suitable accommodation Health system overly oriented towards acute hospitals Lack of access to specialist consultants and diagnostic services Need for a new GP contract Issues with legislation in relation to eligibility Provision of chronic disease management in the community Reactive rather than proactive approach Insufficient performance metrics.

Questionnaire – Analysis of Existing Structures at ISA Level In order to establish the current position in respect of the existing management and governance structures at ISA level a survey questionnaire, comprising of 6 sections with 12 questions was issued to all 17 ISAs. The returns from the questionnaire coupled with the consultation process that involved each ISA management team assisted in an analysis of the existing management and governance structures. (Appendix C) The 6 areas covered by the questionnaire were as follows: x

ISA Management and Governance;

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x

Primary Care Teams (PCTs);

x

Health and Social Care Networks (HSCNs);

x

Management and Governance; Mental Health Services

x

Management and Governance; Older People Services

x

Management and Governance; Disability Services

Overlaid on all of these was a focus on the implementation of a population health approach which is intended to maximise the health and wellbeing of the population.

All 17 ISAs responded to the survey with varying levels of detail provided across the range of questions posed. Based on the responses the following summarises the key findings: x While all of the ISAs provide, in broad terms, the same range of services across care groups and different settings no two ISAs have the same management and governance arrangements. x In each ISA the Area Manager leads the Area Management Team but there is huge variance in the sizes, composition and range of disciplines involved in the Area Management Teams across the 17 ISAs. While many of the management functions are similar in the ISAs the management grading structures are inconsistent across the country. In many areas the General Manager / Operational Manager has excessive numbers of managers directly reporting to her/him (on average 25 and up to 40). There are varied arrangements in place for the provision of support services, e.g. Finance, HR and Estates. Clinical representation on Area Management Teams is very varied with no clinician having responsibility for services beyond their professional domain.

While each area has an Executive Clinical Director for mental health services there are no corresponding roles or standard structures in other services such as primary care, older persons and disability Services. Some ISAs have provided unique approaches to resolving the crossdiscipline managerial challenges. While there is strong evidence of good collaborative working arrangements the management structures in place do not facilitate optimal integrated working. x Particular attention is given to assuring quality and patient safety within the ISAs and all have a Quality and Risk Committee in place to support the ISA management teams. Some ISAs have a large number of committees in place which places an obvious resource burden on local managers and clinicians. x There is strong evidence that individual care group management structures are still very much in place across most ISAs reflecting historical funding and management arrangements. The specialised services of disability, mental health and older people services have more defined management structures in many ISAs with single managers being accountable for services for these specific care groups. Without having well defined and standardised models of care and related care pathways, protocols and procedures it has been difficult to effectively integrate these specialised programmes within primary care and between community services and the acute hospital services. x While Health and Social Care Networks have been developed to varying degrees there is no HSCN in the country operating as a managed network with all services managed by one manager. x Primary care teams are generally self-managed, with a rotating chairman and actively supported by primary care managerial staff, sometimes in a mentoring role. In the main, clinical staff report through their professional line. x Most ISAs have progressed mental health management structures in line with Vision for Change.

The learning from this chapter has been considered by the project team in conjunction with the learning from Chapter 4 and a combined summary is set out at the end of Chapter 4.

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4. Consultation 4.1

Introduction

An important element of the overall approach to the ISA Review was to undertake a comprehensive process of consultation and dialogue with stakeholders, while being mindful of international experience and learning, along with the overall direction set by Government in Future Health: x

Map out appropriate successor bodies and related geographic areas for primary care and community services

x

Bring forward proposals for appropriate governance models at area and sub-area levels

x

Ensure the model supports the direction of travel towards a UHI environment

A real and candid engagement was adopted by the project team throughout the consultation process, and comments, feedback and submissions (formal and informal) on all aspects of the review were encouraged and welcomed by the team. Engagements took the form of a presentation which set out the context of the reform programme, an overview of the current ISAs and scope and approach to the project, followed by a structured engagement and open discussion. All members of the team were available to individuals and stakeholders to submit feedback and a dedicated email address, isareview@hse.ie was established to facilitate ease of access and to ensure that feedback was captured appropriately.

The project team used 3 key questions to frame the discussions, x What criteria should be used in deciding on successor bodies? x What would you take with you – what would you leave behind? x What governance and management structure is required to deliver community services in the successor structures at area and sub-area levels that best serves our people?

The consultation was designed to capture experiences of the current structures, how effective or not they are, challenges around implementing change and opportunities for improvement in the context of the Community Healthcare Organisations. As the consultation / engagement process progressed, the project team ensured that all submissions were considered equally during the entire process. A process of consultation was arranged with a wide range of internal and external stakeholders who proactively engaged and made submissions to the project team. Appendix B

4.2

Phase 1 – Consultation Workshops ISA Teams

The first phase of the consultation took place between the 3rd and the 17th of July, 2013 during which the project team held an ISA specific workshop, for each of the 17 ISAs. In all, a total of 600 people participated in this process, encompassing a broad range of multidisciplinary professionals, support services, management and care staff reflective of the services provided in the ISA including representatives from the acute service, general practice, etc. The feedback from these sessions was captured in real time recording during the sessions and a brief summary of the emerging themes and issues are set out below: x

What criteria should be used in deciding on successor bodies?

Those attending the consultation workshops placed a significant focus on this question, in relation to the criteria to be used to determine the number and scale of Community Healthcare Organisations.

The feedback identified 41 themes of which 24 could be said to be criteria. The remaining 17 referred to a number of embedded outcomes participants would like to see from the new structures such as value, integrity and culture. They reflect the positive values that healthcare professionals aspire to and want to identify within any new organisation construct. Integration, access, population (number, demography and density), Hospital Groups, local authorities and geography were the themes recurring most frequently. These are reflected in chapter 6 in the context of identification of the number of Community Healthcare Organisations.

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The establishment of the Hospital Groups and the emphasis or importance to be given to these planned structures in determining the community structures, was considered at each session. While a strong emphasis was placed on the need to have regard to Hospital Groups, the clear message from a range of clinicians and professionals was that it was not necessary for the Community Healthcare Organisations to be defined by them. The view was that with appropriate and agreed referral and clinical pathways and models of care that patients could travel smoothly through services and the system. A particular emphasis was placed on the relationship and interface between primary care services and the local hospital providing secondary care, rather than on an alignment with a particular Hospital Group.

The key criteria identified during the workshops, to be considered in the approach to designing a Community Healthcare Organisation are summarised below:

o

Integration - this is both a disposition or behaviour on the one hand but also a structural requirement on the other. Capacity for internal integration between services and external integration in the health context with the new Hospital Groups and further with local authorities/other public services is an identified requirement of the new structure

o

Access - Community Healthcare Organisations must facilitate not only ease of access but place a strong emphasis on progressing towards equity of access.

o

Population - not only the actual size but also factors such as demography, multi-cultural make up, deprivation and natural 'flows' of people to services must be taken into account.

o

Geography - the history, size, urban and rural factors, local identity, importance of County for communities and that which "makes sense" must also be incorporated.

o

Local Authorities - many community services provided by the HSE, particularly in the personal social service category, have strong links with local authority services and a range of other statutory and voluntary agencies. It was recommended throughout the consultation that where possible, in identifying Community Healthcare Organisations, that the crossing of local authority boundaries should be avoided.

The foregoing criteria were the most emphasised in the engagements and featured in practically all discussion. They reflect a number of the criteria identified in literature as being important and relevant for consideration in the determination of Community Healthcare Organisations. These criteria, in addition to feedback received during other consultations and written submissions received were used to arrive at the design criteria for Community Healthcare Organisations as set out in Chapter 6.

x

What would you take with you?

The second question was selected by the project team based on the widely acknowledged view that there are many aspects of the current structures and systems which are working well. It would be prudent to ascertain what elements are considered to be functioning well and also to elicit which aspects should be amended or dropped altogether. It was also important in this question to establish the reasons for retention or amendment of particular elements. It also highlighted the requirement to ensure, in as far as possible, that the Community Healthcare Organisations do not impact negatively on existing positive service delivery models and user outcomes. The positive characteristics identified were relatively common to most engagements.

o

Integration - the ISA model had resulted in an improved relationship between primary and secondary care services. The establishment of the initial two Hospital Groups has demonstrated that while there were challenges to integration, it is still feasible. Integration in community services within the existing ISAs was described positively and necessary to be maintained as the new national Divisions develop.

o

Clarity of Roles - The ISA Manager position was identified as having been a positive experience, particularly in having a senior manager to decide on priorities or points of conflict that arose in respect of the various care groups within the community or between the community and hospital services. It was felt that it was necessary to ensure that in the Community Healthcare Organisations there is clarity of role and function on a similar basis to ensure effective and responsive decision making.

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x

o

Primary Care Teams and Health and Social Care Networks Ͳ The work and progress of recent years towards realising the concepts enunciated in the Primary Care Strategy, particularly in the recent challenging economic environment, was acknowledged. The new structures would have to address the exact role and definition of primary care and prescribe a practical management and governance structure. The absence of this to date was viewed as a strong disadvantage and impediment to implementing the strategy. The consultation clearly identified the need for a robust primary care management structure to be a priority in the establishment of the Community Healthcare Organisations. This is borne out in the assessment by the former HSE Board as to the challenges in progressing primary care without clarity of governance.

o

Formal Frameworks and Existing Relationships Ͳ Significant emphasis was placed on the current formal and informal relationships that exist between ISAs and a range of other service providers and agencies. Positive benefits accrue when these relationships are developed with other statutory providers to NGOs, advocacy groups and the political public representative system and the wider public.

o

Local Autonomy Ͳ Some instances of local autonomy were highlighted as being positive in enabling a timely responsive service. Local autonomy, when it was evident, was experienced as a positive characteristic. However, it was indicated as being insufficiently prevalent and limited in scope to make a marked difference. It would be necessary for any new structure to be able to set out national direction and standards and also facilitate local autonomy to respond to the local environment.

o

National Direction and Frameworks – It was acknowledged by most participants that the system required a strong national direction and comprehensive national frameworks and agreed models of care for each care group to govern the implementation of services at local level. The sense was that the balance was not yet right between achieving this national requirement and supporting local autonomy and innovation in the implementation of models of care and delivery of local services.

o

Clinical Governance / Management - There has been a clear trajectory towards improving clinical governance.

However, encouraging clinicians to have formal roles in corporate governance and management was viewed as a critical component in any new structures.

What would you leave behind?

Contributions also focused on current system deficits and the need to address these. o

In this context many participants noted the absence of suitable integrated ICT systems and commensurate infrastructure necessary for a modern day health system. An ICT system is needed which would incorporate a patient management system providing timely performance data and outcome measurement, with a unique client identifier.

It was recognised that substantial investment would be required in implementing significant baseline ICT systems. However, there was a clear request also that these large scale national projects should not prevent shorter term smaller ICT projects being implemented which could support the local implementation of significant change programmes in parallel with the implementation of the large national projects.

o

The absence of an appropriate ICT system contributes in part to another characteristic that many would like to see an end to – information request overload. The repeated demands of various national systems for information were viewed as more excessive, repetitive and demanding of resources than necessary.

o

Disparity remains a feature of services and eligibility criteria in relation to access is not standardised for a large number of services.

o

The feedback highlighted that as a result of the economic downturn and associated moratorium the recruitment process had become overcomplicated and as a result it had caused significant difficulties locally. A speedy decision making process is necessary at all levels to support the recruitment of priority agreed posts.

o

Formal education and the informal systems of mentoring and developing leadership / management skills were viewed as a critical aspect, which due to a number of factors including the economic environment, have been under-resourced over recent years. The

26

moratorium coupled with the various exit schemes had contributed to a loss of 'corporate knowledge' but also the traditional systems of identifying and developing local management capacity. An important issue that requires to be addressed is that the future will be dependent on dealing with this challenge through leadership development and succession planning. x

What community management arrangements are required to deliver services in the new bodies – area and sub-area?

This focused on a number of key areas within the Community Healthcare Organisations. In particular how the issue of primary care teams and networks could be resolved in a practical and implementable way while also addressing the requirement of mental health and social care. In addition to these discussions at sub-area level, there was also detailed discussion on the senior management team level envisaged for the successor bodies. o

Primary Care Team Level – An effective management and governance structure for Primary Care Teams has not been successfully implemented in a comprehensive and consistent way and this has resulted in challenges around the implementation of the Primary Care Strategy.

The PCTs to date have no recognised management or leadership structure. It was identified in consultations, that any new structure needed to recognise the PCT as the core services building block and that this critical block needed an appropriate support, leadership and management structure. The structure needs to deal with the PCT co-ordination requirements and facilitate the PCT to deal with complex cases. Key Worker functions were identified as having significant potential in contributing to a system that supports the co-ordination of complex cases needing input from different professionals. GP involvement was identified as a key requirement, which must be addressed contractually and in structural terms.

o

Primary Care Network Level The consultations unanimously proposed that a Network needed to be a multiple of PCTs, with its own management and governance structure and clarity of relationship with the structures of specialised services from the perspective of integration. Each Network in having a manager would take 'ownership' of its population, have increasing levels of earned autonomy in relation to budgetary and human resource control and responsibility for enabling access of that network population to other specialised services..

It is necessary for the span of control of the Network Manager to be clarified. The Network Manager needs to have full management responsibility and authority for the primary care services within the network. Significant discussion took place on the possibility of this, given the clinical requirements of the various disciplines in primary care and the standards and governance requirements underpinning them.

Throughout the discussions, the importance of direct GP involvement was emphasised, particularly the need to develop mechanisms for effective participation of GPs within the governance and management structure of the system to ensure effective implementation of the reform programme envisaged for primary care.

Scale and size of Network was an important feature in the context of Network Management and span of control challenges.

In discussing the management and governance options and issues it was noted in the consultation that in some cases the PCT was strong and identifiable as originally mapped. In others, such as large county towns, it made sense to focus more exclusively on the Network.

In recognising the PCT and Network as the building blocks this flexibility was strongly requested for the future based on 'what makes sense'.

o

Successor Body (Top Team) Level Ͳ The consultation emphasised the need for the organisations to succeed the ISA as needing to be comparable with the Hospital Groups.

This would assist with the objective of moving from a hospital centric system of care. The size would have to be significant from an economy of scale perspective to support a management architecture and clinical leadership team, together with the necessary ICT, Estate and other support functions. However, it should also be of a scale which can connect

27

with local communities and develop productive relationships within the health service and between the health service and other public sector organisations, community and other voluntary groups.

The Networks and their management systems would need to build up into an organisation of multiple Networks, with specialised services and be managed at that organisational level with sub-structures appropriate to the requirement of size or complexity.

The new organisation at its top level needs to be fit for purpose, reflective of function in order to discharge business requirements.

Possible roles suggested by people for such a top level included; CEO (Chief Executive Officer), COO (Chief Operations Officer), CFO (Chief Financial Officer) GP Clinical Director, Chief Nursing Officer, Mental Health Executive Clinical Director, Quality and Patient Safety Manager, HR Manager, Communications Manager.

There should be arrangements to ensure that services are informed by user representatives.

Arrangements should be in place to ensure that there is structured engagement with the acute hospitals.

At senior management team level of the new Community Healthcare Organisation, the skill set needs to be strategic and reflective of the clinical complexity of the new entity and members should have the professionalism and experience to manage a large organisation.

Most common to the consultation was that management structures at all levels need to be appropriately designed.

In general it was felt that the Community Healthcare Organisations, in terms of overall governance, should follow a similar path to the Hospital Groups with the organisations initially established on an administrative basis. In the context of reorganisation of acute services into hospital groups, there emerged an inferred expectation within the system that any revised structures of Community Healthcare Organisations would also see them established as legal entities in due course, similar to the potential that exists for the hospital groups. Many of those providing feedback assumed that there would be a requirement for the establishment of a board, similar to that envisaged for the Hospital Groups. Where such views were expressed, it was felt that the membership of such a board, if developed, should be determined based on the competencies required for effective governance which should include appropriate representation from local communities. In addition it was felt, to ensure effective integration, that a board member with a hospital perspective would be beneficial.

Consultation was also conducted at national level in the service with the project team meeting a number of contributors. These included the recently established five new service Divisions (Mental Health, Social Care, Acute Services, Primary Care, Health and Wellbeing). In addition the project team engaged with the emerging Child and Family Agency. The wider Leadership Team of the HSE were consulted with collectively in a formal engagement, with follow up meetings and engagement as necessary. There was widespread support for many of the selection criteria put forward in the ISA consultations and significant input into the draft deliberations of the project team on both the new structures and options for Government on the layout and number of new organisations.

4.3

Phase 2 – Consultation with Internal and External Stakeholders

Outside of the acute hospital system there is a wide range of interested parties associated with various aspects of the delivery of health services. This is reflective of the varied and complex range of services provided to communities across all of the different care groups. A cohort of internal and external stakeholders were identified to take part in the consultation, along with a number of stakeholders who contacted the project team, and they proactively engaged and made submissions to the project team. Appendix B In addition to their representative contribution, they provided an interesting perspective which was external to the HSE. Whether the consultation was with a service provider, an umbrella organisation for providers, an advocacy/lobby group or a professional association, they all gave generously and enthusiastically of their time. The project team noted that many participants from different disciplines

28

and organisations expressed common views. Stakeholders were also invited to make written or further submission. The key points are summarised as follows;

x x

Safe and quality based care is the greatest priority.

International and national best practice guidelines need to be evident in the services provided by the structures

x

Client terminology (patient, user, client) needs to be more considered in the context of the specific service being provided.

x x

Integration defined by clear, understandable and simple pathways is critical.

x x x

External resources need to be used more to enhance service provision and choice.

x x

The Money Follows the Patient model needs consideration as to how it will apply and what will be the means of managing while we are getting there.

Clear achievable goals need to be set.

While there are deficits in communication within and between structures there are some positive examples of good communication at local level.

Discharge planning is a particular pathway that needs improvement.

Decision making authority needs to be clear and local in as much as possible without compromising standards.

x

More sophisticated Service Arrangements / Agreements are necessary to reduce bureaucracy and increase outcome focus.

x x x

Resource allocation methodologies while improved are as yet under developed.

x

Innovation is not facilitated in many aspects of current structures.

The private sector has a role in the commissioning concept and should be exploited to benefit communities.

Appropriate competition is positive in improving standards.

There was also consultation on a cross border basis with Northern Ireland.

4.4

Importance of Community

An essential theme which was threaded through the feedback from the consultation processes, both in the first and second phase, was the importance of fostering the notion of community as a core value underpinning the reorganisation and design of Community Healthcare Organisations delivering health and personal social services across the country.

The health service staff working in the delivery of community services, voluntary sector bodies, GPs, as well as external partners, all emphasised this point to varying degrees. What was emphasised in particular was the importance in Ireland, of enabling local communities to support their own people through the life cycle. Community in this sense related to the wider network of organisations and supports, which are at the heart of local communities, ranging from local voluntary organisations of all kinds, not just in the health sector, farming organisations as well as groups such as the ICA or the GAA and other sporting bodies which span both rural and urban communities. It is in the engagement between these informal networks and the more formal state provided agencies such as the health service, local authorities, community GardaĂ­, local schools, educational institutions, community welfare and other support services, come together in a way that support and enable communities to meet the needs of their people.

A clear message in the consultation was that in designing and shaping the Community Healthcare Organisations, we should ensure that they were organised in a way which would continue to support the development of this holistic approach to community. This would maximise the opportunities of promoting the health and wellbeing of people in the broader sense envisaged in the policy document Healthy Ireland.

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4.5

Summary – Chapters 3 & 4

What’s Important x x x x x x x x

Integrated Care for People and their families Equity of access Choice for people in what services they receive and how they receive them Responsive and flexible services Local Identity Linkages with local communities and public bodies Sustainable cultural and organisational change Delivering high quality and safe services

Areas for improvement x x x x x x x x

Autonomy to deliver services to local populations Engagement with stakeholders, advocacy groups and service users Focus on outcomes Standardise eligibility Evidence based decision making Manpower and recruitment planning ICT and standardised business processes How we collect and manage information about the services we provide

x

Patients need to experience an integrated response in appropriate settings.

x

Organisational structures must be designed to support this.

x

From the international evidence, for integration to be effective, it requires careful and sustained work, learning from progress and not undertaking too much change or too complex a range of services at any one time. When these issues are taken collectively, the project team formed the view that it is of critical importance to provide the necessary clarity around the primary care teams and networks. Effective arrangements need to be put in place to engage with and ensure participation by GPs, whose involvement is fundamental if the Community Healthcare Organisations are to be successfully implemented.

x

Governance and management structure for PCTs and Networks is critical as is clarity around arrangements for GP engagement in the process.

x

The importance of integration of the care groups within community services in the first instance i.e. primary care, mental health, social care within an overall Health and Wellbeing population approach and secondly the integration of these services with acute hospitals and other external partners is essential.

x

Overall, at all of the engagements with ISAs there was a clear articulation of the necessity for the development of a structure that suited the need of the “community services”. This encompasses the full breadth of primary care and health and personal social services, taking on board the wider determinants of the health status of the population. It also needs collaboration across the key sectors, e.g. local authorities, Child & Family Agency, education, Gardaí, social protection, etc.

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5. Integrated Care – Research and Learning 5.1

Introduction

In outlining the overall policy underpinning the reform programme, Future Health emphasises important research and learning from the international literature. Future Health goes on to say: “while the reform of individual elements of the service will be informed by the experience of other countries and best practice, the system as a whole will be uniquely Irish. Our goal is not simply to copy other health systems but instead to learn from what works best elsewhere.

This will help us to design a truly Irish model of healthcare which meets the needs and requirements of the Irish people.”

In this context, the project team was conscious in undertaking this review, not only to take on board the learning and experiences from other countries, but also to listen to the inputs and experiences of those who took part in the consultation process. Those involved provided important insights and relayed their experience of how services and structures operated as they were delivered on the ground and what is required to improve how people experience them.

Future Health emphasises the emerging importance in the international literature of integrated care and it is useful to reiterate some of the key points identified in Future Health as follows:

5.2

What is Integrated Care

It is clear from international literature as well as from policy discussion in Ireland that integrated care means different things to different people. Integrated care, as set out in Future Health, can be defined as care that x

improves the quality and outcome of care for patients and their immediate families and carers by o ensuring that needs are measured and understood and that o services are well co-ordinated around these assessed needs.

x

It is preventative, enabling, anticipatory, planned, well-coordinated and evaluated.

x

It is a system of care that critically looks at the impact on health and wellbeing of the patients concerned.

Understanding integrated care means looking at processes and outcomes of care rather than at structural and organisation issues. Achieving integrated care means that services must be planned and delivered with the patient’s needs and wishes as the organising principle.

It is preferable that the term “integrated care” rather than “integration” be used so that it is clear that the focus is where it should be i.e. on people and families and the services they need rather than on funding systems, organisation or professionals. Each of these will be important levers in enabling and facilitating integrated care – but they in themselves are not the objectives.

International research on integrated care shows three things very clearly: x

It can make a real difference to the quality of care received by patients: The danger of a fragmented delivery system is that individuals’ needs will not be fully met, substantially reducing patient outcomes.

x

It is very difficult to turn the concept of integrated care into a cost effective operational reality. One of the main challenges is to target the right individuals and conditions. For instance, it is clear that case management must be a crucial part of integrated care. However, because case management is a labour intensive activity it is unlikely to be cost effective unless it is targeted effectively.

x

There are many ways to implement integrated care: Crucially organisational integration is not necessarily required. The key requirement is clinical and service level integration, supported by an appropriate incentives system.

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5.3

Enabling Integrated Care – Irish Context

The Kings Fund and the Nuffield Trust identified ten key elements to enabling integrated care as follows: x x x x x

x

Provide a compelling and supporting narrative for integrated care; Allow innovations in integrated care to embed; Align financial incentives by allowing commissioners flexibility in the use of tariffs and other contract currencies; Support commissioners in the development of new types of contracts with providers; Allow providers to take on financial risks and innovate;

x x x x

Develop system governance and accountability arrangements that support integrated care, based on a single outcomes framework; Ensure clarity on the interpretation of competition and integration rules; Set out a more nuanced interpretation of patient choice; Support programmes for leadership and organisational development; Evaluate the impact of integrated care.

The final conclusions from Kings Fund and Nuffield Trust can be translated to an Irish context as follows: x

Government policy should be founded on a clear, ambitious and measurable goal to improve the experience of patients and service users and to be delivered by a defined date.

x

Setting an ambitious goal to improve patient experience should be reinforced by enhanced guarantees to patients with complex needs. These guarantees would include an entitlement to an agreed care plan, a named case manager responsible for co-ordinating care, and access to telehealth and telecare and a personal health budget where appropriate.

x

Change must be implemented at scale and pace. This will require work across large populations at a city and county-wide level. There should be flexibility to take forward different approaches in different areas and to evaluate the impact, with the emphasis being on people with complex needs.

The project team, in developing proposals for Community Healthcare Organisations which will have relied significantly on this overall policy direction outlined in Future Health.

The project team has also been cognisant of the importance of community within the Irish context, particularly the importance in Ireland of enabling local communities to support their own people through the life cycle. Community in this sense involves a significant network of voluntary organisations and supports. It is in the engagement between these informal networks and the more formal state-provided services that real partnership is developed and sustained and through which people come together in a way that supports and enables communities to meet local needs.

The project team recognises the challenges involved in integrating care within the community i.e. primary care and the specialised services in social care and mental health, and also between hospital and community services, while at the same time supporting productive relationships with other key sectors such as local authorities, education etc.

However, it was felt that given the importance identified by Future Health around this whole issue of integrated care (as summarised above), that further analysis of this issue was important in finalising the project team’s consideration of Community Healthcare Organisations and associated governance and management arrangements.

To complement this process, a Review of International Experience from the Literature was carried out under the auspices of the Institute of Public Administration on behalf of the project team. The work was undertaken by Dr Katherine Gavin, Healthcare Management Consultant and IPA Associate. With the assistance and support of the Department of Health the project team also had insight into the research undertaken by the Health Research Board on integrated care and related issues and advice on emerging thinking with regard to the implementation of an UHI model in Ireland.

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5.4

Summary of Key Themes and Learning from International Experience of Integrated Care

The output from the international review undertaken by Dr Gavin is attached (Appendix D) and outlined below is a summary of the key themes and learning from the review of international experience from the literature:

It’s introduction is challenging for professionals Culture change

Strong governance & accountability

Journey Cant be achieved in totality in one go - must be phased

Integrated Care Learning

Change process must be supported Leadership

One model & approach does not fit all

Must focus on programmes of care Unique client identifier

Service user involvement

Standardized processes are critical

•

Integrated Care is a journey; even countries recognised as having made significant advances in the area of Integrated Care have been working on the concept for two decades or longer.

•

One size and approach to Integrated Healthcare does not fit all circumstances

•

•

o

Successful integration has followed different paths and approaches in different healthcare systems

o

It is important to be cognisant of the local context, and inherent challenges

It is neither possible nor advisable to attempt to introduce Integrated Care across all areas in one step. A number of countries have adopted a pilot type approach introducing integrated care in pockets of service with a view to expansion e.g. o

Health pathways in Canterbury DHB integrating care around disease states/conditions

o

Care Programmes in elderly care and mental health in Northern Ireland

o

Persuing Perfection in Jönköping Sweden for childhood asthma

Focus on the patient need and journey through the healthcare continuum rather than focusing on the service providers perspective e.g. Mrs Smith (Torbay) and Esther (Jönköping Sweden) o

A named person to co-ordinate patient care

o

Single point of patient contact, co-ordinating care across the continuum

o

Focus on collaboration between health and social services and acute and community sectors rather than competition- CQI in patient care

o

Care in Community wherever possible- shift focus from acute sector

!

33

!

x

x

Leadership o

Strong leadership from the top and at various levels in the process-consider leadership development

o

Buy in from clinicians is essential-clinicians to act as leaders

o

Political commitment

A firm foundation o

A robust primary care system acts as a firm foundation for integrated Care

o

A history of successful collaboration between health and social care may facilitate further integration

o

Structural and organisational stability facilitates the change

x

Synergy regarding drivers for integration is advisable e.g. National Policies support local initiatives, legislation, policy and structures facilitate the process

x

Staff

x

o

Must be included in the decision making process

o

Must be enabled and supported throughout the process

o

Must be trained in the knowledge and skills required to make integration a success. Systems thinking approach may be beneficial

o

Commitment of staff necessary for success

o

Multidisciplinary/Interdisciplinary staff training and development-can help break down barriers and smooth cultural differences and facilitate a unified approach to patient care

Governance o

Representatives from community health and patient on the governing bodies

x

A clear vision regarding the purpose and outcome of integrated care is essential and this needs to be communicated to all stakeholders

x

Capturing robust evidence of improved healthcare outcomes as a result of integration is important o

Recognise difficulties around definition of Integrated Care. Is it primary and secondary, primary, secondary and community any or all of these with social care? Important to define what to measure.

o

Performance Management Systems are important to capture meaningful data on improvements in patient care and efficiency/cost savings.

x

Information Technology plays a key role in communicating and sharing information regarding patients within the system, avoiding duplication, etc. and in evaluating the impact of any changes in outcomes by capturing data.

x

Funding o

A unified health and social care system with a unified budget

o

Flexible sustainable financial mechanisms - enable funding to follow the patient

o

Provide a system of shared resources and mutual accountability for Service delivery and patient outcome

x

Introduce incentives and remove disincentives where possible

x

Accountability o

Be clear on roles and responsibility of all team members. Have a clear line of accountability

o

All providers need to understand what aspect of care they are responsible for and develop and agree protocols for how care is to be delivered. Regular communication between team members is essential. Different systems appear to have different systems of Accountability

34

5.5

In Canterbury New Zealand, responsibility for operational and management duties are delegated to the CEO of the Health Board. The CEO has an executive team. A clinical board provides clinical leadership and clinical governance.

Joint accountability from providers of services for outcomes is proposed to be a factor in enabling integrated care in Scotland (Ham et al 2013).

A named Non-healthcare) person co-ordinates a patient’s care in Torbay trust. It is not clear if the co-ordinator is accountable for patient care

Guiding Principles for Delivery of Integrated Care

International research identifies that the delivery of integrated care has been achieved through a focus on a combination of many, if not all, of the ten guiding principles outlined below. The delivery of integrated care has been more successful where, not only have the ten principles been adopted, but resources have also been allocated to the development of processes and strategies that support implementation of these guiding principles. x

x

x

x

x

x

x

x

Comprehensive services across the care continuum o

Cooperation between health and social care organisations;

o

Access to care continuum with multiple points of access;

o

Emphasis on wellness, health promotion and primary care.

Patient or population focus o

Patient-centred philosophy focusing on patients’ needs;

o

Patient engagement and participation;

o

Population-based needs assessment focusing on defined population.

Geographic coverage and rostering o

Maximise patient accessibility and minimise duplication of services;

o

Roster: responsibility for identified population and recognising the right of patient to choose and exit.

Standardised care delivery through inter-professional teams o

Inter-professional teams across the continuum of care;

o

Provider-developed evidence-based care guidelines and protocols to enforce one standard of care regardless of where patients are treated or who is treating them.

Performance management o

Demonstrates commitment to quality of services, evaluation and continuous care improvement;

o

Clinical diagnosis, treatment and care interventions linked to evidence-based outcomes.

Comprehensive Information systems o

Modern information systems to collect, track and report activities;

o

Efficient information systems that enhance communication and information flow across the continuum of care.

Organisational culture and leadership value collaboration o

Organisational support with demonstration of commitment;

o

Leaders with vision who are able to instil a strong, cohesive culture.

Physician integration o

Recognised that physicians are the gateway to integrated healthcare delivery systems;

o

Are the single-point-of-entry and using a universal electronic patient record;

o

Engaged in leading role through participation on Board and to promote buy-in.

35

x

x

Adequate governance structure o

Strong, focused, diverse governance representing comprehensive membership from all stakeholder groups;

o

Organisational structure that promotes coordination across settings and levels of care.

Financial management o

Alignment of service funding ensuring equitable funding distribution for different services or levels of services;

o

Funding mechanisms promotes interprofessional teamwork and health promotion;

o

Sufficient funding ensuring adequate resources for sustainable change.

5.6

Guiding Principles of Good Governance

As set out in Appendix E international research identifies a number of core principles of good governance which should be considered in the development of organisational and structural arrangements. It is necessary for organisations to; x x x x x x

have clear purpose and outcomes have appropriate capacity and capability to govern effectively engage effectively with stakeholder and be accountable to them perform effectively in relation to defined functions and roles promote values for the whole organisation ensure that decisions are informed, transparent and that risks are managed appropriately.

In the public sector, to assist in ensuring that good governance is in place, organisations must clearly define their outcomes in terms of sustainable economic, social and environmental benefits and determine the interventions necessary to optimise the achievement of those outcomes. To deliver on these outcomes and implement the interventions, the necessary leadership capacity must be developed. In order, to appropriately manage risks and performance a robust internal control and financial management environment must be established, with transparent reporting to deliver effective accountability In the context of health and social care systems, the importance of appropriate clinical governance, involving continuously monitoring and improvement of the quality of services, is acknowledged as a fundamental requirement. The benefits of clinical governance rest in improving patient experiences and better health outcomes in terms of quality and safety and has been widely adopted internationally. A particularly important component of clinical governance is clinical supervision, which can be defined as “the formal process of professional support and learning that addresses practitioner’s development needs in a non – judgemental way”. This enables practitioners to deliver an appropriate standard of care and to keep abreast of developments in care.

5.7

Linking Learning from Research, Consultation and Experience of Change to Date

It is the considered view of the project team that it is not possible to deliver integrated care in the way intended, across an individual care group or between care groups, given the current service delivery structures and absence of standardised processes or agreed outcomes of care. International evidence advises that it is neither possible nor advisable to attempt to introduce integrated care across all area in one step. A number of counties have adopted a pilot type approach, introducing integrated care in pockets of service with a view to expansion. The learning and experience of other countries advises us that the introduction of sustainable integrated care is successful when its introduction is on a phased and planned basis, and when it is targeted on pathways and models of care.

The commitment and supports required, as well as the timelines involved in successful implementation of a sustainable model of integrated care is illustrated in the work undertaken in Scotland around Managed Clinical Networks (App G). This illustrates the scale of what was involved

36

in the Scottish context in establishing a project and commencing implementation (see Appendix G).

From this we can see that within the framework in Scotland it takes a full 12 months to simply put the project plan in place to establish a Managed Clinical Network, and perhaps 18 – 24 months to begin to successfully implement and gain traction from the initiative. This illustrates the scale of work involved in implementing this type of change programme and also the level of support that will be required at all levels to enable the clinical and professional capacity as well as management capacity for successful implementation.

While emphasising this point of step by step progress in a managed way towards a fully integrated model of care, it is important to emphasise also the benefit that will accrue from taking the time and effort to standardise the models of care, business and clinical process and care pathways associated with each individual care group such as primary care, social care, mental health and the health and wellbeing approach. By undertaking this work as an important first step in the journey towards integrated care, it will be possible to deliver significant benefits to local communities, patients and service users over an 18-24 month period, in parallel to the work being undertaken on the development of the integrated care approach.

Equally, it is emphasised that having in place a robust primary care system acts as a firm foundation in implementing integrated care. The fact that in Ireland there is a history of successful collaboration between health and social care will support and facilitate further integration. The work that has been undertaken to date in developing primary care in line with the national strategy will also support this objective. What has not been sufficiently progressed however in the Irish context is the development of the necessary framework for standardised models of care and supporting processes or key measures of performance or outcomes. These would enable a progressive step by step achievement of integrated models of care within specialised services, or between the specialised services and primary care over a reasonable period of time.

The development of these standardised models of care and related processes are a critical foundation phase in the journey if services are to be successfully integrated; x x x x

within community health services i.e. primary care, social care, mental health and health and wellbeing between community services and hospital services between the health and social care system and other public authorities in a way that is sustainable and serves local communities.

It will be necessary firstly for each care group (considering acute hospitals a care group in this context) to develop standardised models of care. These will need to incorporate clear business and clinical processes, care pathways and internal and external outcome measures. The learning from abroad is that this work will need to be phased in over a period of time with clear targets and milestones being set, progressively improving the quality and responsiveness of services in each care group, while also moving in a phased way to the implementation of a sustainable and integrated model of care.

We are fortunate in Ireland at this time, that much of the ground work is already underway to deliver such an ambitious reform programme, building on progress through the National Clinical Programmes. We have also established a System Reform Unit which will be an important enabler in supporting the implementation of the change programmes in a coordinated and prioritised way.

Only when the milestones are successfully achieved, will it be possible to move to the next phase of comprehensive integration, across all service delivery settings. Each individual milestone and goal which is achieved will represent a significant improvement in service delivery to local communities and to the experience of people and service users in terms of quality and access to services.

As outlined above, a first key step will be for each care group to undertake a programme of work to standardise the models of care and service delivery, linking resources provided to outcomes delivered and with an appropriate suite of key performance indicators and other measures.

While these programmes are being developed from a care group perspective, they will also need to build in appropriate mechanisms to incentivise integration and set out measures against which successful implementation can be assessed.

37

Health Service Directorate - The recent establishment of the new Health Service Directorate brings a specific focus to each of the care programmes. This, together with the establishment of the System Reform Unit will support the: x

effective programme management of a project of this scale,

x

development of management and clinical leadership and capacity

x

ongoing education, training and development to support the workforce and teams at all levels

x

translation of the learning on an ongoing basis to inform effective implementation.

National Clinical Programmes - The programmes of care (clinical programmes) will be a key component in providing the overall guidance and framework in supporting this approach.

The establishment of these National Clinical Programmes in 2010, involving collaboration between the health service, the Royal Colleges and with the support of HIQA and the Department of Health, provides a strong platform to develop the standardised models of care and processes referred to above. Its role is to develop a national, strategic and co-ordinated approach for the design of clinical service improvement to deliver improved patient care, improved access and better use of resources.

A revised governance and organisation model has been put in place for the programmes, whose objectives include; x

the enablement of an integrated approach to the design of care models particularly as they cross acute services, mental health, primary care, social care and health and wellbeing

x

maintain and enhance clinical leadership as a fundamental building block of reform of patient care

x

align the programmes with other strategically important areas including national performance metrics, patient safety, workforce planning, and ICT and Informatics strategy.

National Clinical Group Lead - A National Clinical Group Lead is being appointed for each of the Divisions, which will embed clinical and professional leadership within the management structures of the new Divisions, providing the necessary support and advice at national, regional and local level.

System Reform Group – The System Reform Unit, established by the Health Service Directorate, will provide an important support to the system in the implementation, project management and assurance of the reform programme of work. It will also provide programme planning and monitoring of the implementation, together with the education and training supports necessary to deliver sustainable change over time.

During each phase of the reconfiguration of specialist community based services and acute hospital led programmes, all changes will need to be proofed against the ultimate goal of delivering an integrated responsive service to people in the most appropriate possible setting which will be within their communities, serviced by their primary care networks.

The project team, in addressing this issue, have considered “what successful implementation of integrated care might look like in an Irish context” - the type of practical benefits that could be delivered from this approach to the development of a standardised care model in Ireland are: x

Home Care and Community Support Services – Re- alignment of the model of care to enable older persons to live independently, in their own homes for as long as possible, with a service improvement programme to ensure standardised delivery of home help and home care packages.

x

Disability Services for Children and Young People (0 -18s) – A national unified approach to delivering a clear pathway to services regardless of where a child lives, the school attended or the nature of the disability or delay.

x

Diabetes – Integrated management of diabetes, alignment of existing primary diabetes care initiatives to nationally agreed model of care.

x

Chronic Obstructive Pulmonary Disease (COPD) - A model of care including guidelines for the management of COPD including spirometry in the primary care setting

x

An over-arching model of care in Mental Health Services, to provide a relatively standard level of basic services regardless of location, focused on recovery and enhancing clinical excellence.

38

The list above is illustrative of the type of programmes that can be successfully rolled out as “early implementers” in this approach to the development of an integrated care model. Such programmes can be the first phase of work as we move towards the development of a comprehensive, fully integrated model over a period of years. This more comprehensive model will require a body of work by each care group to bring their services to a level where integrated care is delivered in a consistent and sustained way.

The following diagram illustrates the phased approach to the development of integrated care models as we progress the implementation of a commissioning framework and create the environment to support a UHI model.

Integrated Care - Phased Development

Integrated Care – Phased Development 2014 2015 2016 2014

2015

Standardized pathways / models of care - roll out early implementers

2016

Development of additional standardized pathways / models of care each care group

Commissioning Framework Commissioning Framew ork

5.8

Integrated Care

UHIModel Model UHI

Summary

The consultation output, the findings from the literature and research review, the input from the project team and wider HSE Leadership Team emphasises the following: x

One size does not fit all and it is not advisable to attempt to undertake a comprehensive integrated care programme across all areas in one step.

x

Our experience to date in seeking to develop ISAs and PCTs / HSCNs and the evidence from the research indicates that in seeking to integrate all aspects of the service in a comprehensive fashion at the one time within the community services, and between the community services and acute hospitals, may have been too large a task. A more simplified, step by step approach needs to be taken to successfully deliver sustainable change in a systematic way across the system.

With hindsight, the tendency has been to speak in terms of integrating “community services” with acute hospital services, as if it can be assumed that community services themselves are sufficiently developed and integrated to effectively integrate with the hospital system.

x

From the analysis of the project team and the feedback from the consultation and research, it is clear that significant work remains to be done within each of the individual care groups that make up “community services” i.e. primary care, mental health and social care to develop standardised models and pathways of care. These models and pathways must encompass the necessary clinical procedures and protocols, business processes and performance measures necessary to deliver comprehensive and effective outcomes to their service users and patients.

x

It is only when this work has been sufficiently developed can the services encompassed by each of these “care groups” effectively integrate with each other in a way which maximises the experience and outcomes for service users. Similarly, the development of such standardised processes will support effective integration between all aspects of community services with the hospital system and external partners e.g. local authority, education, etc.

39

x

The development of standardised models of care and care pathways, etc. are essential to support the UHI environment, including the development of commissioning and the purchaser / provider split.

x

The National Clinical Programmes and the System Reform Unit position the organisation well as it progresses on this journey of change and will provide the necessary leadership, challenge, evaluation and performance assurance to ensure that the milestones along the journey are reached and deliver integrated care.

The diagram below illustrates the central role of primary care, supported by the specialised services of mental health and social care, within a health and wellbeing framework. The interaction between acute hospital services and community services is also depicted. The significance of Primary Care Teams, Network Managers and GP Lead is emphasised, together with the supporting architecture / enablers required to deliver integrated care e.g. clinical programmes, leadership development, System Reform Unit, etc.

Social Care Social Care Local Communities 50,000

Primary Care Network - GP Lead - Manager Responsible for population Integrator

Supporting them to improve health & wellbeing

Support Change Build Leadership System Reform Unit

Mental Health

Health & Wellbeing Health & Wellbeing Primary Care Team - Team Leader - Key Worker

Integrated Care

Unique client Identifier Standard Business Processes / Pathways / Models of care

Clinical Programmes Programmes of Care

Clear Clinical & Corporate Governance

Acute Hospitals

Mental Health

Acute Hospitals

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6. Options for Community Healthcare Organisations 6.1

Introduction

This chapter outlines a range of options in relation to the number, scale and boundaries of successor Community Healthcare Organisations to the existing ISAs. These options are based on the terms of reference, the output from the consultation process, the learning from the literature and research review and related work. The project team has also drawn on the experience from previous work undertaken in reforming the health service, in particular the previous spatial mapping project which focussed in particular on maximising primary / secondary care pathways.

The focus of the project team has been to develop a design blueprint for the “best fit� local organisational arrangements (both governance and service catchment perspectives) for primary and community care services. This will: x

Deliver excellent health outcomes for the population by driving the delivery of integrated care

x

Support the strategy of shifting balance of activity towards prevention and community based care and away from hospital based care;

x

Ensure more efficient use of resources;

x

Have a clear line of accountability from top to bottom;

x

Ensure services are organised around the population based service delivery model;

x

Streamline and reduce the management layers and numbers bringing decision making as close as possible to service delivery;

x

Develop clinical leadership;

x

Supporting the implementation of the Future Health and Healthy Ireland strategies.

Influencing factors to apply to decisions around service catchments include: x

Catchment areas for new Hospital Groups;

x

Community connectivity / affiliations and social and cultural links;

x

Composition of current Primary Care Teams and Network spatial units;

x

Service catchments of key services such as local authorities, education and social protection that influence the determinants of health;

x

Spatial strategy and travel patterns of the public for general services;

x

Existing ISA catchments;

x

Supports the funding and commissioning model envisaged in Future Health and the development of resource allocation models for the Health service.

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6.2 6.2.1

Current Situation Community Services

As set out in Chapter 3, the Health Boards developed the basis of a community service through a Community Care programme, comprised of thirty-two community care areas, defined geographical areas of service delivery. With the establishment of the HSE, these Community Care Areas became Local Health Offices of which there were thirty-two. In 2010 ISAs were created to form a governance structure which encompassed the services of both the Acute Hospitals and the Local Health Offices under one system. These were designed as the response to the need for a structure of integration and where Local Health Offices were largely grouped around patient flows to local Acute Hospitals in all seventeen possible ISAs, which were mapped. The plan envisaged for the full completion of the ISA structure was impeded by the changed economic circumstances and not fully put into effect.

The HSE currently provides community health services across seventeen ISAs (not all are similar to the seventeen originally mapped). The map below illustrates the location of each ISA. Each ISA is comprised of a number of former Local Health Offices (LHOs) and many of the existing financial systems and reporting systems are based on these. ISAs are illustrated by colour and labelled in blue, with LHO outlines in grey and labelled in grey.

Dublin North

Meath

Louth/Meath

DN

DNW

Dublin North City DNC

DNC

Donegal

Dublin South Central

Donegal

DSC

DW

DSW

DSE

DL

Dublin South East/Wicklow Kildare/W Wicklow

Wicklow

Sligo/Leitrim/West Cavan Sligo/Leitrim

Mayo

Cavan/Monaghan Cavan/Monaghan

Mayo Roscommon

Meath Longford/Westmeath

Galway

Galway/Roscommon

Midlands

Louth

Louth/Meath DN

Dublin North

Dublin North City Dublin South Central

Dublin South West/Kildare/West Wickl Laois/Offaly

Kildare/W Wicklow

Dublin South East/Wicklow Wicklow

Clare

Mid West

North Tipp/East Limerick Carlow/Kilkenny

Carlow/Kilkenny/South Tipperary

Limerick

Kerry

Tipperary SR

North Cork

Kerry

North Lee

Waterford

Wexford

Waterford/Wexford

Cork

South Lee West Cork

SRG Projects Office, Limerick Produced Under OSI License HSE 030601

42

The following map sets out the LHO Boundaries with the local authority boundaries overlaid. It is clearly illustrated that while a number of local authority boundaries are coterminous with the LHO boundaries, this is not the position in respect of all local authorities. Those which are not the same are the LHOs: Sligo Leitrim West Cavan LHO, Tipperary North/East Limerick LHO, Waterford LHO, South Tipperary LHO, Carlow/Kilkenny LHO, Kildare West Wicklow LHO, Wicklow LHO and all 10 Dublin LHOs

DN

Meath

DNW

DNC

DNC Donegal

DW

DSC

DSW

Kildare/W Wicklow

DSE

DL

Wicklow

Sligo/Leitrim Cavan/Monaghan Mayo

Louth

Roscommon Meath Longford/Westmeath DN DNWDNC

Galway

DW DSEDSC DSW DL Kildare/W Wicklow Laois/Offaly Wicklow

Clare North Tipp/East Limerick Carlow/Kilkenny

Limerick

Tipperary SR

North Cork

Kerry

Wexford

Waterford

North Lee

South Lee West Cork

SRG Projects Office, Limerick Produced Under OSI License HSE 030601

43

6.2.2

Proposed Hospital Groups

The following map sets out the location of the acute hospitals. Each proposed new Hospital Group is colour coded as described in the map legend. Appendix H.4 sets out a table of this information.

National Hospital Groups Legend HSE Regions Dublin/Mid Leinster Dublin/North Leinster South West

Hospital Groups Dublin East Letterkenny General

Dublin Midlands Dublin North East Midwest South/South West West/North West Sligo General

Cavan General

Louth County

Mayo General Our Lady's Hospital

Roscommon County Mullingar

Portiuncula

University Hospital Merlin Park

Rotunda Coombe

Tullamore

Naas General

St James St Colmcilles

Portlaoise Ennis General Limerick Maternity St John's

Nenagh General Lourdes Orthapedic St Lukes

Croom Tipperary General Kerry General

Wexford General

Waterford Regional Mallow General

Cork University South Infirmary Mercy University

Connolly Hospital Beaumont

Bantry General

Mater Misericordiae St James

Coombe

Holles Street St Vincents Adelaide and Meath St Michaels St Colmcilles

Inset shows Dublin City Produced by: National Projects Office - Service Operations, Health Service Executive, Plassey Technological Park,Holland Road, Limerick under OSI Licence HSE 030601 July 2013

44

6.2.3

Issues with Hospital Catchment Overlap

The following maps highlight in pink former LHOs which have hospitals in a number of proposed Hospital Groups within them and this does not facilitate the formation of a distinct geographic patch (based on LHO boundaries) for each Hospital Group.

Legend

Legend

Hospital Groups Hosp_Group

(! !( !( !( !( !(

Hospital Groups

Hosp_Group

Dublin East

Dublin Midlands

Dublin North East Midwest

South/South West

!(

West/North West

Letterkenny General

options_based_on_LHO_boundaries

options_based_on_LHO_boundaries

option_2

option_2 0

0

1

1

!(

Our Lady of Lourdes

Sligo General

!( !(

!(

!(

Dublin East (!

Dublin Midlands !( Dublin North East !( Midwest !( West !( Lady's South/South Our Hospital !( !( West/North West

Cavan General

!(

Louth County

Mayo General Our Lady of Lourdes

!(

University HospitalMerlin Park

!(!(

Roscommon County

!(

Portiuncula

!(

!(

Mullingar

Ennis General

!(

!( Hospital Our Lady's

Beaumont Rotunda !((! !( !(Coombe Holles Street !( !(St James St Michaels !( !( !(St Vincents Naas General

Tullamore

!(

Beaumont Connolly Hospital !( Cappagh !( Orthopaedic Mater Misericordiae !( Rotunda St James !( !( Coombe !( !( Holles !( Street St Vincents

!(

!(

!( !(

!(

St Colmcilles

Portlaoise

(!

Nenagh General

!(

Adelaide and Meath

!(

St Michaels

Limerick Maternity St John's Lourdes OrthapedicSt Lukes !(!( Mid Western Regional !(!(

!(

!( !(

Croom

(! !(

Kerry General

!(

Tipperary General

(!

Mallow General

!(

Wexford General

(!

Waterford Regional

St Colmcilles

Naas General

Cork UniversitySouth Infirmary !(!(!( Mercy University

!(

Bantry General

Produced Under OSI License HSE 030601

Produced Under OSI License HSE 030601

Issues with Current Configuration Hospital Catchment overlap Due to the location of the acute hospitals and the overlap of their catchment areas, it is not possible to assign each hospital a discrete catchment area. The map above illustrates those LHOs which have hospitals from multiple groups within them: x

Carlow Kilkenny LHO – this has Lourdes Orthopaedic Hospital, Kilcreene which is in the South/South West Hospital Group and also St Luke’s Hospital, Kilkenny which is in the Dublin East Hospital Group;

x

Dublin South City LHO – the National Maternity Hospital, Holles Street and The Royal Victoria Eye and Ear Hospital, which are in the Dublin East Hospital Group and also St James’s Hospital and the Coombe Women and Infant Hospital which are in the Dublin Midlands Group;

x

Dublin North Central LHO – the Mater Misericordiae University Hospital which is in Dublin East and the Rotunda Hospital which is in Dublin North East Hospital Group;

x

Dublin North West LHO – Connolly Hospital which is in Dublin North East Hospital Group and Cappagh National Orthopaedic Hospital which is in Dublin East Hospital Group.

45

See diagrams below for the Dublin East and Dublin North East Hospital Groups.

!(

Location of Dublin East Group Hospitals with LHOs containing Tertiary/County hospitals highlighted in yellow

Cappagh Orthopaedic

DNC

!(

Mater Misericordiae

!(

DNC

Holles Street Royle Victoria Eye and Ear

!(

!(

Location of Dublin North East Group Hospitals with LHOs containing Tertiary/County hospitals highlighted in yellow

DN Beaumont

!(

Connolly Hospital

DNW

!(

Rotunda

St Vincents

!( DSE

!(

Legend

St Michaels

Legend Dublin East

!(

DL

Dublin North East

!(

LHO Boundaries

Meath Longford/Westmeath

!(

!(

LHO Boundaries

Our Lady's Hospital

!(

Mullingar

!(

Cappagh Orthopaedic

Holles Street Royle Victoria Eye and Ear St Vincents Mater MisericordiaeSt Michaels

!(!(!( !(

Cavan/Monaghan

!( DSEDL St Colmcilles !(

!(

Cavan General

!(

Louth County

Louth

!(

St Lukes

Our Lady of Lourdes

Carlow/Kilkenny !(

Wexford DN Produced Under OSI License HSE 030601

Wexford GeneralOSI License Produced Under !( HSE 030601

Connolly HospitalBeaumont

!(DNW (!Rotunda !(

46

6.2.4

Mental Health Services

Under Vision for Change 16 areas for service provision are set out, the map below sets out these areas based on groupings of former LHOs. The Mental Health Centres are identified on the following map:

Mental Health Centres

Louth/Meath

!( !(

DN

Connolly Hospital

DNW/DNC

!((!

!(

!(

St James Unit

!( !

Joyce Rooms

Mater Misericordiae

St Vincents

Donegal

Tallaght Unit

( DW/DSW/DSC

!(

Letterkenny General

DSE/DL/Wicklow Cluain Mhuire

!(

Midlands/Kildare WW !(

Sligo General

Sligo/Leitrim

Mayo !(

Cavan General Unit

!(

Cavan Monaghan

Mayo General Unit

!(

!(

Louth/Meath Our Lady's Hospital

Roscommon County

!(

!(

Galway/Roscommon !(

University Hospital

!(

St Lomans, Mullingar

DN DNW/DNC Joyce Rooms !(!(

!( St Vincents ! !(

St Brigids

!(

Naas General Unit

Midlands/Kildare WW !( !(

St Brigids Ardee

( !(

!( Tallaght Unit

Cluain Mhuire

!(

Newcastle Hospital

Portlaoise Unit

!(

DSE/DL/Wicklow

Ennis General

Mid West !(

Mid Western Regional

!(

St Lukes

S Tipp/Carlow Kilkenny

!(

!(

Kerry General

St Michaels Clonmel

!(

Waterford Regional

Waterford/Wexford

Kerry Cork

Mercy University Unit St Stephens Hospital

!( !(!( Cork University - Unit

!(

Bantry General

SRG Projects Office, Limerick Produced Under OSI License HSE 030601

47

6.3

Options Identified

6.3.1

Design Criteria

The design criteria below provided broad direction in relation to the number and size of new Community Healthcare Organisations. However it must be recognised that no one factor of itself is capable of determining the answer as the concept of Future Health is rooted in a local integrated approach and in the knowledge that populations are not evenly distributed. A balance had to be found between spatial factors, community integrity, existing patterns of care, justifiable population size to support service levels, manageability issues, etc. Depending on the relative emphasis placed on this criteria the range of options varied. x

o

o o

o

o

o

x

o

Internal Integration Criteria

Maximise co-terminosity with new 6 Hospital Groups; Recognition of the clear relationship between primary and secondary care; The primary care teams must be the building blocks for any new spatial units as their determination followed a robust decision process which took cognisance of a wide range of relevant criteria to form areas which maintained natural community integrity, captured GP populations and followed patient flows; Cognisance needs to be taken of the establishment of mental health areas in the context of “Vision for Change” and that any new areas should minimise the impact on the work already established; Take consideration of existing and historical linkage across former LHOs and ISAs, where service relationships and arrangements have built up; Minimise “change for change sake”, given the extent of change still happening following previous transformation initiatives e.g. ISAs.

x

o

o

o

Demographics/Deprivation

o o o o

x

Geographical/Physical/Cultural

o

Populations are not evenly distributed and a balance must be found between spatial factors, community integrity, deprivation levels and a justifiable population size to support service levels. Key considerations include:

x

o

o

Relatability i.e. there must be a simplicity of service arrangements where people can relate to the new Community Healthcare Organisations and there is an ability to drive integrated responses with local communities and agencies; Area contiguity i.e. the whole catchment area must be physically joined. (The law of contiguity states that things which occur in proximity to each other are readily associated); Issues such as road infrastructure and avoidance of traffic congestion are important in terms of equitable access.

This includes an area being well served by public transport for those on lower income but also connects to natural tendencies and directions of communities and populations and local cultural links; Geography needs to be seen to have relevance beyond size to what can be described by people as “making sense” and deciding what forms “natural communities”.

External integration issues

There is a requirement on the wider public services environment to develop new ways of tackling complex societal goals.

In many reports the adoption of county boundaries or groupings of them is recommended as a key initiative. There are a number of key external boundaries that the project team considered to maximise co-terminosity but the team recognised the fact that some natural community affiliations and historical client flow sometimes work across such boundaries and would work against the benefits for integration with clients.

Population size and density; Deprivation levels; Demographics; Cultural diversity.

Self Sustaining / Manageability Factors o

The new organisations must be capable of facilitating strategic direction as articulated in Future Health.

Viability i.e. each area identified must have a critical mass of population which is sufficient for an area to be self sustaining and in time have its own full governance and management structure; Manageability i.e. the area should be of a size that the senior manager can balance focus on both integration matters and managing accountability; Facilitate clustering of services without too many tiers of management;

The following were considered:

48

Local authority boundaries; Existing and proposed local authority Regional Assemblies; Gardaí catchment areas; Cross border connectivity with Northern Health Authorities

In considering these criteria, there are a number of important points that need to be emphasised as follows: Report of the Expert Group on Resource Allocation and Financing On the issue of resourcing the Report of the Expert Group on Resource Allocation and Financing in the Health Sector 2010, recommends that the basis for geographic allocation of resources within the population health model should be areas with a population of at least 250,000 – 300,000 people and that there would be no upper limit to the range where the areas represent integrated geographical units. This size supports budget sustainability, local management capacity and integrated care.

The Importance of Local Authority Boundaries in Public Service Provision The development of the Healthy Ireland policy document seeks to develop a whole of government approach in addressing the health status of the population. This policy document provides a key framework to guide the development and the delivery of health service on a cross sectoral basis into the future. Healthy Ireland stressed the importance of identifying local structure for implementation of the strategy and how they can be supported to work on common agendas. It is at this local level that individuals, community and voluntary groups and projects, sporting partnerships, local schools, businesses, primary care teams, community GardaĂ­, etc can interact to work together. Local authorities already play a critically important role in protecting and promoting health and wellbeing at local level; this is particularly so in areas of disadvantage.

Action 2.5 of Healthy Ireland requires that the feasibility of co-terminosity of health service areas with local authority city/county boundaries, as aligning service provision and administrative boundaries has been identified as a significant enabler for implementation of actions, be reviewed.

In arriving at the number and composition of the Community Healthcare Organisations, the importance of alignment with local authorities has been taken into account. However due to the variance in size of the local authorities and the requirement for the Community Healthcare Organisations to be of an appropriate scale this has not been possible in every area. In identifying the composition no existing county boundary has been broken other than in Dublin (due to the population density and primary secondary patient pathways).

In addition, in the long term one of the objectives of Healthy Ireland is the publication of health outcomes at county level to facilitate comparison of performance of ISAs and local authorities in achieving the strategic objectives. Therefore it will be important that, insofar as possible, no Primary Care Team or Network crosses county boundaries.

Child and Family Agency With the establishment of the Child and Family Agency as an independent body from January 2014, the development of a productive relationship between the reformed health service and the Child and Family Agency will be important. Both agencies, in addition to working together, will also need to collaborate with a number of other public sector bodies in particular An GardaĂ­ and local authorities.

49

6.4

Proposals

There are many potential configurations which could be explored but this study initially identifies four broad areas to explore: x x x x

Co-terminosity with new Hospital Groups; Maximising primary and secondary care activity, pathways and relationship; Co-terminosity with local authorities including the proposed Regional Assemblies; An alternative approach to the Dublin area.

Each option is set out in detail in this chapter and each option has: x x x x x

A description of the background to the proposal; GIS Map; Description and population size of each new area proposed; A review of the proposal based on the advantages and disadvantages of same across each criterion identified, Estimated resources based on LHO expenditure.

Initially, four options were considered by the project team, however, taking account of the feedback and inputs, etc. variations within the options were developed. This was particularly the case within the context of considering the position in respect of Dublin and concentration of population across four local authorities. In all, when initial options and variations are taken into account, a total of seven options were considered in detail.

50

Option 1 - Based on Hospital Groups

6.4.1

This option sets out a proposal which suggests six successor Community Healthcare Organisations to the existing ISAs (from hereon this shall be referred to as “Option 1”). These areas are based on an amalgamation of former LHO areas which are grouped together based on the new Hospital Groups, as far as possible given the constraints around the Hospital Group configuration. The map below illustrates same and a description of each area in terms of population and localities contained within, is provided.

Population & Description Table – Optio Meath

Area 6 DNW

DN

DNC

DSW

Kildare/W Wicklow

1

704,977

Donegal LHO, Sligo/Leitrim/We Cavan LHO, Galway, Roscomm and Mayo LHOs

2

379,327

Clare LHO, Limerick LHO and N Tipperary/East Limerick LHO

3

886,476

Kerry LHO, North Cork LHO, No Lee LHO, South Lee LH, West C LHO, Tipperary South LHO and Waterford LHO

4

640,099

Carlow/Kilkenny LHO, Wexford Wicklow LHO, Dún Laoghaire L and Dublin South East LHO

5

956,481

Kildare/West Wicklow LHO, Dub West LHO, Dublin South City LH and Dublin South West LHO, Laois/Offaly LHO, Longford/Westmeath LHO

6

1,020,891

Louth LHO and Meath LHO, Ca Monaghan LHO, Dublin North L Dublin North Central LHO and D North West LHO

Option 1 boundary

DNC

option_1

DSC

Area 5

Total 2011

Legend

Donegal DW

Area

Area 1 - pop 704,977 Area 2 - pop 379,327

DSE

Area 3 - pop 886,476

DL

Area 4 - pop 640,099

Area 4

Area 5 - pop 956,481

Area 6 - pop 1,020,891

Wicklow

Sligo/Leitrim Cavan/Monaghan

Area 1

Mayo

Area 6

Roscommon

Louth

Meath Longford/Westmeath DN DNWDNC

Galway

Area 5

DW DSEDSC DSW DL

Kildare/W Wicklow Laois/Offaly Wicklow Clare

Area 2

Limerick

North Cork

Area 3

Kerry

North Tipp/East Limerick Carlow/Kilkenny

Tipperary SR

Area 4 Wexford

Waterford

Average

North Lee

South Lee West Cork

SRG Projects Office, Limerick Produced Under OSI License HSE 030601

Description

764,709

Max

1,102,891

Min

379,327

o

The Hospital Groups do not cover catchment areas as such. In areas such as the Mid West the geographical area covered by the Hospital Group is clear, however in other areas particularly in the eastern half of the country there are overlaps in the areas that the Hospital Groups cover.

o

This is due to the high density of the hospitals in that half of the country and agreed academic alliances between the major teaching hospitals. As such it is very difficult to correlate former LHO areas to all Hospital Groups.

o

This option maximises co-terminosity between the Hospital Groups and new areas, with four of the six Hospital Groups only having to link with one new proposed Area (a table is provided after the analysis of each criterion to illustrate same).

51

The following table details the advantages and disadvantages of this option against each criterion.

ASSESSMENT AGAINST CRITERIA – Option 1 Criteria Internal Integration

Advantages

Disadvantages

This option maximises in so far as possible the co-terminosity with the new Hospital Groups which would clearly support maximising the integration agenda between hospital trusts and Community Healthcare

Organisations

Former LHO boundaries are maintained by this option and they are the key building blocks for these areas The key primary care secondary care linkages are broadly maintained Demographics / Deprivation Self Sustaining /Manageability Factors

The South/South West Hospital Group is in Area 3 in this option with the exception of Lourdes Orthopaedic Hospital which is in Area 4 The Dublin East Hospital Group is in Areas 4, 5 and 6 Existing ISA Boundaries (South East) are not maintained Regional boundaries are not maintained.

Mental Health areas are not maintained in all areas, i.e. South East The average population size for these areas is 764,709, with a large range between 379,327 and 1,102,891

Each area has sufficient population size to be self -sustaining

As community services are very geographically spread, some of the larger areas would require a number of layers of management in order to cluster services

Geographical / Physical /Cultural

Due to the configuration of the Dublin East Hospital Group it is not possible to form a community area which is coterminous with it as contiguity is a prerequisite for same.

In this option the former South East area is divided between two new areas, this may be a significant change from a public perspective, however road networks indicate that this should not be a problem

External Integration Issues

This option does not offer any advantage for improving cross border connectivity beyond what currently exists

Given that it was not possible to match Option 1 with the current Hospital Group configuration the table below associated each proposed area and their relevant hospitals and Hospital Groups. The table also highlights the two Hospital Groups which are split between four areas in this option. In practice given the specialised nature of the hospitals in question (with the exception of Midland Regional Hospital, Mullingar) the impact of this would be that Area 5 and 6 would have to deal with two Hospital Groups. Similar tables are provided for the other options in Appendix H.1 for comparison purposes.

52

Colour coding has been used in the above table to identify instances where Hospital Groups cross the boundaries of areas identified in this option. .

Resources 2013 Budget €m*

W

Area 1 Donegal LHO, Sligo/Leitrim/West Cavan LHO, Galway, Roscommon and Mayo LHOs

621

6,4

Area 2 Clare LHO, Limerick LHO and North Tipperary/East Limerick LHO

308

3,7

674

8,1

563

6,0

668

7,5

763

8,9

3,597

40,8

OPTION1

Area 3 Kerry LHO, North Cork LHO, North Lee LHO, South Lee LH, West Cork LHO, Tipperary South LHO and Waterford LHO Area 4 Carlow/Kilkenny LHO, Wexford LHO, Wicklow LHO, Dún Laoghaire LHO and Dublin South East LHO Area 5 Kildare/West Wicklow LHO, Dublin West LHO, Dublin South City LHO and Dublin South West LHO, Laois/Offaly LHO, Longford/Westmeath LHO Area 6 Louth LHO and Meath LHO, Cavan Monaghan LHO, Dublin North LHO, Dublin North Central LHO and Dublin North West LHO National Total

*The financial figures are indicative of the budget within the proposed Community Healthcare Organisations in this option and do not include PCRS and Fair Deal resources.

53

6.4.2

Option 2 – Based on Maximising Primary and Secondary Care Activity, Pathways and Relationships

Option 2A This option sets out a proposal which suggests nine successor Community Healthcare Organisations to the existing ISAs (from hereon this shall be referred to as “Option 2A”). These areas are based on previous work which identified seventeen ISAs based on potential catchments to maximise primary/secondary care pathways (Appendix H.2). This option was based on Primary Care Teams, and while the original proposal for seventeen ISAs which was recommended in 2011 broke LHO boundaries, the option below, through amalgamations, rejoins many of these. The map below illustrates same.

Population & Description Table – Option 2A Area 8

DN

Meath

Area 9

Legend Option 2A v2

Area

Total 2011

Option_2A DNW

DW

Area 7

DSW

Kildare/W Wicklow

DNC

Area 1 - pop 389,048 Area 2 - pop 445,356

DNC

Area 3 - pop 379,327

DSE

389,048

2

445,356

3

379,327

4

664,533

5

497,578

6

364,464

7

674,071

8

592,388

9

581,486

Average

509,806

Max

674,071

Min

364,464

Area 4 - pop 664,533

Donegal

DSC

1

Area 5 - pop 497,578 Area 6 - pop 364,464

DL

Area 7 - pop 674,071

Area 6

Area 8 - pop 592,388 Area 9 - pop 581,486

Wicklow

Sligo/Leitrim

Area 1

Mayo

Louth

Cavan/Monaghan

Roscommon

Area 2

Meath Longford/Westmeath

DN

Area 9

Area 8

Galway

DNWDNC

DW DSEDSC DSW DL

Area 7

Kildare/W Wicklow

Laois/Offaly

Area 6 Wicklow

Clare

Area 3

North Tipp/East Limerick Carlow/Kilkenny

Limerick

Tipperary SR

North Cork

Kerry

Area 4

Area 5

Wexford

Waterford

North Lee

South Lee West Cork

SRG Projects Office, Limerick Produced Under OSI License HSE 030601

Description Donegal LHO, Sligo/Leitrim/We Cavan LHO and Cavan/Monagh LHO. Galway, Roscommon and Mayo LHOs Clare LHO, Limerick LHO and N Tipperary/East Limerick LHO. Kerry LHO, North Cork LHO, No Lee LHO, South Lee LHO and W Cork LHO South Tipperary LHO, Carlow/Kilkenny LHO, Waterfor and Wexford LHO Wicklow LHO, Dún Laoghaire L and Dublin South East LHO Kildare/West Wicklow LHO, Dub West LHO, Dublin South City LH and Dublin South West LHO Laois/Offaly LHO, Longford/Westmeath LHO, Lout LHO and Meath LHO Dublin North LHO, Dublin North Central LHO and Dublin North W LHO

The emphasis of Option 2A is to align community catchments with local secondary care pathways.

Based on this work nine new areas have been identified, taking cognisance of the following key influencing factors: x

PCT boundaries were the building blocks to achieve maximum co-terminosity between primary and secondary care and this has been maintained;

x

Cross border cooperation could potentially be further developed using this configuration;

x

Maximising co-terminosity with local authorities

x

A minimum population in excess of 350,000 was determined as being a critical mass for a selfsustaining Community Healthcare Organisation.

54

The following map illustrates a more detailed view of the Dublin area for option 2A

Area 8 Area 9

Legend

Area 7 Area 6

SRG Projects Office, Limerick Produced Under OSI License HSE 030601

55

The following table details the advantages and disadvantages of this option against each criterion.

ASSESSMENT AGAINST CRITERIA – Option 2A Criteria

Advantages

Disadvantages

Internal Integration

PCTs are the building blocks for these new areas.

Former LHO boundaries are maintained by this option (similarly all ISA boundaries are maintained).

With the exception of a number of PCTs in South Meath and Boyle in Roscommon - would maximise Primary care and secondary care catchments. (See overleaf; highlighted in yellow, the South Meath PCTs most deemed appropriate to go to Dublin Hospitals based on secondary care pathways) However due to the criterion of maintaining county boundaries if at all possible and the significant reconfiguration of financial and data management systems a decision was taken to maintain Meath and Roscommon as counties for this option.

Demographics / Deprivation

The average population size for these areas is 509,806, with a relatively modest range between 364,464 and 674,071.

Self Sustaining / Manageability Factors

Each area is a viable size to become self-sustaining.

The areas aren’t too large to create additional layers of management.

Geographical / Physical /Cultural

Given the broad co-terminosity with ISAs and LHO areas there would be good relatability from both a staff and public perspective.

External Integration Issues

This area does offer advantages for improving cross border connectivity.

Co. Cavan is no longer divided between two areas thus making linking with local authorities easier for HSE staff and vice versa.

56

The Dublin East Hospital Group crosses four Areas in this option, Dublin North East crosses three areas, West North West crosses two, South/South West crosses two and Dublin Midlands crosses two.

Regional boundaries are not maintained.

Mental Health areas are not maintained in all areas i.e. Midlands and Kildare.

Relatability – the Midlands with Louth and Meath may not make sense to everyone.

Cavan/Monaghan with Donegal and Sligo/Leitrim is new from a health perspective, however this is well recognised from joint border working arrangements. (Louth has not been included in this border area which will match the new proposed Regional Assemblies).

The following map highlights the PCTs identified in South Meath.

Louth

Legend 2011 PCTs 010713

Meath

Area 8

Dunshaughlin

Ashbourne

DN

Ratoath

Area 9

Dunboyne

DNW

DNC

DNC

DW DSC DSW

DSE

DL

Area 7 Kildare/W Wicklow Area 6 Wicklow SRG Projects Office, Limerick Produced Under OSI License HSE 030601

Resources 2013 Budget €m*

OPTION 2 A

W

Area 1 Donegal LHO, Sligo/Leitrim/West Cavan LHO and Cavan/Monaghan LHO.

329

3,

Area 2 Galway, Roscommon and Mayo LHOs

374

4,

Area 3 Clare LHO, Limerick LHO and North Tipperary/East Limerick LHO.

308

3,

Area 4 Kerry LHO, North Cork LHO, North Lee LHO, South Lee LHO and West Cork LHO

513

6,

Area 5 South Tipperary LHO, Carlow/Kilkenny LHO, Waterford LHO and Wexford LHO

349

4,

Area 6 Wicklow LHO, Dún Laoghaire LHO and Dublin South East LHO

375

4,

Area 7 Kildare/West Wicklow LHO, Dublin West LHO, Dublin South City LHO and Dublin South West LHO

467

4,

Area 8 Laois/Offaly LHO, Longford/Westmeath LHO, Louth LHO and Meath LHO

360

5,4

Area 9 Dublin North LHO, Dublin North Central LHO and Dublin North West LHO

523

5,

3,597

40,

National Total

*The financial figures are indicative of the budget within the proposed Community Healthcare Organisations in this option and do not include PCRS and Fair Deal resources.

57

Option 2B This option sets out a proposal which suggests six successor Community Healthcare Organisations to the existing ISAs (from hereon this shall be referred to as “option 2B”). This option is similar to option 2A above with a greater number of groupings to form six rather than nine successor community organisations to the existing ISAs. This option maintains former “LHO boundaries”. The map below illustrates same:

Population & Description Table – Option Area 4

DN

Meath

Area 6

DNW

DW

DNC

Area Legend DNC

Option 2B v2

DSW

Kildare/W Wicklow

DSE

1

834,404

2

1,043,860

3

862,042

4

674,071

5

592,388

6

581,486

Average

764,708

Option_2B

Area 1 - pop 834,404 Area 2 - pop 1,043,860

Donegal

DSC

Area 5

Total 2011

Area 3 - pop 862,042

DL

Area 4 - pop 671,071

Area 3

Area 5 - pop 592,388 Area 6 - pop 581,486

Wicklow

Sligo/Leitrim Cavan/Monaghan

Area 1

Mayo

Louth

Roscommon Meath Longford/Westmeath

DN

Area 6

Area 4

Galway

DNWDNC

DW DSEDSC DSW DL

Area 5

Kildare/W Wicklow

Laois/Offaly

Wicklow Clare North Tipp/East Limerick Carlow/Kilkenny

Limerick

Tipperary SR

North Cork

Kerry

Area 2

Area 3

Wexford

Waterford

North Lee

South Lee West Cork

SRG Projects Office, Limerick Produced Under OSI License HSE 030601

Max

1,043,860

Min

581,486

Description Donegal LHO, Sligo/Leitrim/ Cavan LHO and Cavan/Mon LHO, Galway, Roscommon Mayo LHOs. Clare LHO, Limerick LHO an Tipperary/East Limerick LHO LHO, North Cork LHO, Nort LHO, South Lee LHO and W LHO South Tipperary LHO, Carlow/Kilkenny LHO, Wate LHO and Wexford LHO, Wic LHO, Dún Laoghaire LHO a Dublin South East LHO. Kildare/West Wicklow LHO, West LHO, Dublin South Cit and Dublin South West LHO Laois/Offaly LHO, Longford/Westmeath LHO, L LHO and Meath LHO Dublin North LHO, Dublin N Central LHO and Dublin Nor LHO

The following table details the advantages and disadvantages of this option against each criterion.

ASSESSMENT AGAINST CRITERIA – Option 2B Criteria

Advantages

Disadvantages

Internal Integration

PCTs are the building blocks for these teams

Former LHO boundaries are maintained by this option

Demographics / Deprivation

58

In this option only two Hospital Groups do not have to work with more than one area, and every area has to work with more than one Hospital Group.

Former ISA Boundaries (South East) are not maintained

Regional boundaries are not maintained.

Mental Health areas are not maintained in all areas i.e. Kildare/Midlands.

The average population size for these areas is 764,708, with a large range between 581,486 and 1,043,860

ASSESSMENT AGAINST CRITERIA – Option 2B Criteria

Advantages

Self Sustaining /Manageability Factors

Disadvantages

Each area is a viable size to become self-sustaining.

Geographical / Physical / Cultural

External Integration Issues

This option does offer advantages for improving cross border connectivity

Co. Cavan is no longer divided between two areas thus making linking with local authorities easier for HSE staff and vice versa

There is a broad range of size across areas with some areas being large enough to warrant additional management tiers.

Relatability – Many of these areas are so large that they might not make sense to everyone, e.g. Mid West with Cork and Kerry, traditionally the Mid West has always gone with the West Region

Resources 2013 Budget €m *

WT

702

7,43

821

9,75

709

6,85

482

5,56

Area 5 : Laois/Offaly LHO, Longford/Westmeath LHO, Louth LHO and Meath LHO

360

5,48

Area 6 : Dublin North LHO, Dublin North Central LHO and Dublin North West LHO

524

5,76

3,597

40,85

OPTION 2B Area 1: Donegal LHO, Sligo/Leitrim/West Cavan LHO and Cavan/Monaghan LHO, Galway, Roscommon and Mayo LHOs Area 2: Clare LHO, Limerick LHO and North Tipperary/East Limerick LHO, Kerry LHO, North Cork LHO, North Lee LHO, South Lee LHO and West Cork LHO Area 3: South Tipperary LHO, Carlow/Kilkenny LHO, Waterford LHO and Wexford LHO, Wicklow LHO, Dún Laoghaire LHO and Dublin South East LHO Area 4: Kildare/West Wicklow LHO, Dublin West LHO, Dublin South City LHO and Dublin South West LHO

National Total

*The financial figures are indicative of the budget within the proposed Community Healthcare Organisations in this option and do not include PCRS and Fair Deal resources.

59

6.4.3

Option 3 – Based on Alignment with Local Authorities and Proposed Regional Assemblies

The Regional Assemblies proposed under Putting People First – Action Programme for Effective Local Government, October 2012 were considered as an option to maximise planning between Health and Local Authorities. The map below sets out the Regional Assemblies, with the LHO Boundaries outlined within each.

Eastern & Midlands DN

Meath

DNW

DNC

DNC Donegal

DW

Legend

DSC

DSW

Kildare/W Wicklow

DSE

Regional Assemblies

DL

LHO Boundaries

Wicklow

Sligo/Leitrim Cavan/Monaghan

Border & Western Mayo

Louth

Roscommon Meath Longford/Westmeath DN Galway

Eastern & Midlands

DNWDNC DW DSEDSC DSW DL

Kildare/W Wicklow Laois/Offaly Wicklow Clare North Tipp/East Limerick Carlow/Kilkenny

Limerick

Tipperary SR

Wexford

Southern North Cork

Kerry

Waterford

North Lee

South Lee West Cork

SRG Projects Office, Limerick Produced Under OSI License HSE 030601

As the Regional Assemblies are of a scale that would be well in excess of what was required, the Assemblies were further broken into LHO groupings that would maximise co-terminosity, with the exception of Dublin which does not easily lend itself to this approach. (This is dealt with further in option 4).

There are three new Regional Assemblies proposed, they have been subdivided into nine areas based on maximising co-terminosity with Local Authorities but also cognisant of the other criteria outlined as follows: x

The Border and Western area was too large an area for the Health Service so it was divided into two new areas;

x

The Southern area was also too large and was subdivided into three based on historical service architecture;

x

The Eastern and Midlands area was broken into 4 new areas as it was too large to be an area for the Health Service.

60

These new areas are illustrated below Population & Description Table – Option 3 Area 8

DN

Meath

Area

Area 9

Option 3v2 DNW

DW

option_3 DNC

DSC

Area 7

DSW

Kildare/W Wicklow

Total 2011

Legend

1

389,048

2

445,356

3

379,327

4

664,533

5

497,578

6

509,322

7

529,213

8

592,388

9

581,486

Average

509,805

Max

664,533

Min

379,327

Area 1 - pop 389,408 DNC

Area 2 - pop 445,356 Area 3 - pop 379,327

Donegal

DSE

Area 4 - pop 664,533 Area 5 - pop 497,578 Area 6 - pop 509,322

DL

Area 6

Area 7 - pop 529,213 Area 8 - pop 592,388 Area 9 - pop 581,486

Wicklow

Sligo/Leitrim

Cavan/Monaghan

Area 1

Mayo

Louth

Roscommon

Area 2

Meath Longford/Westmeath

DN

Area 9

Area 8

Galway

DNWDNC

DW DSEDSC DSW DL

Area 7

Kildare/W Wicklow

Laois/Offaly

Area 6 Wicklow

Clare

Area 3

North Tipp/East Limerick Carlow/Kilkenny

Limerick

Tipperary SR

North Cork

Kerry

Area 4

Area 5

Wexford

Waterford

North Lee

Description Donegal LHO, Sligo/Leitrim/W Cavan LHO and Cavan/Mon LHO Galway, Roscommon and M LHOs Clare LHO, Limerick LHO an North Tipperary/East Limeric LHO Kerry LHO, North Cork LHO, Lee LHO, South Lee LHO an West Cork LHO Carlow Kilkenny LHO, South Tipperary LHO, Waterford LH and Wexford LHO Wicklow LHO, Dún Laoghair LHO, Dublin South East LHO Dublin South City LHO Kildare/West Wicklow LHO, D West LHO and Dublin South LHO Laois/Offaly LHO, Longford/Westmeath LHO, L LHO and Meath LHO Dublin North LHO, Dublin No Central LHO and Dublin Nort West LHO.

South Lee West Cork

SRG Projects Office, Limerick Produced Under OSI License HSE 030601

These nine successor Community Healthcare Organisations to the existing ISAs are an amalgamation of former LHOs to achieve co-terminosity with the proposed Local Authority Regional Assemblies and the local authority counties comprised, and also with the following key influencing factors: x

LHO boundaries as a building block, given the development relationship with PCT boundaries over the past number of years and simplicity of structure from both a public and staff perspective.

x

Cross border cooperation could potentially be further developed using this configuration.

x

A minimum population in excess of 350,000 was determined as being a critical mass for a selfsustaining Community Healthcare Organisation.

x

Maintenance of existing ISAs where possible to lessen the impact of change, the Dublin South Central ISA was divided into its two former LHOs to help balance the distribution of deprivation across two new areas.

61

The following map shows this option with the proposed Regional Assemblies overlaid.

DN

Meath

Legend Regional Assemblies Option 3v2

DNW

option_3 DNC

Area 1 - pop 389,408 DNC

Area 2 - pop 445,356 Area 3 - pop 379,327

Donegal DW

Area 4 - pop 664,533

DSC

Area 5 - pop 497,578

Eastern & Midlands DSW

DSE

Area 6 - pop 509,322 Area 7 - pop 529,213

DL

Area 8 - pop 592,388 Kildare/W Wicklow

Area 9 - pop 581,486

Wicklow

Sligo/Leitrim Cavan/Monaghan

Border & Western

Mayo

Louth

Roscommon Meath Longford/Westmeath DN DNW DNCDNC DWDSE DSW DL

Galway

Eastern & Midlands

Kildare/W Wicklow Laois/Offaly Wicklow Clare North Tipp/East Limerick Carlow/Kilkenny

Limerick

Wexford

Tipperary SR

Southern North Cork

Kerry

Waterford

North Lee

South Lee West Cork

SRG Projects Office, Limerick Produced Under OSI License HSE 030601

The following table details the advantages and disadvantages of this option against each criterion.

ASSESSMENT AGAINST CRITERIA – Option 3 Criteria

Advantages

Internal Integration

This option maintains primary care team boundaries.

This option maintains LHO boundaries.

Disadvantages

With the exception of one Area it maintains current ISA boundaries (the Dublin South Central current ISA would be divided between two new areas, this will in some way address deprivation issues in that current ISA).

The Hospital Groups are split between different areas. In this option four areas will work with only one Hospital Group, but only one Hospital Group will only have to work with one area, the other Hospital Groups will have a number of areas to work with.

Regional boundaries are not maintained.

With the exception of South Meath, South Inner city Dublin and Boyle in Roscommon, the Areas would maximise Primary care and secondary care catchments.

Dublin South Central ISA will be split between two new areas, this may cause difficulties given the work to join these areas together.

A number of areas will not match the 16 mental health areas, in the MH areas Kildare is with the midlands, this is not so in this option and Dublin South City is with Dublin South West and Dublin West for Mental Health Services but is with Dublin South East and Dún Laoghaire in this option.

Many of the new areas are in a similar configuration to the former Health Boards – this is an advantage in many ways as existing service relationships can be maintained.

62

ASSESSMENT AGAINST CRITERIA – Option 3 Criteria

Advantages

Disadvantages

Demographics / Deprivation

The biggest area is 665K and the smallest is 379K the average for this option is 510K.

Deprivation in the south / south western part of Dublin City is addressed by putting Dublin South City with Dublin South East and Dún Laoghaire, rather than Dublin South West and Dublin West.

Self Sustaining / Manageability Factors

The areas are of a sufficient size to become self-sustaining.

The areas are not so big as to warrant additional tiers of management.

Geographical / Physical / Cultural

From a public perspective there would be good relatability with perhaps the exception of the Midlands Louth Meath axis.

External Integration Issues

Option is fully co-terminous with the new proposed local authority Regional Assemblies.

Co. Cavan is no longer divided between two areas thus making linking with local authorities easier for HSE staff and vice versa.

This option would achieve greater cross border cooperation as Donegal, Sligo, Leitrim, Cavan and Monaghan form one new area.

There is a disparity in population sizes between areas, if Kerry was moved from the area with Cork to the Midwest (boundaries similar to Enterprise Ireland) there would be less of a disparity in population.

Relatability - Dublin South City is with Dún Laoghaire and Dublin South East which would not be traditional for health service provision.

Resources 2013 Budget €m *

WTE

Area 1: Donegal LHO, Sligo/Leitrim/West Cavan LHO and Cavan/Monaghan LHO

329

3,033

Area 2: Galway, Roscommon and Mayo LHOs

374

4,399

Area 3: Clare LHO, Limerick LHO and North Tipperary/East Limerick LHO

308

3,713

Area 4: Kerry LHO, North Cork LHO, North Lee LHO, South Lee LHO and West Cork LHO

513

6,046

Area 5: Carlow Kilkenny LHO, South Tipperary LHO, Waterford LHO and Wexford LHO

349

4,069

Area 6: Wicklow LHO, Dún Laoghaire LHO, Dublin South East LHO and Dublin South City LHO

477

4,058

Area 7: Kildare/West Wicklow LHO, Dublin West LHO and Dublin South West LHO

365

4,289

Area 8: Laois/Offaly LHO, Longford/Westmeath LHO, Louth LHO and Meath LHO

360

5,488

Area 9: Dublin North LHO, Dublin North Central LHO and Dublin North West LHO.

523

5,762

3,597

40,857

OPTION 3

National Total

*The financial figures are indicative of the budget within the proposed Community Healthcare Organisations in this option and do not include PCRS and Fair Deal resources.

63

6.4.4

Option 4 – An Alternative Approach to Dublin

Option 4A The issue of Dublin has been raised at many workshops, i.e. that Dublin is an area which needs to be treated differently and that approaches in the past have not worked. This issue has been identified by other state departments too (see Putting People First – Action Programme for Effective Local Government, October 2012). The map below illustrates an alternative approach for health service delivery. In this example the all 4 Dublin Councils are joined together to form a discrete service area.

To maintain relevant scale and size the rest of the country is broken up into three Areas for the rest of this option.

Population & Description Table – Option 4A Area

Total 2011

1

704,977

2

1,265,803

3

1,344,402

4

1,273,069

Average

1,147,063

Max

1,344,402

Min

704,977

DN

Meath

Area 3 DNW

Area 4 DNC

DNC

Legend

Donegal DW

Option 4a

DSC

DSW

option_4a

DSE

Area 1 - pop 704,977

DL

Area 2 - pop 1,265,803 Area 3 - pop 1,3444,402

Kildare/W Wicklow

Area 4 - pop 1,273,069

Wicklow

Sligo/Leitrim Cavan/Monaghan

Area 1

Mayo

Louth

Roscommon Meath Longford/Westmeath DN

Area 4

Galway

DW DSEDSC DSW DL

Area 3

Kildare/W Wicklow Laois/Offaly Wicklow Clare North Tipp/East Limerick Carlow/Kilkenny

Limerick

Kerry

North Cork

Tipperary SR

Area 2

Wexford

Waterford

North Lee

Description Donegal LHO, Sligo/Leitrim/We Cavan LHO, Galway, Roscomm and Mayo LHOs Clare LHO, Limerick LHO, Nort Tipperary/East Limerick LHO, K LHO, North Cork LHO, North Le LHO, South Lee LHO West Cor LHO, South Tipperary LHO, Waterford LHO Laois/Offaly LHO, Longford/Westmeath LHO, Lou LHO and Meath LHO, Wicklow Cavan/Monaghan LHO; Kildare Wicklow LHO, Carlow Kilkenny and Wexford LHO Dublin North LHO, Dublin North Central LHO and Dublin North W LHO; Dún Laoghaire LHO, Dub South East LHO and Dublin So City LHO; Dublin West LHO and Dublin South West LHO

South Lee West Cork

SRG Projects Office, Limerick Produced Under OSI License HSE 030601

The following table details the advantages and disadvantages of this option against each criterion.

ASSESSMENT AGAINST CRITERIA – Option 4A Criteria

Advantages

Disadvantages

Internal Integration

This option maintains primary care team boundaries.

This option maintains LHO boundaries

64

The Hospital Groups are split between different areas, only two Hospital Groups will deal only with one area, all the others will deal with two or more areas.

Regional boundaries are not maintained.

It does not maintain ISA boundaries.

A number of areas will not match the 16 mental health areas i.e. Carlow Kilkenny and South Tipperary are not together and Waterford is not with Dún Laoghaire and Dublin South East

ASSESSMENT AGAINST CRITERIA – Option 4A Criteria

Advantages

Disadvantages

Demographics / Deprivation

The biggest area is 1,344K and the smallest is 705K the average for this option is 1,147K.

Self Sustaining / Manageability Factors

The areas are of a sufficient size to become self-sustaining.

The areas are so big they may warrant additional tiers of management.

Geographical / Physical / Cultural

From a public perspective there would be good relatability to the Dublin area.

The rest of the country is of such a scale that the relatability of the areas is in question.

External Integration Issues

This proposal would ease working relationships with the Dublin local authorities and the Dublin health area.

The population of the greater Dublin area, particularly Kildare and Wicklow, may be impacted as they would normally gravitate to Dublin for secondary care services.

65

Option 4B This option sets out a proposal which suggests eight successor Community Healthcare Organisations to the existing ISAs (from hereon this shall be referred to as “option 4B”). This option maintains former “LHO boundaries” except the Dublin Area where all four Dublin Councils are joined together to form a discrete service area. This option was to maximise in so far as possible primary and secondary care with an alternative approach to Dublin. However keeping Dublin as an entity in itself leaves Kildare/Wicklow area not being a natural configuration in that context as many of the secondary care flows would be to Dublin and there are geographical difficulties in this area.

Population & Description Table – Option 4B Area 7

DN

Area

Meath

DNW

Area 8 DNC

Option 4b option_4b

DNC

Area 1 - pop 389,048

DSW

Area 6

389,048

2

445,356

3

379,327

4

664,533

5

497,578

6

346,952

7

592,388

8

1,273,069

Area 3 - pop 379,327

DSC DSE

1

Area 2 - pop 445,356

Donegal DW

Total 2011

Legend

Area 4 - pop 664,533 Area 5 - pop 497,578

DL

Area 6 - pop 346,952 Area 7 - pop 592,388

Kildare/W Wicklow Wicklow

Area 8 - pop 1,273,069

Sligo/Leitrim

Cavan/Monaghan

Area 1

Mayo

Louth

Roscommon

Area 2

Meath Longford/Westmeath DN

Area 7

Galway

Area 8

DW DSEDSC DSW DL Kildare/W Wicklow

Area 6

Laois/Offaly

Wicklow Clare

Area 3

North Tipp/East Limerick Carlow/Kilkenny

Limerick

Tipperary SR

North Cork

Kerry

Area 4

Area 5

Wexford

Waterford

Average

North Lee

South Lee West Cork

SRG Projects Office, Limerick Produced Under OSI License HSE 030601

Description Donegal LHO, Sligo/Leitrim/We Cavan LHO and Cavan/Monagh LHO. Galway, Roscommon and Mayo LHOs Clare LHO, Limerick LHO and N Tipperary/East Limerick LHO. Kerry LHO, North Cork LHO, No Lee LHO, South Lee LHO and W Cork LHO South Tipperary LHO, Carlow/Kilkenny LHO, Waterfor LHO and Wexford LHO Wicklow LHO, Kildare/West Wic LHO Laois/Offaly LHO, Longford/Westmeath LHO, Lou LHO and Meath LHO Dublin West LHO, Dublin South LHO, Dublin South West LHO D Laoghaire LHO, Dublin South E LHO, Dublin North LHO, Dublin Central LHO and Dublin North W LHO

573,531

Max

1,273,069

Min

346,952

The following table details the advantages and disadvantages of this option against each criterion.

ASSESSMENT AGAINST CRITERIA – Option 4B Criteria Internal Integration

Advantages

Disadvantages

LHOs are the building blocks for these new areas.

All but two current ISA boundaries are maintained.

With the exception of Boyle in Roscommon and PCTs in South Meath and Kildare and Wicklow, would maximise primary care and secondary care catchments.

66

One area has only one hospital within it; the Hospital Groups are spread across multiple areas with the exception of the Mid West.

Regional boundaries are not maintained.

Mental Health areas are not maintained in all areas i.e. Midlands and Kildare or for Wicklow with Dún Laoghaire and Dublin South East.

ASSESSMENT AGAINST CRITERIA – Option 4B Criteria Demographics / Deprivation Self Sustaining /Manageability Factors Geographical / Physical / Cultural

External Integration Issues

Advantages

Disadvantages

The biggest area is 1,273K and the smallest is 347K the average for this option is 574K

Each area is a viable size to become self-sustaining.

The areas aren’t too large to warrant additional layers of management.

The LHOs of Kildare and W/Wicklow and the LHO of Wicklow are not a workable option due to travel patterns and primary and secondary care flows.

This area does offer advantages for improving cross border connectivity.

Co. Cavan is no longer divided between two areas thus making linking with local authorities easier for HSE staff and vice versa

Relatability – the Midlands with Louth and Meath may not make sense to everyone

Cavan/Monaghan with Donegal and Sligo/Leitrim is new from a health perspective, however this is well recognised from joint border working arrangements. (Louth has not been included in this border area to match the new proposed Regional Assemblies)

Resources 2013 Budget €m*

WTE

Area 1 Donegal LHO, Sligo/Leitrim/West Cavan LHO and Cavan/Monaghan LHO.

329

3,033

Area 2 Galway, Roscommon and Mayo LHOs

374

4,399

Area 3 Clare LHO, Limerick LHO and North Tipperary/East Limerick LHO.

308

3,713

Area 4 Kerry LHO, North Cork LHO, North Lee LHO, South Lee LHO and West Cork LHO

513

6,046

Area 5 South Tipperary LHO, Carlow/Kilkenny LHO, Waterford LHO and Wexford LHO

349

4,069

Area 6 Wicklow LHO, Kildare/West Wicklow LHO

209

3,923

Area 7 Laois/Offaly LHO, Longford/Westmeath LHO, Louth LHO and Meath LHO

360

5,488

Area 8 Dublin West LHO, Dublin South City LHO, Dublin South West LHO Dún Laoghaire LHO, Dublin South East LHO, Dublin North LHO, Dublin North Central LHO and Dublin North West LHO

1,156

10,186

National Total

3,597

40,857

OPTION 4B

*The financial figures are indicative of the budget within the proposed Community Healthcare Organisations in this option and do not include PCRS and Fair Deal resources.

67

Option 4C This option is to show the 4 County Councils in Dublin overlaying the former Local Health Office Boundaries.

Area

Total 2011

Dublin City

527,612

Dún Laoghaire – Rathdown

206,261

Fingal

273,991

South Dublin

265,205

The following map sets out the Vision for Chan areas with the Local Authorities superimposed on it

The following map sets out the Dublin LHOs with he Local Authority boundaries overlaid in black

Louth/Meath Fingal Co. Co. DN

Fingal Co. Co. DN

DNW

DNC Dublin City Co.

DNW/DNC DNC

Dublin City Co.

DW South Dublin Co. Co. DSW

DSC

DW/DSW/DSC South Dublin Co. Co.

DSE DL Dun Laoire/Rathdown Co. Co.

Dun Laoire/Rathdown Co. Co. DSE/DL/Wicklow Midlands/Kildare WW

SRG Projects Office, Limerick Produced Under OSI License HSE 030601

SRG Projects Office Produced Under OS HSE 03060

68

Population table – Option 4C – Populations of Dublin Local Authorities Area

Total 2011

Dublin City

527,612

Dún Laoghaire – Rathdown

206,261

Fingal

273,991

South Dublin

265,205

Total

1,273,069

The following table details the advantages and disadvantages of this option against each criterion.

ASSESSMENT AGAINST CRITERIA – Option 4C Criteria

Advantages

Disadvantages

Internal Integration

Clearly cuts across all Local Health Offices, and ISAs and Mental Health areas, this would impact from a change management perspective especially in the context of financial and data management systems.

Significant reconfiguration would be required with this solution.

Due to the close proximity of the major hospitals almost all would fall into the area of Dublin City, Fingal would just have Connolly Hospital, South Dublin would have ANMCH and Dún Laoghaire would have St Michael’s and St Colmcille’s Hospitals.

Demographics / Deprivation

Three of the new areas in this solution have very small populations; if equity of approach was taken towards the rest of the country then there would be a very limited reduction in overall ISA numbers from the current 17.

Self Sustaining / Manageability Factors

Areas of this size are too small to be self sustaining.

Geographical / Physical / Cultural

Culturally this would be a difficult change to adopt for health care services.

External Integration Issues

For Dublin this would be a positive step towards integration with local authorities.

69

6.5

Options Appraisal Process

Having regard to the consultation process and best practice approaches, the project team developed key criteria to guide decision making on the number, scale and geography of the Community Healthcare Organisations. However, it must be recognised that no one factor in itself is capable of determining the outcome.

Four main options were identified and in respect of two of these, option 2 and 4, a number of variations were identified. In total therefore seven options were identified for consideration.

The criteria identified are: Internal Integration; Demographics/Deprivation; Self sustaining / Manageability Factors; Geographical/Physical/Cultural; External integration issues – These are elaborated on 6.3.1. In the context of these criteria particular note and consideration was given to x Co-terminosity with Hospital Groups; x Maximising primary and secondary care pathways; x Co-terminosity with Local Authorities; x An alternative approach to Dublin.

A proposal or number of proposals were developed for each approach. In total therefore the project team has developed comprehensive information in respect of seven proposals, which are outlined and discussed in detail in this chapter. If the dominant weighting is placed on the four considerations above the following emerges.

6.5.1

Phase 1

x

Co-terminosity with Hospital Groups Option 1 – this proposal places an emphasis on the closest fit and co-terminosity with the Hospital Groups. This identifies 6 successor Community Healthcare Organisations to the existing ISAs. It should be noted that due to the location of the hospitals in some former LHOs which have hospitals from a number of the groups in them, it is not possible to assign each hospital a discrete catchment area.

x

Maximising Primary and Secondary Care Pathways Option 2A - emphasises the relationship between the PCT and Networks and secondary care pathways. This identifies nine successor community organisations to the existing ISAs. Option 2B - is based on the same premise as option 2A, however it puts a particular emphasis on securing benefits of scale, equivalent to that of the hospitals in terms of size, etc. This identifies 6 successor community organisations to the existing ISAs with a different geographic configuration to option 1.

x

Co-terminosity with Local Authorities Option 3 - places an emphasis on local authority boundaries and the new proposed Regional Assemblies. This identifies nine successor community organisations to the existing ISAs.

x

An Alternative Approach to Dublin Option 4A - places a particular emphasis on the greater Dublin area, which was identified during the consultation process as potentially requiring a different approach to the rest of the country.

This has also featured in previous discussions on reorganisation. The illustration in this option separates Dublin and breaks the remainder of the country into three areas. In this option the focus less on how the rest of the country is to be divided– a single Dublin body is the key issue reflected.

Option 4B - The illustration in this option separates Dublin and breaks the remainder of the country broadly similar to option 2A. This has the benefit of both an alternative approach to Dublin and also maximises primary and secondary care pathways for the rest of the country.

There are however issues surrounding the geographical isolation of Wicklow and Kildare when this approach is taken as they would gravitate towards Dublin and do not form a natural Community Healthcare Organisation area. This area in itself would not maximise secondary care/primary care interface and also it would isolate east Wicklow.

Option 4C - This proposal only shows Dublin, and illustrates the four Local Authorities in Dublin superimposed over the previous ten LHOs. This would involve significant reconfiguration for the Health Service especially from a financial and data reporting perspective and may not form Community Healthcare Organisation areas which would be sufficiently large enough to become self sustaining. It would also lessen natural primary and secondary care linkages

70

6.5.2

Phase 2

In its deliberations a number of key considerations were identified and examined by the project team, namely: Emphasis on Community and Integration Local Authorities Childcare Services Efficiency of Scale Design of Governance and Management Structures at Area and Sub-Area level Supporting UHI Environment.

The implications of each of these was examined: x

Emphasis on Community and Integration Informed by the literature and from experience in both service delivery and change management, an important consideration throughout the consultation process centred around striking the right balance between two considerations: Sufficiently large scale to justify the organisational architecture, business and service capability.

Sufficiently small scale to provide the local agility, community connectivity and responsiveness required to deliver effective integrated care on a sustainable basis.

Much of the deliberation of the project team and throughout the consultation process has come back to these issues. Ultimately, having considered all of the evidence striking this balance appropriately in an Irish context is a matter of judgement. It is appropriate therefore that the final decisions in these matters will be determined by Government. The responsibility of the project team has been to establish a strong evidence base to support decision making and bring forward a recommendation based on the project team’s best judgement, as to the proposal best suited to meet the needs of the Irish Health System. The proposal needs to safely support the delivery of services through the next transition phase to the ultimate destination of a commissioning model with a purchaser/provider spilt and a UHI environment.

The project team has been struck by the importance which has been placed by stakeholders on developing an organisational structure (number, scale and boundaries) and governance model, which will meet the needs of people in terms of community service provision and can ensure appropriate integration with other health services such as hospitals as well as the wider public sector. Healthy Ireland stressed the importance of identifying local structure for implementation of the strategy and how they can be supported to work on common agendas. It is at this local level that individuals, community and voluntary groups and projects, sporting partnerships, local schools, businesses, primary care teams, community Gardaí, etc. can interact to work together.

This wider concept of community was emphasised throughout the consultation, indicating a requirement for the new Community Healthcare Organisations to be developed in a way that supports and enables communities to meet the needs of their people.

x

Local Authorities The importance of maximising the capacity for effective engagement and integration in service delivery, between the new provider organisations on the community side with local authorities, was emphasised throughout the process. Each of the Divisions within the Health Service Directorate highlighted specific requirements which are important into the future. The necessity for close engagement in relation to planning and development were obvious for all. Equally there are well established arrangements in respect of ambulance and emergency services generally, including emergency planning, transport and other related issues.

It is important to recognise and plan for effective collaboration in relation to social care services for older people and people with a disability, including all aspects of housing and engagement with voluntary sector partners. This is equally important for example in the mental health services where the issues of residential accommodation are important as is the development of cross sector initiatives in the areas of suicide prevention, etc.

The necessity for a whole of government approach to the health and wellbeing of the population as articulated in government approved policy Healthy Ireland, will require significant collaboration between the health service and local government at all levels to ensure the necessary cross sectoral approaches, which are at the root of effectively tackling the determinants of health, in a long term sustainable manner.

71

The development of models such as the County Committees for Childcare and county wide initiatives around Ageing Well Networks, etc. provide potentially beneficial frameworks for effective integration of services into the future which will better serve local communities and maximise the utilisation of resource on a cross-sectoral basis.

Apart from all of these aspects, identification with counties in an Irish context is very strong and the project team was encouraged not to breach the integrity of counties if possible in the development of the Community Healthcare Organisations. The importance of local government and county constituencies in terms of local accountability and communication were also emphasised. While these are important they need to be balanced with wider considerations in terms of health service provision relating to resource allocation and delivery of services to an appropriate scale of population. x

Childcare Services Many of the issues referenced above relating to local authorities and integration are also relevant to the Child and Family Agency and were emphasised throughout the consultation process. The setting up of the new Child and Family Agency will place an onus on both agencies to ensure collaboration and a seamless service to achieve good outcomes for children.

x

Efficiency of Scale Clearly, given the overall economic situation, it is imperative that the organisational structure within the health service is fit for purpose and maximises benefits in terms of efficiency of scale in the use of shared service platforms, eliminating the duplication of management structures. At the same time, as outlined earlier, the benefits in terms of value for money which can be achieved through scale must be balanced in ensuring that the Community Healthcare Organisations are fit for purpose in delivering high quality outcomes and a sustainable service model to support local communities into the future. In this context all of the options and proposals brought forward in this report recommend a reduction in the number of current ISAs. The various options recommend a variety of six, eight or nine Community Healthcare Organisations.

x

Design of Governance and Management Structures Area and Sub Area Level An important focus of the deliberations of the project team has been to assess the balance of advantage of these proposals in the context of the criteria outlined in this chapter. However, the project team has also taken account of the impact of the boundaries, number and scale of the Community Healthcare Organisations on the governance and management model required to successfully implement the change programme. The proposals will not give rise to unnecessary layers of management which may be inefficient from a cost point of view but also in terms of minimising the number of layers from the head of the organisation to the front line. It is important to emphasise also that there will continue to be a national focus in the development of integrated financial and HR systems as well as a shared service platform across the wider health sector.

x

Supporting UHI Environment The project team is also cognisant in determining boundaries, number and scale of Community Healthcare Organisations that these would need to support the governance and management structure required to deliver on the phased implementation of a commissioning model with a purchaser / provider spilt operating within a UHI environment.

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6.5.3

Discussion on Options

In reviewing all of the above and considering the options identified earlier informed by these considerations the project team identified two options i.e. six or nine Community Healthcare Organisations as best fits to achieve delivery on the considerations identified. These two options as well as specific consideration of Dublin were then the subject of further analysis. x

Options Around Six Community Healthcare Organisations In considering the options with proposals for six Community Healthcare Organisations there was a clear view within the project team and evident in the consultation process in relation to the preference among these options.

Notwithstanding that option 2B was developed on the basis of rolling up option 2A to achieve the level of scale more comparable to the Hospital Group; the proposal on reflection held considerable disadvantages in that it was clear that a number of areas were regional in scale (particularly Areas 1, 2 and 3 in this proposal). Area 1 and 2 between them covered over half the geography of the country as well as half the population. The sub structures required under this heading would be significant and in addition there was a strong view that these areas would not facilitate the level of connectivity required at local community level to achieve the objectives of the overall strategy of Future Health and indeed the emphasis and criteria outlined in this report.

Of these options, option 1, which maximises the alignment with the Hospital Groups, was regarded as a far more viable option than option 2B. It remains a challenge to option 1 that some of the areas were regional in scale and would require levels of sub structure, which while being less than option 2B were more than option 2A. In addition while this option did align broadly with the local authority at county level, option 2A provided a better fit, while also maximising the primary / secondary care interface. Option 1 also loses the benefit of the border connectivity.

x

Options around nine Community Healthcare Organisations Option 2A emphasised the relationship between the Primary Care Team and Networks and secondary care pathways. Very significant work has been done on patient flows and primary care catchment referrals to secondary care over the past number of years, both in the original establishment of the HSE, the establishment of regional boundaries and in particular ISA structures thereafter.

It is noted that Option 3 placed an emphasis on local authority boundaries and the new proposed Regional Assemblies. It was clear at an early stage that the scale of the Regional Assemblies – three proposed for Ireland – were of such a scale that to be too large to meet the majority of the criteria outlined by the project team. At the same time however, the Regional Assemblies are drawn together from the local authority boundaries.

Option 2A and Option 3 gave rise to very similar proposals identifying nine Community Healthcare Organisations even though there was a fundamentally different approach taken to their development. While there are some minor differences between the proposals under both options, it was considered that Option 2A was the more appropriate of these two, as it met a broad range of the criteria, but in particular met the key requirement of linking the PCTs/Networks and secondary care while also providing a very strong basis for linkage with local authority boundaries, both in the context of county councils and the proposed Regional Assemblies in the future.

The approach outlined in Better Local Government - “Putting People First – Action Programme for Effective Local Government, October 2012” in respect of the Regional Assemblies and their role for high level spatial planning around larger geographic areas, provides a useful model for potential future collaboration between local government and the nine Community Healthcare Organisations identified in Option 2A.

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In the future consideration might also be given to reorganisation of the Regional Fora within the health service along these lines to develop collaboration at a regional level between local authorities and the health service which hasn’t been sufficiently evident to date.

This higher level process for engagement could also address the anomalies within the proposal, whereby North Tipperary and South Tipperary are split between the proposed Mid-West and the South-East areas. Similarly this Regional Assembly approach may provide a mechanism to provide the high level of collaboration required in Dublin and the greater metropolitan area.

Option 2A therefore meets a very significant number of criteria outlined providing the best range in terms of population and resources; significantly reducing by nearly 50% the number of ISAs; while not requiring additional layers or sub-layers of management within the Community Healthcare Organisations proposed under this option. This option has a population average of 510K with a modest range of population from 364K to 674K.

x

Dublin Issues The remaining options and proposals flowed from a recognition of particular challenges associated with the Dublin area, both in terms of the density of population within a relatively small geographic area compared to the rest of the country and also the alignment with local authorities.

Given the importance of relationship with local authorities, the project team looked carefully at the options in this regard. The challenge in dealing with particular issues in Dublin (around social inclusion, homelessness, drug and alcohol addiction services, housing issues across a range of services) it required a consideration of the potential of developing one organisation for Dublin.

The details of this are set out in Options 4A, 4B and 4C. Option 4A sets out Dublin as an option on its own with a population of 1.3 million people and with the areas across the country of equivalent scale in population size. It was evident early on that similar to the scale of Regional Assemblies and existing regions, that such bodies outside of Dublin would be too large and not meet a significant number of the criteria or requirements of the health sector in respect of delivery of community services.

The alternative therefore was to broadly apply option 2A to the scenario while maintaining Dublin as an area on its own and in this context a proposal with eight areas emerges, this is Option 4B. Many areas remain the same as option 2A, however area 6 Kildare Wicklow emerges as a challenge, not being a natural configuration. It also poses challenges as many of the secondary care flows would be to Dublin. In addition there are significant challenges with one area of the scale of 1.3 million people and a resource in the order of €1.9bn, while the remaining range on average at 500,000 population and a budget of between €380m -€700m.

Such an arrangement, while providing benefits in relation to the challenges of social inclusion and local authority issues, provide significant disadvantages both in terms of the hospitals and the wider community services. There is also a concern of significant imbalance between Dublin and the rest of the country if such a model was developed. With the concentration of both hospital and community services in Dublin of such a scale that they would undermine the potential benefits of a UHI environment and a commissioning purchaser / provider spilt.

Option 4C gives consideration to configuring Dublin with the four local authority areas. However this option proves particularly challenging for the health services given the existing financial, HR, planning and data systems as these have been developed on the basis of the LHO (and the old Community Care Areas). It is not possible to configure the Dublin local authorities in a way which does not significantly cut across these existing boundaries.

It is clear however, that for certain services, it may be advisable to develop a mechanism to support an approach for planning and other purposes across Dublin as a whole. It is the view of the project team that such a mechanism could be developed as part of the regional assembly arrangements, which are being developed through local government. A Dublin wide group could be developed to engage with the health sector specifically in relation to these issues to ensure the type of integrated approach that is required.

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6.5.4

Evaluation of Options Against Decision Criteria

The following schematic illustrates how each option is evaluated against each of the decision criteria discussed in this chapter

Option 1

Option 2A

Option 2B

Option 3

Option 4A

Option 4B

Diameter of circle indicates greater advantages

Internal Integration Criteria

Demographics / Deprivation

Self Sustaining / Manageability Factors

Geographical / Physical / Cultural

External Integration Issues

It is clear from the above schematic that Option 2A and to a lesser extent Option 3 offer greater advantages when evaluated against the various criteria. (Option 4C is not evaluated here as it was only specific to Dublin counties).

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6.6

Outcome of Option Appraisal and Recommended Option

Area 8

DN

Meath

Area 9

Legend Option 2A v2 Option_2A

DNW

DW

DNC

Area 1 - pop 389,048 Area 2 - pop 445,356

DNC

Area 3 - pop 379,327

DSC

Area 7

DSW

Kildare/W Wicklow

Area 4 - pop 664,533

Donegal

DSE

Area 5 - pop 497,578 Area 6 - pop 364,464

DL

Area 7 - pop 674,071

Area 6

Area 8 - pop 592,388 Area 9 - pop 581,486

Wicklow

Sligo/Leitrim

Area 1

Mayo

Area 2

Meath Longford/Westmeath

DN

Area 9

Area 8

Galway

DNWDNC

DW DSE DSC DSW DL

Area 7

Kildare/W Wicklow

Laois/Offaly

Area 6 Wicklow

Clare

Area 3

Limerick

North Tipp/East Limerick Carlow/Kilkenny

Tipperary SR

North Cork

Kerry

Louth

Cavan/Monaghan

Roscommon

Area 4

Area 5

Wexford

Waterford

North Lee

South Lee West Cork

x

x

SRG Projects Office, Limerick Produced Under OSI License HSE 030601

Option 2A, is considered the most appropriate proposal to recommend as: o

it met a broad range of the criteria;

o

met a key requirement of linking the Primary Care Networks and PCTs and secondary care;

o

while also providing a very strong basis for linkage with local authority boundaries, both in the context of county councils and the proposed Regional Assemblies in the future;

o

provides the best fit in striking the right balance between an organisation of sufficiently large scale to justify organisation and business capability, while at the same time being sufficiently small scale to provide the local community connectivity and responsiveness required to deliver integrated care.

It would be advisable to develop a mechanism to support an approach for planning, social inclusion and related purposes across Dublin as a whole. This could be developed as part of the Regional Assembly arrangements, through which a Dublin wide group could be developed to engage with the health sector.

In the future consideration might also be given to reorganisation of the Regional Fora within the health service along these lines to develop collaboration at a regional level between local authorities and the health service which hasn’t been sufficiently evident to date.

x

The option 2A of nine Community Healthcare Organisations is recommended.

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7. Governance and Management Arrangements for Community Healthcare Service Delivery Organisations 7.1 Introduction and Context Chapter 6 addressed the options regarding the number, scale and boundaries of successor Healthcare Organisations to the existing Integrated Service Areas (ISAs) and recommended nine successor structures as outlined in 2A of Chapter 6. This chapter outlines the recommendations on the governance and management arrangements to apply.

In 2012, the Minister for Health published Future Health – A Strategic Framework for Reform of the Health Service 2012-2015. This framework, based on commitments in the Programme for Government, outlines the main healthcare reforms that will be introduced in the coming years with a focus on the four pillars of reform: Structural, Financial, Service, and Health and Wellbeing.

Future Health outlined the principles and approach to the structural reform of the health service which would be undertaken on a phased basis which is summarised at 7.1.1 below.

7.1.1 Future Health Structural Reform – A Phased Transition Phase 1 x Establish New Directorate – As governing body. x New Management and Governance Structure. x Hospital Groups on Administrative Basis. x Review ISAs to inform successor structures, executive management and governance. x Child and Family Agency established. x Moving to the “post HSE” era – in effect Healthcare Commissioning Agency in shadow form.

Phase 2 x Development of a formal purchaser / provider spilt. x Commissioning Model. x Healthcare Commissioning Agency formally established. x Legislative Framework.

Phase 3 x UHI Any recommendations on the governance and management arrangements for Community Healthcare Organisations must be considered within this overall context.

7.1.2

Delivery of Phase 1 - Future Health Structural Reform

Delivery of the first phase of the reform of health structures has already commenced with the establishment of the Health Service Directorate in July 2013, as the precursor to the Healthcare Commissioning Agency. Services are now organised into Divisions covering acute hospitals, primary care, social care, mental health, and health and wellbeing services. In addition the Childcare Agency has been established and we are moving into the “post HSE” era.

The enactment of the Health Service Executive (Governance) Act 2013 has strengthened the accountability arrangements between the Health Service and the Minister for Health. In this context, a Directorate has been established as the governing body for the Health Service. The Director General, as Chair, and seven Directors have been appointed. A formal scheme of delegations is also in place which clearly defines the line of accountability for each service area.

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A formal governance framework is also in place to manage the funding relationship with the nonstatutory sector. All funded agencies are required to enter into and sign formal and comprehensive service agreements or grant aid agreements.

These new national governance and accountability arrangements are illustrated in the diagram below: Health Service Directorate and Leadership Team Health Service Directorate

National Lead for Transformation and Change L. Kearns

COO / Deputy Director General L. McGuinness

CFO S. Mulvany

Director General T. O’Brien

National Director Acute Services T. O’Connell

National Director Primary Care J. Hennessy

National Director Internal Audit M. Flynn

National Director Social Care P. Healy

National Director Health & Wellbeing S. O’Keeffe

National Director Mental Health A. O’Connor

National Director Quality & Patient Safety P. Crowley National Director HR B. O’Brien

National Director Clinical Programmes A. Carroll

National Director HBS L. Woods

National Director Cancer Control Programme S. O’Reilly

National Director

Communications

P. Connors

National Director Strategic Development I. Carter

The Directorate is responsible for implementing the strategic policy direction of Future Health and the development of standard national service frameworks.

The Directorate will also provide leadership and direction on shared service platforms, new financial systems, the development of a commissioning framework, procurement and other business supports through which the new Community Healthcare Organisations will be enabled to deliver services more efficiently and eliminate the unnecessary duplication inherent in previous systems.

The project team, in considering the governance and management arrangements for Community Healthcare Organisations, had full regard to these new national structures.

An important priority for the Health Service Directorate is to drive forward the implementation of Phase 1 of the Reform Programme as outlined in Future Health and to work with the DoH in planning for Phase 2.

The Reform Programme envisages a move from the current centralised management model for health services to a model that will see greater autonomy for front line services through the establishment of hospital groups and the organisation and management of primary care and community services within identified geographic areas. The changes to be introduced will; x

Provide direct line accountability between the individual National Directors for services and the managers responsible for hospitals and primary care and community services as a precursor to moving to a purchaser provider split and commissioning model.

x

Ensure the foundation for greater autonomy at service level is in place and provide the stepping stone to independent trusts on the hospital side and effective Community Healthcare Organisational Structures on the Community side.

x

Primary care, social care, mental health and health and wellbeing services will be delivered and managed through an integrated management structure within geographic areas, which will be identified in this review. This will include HSE funded agencies in these service areas.

x

There is a clear commitment to provide Primary Care and Community Services with governance and management arrangements of equal weight and esteem to those that are now envisaged for the Acute Hospital services. At the same time it is acknowledged that the

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detail of the respective structures may differ, reflective of the different models and range of service provision across hospital and earlier. x

Move from emphasis on acute care towards preventative, planned and well co-ordinated community based care.

x

Primary Care Teams and Social Care Networks provide the foundation for a new model of integrated care.

An important outcome from this reorganisation of service is to devolve greater autonomy and decision making to frontline services at local level through the establishment of the Hospital Groups on the one hand, and the new Community Healthcare Organisations on the other. This earned autonomy, will support the development of leadership capacity and innovation locally. However, there is a critical balance to be achieved with this independence on the one hand and the necessity for clear accountability and the standardisation and delivery of services locally in a consistent and equitable manner in line with national frameworks. Striking the right balance in this regard will be an important consideration for the management and governance arrangements to be put in place in respect of the Community Healthcare Organisations to replace the existing ISAs. Other important outcomes from this service reorganisation will include an improved focus on quality and patient safety, an enhanced focus on health and wellbeing and an enhanced ability to plan and deliver integrated care.

7.1.3

Planning Phase 2 – Future Health

Future Health noted that it is vital to develop the right organisational structures for our health services so that we can deliver a high quality, responsive and cost effective service to our people. It also recognised that ensuring these structures are appropriate is a complex exercise, which requires that each phase of the transition would be carefully evaluated and inform planning and implementation of the next phase.

Outlined above are the key elements of Phase 1, which are being implemented with the establishment of the Health Service Directorate and these national structures will remain in place throughout Phase 1 of the process and will support implementation of Phase 2.

Planning for Phase 2 is well underway involving work by the DoH and the health service.

Commissioning Framework Work on the development of an appropriate Commissioning Framework is currently underway under the Leadership of the Chief Operations Officer of the health service in consultation with all stakeholders.

It is the intention of the Health Service to gradually transition to a commissioning model on an administrative basis, as both provider and commissioner capabilities strengthen, with the clear aim of achieving the greatest progress possible on a commissioner / provider split prior to the introduction of the statutory functions. This will reduce the risk at the point of statutory transition.

DoH Work on Structures and Related Matters across the Health System Significant high level work has already been undertaken by the DoH on a wide range of relevant issues, these include not only the development of Future Health, but also the ‘Money Follows the Patient” Policy Paper, the white paper on Private Health Insurance, the Establishment of Hospital Groups as a Transition to Independent Hospital Trusts Report, the Framework for Development of Smaller Hospitals, Healthy Ireland, the E-Health Strategy, as well as work on the development of a white paper on UHI addressing such issues as the “basket of services” that would be covered under this insurance model, etc. The impact of these separate but related elements of the reform programme will need to be drawn together to ensure cohesion in the overall health system and this work is currently underway within the DoH in collaboration with the Health Service. The output of these deliberations will influence the overall governance and management arrangements.

Legislative Requirements It should be acknowledged that a significant range of work is required to ensure that an effective legislative framework is put in place to give legislative effect to the reform programme. The DoH

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recognises that while a number of these changes will require legislation for their final enactment, it is clear that a great deal of progress can be made through administrative reform within existing structures, ahead of any legislation. This approach will not only help ensure the changes are made in a timely way but will also allow the various changes to be made in a planned and incremental basis, so that the final transition from the current system to the reformed service is as smooth as possible.

This overall approach is very much in line with the recommendations of this report based on the consultative process and international research and experience, which emphasises the need for a phased implementation of the change programme towards a fully integrated model of service, roadtesting the planned changes and integrating learning as we move from one phase to the next.

The outcome of this work in the planning of Phase 2 of the reform programme, will inform the shape of the final governance and management structures required, particularly at national level, to ensure cohesion in a reformed health system.

7.1.4

Implications for Governance and Management Arrangements for Community Healthcare Organisations

In the context of all of the issues outlined at 7.1.3 above, it is clear that there are a number of important variables which have the potential to impact on the overall national structures and governance arrangement for the system, including Community Healthcare Organisations, which are unresolved at this point and which will take some time yet to work through.

Consultation with Stakeholders Throughout the consultation process it was also fully recognised and communicated that any proposals would need to be considered by the DoH and Government within the overall context of health service reform, including the requirement to ensure a cohesive and integrated structure for the whole health system. Similarly, it was recognised that any reorganisation at local level would need to have regard for the emerging commissioning type model and the associated purchaser/provider spilt appropriate to the Irish context.

It is fair to say that the expectation of the majority of stakeholders was that the Community Healthcare Organisations to replace the ISAs would become the local service provider of Primary Care and Community Services, working within national frameworks and direction, and accountable to the national system through the Healthcare Commissioning Agency or other national entity, through a performance contract type arrangement.

In the context of reorganisation of acute services into hospital groups, there emerged an inferred expectation within the system that any revised structures of Community Healthcare Organisations would also see them established as legal entities in due course, similar to the potential that exists for the hospital groups.

Following consultation with DoH it is important to note in designing a new organisational structure for the health services we need to be conscious of the number of agencies required. In developing proposals for new organisational structures, a strong emphasis will be placed on streamlining functions, avoiding duplication and having full regard to the Programme for Government and Future Health.

In this context, consideration should be given to options which range from the nine successor ISAs progressing to individual agency status or being operational divisions within a single national delivery organisation.

“Best Fit” Community Structures Having considered both of the options outlined above and having regard to recommendations in Chapter 6 of this report, the considered view is that the nine boundaries and the associated management and governance arrangements for these structures at local level outlined later in this chapter are the most appropriate to deliver the type of significant reform and responsive service delivery envisaged in Future Health and the Programme for Government. These structures are sufficiently robust to deliver the current requirements for service management, while being flexible enough to support the system from the current state through a number of transition phases to the UHI environment. They provide the “best fit” structure to dovetail with whatever final national organisational arrangements emerge.

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The primary emphasis of the future Community Healthcare Organisations, as outlined in this report, is on service delivery within the context of nationally prescribed frameworks. They will concentrate on implementation of the nationally agreed standardised models of care for each care group, bringing a local community focus to service delivery, and ensuring integrated services are provided to their primary care networks serving average populations of 50,000. Our primary focus has been to establish the appropriate leadership and management team arrangements that need to be put in place to ensure the new structures are fit for purpose in implementing the challenging reform agenda ahead.

7.2 Clinical and Corporate Governance In considering the governance and management arrangements for future Community Healthcare Organisations, the project team also gave full regard to the overview of best practice in clinical and corporate governance referenced in Chapter 5 and outlined in detail in the Reviews of International Experience, Good Governance and Clinical Supervision in Appendices D, E and F. The project team is satisfied that the arrangements recommended, while new in an Irish context, are consistent with evidenced based best practice.

7.3 Transition Arrangements As referenced above, the clear intention is that the reform programme will be implemented on a phased basis as outlined in Future Health.

In this first phase, the intention is that from March 2014 the current ISAs will report directly to the National Directors of Primary Care, Social Care, Mental Health and Health and Wellbeing. It is essential, to ensure the continued effective management and organisation of the service and to progress implementation of the reform programme, that we move rapidly with the implementation of the recommended 9 Community Healthcare Organisations on an administrative basis. This reorganisation can take place smoothly within the existing governance arrangements of the Health Service Directorate. This approach will allow the new arrangements to bed down at local level while work is continuing in finalising the overall national approach to be taken with regard to the commissioning model and other issues referred to at 7.1.3 above.

During transition, the appropriate governance at national level will be provided through the National Directors, the Leadership Team and the Health Service Directorate. During this period arrangements will also be put in place to ensure effective integration and performance management across the system.

7.4 Recommendations for Governance and Management Arrangements for Community Healthcare Organisations 7.4.1

Management Team of Community Healthcare Organisations Replacing Existing ISAs

The Chief Officer and Management Team will operate at the highest level of the local community healthcare organisation and will have full authority and responsibility for service delivery. In the transition phase, the Chief Officer will report to the relevant National Director and executive authority and accountability will be derived from the Health Service Directorate. In the long term the governance relationship can be to the Healthcare Commissioning Agency or alternative area, regional, or national structures when established.

The Management Team will comprise of: x

x x x

Chief Officer of Community Healthcare Services, to lead Management Team and accountable for all service delivery within the Community Healthcare Organisations Head of Primary Care Head of Mental Health Head of Social Care

x x

x

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Head of Health and Wellbeing Business Management ƒ Head of Finance ƒ Head of Human Resources ƒ Head of Corporate Support Lead Quality and Professional Development

The key role of the Chief Officer and Management Team is to deliver high-quality and safe services to meet the needs of the population. Every effort should be made to progress speedily with the establishment of these management teams so that the momentum of reform is maintained.

The management arrangements are illustrated below in summary form: Chief Officer Chief Officer

Lead Lead- Quality Quality&& Professional Professional Developmen tt Developmen

GP GP Lead Lead

Head Headofof Primary Primary Care Care

Head of Head of Social Social Care Care

Head Head of Health Health & Wellbeing Wellbeing

Head of of Head Mental Mental Health Health

Business Business Management Management Finance HeadofofFinance Head Head HeadofofHuman Human Resources Resources

Quality&& Quality Safety, Safety, Standards&& Standards Professional Professional Development Development

PrimaryCare CareNetworks Networks Primary (Between8-14 8-14networks networks (Between per CHO per CHO) 90 Networks 90 Networks Nationally avg.

Nationally50,000 50,000 avg. per network

Leadership Leadership Team: Team: MedicalLead Lead - - Medical NursingLead Lead - - Nursing AlliedHealth Health - - Allied Professionals Professionals Lead Lead

Manager NetworkManager Network GPLead Lead GP PrimaryCare CareTeams Teams–– Primary Average55per pernetwork network Average Multi-disciplinaryworking working Multi-disciplinary HeadsofofDiscipline Discipline Heads

7.4.2

CLINICAL LEADERSHIP / CLINICAL LEADERSHIP PROFESSIONAL DEVELOPMENT /DEVELOPMENT PROFESSIONAL PROGRAMMES OF CARE PROGRAMMES

Head Headofof Corporate Corporate Support SupportServices Services (ICT, (ICT,Estates, Estates, Comms, Comms,Legal) Legal)

Central Role of Primary Care

The Primary Care Strategy which set out the policy direction for the future of primary care services in Ireland acknowledged “the central role of primary care in the future development of modern health services”. It proposed the introduction of an inter-disciplinary team based approach through Primary Care Teams and Health and Social Care Networks (HSCNs).

While progress has been made in the implementation of the strategy, and there are some examples of highly effective PCTs, overall implementation of the model and achievement of the outcomes identified in the strategy has not been as comprehensive as originally envisaged. As identified in the HSE Board Report (April 2011) – Update on the Development of Primary Care Teams and their Operational Effectiveness: “it is evident that in some cases that everything is not working in accordance with expectations and there is a need to establish why certain teams are working well and why others are not as good and why some are far more productive than others. Two of the main issues of Teams operation are the competing demands on existing staff with many Teams indicating that they are not adequately resourced to cope with demand and the lack of co-located Team members. Other barriers include lack of administration support, lack of management and governance structures, issues with GP engagement and lack of ICT infrastructure.”

There was a consensus throughout the consultation process that it will be essential to ensure that the new Community Healthcare Organisations are ready to implement the reform agenda as set out in Future Health and continue the journey towards ensuring that people experience care that is integrated and allows them to navigate smoothly through the system.

During the consultation phase of this review, the importance of ensuring that there is a robust governance and management model with clear lines of accountability for the PCTs and Networks and the broader organisation was stressed. The most recent guidance document for governance of PCTs and Networks, agreed in February 2012, was referenced throughout the consultation process and while it was acknowledged that significant work had been undertaken and discussions held with staff and unions, etc. the approach had not been successfully implemented. The consultation process identified this as one of the key issues requiring resolution in the establishment of the ISA successor bodies.

The consultation process also emphasised the necessity for more effective engagement with general practice and clarity around roles for GPs and how they can be more effectively engaged in the

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process into the future. In addition, it was specifically highlighted by the ICGP in the project team’s consultation with them, and in their 2011 review of the effectiveness of PCTs (ICGP report published October 2011). That report highlighted the perspective of GPs on this issue as follows: x

Clinical governance structures are not clear with lack of clarity with regard to final clinical responsibility for team decisions.

x

Management of team members does not appear to be optimal – difficult to ascertain who is in charge with team members reporting to multiple managers. This silo effect where team members are reporting to largely hospital based discipline managers is not conducive to team cohesion and productivity.

x

Clerical support is essential otherwise team members can spend up to 50% of their clinical time doing administration – appointments etc. rather than seeing patients.

Having considered all of these issues it is clear that there is a real need to reorganise and streamline the existing uni-disciplinary approach to delivery of primary care services in a way which supports the development of professional and clinical leadership within the community, and supports a more inclusive involvement of general practice.

Ownership and responsibility for the provision of health and social care services, through the life cycle is best placed within the communities that people live. In future, it is recommended that the fundamental unit of organisation for the delivery of services will be the Primary Care Network, serving an average population of 50,000 people. The network will support and resource the primary care teams with an identifiable responsible manager in each network. A GP Lead will also be identified to support the network and to act as a GP leader. Consequently every large town and its hinterland, and district of a city, will have a network with an identifiable manager. These positions will be developed through the reorganisation / reassignment of existing resources. x

90 primary care networks of 50,000 average population will be developed across the country.

x

Leadership of the network will be provided by re-assigning existing senior professional and clinical staff to the new leadership roles as the identifiable and responsible manager of the new primary care networks, serving a population of average 50,000, working with a GP Lead.

x

The role of the Heads of Discipline will be redesigned to provide the necessary clinical governance and supervision across all primary care networks in the new Community Healthcare Organisations.

x

Greater participation by GPs at primary care network level, with the establishment of the GP Lead for each network, supporting the Network Manager in developing professional relationships, innovative solutions and multi-disciplinary approaches to challenges within the network.

x

The role of Team Leader with protected time will be established for each Primary Care Team.

x

A Key Worker will be assigned to support people with complex needs.

x

The network will support the maximum provision of primary care services locally, and will ensure appropriate access to specialised services e.g. social care and mental health, etc. for the people living within the network.

x

A national process will be put in place to oversee the establishment of the primary care networks as envisaged in this report and to maximise co-terminosity between primary care and specialised services at network level.

x

Re-align clerical and administrative supports to ensure effective frontline administrative resource for all primary care networks, to the benefit of primary care teams locally.

x

The success of the network over time, will depend on how people experience joined-up, integrated care.

x

The reorganisation of governance and management arrangements will be delivered from within existing resources.

The project team has considered the feasibility of implementing these proposals within the existing resources in primary care and are satisfied that this approach can be effectively implemented. There are over 10,500 professional staff working in primary care, many of which have been reconfigured to align with the existing PCTs and networks. To illustrate what can be achieved, it is instructive to consider the position relating to some of the core primary care professions of nursing, physiotherapy, occupational therapy, speech and language therapy, medical services, dietetics and psychology.

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There are in excess of 200 Heads of Discipline providing line management as well as clinical governance and supervision to these core professions. The new approach to primary care networks envisaged as part of the development of the new Community Healthcare Organisations will see the reassignment of these existing senior professionals / clinicians as the leaders of the primary care networks (approx. 90 required nationally), working with a GP Lead. It will also see the re-design of the Heads of Discipline role towards leadership of clinical governance and supervision for all networks in the Community Healthcare Organisations (approximately 63 required nationally). The requirement for the revised roles would equate to approximately 153 staff from an existing pool of in excess of 200.

The detail of these new arrangements will be implemented in consultation with staff associations and representative bodies in line with the Public Service Stability Agreement (Haddington Road). The development of the GP Lead role and its specifications will be undertaken in collaboration with the ICGP and relevant representative bodies.

7.4.3

Primary Care Management Arrangements

Primary Care services are provided by multi-disciplinary teams including GPs (Primary Care Teams) to a defined population of 10,000 approx. The Primary Care Team (PCT) has two key roles in relation to its defined population: x

The delivery of front line primary health care services predominantly within the remit of GP, nursing and allied health professionals

x

The referral and access to services not delivered at PCT level and the appropriate management of care in conjunction with other services including acute hospitals. The role also includes developing clinical care pathways and shared care models across service provision i.e. primary and social care, and mental health, etc.

Individual team members provide services to individuals through surveillance, advice, assessment, diagnosis, referral, treatment and review. Team members collectively focus on individuals with complex care needs. Collectively team services are focussed on groups within the population for health promotion, early intervention, chronic disease management and access to specialist input.

Primary Care Teams primarily consist of: x x x x

General Practice (GP)1 Public Health Nurse (PHN) Registered General Nurse (RGN) Speech and Language Therapist

x x x

Occupational Therapist Physiotherapist Administrative Support

In order to put in place an appropriate management structure for the delivery of primary care services the following roles and functions must be put in place. The project team assessed the overall resource available within the system at community level and is satisfied that these posts can be put in place through reassignments from existing resources: x x x x x

Primary Care Key Worker Primary Care Team Leader Primary Care Network Manager GP Lead Head of Primary Care.

1

General Practice staff may include GPs, practice nurses, practice managers etc.

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Primary Care Key Worker The Key Worker can be any healthcare professional on the Primary Care Team who has a significant role to play with the service user. The role of the Key Worker is defined as someone who “takes a key role in coordinating the patient’s care and promoting continuity, ensuring the patient knows who to access for information and advice “(NICE 2004) The Primary Care Key Worker will: assess the service users’ needs and their care plan liaise with the other team members involved in the person’s care and agree the care plan with the service user ensure that the findings from the assessment and care plans are communicated to the others involved in the care of the user on an ongoing basis contribute to discussions about the user’s care be the nominated member of the team to communicate issues and coordinate care for the user be accessible to the user and ensure there is a continuity of the role by another team member in the Key Worker’s absence provide any relevant information to the user and, where appropriate, to his/her family or carer ensure the user’s pathway is coordinated as they move across various services such as acute hospital, mental health, social care, etc.

Ensure user’s pathway and/or careplan is focused on health improvement, self care, self management, in addition to treating illness

x x x x x x x x x

Primary Care Team Leader Each PCT will have a Team Leader, who is a member of the team, with protected time to co-ordinate daily working arrangements. The role of the Team Leader is central in co-ordinating the selfmanaged work of the individuals who make up the team and is not a line management role.

The Primary Care Team Leader will: ensure that a Key Worker is assigned to people with complex care needs and that appropriate care plans are developed, implemented and reviewed by the team co-ordinate the provision of performance and activity related information on behalf of his/her colleagues on the team ensure that appropriate common case notes are maintained as required ensure that clinical meetings are held and undertaken appropriately support the maintenance of a good professional relationship including the GPs on the team ensure that there is appropriate liaison and communication with other professionals outside the team, in other divisions and at other levels of service provision.

x x x x x x

Care Team

Sample Primary

PCT Leader

GP 1

GP 2

GP 3

PHN 1

PHN 2

RGN

Team Leader

Admin

OT

SLT

PT

The roles of Key Worker and Team Leader are important developments in supporting effective collaboration among primary care frontline staff in the delivery of services. These roles will bring a sense of identity to the teams and establish important points of contact for service users, GPs and other professionals. They will support the achievement of the goal of Primary Care Teams operating as the key access point from the community and will be enablers of integration, particularly in the development of clinical care pathways.

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Primary Care Network Manager The Network concept was originally created for the specific purpose of service organisation and delivery in relation to its defined population. While previous mapping in the development of networks identified a population range of 30,000 – 50,000, the structure referred to in this document is specifically at an average of 50,000 and with a range of 35,000 to 70,000. This approach will ensure the development of a Primary Care Network in each large town and its surrounding hinterland, or for a district of a city. The specific purposes of defining a network are: x To provide management of the PCTs within the Network. x To manage and organise the Primary Care Network services shared across the PCTs. x To liaise on behalf of the PCTs and the population as the key point of management integration with all other health and personal social care services.

By defining Network Management in terms of population size of 50,000 approx. there is an opportunity to develop very specific assessment of needs for each network population. This will support the targeting of resource and service provision to defined areas e.g. high levels of social deprivation, specific demographics, etc. This will in turn support the development of a commissioning model for service provision across each of the divisions and bundles of care under the proposed UHI funding model.

The Primary Care Network Manager is the accountable and responsible person for ensuring the delivery of primary care services to the population within the defined network area. The role of Network Manager will be developed so as to provide a high level of autonomy and decision making in relation to frontline services. It will also be the integrator of other services provided to the network area and will “champion� the needs and requirements of the population. The Network Manager will have full responsibility and accountability for managing the Primary Care Teams within the network.

This will see a move away from uni-disciplinary management of Primary Care Teams through the current Head of Discipline system to a management structure where: x the Network Manager provides the day to day operational line management function x the Heads of Discipline will provide the clinical assurance, governance and supervision regarding the practice of each professional in the Primary Care Teams. This is elaborated further in the section below.

The Network Manager will: x manage the Primary Care Teams and ensure that the services are delivered in accordance with the service plan. This includes full accountability and budget responsibility for the primary care resources within the network area x act as an integrator with other service providers e.g. acute, mental health, social care, etc. so that appropriate care pathways can be accessed and maintained x ensure that the outcomes and key performance indicators of the individual Primary Care Team members and their collective responsibilities are achieved x provide day to day management of Primary Care Team members (HSE staff) and collaborate with Heads of Discipline on clinical or professional issues on an individual or collective basis x liaise and manage the relationship with the respective GPs and their practices through a performance framework and based on key performance indicators in relation to outcomes. It is also envisaged that this role will include a performance management function in relation to pharmacy services in each network x co-ordinate the health and social care needs assessments for the population x collaborate with Heads of Discipline on key performance related issues as well as the roll out of initiatives and best practice models and staff development.

SAMPLE PRIMARY CARE NETWORK

Primary Care Network Manager Network Manager

Primary Care Team

Primary Care Team

Primary Care Team

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Primary Care Team

Primary Care Network GP Lead: A key component of building an appropriate primary care management structure is the development of an appropriate relationship between GP practices and PCTs/Networks. While the contractual arrangements for GPs will be managed at a more central level, a performance management framework will be implemented at network level. In order to support this process and also to facilitate the roll out of clinical programmes, there is a requirement to develop a “GP Lead" role for each network which is essentially a practitioner with protected time to undertake this role.

The GP Lead role will include: x x x x x

providing leadership in relation to quality improvement initiatives contributing to operations, planning and performance management supporting the Network Manager in the implementation of clinical programmes in such areas as diabetes, asthma, heart failure, stroke, etc. by liaising with other GPs and professionals in the Network the implementation of agreed protocols within the network including referral procedures and integrated care pathways across the primary care teams, including GP practices supporting the Network Manager in developing professional relationships, innovative solutions and multi-disciplinary approaches to challenges within the network.

Head of Primary Care There will be a Head of Primary Care with full accountability for the provision of primary care services in each of the new Community Healthcare Organisations managing the services across Networks and Primary Care Teams. The Head of Primary Care will ultimately be responsible for the operational performance and leadership of all Primary Care services (including Social Inclusion Services) across the Community Healthcare Organisation area. Their relationship with the Head of Health and Wellbeing will be key to ensuring a stronger emphasis on prevention, early detection, health promotion and improvement.

The Head of Primary Care will: be the accountable person and budget holder and provide leadership and direction for primary care services in the Community Healthcare Organisation area x be responsible and accountable for the efficient, effective and safe delivery of these services for patients and clients for a defined population, within national frameworks and for the resources allocated x be a member of the Community Healthcare Organisation Management Team x provide line management of the Network Managers and Heads of Discipline of Primary Care Services and ensure that there is collaboration in approach across the service provision and supervision of clinical care (this will be elaborated further in the following section) x manage and organise those services which are shared across multiple Networks e.g. oral health, audiology, ophthalmology, etc. x lead the development of effective relationships and structures across all services x be the leader and promoter of integrated care with other divisional managers across all care settings x be the leader and promoter of external integration with local authorities, GardaĂ­, education, etc. giving due regard to county and other geographic boundaries. In addition, coordinating communication with public representatives, media and other community interest groups in relation to all service provision within a specified geographic area.

The position of the Head of Primary Care in the Community Healthcare Organisation, with the supporting structure of Network Managers, Heads of Discipline and PCT Leaders, ensures that there will be a strong spine of accountability and governance in place with clarity of roles and responsibilities. Dependent on the population, size and geography of the new Community Healthcare Organisations, there will be a need to provide the necessary supports to the Head of Primary Care. In addition, as we transition to a commissioning model, the Head of Primary Care will be required to support innovation and local commissioning including incentivising good practice. The Head of Primary Care will ensure that there is a needs assessment undertaken for the respective populations of the networks and will support the Network Managers to do so. x

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Needs Assessment A key element of health service planning and delivery will be effective needs assessment. In each CHO, needs assessment and health intelligence will be coordinated by the Head of Health and Wellbeing in partnership with the other Heads of Service. Key features of this will be the involvement of key operational staff in this process e.g. Primary Care Team professionals, Social Care and Mental Health professionals as well as Community Development Workers, the involvement of service users in needs assessment, engagement and cross reference with other services involved in needs assessment and the coordination of existing needs assessments that have been undertaken to date.

7.4.4

Primary Care Clinical Governance and Supervision

Currently the Heads of Discipline of the various professions within primary care provide both line management and governance to their staff. Clinical governance will continue to be provided by the Heads of Discipline with the Network Manager assuming responsibility for day to day line management of staff and general management of the Network. This will allow for the development of the role and function of the Heads of Discipline in providing a structured programme of clinical governance and supervision. Similar to the Network Manager, the Heads of Discipline will report to the Head of Primary Care.

The Heads of Discipline will provide the clinical assurance and governance regarding the practice of each professional in the Primary Care Team. The specific role of the Head of Discipline is to: x

provide clinical leadership and ensure that models of care, including clinical pathways, are implemented

x

implement systematic clinical supervision processes including peer supervision, mentoring, self-directed learning, etc.

x

provide direct clinical supervision when required of nominated individuals to facilitate reflection on clinical practice, encourage professional growth and provide direction on clinical issues as required

x

x

x

undertake, and make arrangements for the auditing of individual clinical performance and practice support staff rotation to meet service and professional development requirements in conjunction with Network Managers support and advise Network Managers on the deployment of staff across and within networks or to specific roles as required

x

ensure that information is disseminated on clinical issues and that there is a sharing of evidence based practice across the profession

x

collaborate with Network Managers on policy and guideline development and update

x

maintain education and training records for their respective disciplines

x

facilitate the implementation of professional competency maintained schemes as required by professional regulators

x

identify the overall requirements for professional development and make provision for specialist competencies

x

collaborate with Network Managers in ensuring compliance and implementation of quality and patient safety frameworks and HIQA standards

Both the role of Network Manager and Head of Discipline are critical to the safe and effective provision of service at PCT level. The network manager position is the key role within the overall operational management and delivery system taking ownership of the integration of services within the network, and with other service providers relevant to the network. The Heads of Discipline (with support from senior therapists and Assistant Directors of Public Health Nursing [ADPHNs]) is the key role in providing clinical assurance and quality and patient safety.

It is vital that the respective roles of network manager and head of discipline are collaborative in nature while being clear about their respective functions so that there is no ambiguity, duplication of purpose or confusion of responsibilities.

The number of frontline staff that would be reporting directly on day to day matters to a Network Manager is significant (25 – 35 wte approx) and not in line with management best practice. To address this, the position of ADPHN will provide both line management and clinical oversight to nursing on behalf of the Network Manager and Director of Public Health Nursing respectively. This is

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appropriate as nursing (PHN and RGN) generally represents up to 60% of the current staffing of PCTs. The ADPHN will report directly to the Network Manager and will report to the DPHN for clinical supervision.

All therapies will report directly to the Network Manager as outlined, and senior therapists working in the Primary Care Teams will support basic grades by providing clinical supervision, supporting skill development, and giving clinical oversight in conjunction with the Heads of Discipline.

7.4.5

Mental Health Management Arrangements

Mental Health services are a secondary service with referral from primary care. In keeping with the ethos of primary care it is the objective that people with mental health needs would be supported in as much as possible, at primary care team level. This is generally provided by GP practices but in some areas there are mental health liaison nurses who provide an additional support. Where it is not possible to fully support the person with mental health needs at primary care level, a referral will be made to mental health services for diagnosis, treatment and support. There will also be circumstances where “shared care” arrangements across primary care and mental health services will be appropriate.

The structure for the organisation and management of the mental health services has evolved since the publication of the national policy Vision for Change (2006). The organisation is specified up to the level of Vision for Change area management team which in original design was to be managed by an Executive Clinical Director (ECD), and in practice has developed with the ECD currently working alongside a senior manager in many areas.

Community Mental Health Teams The direction of travel within mental health is that services will be delivered to a population of on average 50,000 with Community Mental Health Teams (CMHTs) and the Child and Adolescent Mental Health Services (CAMHS) being provided at that level. While this approach is not yet fully implemented, significant progress is being made. There is an opportunity to enable integrative working by having the Primary Care Networks co-terminus with these mental health sectors. This will be important from the service users’ perspective as the GP, PCT and the specialist multidisciplinary services (CMHTs) will work to the same population base and geography. Therefore their relationships and working arrangements in the area of communication, patient pathways, etc. can be optimised. A number of specialised teams e.g. Psychiatry of Age, Rehabilitation will be provided to populations of 100,000 or more, and these will align, or be co-terminous with a number of primary care networks.

Mental Health Management Team Each Community Healthcare Organisation will have a Mental Health Management Team. It is acknowledged that currently there are management teams in place which will need to be reconfigured on an area basis within the new successor bodies. There will be a Head of Mental Health services for each Community Healthcare Organisation who will lead the Mental Health Management Team and will also be a member of the Management Team.

The proposed membership of the Mental Health Management Team is broadly in line with Vision for Change and includes: x x x x x

Executive Clinical Director (ECD) Director of Nursing Heads of Discipline for Psychology, Social Work and Occupational Therapy Operations Manager Service User

Vision for Change envisaged that the role of Head of Mental Health services would be a senior clinician and currently this is a role that is in development within the services. Therefore there may be a transitional stage whereby the Head of Mental Health will be either the Senior Operations Manager or the ECD on an interim basis until the clinical role and leadership function is fully developed.

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The Mental Health Management Team will manage all of the services at the various levels of the future Community Healthcare organisations both in terms of day to day duties and clinical governance arrangements. Their duties will include: x

Delivering a recovery focussed clinically excellent mental health service that involves service users in the design and delivery of their services.

x

Ensure there are appropriate structures in place to facilitate consultation and involvement of service users, carers and family members in the design and delivery of their mental health service.

x

Ensuring that CMHTs in all specialties are delivering on agreed service levels and in accordance with mental health clinical programmes.

x

Being accountable for the delivery of all mental health services safely

x

Ensuring that there is a commitment and process in place to deliver these services based on quality standards and the regulations inspected by the Mental Health Commission.

x

Managing the services within the available resources.

x

Reorganising current services to a community based model and reducing the requirement for residential care.

x

Progressing the implementation of the recommendations of Vision for Change across the Community Healthcare Organisation area.

Reorganisation of Mental Health Management Arrangements It is important in the development of new governance and management structures that the progress made to date in mental health services can be sustained and developed in line with the policy direction of Vision for Change. To this end, and taking account of the feedback from the consultation process as well as submissions made by the National Mental Health Division, the following actions are required: x

each mental health catchment area will be aligned to the geography of the new Community Healthcare Organisations, and should not cross their boundaries. There will be a requirement to review the current 16 mental health super catchment areas to comply with this arrangement i.e. the Midlands and Kildare

x

the 16 Vision for Change Service Areas will be reviewed to combine them where possible in terms of scale (geography and population) so that there would be one single mental health service area co-terminus with the Community Healthcare Organisation.

x

While there will be one Mental Health Management Team in each of the new Community Healthcare Organisations, there will in some cases be a need to put in place appropriate substructures where geography and population merit this. These sub-structures will particularly seek to enable greater local ownership around clinical governance and service improvement

x

there will be one Mental Health Management Team and where there are two mental health service areas, a supporting sub-structure will be put in place

x

Mental Health Sectors will be aligned to Primary Care Networks for the provision of services and to optimise integrated care.

x

Certain services may require to be managed as national services within mental health. One possible example of this is the Forensic Mental Health Service.

Conclusion In the context of all of the above, it would be premature to seek to specify the detail of a number of the structural issues, including: x Any potential sub-structures. x What, if any services, may be operated nationally.

Consideration of these issues will take some time to address and will be determined by the Mental Health Division in consultation with the relevant stakeholders during 2014.

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7.4.6

Social Care Management Arrangements

Social Care services include older person services and services for people with disabilities. The Social care Division provides its services in line with the Healthy Ireland strategy by encouraging and supporting older people to keep healthy, remain at home and stay out of hospital for as long as possible. Similarly in relation to people with disabilities, the aim is to facilitate people to live lives of their own choosing and to support their independence. To achieve these principles, services need to be provided through a person centred model of care and in a collaborative way, with shared responsibility between the person, their families and carers, health and social care professionals, a multiplicity of agencies and society as a whole. This requires further reorganisation of existing services within an environment of a higher level of demand and a diminishing resource. There is also a need to address the opportunities and challenges of people living longer and healthier lives, developing models to suit individualised budgeting where people have increased control of their own resources and have choices in relation to their care. This requires clear and comparable information and advice available to service users to make good decisions about their services.

Social Care services have traditionally been provided by two separate care group structures i.e. older people and disability services. In this context, each of these care groups had its own distinct structure and as with primary care and mental health, the structure has tended to vary from one ISA area to another. Both models of service delivery and management had the requirement to work closely, particularly with primary care services, and the high level of integration of service provision that is required between social care and primary care specifically, remains paramount.

In general, the majority of disability services are provided by Voluntary Agencies and local organisations which are funded by the Health Service through Section 38 and 39 of the Health Act. Disability services vary significantly in scale and complexity and those which are funded under Section 38 tend in the main to be large residential care providers. However, both Section 38 and 39 funded agencies provide a range of multi-disciplinary, day and residential services and have significant linkages with education services, local authorities and other statutory agencies in order to provide a wide range of services to users.

With regard to services for older people, long stay residential care is provided by public, private and voluntary providers and is funded under the nationally managed Nursing Home Support Scheme (NHSS). Short stay residential services e.g. rehabilitation is provided in the main in public units.

The current management structure of both care groups at ISA level features both Service Managers of disability and older people services. x

In disability services, the structure also features professional Case Managers (for organising and coordinating services for people with complex care needs) and Assessment of Need Officers (related to the Disability Act legislative requirements).

x

In older people services, the current management structure also features Home Help Coordinators, Home Care Package / Home Support Service Managers, Directors of Nursing / Service Managers for Residential Care and Day Care Centres.

x

Individual areas have other supporting roles in both care groups, particularly in relation to the development and oversight required for service level agreements, multi-disciplinary disability teams, discharge coordinators / acute hospital liaison staff, etc. A range of staff also work in the area of community work and community development which is provided across all divisions of service.

As referenced in Future Health, international research suggests strongly, that the most effective way to meet the needs of individuals in the social care domain is through an integrated system, where there is a common funding source as part of a purchaser / provider split, a single care assessment framework, a robust governance and accountability framework, a greater emphasis on individualised budgeting all of which would be underpinned by appropriate quality assurance and regulatory frameworks.

The sustainability of social and continuing care provision, particularly in light of the current budgetary climate and the changing demographic profile, means that increasingly scarce resources must be efficiently managed, targeted at areas of greatest need and delivered at the point of lowest complexity.

Work has commenced on the development of a commissioning framework, under the leadership of the COO, however, the detailed arrangements to apply will only be settled during 2014. At the same time, within social care, the Fair Deal scheme already encompasses many of the elements of the

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Money follows the Patient approach, and work will commence in expanding this model by developing a similar approach in respect of other services in 2014, including home care and short stay residential provision for older people.

While the significant role of voluntary agencies in delivering services is acknowledged, it is clear that their role will have to evolve to meet the new approach as outlined above. In respect of the disability sector, 2014 will represent a step change in the pace of implementation of the recommendations of the VfM Report & Policy Review, which is intended to deliver transformational change in the model of service delivery, moving away from the traditional and often institutionally based service to a more person centred model, with a community focus. Service level arrangements will be revised and redrawn to reflect a more rigorous emphasis on budgeting and monitoring in preparation for eventual changes to the procurement or commissioning of individual based services.

In this overall context it would be premature at this point to specify the detailed management arrangements required to support this evolving service model. The Social Care Division nationally will, in 2014, review the existing arrangements, drawing on much of the work undertaken as part of this review and elsewhere, to develop a blueprint for more appropriate management arrangements for social care. This review will be undertaken in consultation with all stakeholders in line with the Public Service Stability Agreement (Haddington Road Agreement).

The Head of Social Care will lead the management of the services and the implementation of the reforms at Community Healthcare Organisation level.

7.4.7

Health and Wellbeing Management Arrangements

Improved Health and Wellbeing is one of four pillars of reform outlined in Future Health. This pillar of reform demarcates a shift in policy, service design and practice away from treating sick people to keeping people healthy. This underlying principle informs many of the other reforms in Future Health, including service, financial and structural reforms. Many areas of the health service already successfully deliver prevention, early detection and self-care programmes, e.g. immunisation, screening and tobacco cessation support. However, leading clinicians, other healthcare professionals and healthcare managers have identified the need to redesign healthcare services and practice to improve the quality of care and to close the gap between what is known to improve outcomes, and what is practiced.

The Health and Wellbeing Division has operational responsibility for all aspects of delivery of a range of services including: x x x x x x x

Public Health, Child Health and Health Protection including the work of the Directors of Public Health, National Immunisation Office and the Health Protection Surveillance Centre Health Promotion and Improvement including the work of the Crisis Pregnancy Programme Environmental Health Services Emergency Management Health Intelligence National Screening Programmes Development of national service strategies and strategic commissioning frameworks for Health and Wellbeing

Given the criticality of health and well-being services to the health of the population and its status as a pillar within the Future Health document, the review proposes that a Head of Health and Wellbeing be appointed to the Leadership team of the new Community Healthcare Organisations. As part of the continued development of the Health and Wellbeing Division at national level, a significant programme of work is underway to align, and where relevant, more fully integrate its operational service components. The specification for the role of Head of Health and Wellbeing at CHO level, potentially encompassing responsibility for a range of services hitherto managed discretely will be informed by the output from this programme. Clarity around governance, the ‘best-fit’ for such a post relative to the current delivery models (spread of national, regional and departmental resources) and its role within a commissioning environment are key here. The pace at which this process can be meaningfully completed, relative to the timeline for the creation of Community Healthcare Organisations, may mean that the role specification, accountabilities and competencies of a Head of Health and Wellbeing will be interim.

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Healthy Ireland The Department of Health is leading a new, whole-of-Government, whole-of-society, approach to health improvement, Healthy Ireland. The publication of Healthy Ireland – A Framework for Improved Health and Wellbeing 2013 - 2025 is a major milestone for the future provision of health and social care in Ireland. It provides the structure to enable service providers to influence major change in the development, implementation and delivery of health and social care for future generations. It emphasises the need for a collaborative approach between the health sector and other areas of Government and public services to work together, to affect improvements in social protection, food safety, education, housing, transport and the environment. These are the key factors which influence health and social outcomes for the entire population. Tackling health inequalities, introducing preventative health measures and health promotion activities, to be delivered in the community, were the key messages in the consultative process which informed the publication of Healthy Ireland. It is widely recognised that these factors are economically more prudent than costly acute care and treating increasingly costly long-term chronic diseases.

Intersectoral Collaboration Healthy Ireland highlights the importance of intersectoral relationships in promoting the health agenda. At a national level and at a policy level the Health and Wellbeing Division will support the Health and Wellbeing Programme in the Department of Health in the co-ordination of the ‘development of models and supports to promote and foster advocates for health and wellbeing in all sectors of society and develop key partnerships with voluntary and other organisations, which can favourably influence health and wellbeing.’

Healthy Ireland also refers to the importance of local operational intersectoral engagement as follows: ‘Local health partners will engage with local authorities in their work to address local and community development, with the aim of co-ordinating actions and improving information-sharing for improved health and wellbeing.’ And ‘It is important to identify local structures for implementation and how these can be supported through this Framework to work on common agendas. It is at this level that individuals, community and voluntary groups and projects, sporting partnerships, local schools, businesses, primary care teams, community gardaí, etc. can interact to work together.

While the Health and Wellbeing Division will lead on intersectoral collaboration at national level enhancing, developing and supporting effective intersectoral linkages as a key support to all Divisions and CHOs, at the CHO level intersectoral collaboration will be lead by the local operational health services – Primary Care and Community Services. This will ensure effective intersectoral engagement both nationally and locally.

A practical example of this is as follows: In relation to local intersectoral working one of the main alignment reforms the Government has directed is the establishment of new Local Community Development Committees (LCDCs) in each county/city, to have oversight and responsibility for local development and community-related funding in their area. LCDCs will have a key function of achieving a more strategic, joined-up approach to local and community development locally. From the health service perspective locally, the CHO representation on the LCDC will be lead by the local operational health services - Primary Care / Community Services to ensure practical operational engagement at a local level.

The work of the LCDCs will also be underpinned by collaborative Departmental working at central government, to support the streamlining of local development structures, improved programme impact assessment, more targeted resource allocation and sustainable funding/administrative arrangements. In this regard that the Health and Wellbeing Division will engage with the process at the national inter-departmental level which in turn will support the with local engagement lead with LCDCs by the Primary Care / Community Services local operational system.

Reorganisation of Management Arrangements Management arrangements within this new division are currently being established and it is the view of the project team that it is appropriate that there would be a Head of Health and Wellbeing on the Management Team of each of the Community Healthcare Organisations.

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7.5 Clinical Leadership Clinical governance is a framework through which healthcare teams are accountable for the quality, safety and satisfaction of patients in the care they deliver. It is built on the model of senior managers working in partnership with senior clinicians. A key characteristic of clinical governance is a culture and commitment to agreed service levels and quality of care to be provided.

Over recent years the health service has placed an important emphasis on quality and patient safety by developing an infrastructure for integrated quality, safety and risk management with the aim of achieving excellence in clinical governance.

The Quality and Patient Safety Division is building on this. Formalised governance arrangements ensure that everyone working in the health and personal social service are aware of their responsibilities, authority and accountability and work towards achieving improved patient outcomes.

Effective governance recognises the inter-dependencies between corporate and clinical governance across services and integrates them to deliver high quality, safe and reliable healthcare.

Clinical governance helps ensure people receive the care they need in a safe, nurturing, open and just environment arising from corporate accountability for clinical performance. The benefit of clinical governance rests in improved patient experiences and better health outcomes in terms of quality and safety. This has resulted in the clinical governance approach being widely adopted internationally.

Clinical governance is an integral component of governance arrangements, where: x

x x

x

each individual, as part of a team, knows the purpose and function of leadership and accountability for good clinical and social care; each individual, as part of a team, knows their responsibility, level of authority and who they are accountable to; each individual, as part of a team, understands how the principles of clinical governance can be applied in their diverse practice; a culture of trust, openness, respect and caring is evident among managers, clinicians, staff and patients;

x

x

each individual, as part of a team, consistently demonstrates a commitment to the principles of clinical governance in decision making; and clinical governance is embedded within the overall corporate governance arrangement for the statutory and voluntary health and personal social services in realising improved outcomes for patients.

The Health Service has developed a suite of principles to assist in the development of good clinical governance throughout its services – these are outlined below: x x x x x

Patient First Safety Personal responsibility Defined authority Clear accountability

x x x x x

Leadership Inter-disciplinary working Supporting performance Open culture Continuous quality improvement

To give effect to clinical governance and ensure that practice is developed in line with the principles set out above in a uniform manner, a framework will be embedded in each Community Healthcare Organisation with the appointment of a Lead – Quality and Professional Development, who will be a non-executive member of the Management Team. The Lead – Quality and Professional Development will be supported by a Quality and Safety, Standards and Professional Development Leadership Team comprising of lead clinicians in medicine (including GPs), nursing, therapies and also including expertise in the areas of quality and patient safety, clinical audit, advocacy and education and training and representatives of frontline service provision. The appointment of clinicians to some of these roles will be made on a rotational basis and will be representative of the various services that are provided across the Community Healthcare Organisation. The function of the Quality and Safety, Standards and Professional Development Leadership Team will be to inform the Lead – Quality and Professional Development on a range of processes required to drive effective clinical governance and which will in turn support the Management Team in terms of its overall strategy and responsibilities.

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Examples of these processes include: x x x x

Quality and Performance Indicators Learning and sharing information Patient and public community involvement Risk management and patient safety

x x x x

Clinical effectiveness and audit Staffing and staff management Information management Capacity and capability

This framework will support the delivery of a range of positive outcomes in the areas of patient care, patient experience, staff experience and service improvement.

Commissioning and Resource Allocation A priority for the specialised community based services will be to ensure the delivery of appropriate services to the population of the Primary Care Network. This will involve new management arrangements such as memorandums of understanding or service agreements which bring clarity to the type, volume and range of services which are accessible to the network from these specialised services.

7.6 Summary x

The provision of care services in the community will be grounded in Primary Care Teams, serving an average population 7,000 – 10,000 people.

x

The Primary Care Team will be supported by the Primary Care Key Worker and Primary Care Team Leader working closely with GPs and other professionals in the delivery of the maximum possible services.

x

Groupings of on average five primary care teams will form a Primary Care Network, the total number of networks will be 90 approx.

x

A designated Network Manager will be appointed with the responsibility of support for the provision of direct services by the Primary Care Team and ensuring the appropriate integrating linkages with both the specialist community services and the acute hospital services.

x

The Community Healthcare Organisation will provide organisational support for an average of ten Networks.

x

The considered view is that the nine boundaries and the associated management and governance arrangements for these structures at local level are the most appropriate to deliver the type of significant reform and responsive service delivery envisaged in Future Health and the Programme for Government. These structures are sufficiently robust to deliver the current requirements for service management, while being flexible enough to support the system from the current state through a number of transition phases to the UHI environment. They provide the “best fit� structure to dovetail with whatever final national organisational arrangements emerge.

x

The primary emphasis of the future Community Healthcare Organisations, as outlined in this report, is on service delivery within the context of nationally prescribed frameworks. They will concentrate on implementation of the nationally agreed standardised models of care for each care group, bringing a local community focus to service delivery, and ensuring integrated services are provided to their primary care networks serving average populations of 50,000. The primary focus has been to establish the appropriate leadership and management team arrangements that need to be put in place to ensure the new structures are fit for purpose in implementing the challenging reform agenda ahead.

x

The Community Healthcare Organisations will be responsible for the delivery of primary and community based services within national frameworks responsive to the needs of local communities.

x

The Management Team will be led by a Chief Officer of Community Healthcare Services and will be comprised of the Head of Primary Care and the Heads of the specialist community services i.e. Mental Health, Social Care and Health and Wellbeing, as well as the appropriate corporate and clinical support services.

x

During transition, the Chief Officer will report to the relevant National Director and executive authority and accountability will be derived from the Health Service Directorate. In the long term the governance relationship can be to the Healthcare Commissioning Agency or alternative area, regional, or national structures when established.

95

x

Achieving improved patient outcomes through ensuring robust quality and safety standards across all services will be a key focus of the Management Team and leadership at all levels.

x

The Heads of individual Discipline will provide the clinical assurance and governance of practice standards throughout the services with a reinforced focus on delivering and measuring service performance on the basis of an integrated service response. The change management challenges arising in delivering services across traditional boundaries is recognised and will be the subject of specific training and reinforcement.

x

It is essential, to ensure the continued effective management and organisation of the service and to progress implementation of the reform programme, that we move rapidly with the implementation of the recommended nine Community Healthcare Organisations on an administrative basis.

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8. APPENDICES

PAGE

APPENDIX A..................................................................................................................

ISA REVIEW – ESTABLISHMENT / PROJECT SCOPE /TERMS OF REFERENCE

98

APPENDIX B..................................................................................................................

STAKEHOLDER ENGAGEMENT

105

APPENDIX C..................................................................................................................

ISA REVIEW – SURVEY QUESTIONNAIRE

108

APPENDIX D..................................................................................................................

REVIEW OF INTERNATIONAL EXPERIENCE FROM THE LITERATURE

110

APPENDIX E..................................................................................................................

REVIEW OF PRINCIPLES OF GOOD GOVERNANCE

150

APPENDIX F ..................................................................................................................

REVIEW OF GOVERNANCE & CLINICAL SUPERVISION

155

APPENDIX G .................................................................................................................

MANAGED CLINICAL NETWORKS – SCOTLAND

168

APPENDIX H Appendix H.1....................................................................................................

Hospitals and hospital groupings for each option Appendix H.2....................................................................................................

ISAs - Proposals Identified Appendix H.3....................................................................................................

LHO Populations Appendix H.4....................................................................................................

Hospital Groupings Appendix H.5....................................................................................................

Options with Mental Health Boundaries Overlaid

APPENDIX I ...................................................................................................................

LEVELS OF SERVICE DELIVERY FOR EACH DIVISION / CARE GROUP

97

170 177 178 179 180

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APPENDIX A ISA REVIEW – ESTABLISHMENT / PROJECT SCOPE / TERMS OF REFERENCE

98

Project Scope Statement – ISA REVIEW Project Name: Project Lead:

Proposals for future organisation and arrangement of our non-acute sector services – Successor structures to ISAs Pat Healy, National Director Social Care Designate

Date:

18th June 2013

Project Justification:

Introduction: In order to achieve the overarching objectives of the reform programme, real changes are required in the organisational arrangements, both from a governance and service delivery perspective. It is a key enabler that will facilitate the achievement of the vision for Primary Care & Community Services and inform our approach in developing a stable environment for delivering integrated care throughout the reform process and as we move towards the UHI environment.

The Reform Programme envisages a move from the current centralised management model for health services to a model that will see greater autonomy for front line services through the establishment of hospital groups and the organisation and management of primary care and community services within identified geographic areas. The changes to be introduced in 2013 will; Provide direct line accountability between the individual National Directors for services and the managers responsible for hospitals and primary care & community services as a precursor to moving to a purchaser provider split & commissioning model.

Ensure the foundation for greater autonomy at service level is in place and provide the stepping stone to independent trusts Primary care, social care, mental health and health and wellbeing services will be delivered and managed through an integrated management structure within geographic areas, which will be identified in this review. This will include HSE funded agencies in these service areas.

It is intended that the future governance of primary care & community services will be similar in approach to the development of hospital trusts, ensuring robust management structures and ‘parity of esteem’ with the acute hospital sector.

The following points are instructive in focussing the work of the review: Commitment in Future Health to reforming the way services are provided in the areas of Primary, Social and Mental Health care and review Integrated Service Area Structure The output and findings from the review will inform decisions in relation to establishing a stable environment for delivering integrated care during the course of and beyond the health reform process and into the UHI environment.

Move from emphasis on acute care towards preventative, planned and well co-ordinated community based care Primary Care Teams and Social Care Networks provide the foundation for a new model of integrated care ISA review timely and necessary now with launch of new hospital Groups and governance arrangements.

Requirements: It is necessary to delineate and map out appropriate successor structures and related catchment areas for Primary Care & Community Services and design appropriate governance models at Area and Sub Area levels that will: clarify the lines of governance and the operational management structure including frontline management arrangements to support effective service delivery and policy implementation drive and support safe, quality care for patients and clients bring decision making close to where services are delivered allow clinicians to shape and assure the services they work in get the best health outcomes for the money spent plan and organise around what we know people need and what we know works to give the best results. facilitate meeting increasingly complex patient and client needs remove any barriers to integrated care

99

Project Approach

There will be four elements to the project approach which will be run in parallel due to the limited timeframe available i.e.: 1.

2.

3.

4.

Extensive Consultation with stakeholders Research & Evidential Base Preparation of Report and Proposals for the successor structure External Validation

1. Consultation The project lead will be supported by a small project team to undertake a comprehensive process of consultation and dialogue with all stakeholders to identify options for the future and bring forward proposals in this regard.

The consultation and engagement will be the most important element of the process providing direct engagement with stakeholders at all levels of the service and facilitating their input to shaping the future direction The process of consultation will involve a series of facilitated workshops and meetings guided by a structured framework around the following key stakeholder groups Ń 17 ISA Managers Ń Operational GMs/LHMs/SOMs Ń Workshop in each of the 17 ISAs with a multi-disciplinary group including the local acute hospital(s) / community services / General Practice representation together with Finance, HR, Estates and other functional supports, local care group Specialists / Managers etc. Ń Meetings with a wide range of stakeholders i.e. relevant national organisations and bodies (meetings will be arranged individually or collectively dependent on the nature of the group) Ń National Directors and members of the top team, National Leads and care group specialists etc.

Consultation with Department of Health – a specific engagement will be required with DoH to ensure that the approach is in line with their current thinking and takes account of work already done A focussed consultation, in conjunction with the national Director of HR, with staff associations / unions to comply with the consultation element of public sector agreement.

2. Research & Evidential Base The approach will also require the normal literature review and research to provide the evidential base to support the final proposals or recommendations of the report. The approach envisages: Secondary Research – A review of reports, documents, previous designs and reviews of Health Structures in the Irish context taking account of other relevant literature.

Primary Research – An audit of existing structures and their stage of implementation of what was the intended ISA process.

The intention is to provide the learning from what has already been done to support any move to the future direction.

3. Preparation of Report and Proposals for Successor Structure The intention is that the final report will succinctly identify the issues and recommend a way forward for the organisation based on the output from the consultation and research work.

The intention is that a preliminary report will be produced which will enable focussed engagement and input from key stakeholders in advance of progressing to a final report.

4. External Validation Consideration will need to be given to requirements around external validation of the proposals.

Project Description:

Develop a design blue print for the “best fit” for local organisational arrangements (both governance and service catchment perspectives) for Primary Care & Community Services that will: Deliver excellent health outcomes for the population by driving integration of services Ensure more efficient use of resources

100

Have a clear spinal cord of accountability from top to bottom Support the strategy of shifting balance of activity towards prevention and community based care and away from hospital based care Ensure services are organised around the population based service deliver model Streamline and reduce the management layers and numbers bringing decision making as close as possible to service delivery Develop clinical leadership Support the implementation of the Future Health and Healthy Ireland strategies.

Influencing factors to apply to decisions around service catchments include: Catchment areas for new hospital groups.

Community connectivity / affiliations and social and cultural links.

Composition of current Primary Care Teams and Network spatial units.

Service catchments of key services such as local authorities, education and social protection that influence the determinants of health.

Spatial strategy and travel patterns of the public for general services.

Existing ISA catchments.

Supports the funding and commissioning model envisaged in Future Health Principles to apply to the governance include: Operational responsibility and performance management must be vested at the lowest level of authority.

Arrangements should support end to end service responses across patient care.

Be consistent with the new organisational arrangements for the new HSE Directorate.

Be applicable across all areas to drive consistency nationally.

Business support services/ functions should be set at the appropriate levels to support service management and ensure economies of scale.

Project Deliverables

Task

Set up project team - underway

Review of existing governance arrangements in each of the 17 areas

Review of existing mapping of 17 Areas and previous HSE mapping options for local areas

Carry out comprehensive consultation process within each of the 17 ISAs Design Implementation

Literature review

Mapping of essential data

Analysis from consultation process ISA’s - Phase 1

Analysis from other stakeholders - Phase 2

Design Workshop(s) to consider potential options for service catchments using GIS

Design workshop(s) to consider governance arrangements at Area and Sub Area level

Interim draft report for SMT

Validation engagement / workshop with key stakeholders

Final report and recommendation for decision

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Assumptions

Sign off by Director General of decision criteria and scope of work.

Release of core team members for project work as required.

Availability of data from key stake holders.

Stakeholder involvement in relevant workshops and meetings.

Project Quality:

Have “design” workshops with key stakeholders Internal and external literature reviews will be carried out Governance arrangements will meet organisational theory and design principles GIS Mapping will be used to support visualisation and integration of key data/information.

Project Management methodology will meet key PMBOX standards

Outside of Scope of Project:

Implementation phase of Project.

Resource allocation

Project Lead:

Pat Healy, National Director Social Care Designate

Project Team:

Bernard Gloster - ISA Manager West Michael Fitzgerald - ISA Manager South Public Health input Brian Murphy – Primary Care Lead Seamus Woods - Head of Change Management, C&FS Geraldine Crowley - Business Manager, South Imelda O’Regan – HSE South

Project Sponsor:

Tony O’Brien, Director General Designate

102

103

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APPENDIX B STAKEHOLDER ENGAGEMENT PHASE 1: The following is a list of the consultation engagements undertaken in Phase 1 of the consultation process

Integrated Service Area Managers

Primary, Community and Continuing Care (PCCC) Operational Managers

Workshops in each of the current 17 Integrated Services Areas (ISAs):

Carlow/Kilkenny & South Tipperary ISA Cavan/Monaghan ISA Cork ISA Donegal ISA Dublin North City ISA Dublin North ISA Dublin South Central ISA Dublin South East / Wicklow ISA Dublin South West, Kildare/ West Wicklow ISA Galway/Roscommon ISA Kerry ISA Louth/Meath ISA Mayo ISA Midlands ISA Mid-West ISA Sligo/Leitrim/West Cavan ISA Waterford & Wexford ISA

PHASE 2: This Phase of the consultation process involved a series of consultative engagements to which the following internal and external key stakeholders were invited:

HSE National Directorate & Leadership Team National Director Mental Health & Senior Team National Director Primary Care & Senior Team National Director Social Care & Senior Team National Director Health & Wellbeing & Senior Team National Director Acute Services National Director Children & Families Chief Operating Officer Chief Financial Officer National Director Clinical Strategies & Programmes National Director National Cancer Control Programme National Director Quality & Patient Safety National Director Shared Services National Director HR National Director Communications National Lead Transformation and Change Systems Reform

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Services for Older People Organisations

Age Action Ireland Ageing Well Network Alzheimer's Society of Ireland Carer's Association Caring for Carers Ireland Home & Community Care Ireland Irish Senior Citizen's Parliament Third Age

Disability Services Organisations

Disability Federation of Ireland Federation of Voluntary Bodies Not for Profit Business Association

Professional Representative Bodies

Association of Occupational Therapists of Ireland Association of Social Care Workers Head of Psychology Services Ireland Institute of Chiropodists & Podiatrists Institute of Community Health Nursing Irish Academy of Audiology; Irish Association of Directors of Nursing Irish Association of Social Workers Irish Association of Speech & Language Therapists Irish Chiropody & Podiatry Organisation Irish Dental Association Irish Nutrition & Dietetics Institute Irish Play Therapists Association Irish Society of Chartered Physiotherapists The Psychological Society of Ireland The Society of Chiropodists & Podiatrists in Ireland

Irish College of General Practitioners (ICGP)

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Palliative Care Voluntary Organisations

Association of Hospital Chief Executives (non acute hospitals)

Unions:

IMPACT IMO INMO IHCA PNA SIPTU IDA

Focus Group Meetings:

Dublin North City ISA South East ISA Mid-West ISA Kerry ISA Ayrfield Primary Care Centre Belfast Trust, Northern Ireland

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APPENDIX C ISA REVIEW – SURVEY QUESTIONNAIRE

ISA REVIEW

SURVEY QUESTIONNAIRE Guideline: The purpose of this questionnaire is to assist a survey of existing ISA management and governance structures.

The questionnaire should be completed and signed off by each Area Manager. The completed questionnaire should be returned to: isareview@hse.ie by 19th July 2013.

Region ISA Section 1 – ISA Management and Governance: 1.1 Please provide details of current Title, Grade and reporting relationship of Area Management Team Area Management Team (AMT) Members No.

Title of AMT Member

Grade of AMT Member

Responsible for

Reporting to

1 2 3 4 5 6 7 8 9 10 11 12 Please provide a brief description of the management arrangements in your ISA i.e. managed on care group or geographic basis etc.

1.3 1.4 1.5

Please provide an organogram to describe current management structure Please provide an organogram to describe current governance structure Please list existing management and governance committees in your ISA (e.g. Clinical governance, Risk Management etc.) please specify reporting arrangements to AMT etc.

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Committees No.

Title of Committee

Title of Committee Chairperson

Purpose of committee

Reporting to

1 2 3 4 5 6 7 8 Section 2 – Health & Social Care Networks (HSCNs) Is there any Health & Social Care Network managed as a network in its totality?

Yes / No: Please list any services in your ISA which are managed at health & social care network level e.g. Specialist Disability Service, Home Care Services, Nursing etc.

No.

Service Type (e.g. Specialist Disability Service, Home Care, Nursing etc.)

Name of HSCN

1 2 3 4 5 6 7 8 2.3

If applicable, please provide an organogram to illustrate the management of the above services

Section 3 – Primary Care Teams (PCTs) Management & Governance 3.1 Please provide a brief description of how Primary Care Teams are managed in your ISA? Section 4 – Mental Health Services Management & Governance 4.1 Please provide a brief description of how Mental Health services are managed in your ISA together with an organogram?

Section 5 – Older People Services Management & Governance 5.1 Please provide a brief description of how Older People services are managed in your ISA together with an organogram?

Section 6 – Disability Services Management & Governance 6.1 Please provide a brief description of how Disability services are managed in your ISA together with an organogram?

Signed by ISA Manager:

__________________________________________________

Date:

__________________________________________________

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APPENDIX D REVIEW OF INTERNATIONAL EXPERIENCE FROM THE LITERATURE

````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````` `````````````````````````````````````````````````````````````````````````````````````````````````````````````````

AN INTERNATIONAL REVIEW OF INTEGRATED HEALTH AND SOCIAL CARE

NOVEMBER, 2013 DR KATHERINE GAVIN

110

Table of contents Page 1. Background to the report

................................................................................................. 112

2. Individual country analyses................................................................................................... 112 a. Northern Ireland’s experience of integrated care

............................................ 112

b. Scottish experience of integrated care ................................................................ 115 c.

Torbay’s experience of integrated care (UK NHS Trust)...................................... 120

d. North West London experience of integrated care............................................... 122 e. Australian experience of integrated care ............................................................. 124 f.

New Zealand (Canterbury’s experience of integrated care)................................. 127

g. Sweden (Jönköping County Council’s experience of integrated care .................. 130 h. Israel’s experience of integrated care................................................................... 134 i.

Netherlands experience of integrated care........................................................... 136

3.

Critical review papers on successful health services Integration

4.

Summary of key themes & learning from international experience with integrated care.... .144

5.

References .......................................................................................................................... 147

111

................................ 141

1. Background to the report This report is the result of a request by the HSE for an International Review of Integrated Health and Social Care. The review summarises the experience of a number of countries, with a variety of health and social care structures and systems, with the implementation of Integrated Health and Social Care.

The countries chosen were recognised as having made significant progress with Health and Social Care integration and were considered examples of Best Practice in integrated care.

The information for the report was obtained following an extensive literature review (see References section 5).

2. Individual Country Analyses a. Northern Ireland ‘s (NI) Experience of Integrated Care In the case of Northern Ireland, a King’s fund review by Chris Ham, et al., (2013) was particularly helpful.

Northern Ireland is unique in the UK having a structurally integrated system of Health and Social Care since 1973. Hospitals (Acute care) and specialist services, local authority and health and welfare services are all integrated into one system.

Years of civil and political unrest have impeded progress with integrated care. Devolution has been in existence continuously since 2007 providing a more stable environment for advancing integration. .

Demography Northern Ireland has a population of 1.8 million with 2/3 residing in the greater Belfast area. It is acknowledged to be one of the most deprived regions in the UK with relatively high unemployment, disability and poverty. The population is predicted to grow to 2 million by 2025 (increase by 8%). By 2025, those aged 65 years are predicted to increase by 42% (from 260,000 to 370000). By 2025 those aged >85 years are predicted to increase by a factor of 2 compared with 2010 (from 30,000 to 55,000) (Department of Health and Social Services, DoHSS & Public Safety, 2013).

There is a documented Increase in chronic condition amongst the population e.g. Diabetes mellitus, respiratory problems, stroke and obesity.

Health Service Funding The health service is funded through general taxation across the UK using the Barnett Formula with funding allocated in blocks of 4 years with a fixed yearly budget*. Funding is calculated using a population based share approach. NI gets 3.8 billion sterling per year (equivalent of 4.5 billion euro) for a population of 1.8 million (compared with Ireland 13.81 billion euro -equivalent 11.65 billion sterling) for population 4.59 million 2013). NI receives circa 2.5 billion/million population versus 3 billion per million population in Ireland.

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Evolving Structure of Health and Social Care ¾ In 2009 Health and Personal Social Services were restructured as follows (Figure 1): Department of Health Social Services and Patient Safety (includes public health & patient safety, DoHSS & PS).

A Health and Social care board, 5 large health and Social Care Trusts and 5 corresponding local commissioning Groups. The Trusts deliver the care. There is a separate Ambulance Trust.

Figure 1.

Structure of Health and Social Care Northern Ireland Department of Health Social Services and Patient Safety (includes public health & patient safety)

A Health and Social care board, 5 local Commissioning Groups

TRUST Primary, Secondary and Community Care

TRUST

TRUST

TRUST

TRUST

Ambulan Trust

The DHSS & PS is responsible for Acute care, General Practice (GP), Community, PSS, Public Health and Public Safety. The department answers to the Minister for health. The Board commissions care from the trusts and also from General Practitioners (GPs), dentists, opticians and community pharmacists.

The trusts provide the services; Each trust controls their own budgets, staff and services. The average population per trust is 359, 878 versus a figure of 307,753 in the UK. ¾

General Practice (GP) and Health Service Structure

GPs are generally in group practices and care is delivered by multidisciplinary teams including nurses and others. The service is generally proved by public hospitals and there are only 2 small private hospitals in NI. The majority of residential home places are private. The GPs are accountable to the HSC board directly and not the trusts and are funded through the HSC board. ¾

Integrated Care Partnerships (2011)

Following the Compton review (2011), a new proposed system was put forward for NI, “Integrated Care Partnerships” (ICPs). These were proposed to join a full range of H & SCC in each of 17 areas.

Each ICP would perform a needs assessment of its local population and then plan and integrate the delivery of Services. GPS were to take a leadership role. ICPs are described as a co-operative network between service providers for the design and delivery of services and are clinically led. The focus initially was on certain aspects of care e.g. “frail elderly and chronic disease conditions e.g. DM. It was aimed to be proactive by identifying people at risk in the community and putting care in place to keep them in the community for care as much as possible. Questions were asked regarding the need for 17 bodies and the resourcing of such a system with increasing health care costs amid funding pressures. In addition it was feared that Social care would get lost within the priorities of Health.

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Evidence for progress with Integrated Care in Northern Ireland There is an absence of an explicit performance management system in order to make meaningful comparisons with other countries E.g. England, Wales and Scotland.

Lack of rigorous evaluation of the system is evident in NI however there are reports of some pockets of progress reported (Heenan & Birrell in 2006, 2009 and 2012).

Integrated management is having a positive impact in addressing the gap between health and social care and decreased delay in discharging patients from hospital has been noted.

Challenges remaining include the dominance of Health over Social care on the agenda and a lack of inter-professional training. ¾

Programmes of Care

Nine Programmes of Care have been introduced in NI in the following areas; acute service, maternity and child health, family & child care, elderly, mental health, learning disability, physical and sensory disability, health promotion and disease prevention, primary health/adult community care.

These programmes are made up of interdisciplinary teams. Professional support is reportedly high for this scheme Patients have a named key worker and care is co-ordinated. Having one agency and one budget in NI is seen as a positive as in the UK interagency tensions in their Care Programme have been difficult to overcome. The UK have reported increased MDT working in the area of elderly care and Mental health but have not yet achieved full integration of services (Snappe 2003).

Other suggested positives in the NI system are the management structure of the Programme of Care teams where any profession can be the team leader, leading to greater respect and parity of esteem amongst the different disciplines. In addition, patient discharge is the responsibility of a single body which leads to a more streamlined process. One area where improvement could be made is in the area of core professional training which is separate, whereas in the trust training is multi-professional.

It is suggested that the existence of a single unified Health & Social Community Care system in NI might help alleviate many of the issues impeding successful integration of care and service delivery.

Difficulties with Integration in NI o

Unequal partner Health versus Social Care; o o o o o

Most of funding goes towards health and not social care especially Acute care Nearly all targets set are regarding health-need other targets of wellbeing The medical model of need identification is dominated by health agenda and priorities.

The composition of the Team on HSC trusts has heavy health bias and this needs changing Pay and status of social care should be addressed

Although robust evidence is lacking as to improved healthcare outcomes as a result of integration, there is some evidence that integration of health with social care in certain areas, namely domiciliary care for elderly, community mental health and learning disability and physical disability is progressing.

A good example of integration is the “rapid access for GP referral and community stroke rehab” initiative. Less integration is evident in other areas such as individual budgeting and children’s services.

Recommendations to achieve full Integration of Services (Heenan and Burrell, 2006) x x x x x x x

Raise the profile of Social Care Joint training for Health and Social Care professionals Focus on outcomes Debate social models of care Have a balanced composition of Bodies (Heath and Social Care) Robust research and evaluation to provide evidence for the impact of integrated care on outcomes Good leadership

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Overall Conclusions from the NI experience of Integrated Care x

System is evolving in NI

x

Need robust evidence to assess and evaluate outcomes and for international comparison.

Small studies suggest advantages to integrated care. Need evidence of improved patient care to support integration.

Key advantages of the set up in NI x

Single employing body

x

Single budget

x

Agreed strategies and plans

Disadvantages x

Health care dominates social care

x

Cultural differences between health and social care

x

Separate training of the professions-lack of awareness of other’s roles, lack of parity of esteem

x

GPs not yet fully integrated

x

Need strong leadership and buy –in for success

b. Scottish Experience of Integrated Care In the case of Scotland, a King’s fund review by Chris Ham et al., (2013) and a Government report on the integration of Adult Health and Social Care in Scotland (2012) were particularly helpful.

Demography Scotland has a population of 5.2 million. Population density is low compared to rest of the UK. Similar demographic trends exist to those reported in the rest of the UK; the proportion of people aged 65 and older has grown significantly and is projected to increase by over 2/3 over the next 20 years (www.scotland.gov.uk/Topics/Statistics).

Health Service Funding Funding of Health and Social Care is devolved. Funding is through general taxation across the UK using the Barnett Formula (see Northern Ireland). In addition, funds may be realised by local authorities through council tax and non-domestic rates. There is also the capacity to borrow funds.

There is a small independent health sector with which the NHS contracts to very limited extentindependent and 3rd sectors are important providers of care & support for elderly (88 % of care home places and 51% of home care hours are provided in this way). These services are often delivered in partnership with statutory sectors funded by the NHS and local authority users.

Funding for 2011/12 for Health was 11.68 billion sterling. Spending per capita is higher than in other UK countries (2,072 in 2010/11 for Scotland versus 1,900 for England). Spending for local authorities in 2010/11 was 18.5 billion. Spending was 3 billion on social care services in 2010/11 – (thought to be an underestimate as does not take account of personal contributions and other sources). Free personal care for the elderly was introduced in 2002.

Evolving Structure of Health and Social Care Between 1974 and the early 1990’s there were 15 health boards with responsibility for hospital and community services including primary care.

In the early 1990’s this structure was replaced by a model based on market principles. Health boards were purchasers of care for their populations and hospitals and community services were

115

separate NHS trusts supplying services to the boards. GPs purchased a limited range of services from NHS trusts for their patients.

In 1996, 29 unitary authorities were added to the 3 pre-existing island authorities making a total of 32 local authorities to replace regions and districts. The local authorities have populations ranging from 600,000 to less than 51,000. The local government system mainly operates through committees with delegated accountability. In each local authority area, a Community Planning Partnership (CPP) has been established to oversee public services.

Creating Conditions for Integration in Scotland There has been a focus on integrated care in Scotland for over two decades. The system structure of unified boards is designed to promote integration. There is evidence of steady progress in establishing formal health and social care partnerships between NHS boards and local authorities.

The Community Care and Health Scotland Act (2002) was designed to break down perceive barriers to collaboration giving power to transfer functions without removing statutory responsibilities and giving powers to create pooled budgets between health and social care partners.

Performance Management A National Performance Framework aligns performance management. Progress towards these outcomes is measured through 50 National Indicators and targets-a significant number of these relate to health and social care. There is a Single Outcome Agreement (SOA) between government and each Community Planning Partnership (CPP). SOAs are the means by which CPPs agree strategic priorities for their area and express these as outcomes to be delivered by the partners (individually and jointly) A Quality Measurement Framework provides a structure for understanding and aligning the wide range of measurement occurring across the NHS showing how it all leads towards the various Quality Ambitions (including long and short term targets and local and national targets).

Responsibility for External Regulation of Health & Social Care in Scotland is divided between Healthcare Improvement Scotland (HIS) and the Care Inspectorate. Audit Scotland oversees both health and social services.

Scotland reports progressive integration of hospital, primary and community services alongside mental health and learning disability. Through Community Health Partnerships (CHPs) links are strengthened between GPs and local authorities.

There are 2 types of CHP; health only (29 in 2010) and integrated health and social care structures, CHCP, of which there are 7 (community Health and Care Partnerships). Glasgow has a single CHP. All are statutory committees or sub-committees of NHS boards and are accountable to their respective boards. The integrated CHPs have dual accountability to the relevant local authority.

Structure of Community Health Partnership teams The make-up of the CHP teams are well defined and consist of a general manager, GP, nurse, doctor (not providing primary medical services), councillor/officer of local authority, staff member of public partnership forum, community pharmacist, allied health professional (AHP), dentist, optometrist, and a member of a health related voluntary sector organisation.

Two reviews of CHPs in Scotland provide evidence of some shift in the balance of care yet few examples of joint planning and suggest that a comprehensive understanding of shared resources is needed. The cultural differences within organisations are recognised. Clarity around the roles and, authority of the CHPs are needed.

Evolving Structure of Health & Social Care Partnerships In 2000, responsibility for health and adult social care was combined in Scotland. There are Health and Social Care Directorates, 32 local authorities, 14 NHS Boards and 9 National health bodies. The 14 health boards are responsible for the planning and delivery of services for their populations (Figure 2). The sizes of these populations range from 113,000 to 1.2 million. The boards focus on strategic leadership and performance measurement. Responsibility for service delivery is delegated to 11 operating divisions for acute services and to one of 36 Community Health

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Partnerships for community and primary care services. Some of the boards have unified this function and have a model of a single operating system combining both acute and community health functions.

The 9 national bodies work in partnership with the 14 boards for services such as ambulance, education & training, quality improvement-issues best provided on an all Scotland basis.

GPs and general dental practitioners are independent contractors providing services to the NHS. Figure 2. The Structure of Health & Social Care Partnerships Scotland Scottish Parliament Scottish Government Cabinet Secretary & Ministers

Health and Social Care Directorates Local Authorities (32)

dependent sector .

Territorial NHS Boards (14)

social work & related depts.

Care Homes, home care

National health bodies (9)

Community health partnerships (36)

Operating divisions (11)

Hospitals Community services

Independe sector

Hospital hospices clinics

GPs, dentists, community pharm.

Accountability relationships Other relationships (e.g. funding, contracting, regulating)

Since 2012, the Government decided to replace CHP with Health and Social Care Partnerships to secure greater integration between health and social care for all adults. The arrangement provided freedom to extend to other areas of service by local agreement & and allowed for mandatory extension in the future Functionally, the NHS boards work closely with the local authorities to deliver a range of community health and social services. Each local authority has representation on the relevant NHS board, and through local authority membership of all CHPs and some joint appointments & joint accountability.

Key principles of integration; o o o o

Services should be integrated around needs Strong leadership Joint accountability from providers of services for outcomes Flexible sustainable financial mechanisms-around needs of people not the organisation

delivering

In the Scottish system, Managed Clinical Networks (MCNs) are linked groups of health professionals and organisations from primary, secondary and tertiary care working in a co-ordinated way, unconstrained by existing professional or health board boundaries. There are currently 130

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MCNs. Coverage varies - 29 are countrywide, 22 are regional and the remainder are local. The MCNs also vary in their scope, some cover conditions e.g. diabetes, epilepsy and others cover specialities e.g. neurology, palliative care. There are 5 areas where coverage is universal, that is there are MCNs in each Board Area for cancer, respiratory, stroke, diabetes, and coronary heart disease. There are 3 regional cancer networks.

In the area of mental health and learning disability MCN have full local authority involvement.

Evidence of impact of MCN There is limited evaluation of the impact of MCN but there are some positive findings. Analyses of a local cardiac MCN and 2 cardiac and 2 diabetes MCNs, a positive impact on inter-professional and inter organisational activity reported along with some changes in professional practice and service improvement (Hamilton et al. in 2005 , Guthrie et al 2010) It was felt that the MCNs had facilitated the implementation of national initiatives such as clinical guidelines. There was however limited evidence of decreasing emergency hospital admissions.

The fact that MCN are in existence in Scotland for 15 years indicates support from Government, clinicians and management for the concept.

Role of Information Technology (IT) The importance of IT in promoting service integration in Scotland is stressed. Since 2005, there has been a drive in Scotland for the development of a comprehensive health information system based on an electronic health record (Scottish executive 2005). Two major advances are already reported; universal use of unique patient identifier and national emergency care summary, accessible to NHS staff in out of hours centres (*NHS24 and A & E departments). The NHS works in partnership with local authorities to develop health and social care IT strategy for information sharing towards an appropriate community based service. Scotland is seen to be a leader in the area of Telehealth and telecare. It is believed that such advances could be useful in monitoring long term conditions e.g.

Chronic Obstructive Pulmonary Disease, (COPD), Coronary Heart Disease (CHD), Mental Health with results being sent to a Hub call centre daily and raising an alert if results are abnormal.

Key principles of Managed Clinical Networks in Scotland o o o o o o o o

Lead clinicians Structure Annual plan with roles and responsibility to deliver, specified standards Evidence base , Continuous Quality Improvement (CQI) MDT with role clarity User involvement & voluntary sector input Education and training, Continuous Professional Development (CPD) Opportunity for Value for Money (VFM), value added regarding patient care

The Government is setting up an Integrated Resource Framework to facilitate budgetary integration in the future. The framework increases clarity around cost and quality implications of local decision making around health and social care. It is recognised that the financial relationship should be around populations served and not organisations-the framework aims to show this. Integrated Resource Maps provide cost and activity information in health and adult social care. Boards have begun mapping in this way, some with local authority partners. A report on the experience of 4 sites and their 12 partners in local authority indicated it was easier to capture data on cost and activity in the hospital setting compared with social and community care (Ferguson et al 2012).

Successful Integration needs x x x x x

Clarity of purpose and outcomes Strong leadership Staff empowerment and carer empowerment Agreement on appropriate scale and scope Alignment of all available drivers; policy, legislation, structures, information, incentives, outcomes.

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There are examples of successful integration including: o Risk Prediction of patients with long term conditions 2008-2011 (which showed a 13.5% reduction in rate of emergency bed days for long term conditions from 2006/7 to 2010/11), o The hospital in the Home initiative , o Anticipatory Care Planning for at risk groups for hospital admission. o Provision of intermediate care by community hospitals providing extended primary care facilities with 24 hour cover.

CHPs were encouraged to use community hospitals as a platform to bridge the gap between home and specialist hospital care. Community hospitals could extend their role to provide Outpatients and or inpatient services e.g. Invergodon.

The National Framework has seen development of 32 local partnerships with joint strategic plans and with the Change Fund acting as a catalyst for the health and social community to work together.

A Multiagency Improvement Network acts as a support for these partnerships. The change fund is seen as a stepping stone towards longer term commissioning strategies Lessons for Scotland Performance Management has been a focus for some time. In 2008, A National Outcomes Framework for Community Care has been provided with National Outcomes identified and 16 performance measures. Some official targets include; o o

Decrease rate of bed days as a result of emergency admission of elderly Speed up discharge from hospital to an appropriate setting

Challenges remain o o o o

The trend in the numbers of A&E admissions of people •65 years continues to rise Delayed patient discharge requiring new targets are evident e.g. get to zero the numbers in hospital more than 4 weeks by 2013 and to 2 weeks by 2015.

Curb numbers of elderly in care homes and increase numbers receiving intensive care in home For Integrated care to be sustainable need transfer of resources from hospital to community setting and from the NHS to local authorities. The CHP were to have a key role in initiating this process but in reality not much has changed.

Enablers for Integration in Scotland x x x x

Structural/organisational stability in NHS and local government facilitates the change coupled with on-going Political commitment to the Integrated care and Partnership approach The fact that the NHS boards unify acute primary and secondary care is a strong enabler and that local authority representation is evident at Board level and in CHP. This brings an emphasis on collaboration and not competition The strong Performance Management Culture in the NHS as evident by the National Performance Framework which also encompasses local government and public service A small size allows brokerage amongst a small number of senior leaders to happen more easily

Barriers for Integration in Scotland x x x x x x x

In health care there is a history of dominance by the Acute speciality sector which is hard to shift towards the community There are barriers between health and social care in structure, responsibilities, roles, culture, educational background and professional differences Tensions exist around joint working , information sharing and respective roles Separate training for the key professions is not conducive to increased understanding of each other’s roles The new system challenges conventional hierarchical arrangements and reporting structures Terms of employment and efforts to harmonise the conditions of employment are needed 2 distinct disconnects have been reported between primary and secondary care in the NHS and between health and social care.

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c. Torbay’s Experience of Integrated Care (UK NHS Trust) Much of the information and analysis on Torbay is from the official Torbay government website. (www.torbay.gov.uk/index/council/factsfigures/torbay201213jsna.pdf) and a policy paper by Ham (2010).

Demography and Background Torbay is a small unitary council area that includes the 3 towns of Torquay, Paignton and Brixham. It is a generally impoverished area. It is predominantly urban and has a higher than average elderly population (23% over 65 years) versus the national average of 16% in the UK).

South Devon Healthcare NHS Foundation Trust (Torbay Hospital) is described as a medium-sized District General Hospital, situated on the SW coast of England. It serves a population of approximately 280,000, rising to >350,000 in the summer months. The hospital works very closely with its Primary Care system and is striving towards fully integrated healthcare. It is acknowledged nationally as a progressive and innovative organisation with good patient outcomes (Health Partnerships-THET).

There is a history of whole-systems thinking in Torbay and a strong foundation of primary care services for some time with the council and primary care team having a shared territory. For over 20 years the PCT and the Council are reported to have had good relations.

Torbay Primary Care Trust came into existence in 2000 and became Torbay Care Trust in 2005 (taking on responsibility for social care in a partnership agreement with Torbay Borough Council) and Torbay and Southern Devon Health and Care NHS Trust in 2012. There are 19 GP practices in Torbay with a registered population of 145,000 and an average practice size of 7,600 (slightly higher than the UK average of 6,900). The 19 GP practices are encouraged to work together in 5 small clusters.

The Care trust provides community health services in Torbay and Southern Devon and in Torbay provides and commissions adult social care services The Chief Executive of the Care Trust is accountable for the delivery of the aims and objectives of the organisation and the Partnership Agreement with Torbay Council. As an NHS body, the Trust is formally accountable in accordance with the relevant NHS legislation.

Trust staff operates from a range of different premises across Torbay and South Devon such as community hospitals and clinics.

Since 2012 healthcare commissioning became the responsibility of the Commissioning Cluster for Devon, Plymouth and Torbay.

Funding of the Care Trust Torbay and Southern Devon Health and Care NHS Trust receive funding directly from the Department of Health. The trust works with other organisations across the South West in the provision of directly managed health services, primary care and prescribing, community health services and commissioning, public health and other locally delivered services.

In addition the Trust receives funding for adult social care expenditure delegated from Torbay Council under a Section 75 Agreement. The Partnership Agreement details the financial contribution from Torbay Council to Torbay and Southern Devon Health and Care NHS Trust and the accountability arrangements.

Budgets and Expenditure Reports Torbay and Southern Devon Health and Care NHS Trust reviews its funding arrangements annually and agreement on the application of these funds is made by the Board.

A key target set by the Department of Health, is for the Trust to deliver a financial surplus by the end of each financial year. A Director of Finance & Corporate Services has responsibility for the oversight of the Trust’s finances and provides a monthly finance report to the Board. The Board monitors spending against this budget through this report. At the end of the financial year, a set of Annual Accounts are produced.

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As of 2013, Torbay and Southern Devon Health and Care NHS Trust will sit at the heart of the health and social care system. As a result, the commissioning of care for Torbay residents now happens as part of what is called a commissioning cluster – a group of NHS organisations consisting of Torbay, NHS Devon and NHS Plymouth. This cluster has its own Board and its own decision making processes, designed to ensure the residents of Torbay, Devon and Plymouth have access to the best care possible.

Governance of the Care Trust The Care Trust has representation from the council at a number of levels. The Trust Board has 2 councillors nominated by the local authority, a cabinet member for adult social care attends board meetings and a number of the Council’s executive directors attend the board. There are 5 executive and non-executive members of the Board. Torbay council has a CEO and a nominated officer. There is a chief executive director of adult social services, a company secretary and a professional executive committee chaired by the medical director. There are 5 acting directors reporting to the CEO; directors of public health, operations, finance and corporate services, Human Resources (HR) and commissioning. 5 general managers representing Brixham, Peigton (2), and Torquay (2) report to the director of operations. Support services provide assistance to the General Managers.

Evolution and functioning of the Care Trust Torbay is one of three areas in England who have tried to adapt the experience of Kaiser Permanente (one of the longest established and best known Health Maintenance Organisations or HMOs in the USA). At Kaiser there is a drive toward integrated Health and Social care, a focus on improving care for people with long term conditions and strengthening the role of clinical leaders.

The vision for the Care Trust was centred on a fictional character “Mrs Smith” and how the health and social care services should operate to deliver seamless integrated care. Torbay established 5 integrated health and social care teams organised in zones or localities aligned with general practices. This would equate to a catchment population for each team ranging from 29,000 based on a registered GP population of 145,000.

A pilot project in the Brixham area discovered a number of users who needed intense support from the community and integrated care teams. The teams are co-located, have a single manager, single point of contact and use a single assessment process for patients. The team meet very regularly to review these complex cases and decide on a course of action. The format facilitates understanding of each other’s roles and facilitates co-ordination of care. As with other successful care programmes, Torquay teams focus on the needs of the populations they serve. The teams work with GPs acting in partnership across all areas including long term care, palliative care and disabilities.

Health and Social Care Coordinators work within each team to accept referrals and are the single point of contact for patients. They are not professionally qualified-this aspect of the Torbay experience is being regarded as particularly innovative. Budgets are pooled and can be accessed by any member of the team to commission whatever care is needed by each patient. Since 2009, a fully integrated electronic health and social care record has been created to facilitate this process.

Another development in Torbay is investment in intermediate care services to treat patients in the home whenever possible and facilitate discharge in a timely fashion with adequate home support. The review of the role of community hospitals towards an active intermediate care role is supporting this endeavour.

A collaborative project by the Care Trust sees a team review patients in hospital, when beds are under pressure, to work with hospital staff to discharge patients. Torbay is involved with a national integrated care organisation pilot focusing on elderly patient discharge.

Enablers ¾ ¾ ¾

Solid foundation of Health and social care working together for 20 years Commitment of the staff to integrated working The evidence of benefits to the new approach

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Evidence for Progress with Integrated care in Torbay There is considerable objective evidence for progress towards integrated care in Torbay. Torbay has the lowest use of hospital beds in the region and has the shortest length of stay. Favourable performance in the areas of emergency admissions for the elderly, use of emergency beds for the elderly, day surgery rates and low rates of discharge to residential homes has been recorded. The Care Trust has received external validation from the Healthcare Commission, in the form of the Health Service Journal (HSJ) award for innovation and achievement in the UK in long term care management and good financial performance (2008). Reports of staff and user satisfaction have also been high.

Future challenges Budget constraints -tighter funding from the NHS will challenge providers trying to advance the integration process A potential conflict may result for PCTs and Care Trusts from the Transforming Community Services Programme in the NHS which will require a clear separation between provider and commissioner functions. This will challenge integrated team function by introducing competition and choice into the mix.

There is a need to; ¾

build stronger links with mental health services and health care elements of learning disability provided by Devon partnership NHS trust for the past 10 years,

¾

build stronger links with secondary care and specialist care,

¾

operate a new approach to commissioning. Clinical Commissioning Groups (CCGs) replaced primary care trusts (PCT) from April 2013 as part of the Government’s Health and Social Care Act (2012).

This sees the responsibility for buying services for patients shifting to the clinicians (doctors, nurses and other healthcare professionals) who provide the care.

It is suggested that the planned integration of the Care Trust and Foundation Trusts into one new Trust from 2014 may facilitate further progress with integrated care in Torbay. The Foundation Trust will take on responsibility for running all services, in one new integrated trust providing services to over 375,000 people across the entire hospital community spectrum. GP services, NHS dentists, pharmacies and opticians will remain separate.

d. North West London’s Experience of Integrated Care Curry et al. (2013), reports on a large scale integrated care initiative in North West London. The population of the North West region is 550,000. Primary, secondary, community, mental health and social care is provided by the pilot (Figure 3). For the purpose of the pilot, the aim was to reduce emergency admissions in residents aged 75+ and/or living with diabetes over a one year period. The project involves 2 hospitals, 2 mental health providers, 3 community health care service providers, 5 municipal providers of social care, 2 Non-Government Organisations, (NGOs) and 103 GPs. The aim was to proactively manage the target group of patients and prevent unnecessary hospital admissions.

The pilot operates as a Network – virtual integration type model as care is provided by a number of professionals working across many organisations. Separate providers work together towards common goals according to contractual agreements which are signed on joining the pilot. Agreements state that providers must operate within a governance structure based on weighted voting rights if consensus not reached and financial savings must be shared according to pre-agreed proportions.

The pilot was expected to target an estimated population of circa 30,000 patients fulfilling the criteria (>75 and or diabetes).

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Figure 3. Structure North West London Primary Care Pilot (Adapted from Curry et al., 2013) Hospitals

Mental Health Providers

Operations Team Admin & T support

Report to

Social Aare

GPs

Community health Providers

NGO

Integrated Management Board (IMB) and committees

9 Multidisciplinary Groups (MDGs)

Participate Support Organisations participation is voluntary. Representatives from all organisations participating are invited to attend monthly Integrated Management Board meetings.

Locally, representatives from all provider organisations belong to Multi- Disciplinary Groups (MDGs) set up to improve care across different services especially those at high risk of hospitalisation.

Representatives work collaboratively to improve care. GPs create care plans for all patients intended to bring standardisation to care and best practice. The care plans are shared amongst service providers via IT. An innovation fund allows MDGs to commission community services to support outof- hospital care. The MDT decides how to use the allowance from the innovation fund and submits proposals to the Integrated Management Board for approval. Curry et al., (2013) refer to the literature for suggestions of key elements crucial for successful and effective integrated care. They indicate that the pilot was built around these key elements; governance structures, financial arrangements, care process common, information sharing enabling collaboration, shared vision and culture.

The pilot set out to run on a voluntary basis as a “club� to encourage engagement from participating organisations. Agreement to share savings/surplus was seen as a key factor in overcoming mistrust.

Curry et al (2013) suggest the governance arrangement was complex and that this gave rise to concerns regarding accountability and clarity of decision making. In addition, close to 1/3 of survey respondents were unclear about their roles and responsibilities. Active engagement amongst clinicians was variable and 64% felt they were not involved in the planning and development of the project pilot. The design & roll out of the IT platform was suboptimal leading to frustrations. MDGs were set up to improve care & planning for the target population. Some evidence of inter-professional working and learning emerged during this process although sessions were reported to be dominated by the presenting GP/consultant with little input from other GPs and healthcare professionals in attendance. Discussions did not tend to extend to systems of care and rather focused on individual cases. Care planning was hampered by the poorly functioning IT system. Quality of the care plans was an area where no clear mechanisms for assessing quality were apparent.-pressure to complete a

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care plan but what about quality. The Integrated Management Board was charged with scrutinising the performance of MDGs in terms of care plan completion. Patients were supportive of the pilot.

However, real evidence of improved outcomes e.g. decreased hospital admissions was not evident.

More time for the system to embed is requested before real outcome measures can be realistically captured. Key lessons learnt from the pilot are reported to aid those embarking on similar journeys Enablers x

Up- front funding

x

Strong support from London strategic health authority

x

Leadership across all participating organisations

x

Common goal and vision which organisations are committed to

x

Vision needs to be extended to middle management and clinicians delivering the care

x

Streamlining of the decision making process is required and

x

Stronger accountability mechanisms are needed. E.g. Mechanisms for holding MDGs to account for quality are weak and need strengthening

x

Vision needs to be embedded.

x

MDTs need tools and skills to establish new models of community based –care-training and education MDT.

x

Advise organisations not to be too impatient for outcome change as complex change processes have proved to be a marathon not a sprint. Chose appropriate short term targets and give sufficient time for more ambitious outcomes targets to be realised.

x

A functioning IT system is important for collaboration e.g. EPR etc. and sharing information.

e. Australian experience of integrated care Demography The population of Australia is around 23 million (Australian Bureau of Statistics, 2013). There is significant urbanisation with 32% of the population living in New South Wales and a further 25% in Victoria (2012 statistics). 15 million people live in a capital city (2/3 of the population. The population density ranges from 160/sqkm in Australian Capital territories down to 9 /sqkm in New South Wales and 3 per sq/km in the extreme rural areas. The bulk of the population is aged between 15-64 years (15.2 million, 67%). There is a sizable and growing elderly population with 3.22 million (14%, aged 65 years (Australian Bureau of Statistics, 2012). In addition there are 4.29 million children <15 years old, (19% of the total population).

Political Context & Health Service Funding The Australian health System has a mix of Federal (Commonwealth) and State funding and control.

Service is provided through public and private sectors. A National Universal Health Insurance System, Medicare, was introduced in 1984. There is subsidised access to primary care, private specialist care and pharmaceuticals. GPs act as gatekeepers to specialist care as Medicare will only reimburse for referred consultations. The States provide drug and alcohol addiction and infectious disease care.

The Australian Federal Government consists of 3 political and administrative Tiers; The Commonwealth, States and Territories and local government. In 2007, a new Framework for Health Care - the National Health and Hospital’s Network Agreement proposed changes to the governance and funding of public hospitals and performance measures against national standards of care. Based on the recommendation of the Australian Government’s National Health and Hospital Reform Commission (2009), the Commonwealth government assumed full responsibility for the policy and public funding of Primary Health Care Services and the dominant funding role for the entire public hospital system. Previously, the States, Territories and local government had a greater role in funding and administering health services.

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For the public hospital system, the Commonwealth and State Governments now share funding in a 60%/40% split. The States & territories are enabled to negotiate for additional funding from the Commonwealth due to an agreement reached in 2010 between the Council of Australian Governments (COAG) and the Commonwealth Government. Western Australia has not yet signed the Agreement arguing against the Government withholding of 1/3 of Government State Tax, (GST) to fund the arrangement.

Hospital Networks and Primary Health Care Organisations Hospital Networks have grouped hospitals generally geographically around a principal referral hospital serving populations from 400,000-500,000. (For a population of circa 20 million this would amount to around 50 Local Hospital Networks, (LHNs). Hospitals will be operated by the Networks under service agreements on volume, mix, and quality of services negotiated with the States. Each Network will have a governing Council with expertise from business, management and accounting. Although, there is no community representative, the Governing Council of each Network is required to incorporate the views of the community and local clinicians. The emphasis is on decision making close to the site of service delivery and clinical leadership. There are 50 new Primary Health Care Organisations (PHCO)/Medicare Locals servicing the same population and regions as the Local Hospital Networks with some overlapping Board membership. This would result in a Primary Health Care Organisation, (PHCO) per 8,000- 10,000 of the population. The PHCOs were predated by Local GP Practice Networks (data from 2010 indicated that > 90% of GPs and an increasing number of practice nurses and allied health professions were members of a local practice network). 他

Role of the PHCOs/Medicare Locals

Since 2009 there has been increasing regional integration within the PHC teams and with other sectors. In 2010, the first Australian National PHC Strategy identified priorities including regional integration, IT development, improved access to services, chronic disease management, and disease prevention. The Medicare Local is the structure proposed to act as a framework for integrating primary and community care and to work closely with the Local Hospital Networks to identify and address the population needs of their regions. Details on how the Primary sector and Acute hospital sector will be integrated are scant. However, it is clear that integrated governance is key to successful health care integration. A single regional health entity has been proposed.

PHCOs/ Medicare Locals include representation from the community, other professional groups, business and management. There are reports that the new structure has encouraged local networking between GP practices and the wider health system.

Although evidence suggests that Australia rates highly in recognised primary health care outcomes (Davis K, et al. 2010). The COAG reform Council (2010) reported that 2 million Australians attended A & E in 2007-8 (accounting for >40% of all A & E activity) and that these cases could have been treated by a GP. It is proposed that the new structures encourage a population focus providing targets and defined outcome measures and funding based on performance. There is an emphasis on the provision of health care in the community setting whenever possible.

Incentives/Enablers towards integration x x x

Incentives identified include the Practice Incentive Programme and the Service Incentive Payment which funds practices for quality services such as immunisation targets, quality prescribing and the management of diabetes mellitus.

Multi-disciplinary Team training is provided locally for the PHCO to equip staff with the necessary skills and knowledge to best meet the needs of the populations they serve.

The Australian Primary Care Collaboratives Program, plan-do-study-act methodology developed at the institute for Health Care Improvement (Boston MA) has seen 1000 GP practices (12% of all) get involved in the improvement of diabetic and cardio vascular disease care and access initiatives. Results show substantial improvements in practices participating (Nicholson et al., 2012).

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x x

x x

The option for capitated payments for the management of Diabetes could encourage care in the community setting and could be expanded for other chronic diseases, should outcomes prove favourable.

The extension of Medicare cover to include additional health professionals for community care such as community allied health cover for chronic disease and elderly care and practice nurses is seen as a positive move towards integrated community care. Similarly, the funding of access to the Allied Psychological Services programme delivers packages of co-ordinated care for people with severe mental illness being managed in the community setting/primary care.

IT development is making it possible for a person to more easily access their health information and for appropriate access by other Health Care providers across the Primary and Secondary care interface.

Appropriate IT systems allow for the collection of accurate demographic and performance data to aid decision making and funding allocation to meet identified population priorities.

Challenges to integration identified were; -

The exact governance structure to integrate primary and secondary health care is unclear

-

How best to ensure all stakeholders understand the vision and priorities.

-

Ensure stakeholders are supported in the process.

-

There is recognition that the PHCO need the HR capacity (skills and expertise) to deliver the service in the community setting.

-

IT development is required to facilitate data collection on Performance and to facilitate communication across the health system and enable the tracking of patients through the care continuum.

-

Quality improvement strategies and Continuous Quality Improvement (CQI) need to be prioritised.

-

A system of shared resources & mutual accountability for service delivery and patient outcome is proposed.

-

Providing incentives and financial resources to encourage co-ordinate care (move from fee per item) and align incentives across care (Ham & Smith J. 2010 and Zwar 2010).

-

High quality communication.

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f.

New Zealand (Canterbury experience of integrated care)

(the bulk of the analysis refers to the experience of Canterbury District Health Board)

For New Zealand, the critique of Canterbury District Health Board relied on a King’s Fund review by Timmins and Ham (2013), a research report by Thorlby et al. of the Nuffield trust (2012) and Canterbury district health board’s official website.

Demography The population in New Zealand is circa 4.5 million (www.stats.govt.nz). In the 1990’s and early 2000s, a purchaser provider split approach to health care was explored. This was deemed unsuccessful.

During this time, GPs began to organise themselves into collectives resulting in a well-organised GP healthcare system which is seen as one of the key enablers of establishing integrated health care (Timmins and Ham, King’s Fund 2013) .

Structure of Health Service District health Boards In 2000, twenty District Health Boards were established in New Zealand with populations ranging from 32,600 in the West Coast district health Board http://westcoastdhb.org.nz to 528,500 in Waitemata District health Board http://www.waitematadhb.org.nz DHBs are responsible for ensuring the provision of health and disability services (hospital and primary health services) to the populations within defined geographic areas, either directly or through contracts. They are funded from central government by the Ministry of Health based on population based funding with adjustments for variables including higher proportions of elderly or deprived persons in the area.

Independent Practitioner Associations (IPAs) and Primary Health Organisations (PHOs) The Independent Practitioner Associations (IPAs)/ autonomous networks of GP practices formed in the early 1990s, have evolved over 2 decades with many forming larger organisations and providing primary care and management support services with an increasingly multidisciplinary work force.

They are privately owned, non-statutory and have a mixture of for profit and not- for- profit status.

Primary Health Organisations were introduced by the Government as part of the Primary Health Care Strategy in 2002 as the new non-governmental bodies with a variety of community focused governance forms. Primary Health Organisations contract with their DHB for funds to support the provision of essential primary health care and preventative services through general practices to those people enrolled with the PHO. There are 31 PHOs of varying size and structure in New Zealand.

All are not for profit.

Canterbury District Health Board The remainder of the analysis in New Zealand is on the Canterbury District Health Board’s (CDHB) and the CDHB’s experience with integrated care. CDHB is recognised as an area of best practice in the area of Health Services Integration.

Background Since the late 1990s, Canterbury has been engaged in a number of nationally funded projects aimed at bridging the divide between primary and secondary healthcare e.g. in the area of elderly care and under Pegasus PHO programme tried to limit acute demand on hospital services by diverting patients to GP and community settings. This pioneering approach has continued and gained momentum over the years.

Demography Canterbury is the south islands largest and most populated region with a population 510,000 (circa 400,000 live in Christchurch the main city). Canterbury covers circa 42,000km2. It is the second largest DHB in New Zealand (by both geographic area covered and population size). Canterbury is experiencing similar demographic changes to Ireland and many other countries with an increasing

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elderly population; it is estimated that by 2025, 20% of its population will be over 65. There are around 130 General practices in the Canterbury area and more than 50 mental health providers (Timmins and Ham, 2013). This would equate to each GP practice serving a population of circa 4,000. Almost all general practices in Canterbury are aligned with one of 3 Primary Health Organisations; Christchurch PHO, Pegasus Health and Rural Canterbury PHO. (www.cdhb.govt.nz).

As well as providing services for its own region, the Canterbury DHB also provides services to people referred from other DHB for services on a regional basis or National/Semi-National Basis for services not available in other Districts (e.g. neurology, cardiothoracic neurosurgery, paediatric oncology). One of these collaborations, with the population of the West coast DHB, has been formalised into a clinical partnership arrangement.

Governance Canterbury District Health Board is the hospital and healthcare provider for the Canterbury region and uses the funding received from government to purchase and provide health and disability services for its population. Like all DHBs in New Zealand, the CDHB is governed by a Board of up to 11 members, 4 appointed by the Minister for Health and 7 elected members***(see below for composition of the board) . There is a chair and co-chair (both from non- healthcare backgrounds). DHB members meet monthly and are accountable to the Minister (through the Chairperson of the Board) for the performance of the DHB. Public hospitals are owned and funded by DHBs. The Board is responsible for the overall performance and management of the DHB. Operational and Management matters are delegated to the Chief Executive (CEO) of the Board who is supported by an Executive team. ***The Executive Management Team consists of the CEO, the General Manager for population and Public Health, Executive Director of Nursing, General Manager Planning & Funding, , Maori representative, General Manager in HR, Chief Medical Officer, Director of strategic management and business development, Strategic Communications Manager, Executive Director of Allied Heath, General Manager-Finance. The Executive Management Team reports directly to the CEO who reports directly to the chair of the DHB. There is a General Management Team with 5 members representing different specialities (rural health, medicine/surgery & women’s & child care, elderly & orthopaedics/rehabilitation, hospital support and laboratory and mental health).

There is a Planning and Funding division of the CDHB which is accountable to the CEO and the Board for determining how best to invest the funds. The Planning and Funding Division’s Core Responsibilities are (www.cdhb.govt.nz) : x

Assessing the population's current and future health needs;

x

Determining the best mix and range of services to be purchased;

x

Building partnerships with service providers, government agencies and other DHBs;

x

Engaging with stakeholders and community through two-way consultation;

x

Leading the development of new service plans and strategies in health priority areas;

x

Prioritising and implementing national health and disability policies and strategies in relation to local need;

x

Undertaking and managing contractual agreements with service providers;

x

Monitoring, auditing and evaluating service delivery.

In addition, there are a number of committees/advisory bodies established by the DHB (Advisory Committee, Consumer Council, Clinical Board, Hospital Advisory Committee, Quality Finance Audit and Risk committee).

There is some overlap in appointments when deemed appropriate. E.g. The CEO of the CDHB is also the CEO of the West coast DHB and there are number of joint clinical leadership and management positions supporting both DHBs at executive level. The General Manager of the Planning & Funding division is a member of the Executive Management Team.

The Clinical Board is a multidisciplinary clinical forum with membership from primary, secondary and community sectors. There are 26 members (17 elected). The clinical board is chaired by the DHB’s Chief Medical Officer. The members play an important clinical leadership role and are responsible for the clinical governance of the DHB and are accountable to the Minister for the performance of the DHB. The board advises the CEO of the DHB on clinical issues.

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Accountability for Canterbury’s DHB. www.cdhb.govt.nz/About-CDHB/Planning-Funding On behalf of the DHB, the Planning and Funding Team holds and monitors alliance contracts and service agreements with the organisations and individuals who provide the health services required to meet the needs of the population. This includes an Internal Service Agreement with the Hospital and Specialist Services Division and over 1,000 service contracts and alliance agreements with external providers including the three Primary Health Organisations (PHOs) in Canterbury.

Planning and Funding Team members maintain on-going relationships with these providers and ensure the efficient management of these service contracts and agreements. The monitoring of service contracts occurs through a number of mechanisms, including relationship development, reporting mechanisms and audit.

The Planning and Funding Division is also responsible for producing key accountability documents on behalf of the Canterbury DHB and monitoring performance against national health targets, expectations and the Funding Agreement between the Crown and the DHB. Together with national policy, the DHB's accountability documents help to maintain transparency and enable robust review of the intentions of both the Ministry and of DHBs. The documents provide a long-term planning element to demonstrate capacity, sustainability of services and best use of resources. The use of short-, medium- and long-term performance targets in these documents also assists in evaluating DHB progress and effectiveness (www.cdhb.govt.nz/About-CDHB/PlanningFunding).

Enablers for change in Canterbury (Timmins and Ham, King’s fund 2013) There is evidence that Canterbury has made considerable progress towards health service integration.

Factors proposed to have contributed to this process include; x x x x x x x x x x x x

Vision for change (one system , one budget –even though funding was separate for hospital and PHOs-it was clear to staff that they needed to work together to integrate services). Staff were involved in developing the vision.

Investment in providing staff (board employees and contractors) with skills needed to innovate and providing them with support during the process.

Staff training and development - Programme for leadership development, an innovativedifferent approach to healthcare delivery was fostered. Business development units in CDH since 2000. Business process engineering type focus, Canterbury Initiative is the operational arm of funding and planning and through Clinical Networks, key leaders and organisations are brought together IT –an electronic request management system allows for appropriate access to the health service for referrals and sharing of patient records.

Well organised GP service through PHOs is a big plus Stability and continuity of leadership.

Organisational structure stable A shared funding system covering health and social care National targets and local definitions and drivers for success.

Empowering and enabling clinics to make changes.

Recognising that integrated care is not a quick fix. CDHB is still on a journey 5 years into the process

Lessons learnt from the Canterbury experience x Need robust performance measurement systems to capture improved outcomes x Must take account of the local context and challenges x Integrated care cannot be judged solely on current performance-improved patient outcomes often only become evident after an initiative has had a chance to bed down. x There are many different paths to sustained successful integrated care. Pilot projects can be useful to assess new initiatives before roll out on a larger scale.

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Evidence for Integration of Health care x

HealthPathways across the Primary Secondary divide were devised by clinicians from each sector working together. HealthPathways are essentially care pathways based on local agreements on best practice. Hospital doctors and GPs work out together the best way to manage conditions between them and agree a pathway. Initially doctors but later other MDT members were included to determine the services need around the agreed pathway.

x

Three initiatives promote care in the community by either preventing acute admission and or facilitating early discharge. o The Acute Demand Management System which is aimed at preventing hospital admission provides GPs with a means (board funding) to treat patients in the community whenever possible. o 24 hour GP services are provided by GPs in centres with 5 bed observation units, and a range of diagnostic tests capabilities. o Intermediate care type programmes were introduced to reduce length of hospital stay.

g. Sweden­ Jönköping County Council’s experience of Integrated Healthcare (the bulk of the analysis refers to the experience of Jönköping County Council) Demography Sweden is the third-largest country in the European Union, with a population of 9.5 million in 2013 (Statistics Sweden). Population density is recorded as 20.6 people per square kilometre, (53.3 per square mile), with a higher population density in the South than in the North.

Life expectancy at birth is 83.5 years for women and 79.5 years for men. The bulk of the population lives in the urban areas (approximately 85%). A significant portion of the population is 65 years and above (19.7%). Most of the population are middle-aged: 15-64 years (64.8%), (2011), (Statistics Sweden).

Healthcare Everyone in Sweden has equal access to health care services under a largely decentralized, taxpayerfunded system. Costs for health and medical care represent about 10 per cent of Sweden’s gross domestic product (GDP), which is on par with most other European countries. The bulk of health and medical costs in Sweden are paid for by county council and municipal taxes. Contributions from the national government are another source of funding, while patient fees cover only a small percentage of costs. Chronic diseases that require monitoring and treatment, and often lifelong medication, place significant demands on the system.

Structure of the Swedish Healthcare System Sweden is divided into 290 municipalities, 20 county councils and four regions – Gotland, Halland, Skåne and Western Götaland. Sweden’s regions are based on county councils or municipalities that have assumed responsibility for regional development from the state.

County councils are political bodies whose representatives are elected by county residents every four years on the same day as national general elections County councils are also responsible for dental care for local residents up to the age of 20.

There is no hierarchical relation between municipalities, county councils and regions. Around 90 per cent of the work of Swedish county councils concerns health care, but they also deal with other areas such as culture and infrastructure.

Sweden’s municipalities are responsible for care for the elderly in the home or in special accommodation. Their duties also include care for people with physical disabilities or psychological disorders and providing support and services for people released from hospital care as well as for school health care.

County council costs for health and medical care, excluding dental, were €21 billion in 2010. It is now more common for county councils to buy services from private health care providers — 12 per cent of

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health care is financed by county councils but carried out by private care providers. An agreement guarantees that patients are covered by the same regulations and fees that apply to municipal care facilities.

Governance The responsibility for health and medical care in Sweden is shared by the central government, county regulates the responsibilities of councils and municipalities. The Health and Medical Service Act county councils and municipalities, and gives local governments more freedom in this area. The role of the central government is to establish principles and guidelines, and to set the political agenda for health and medical care. It does this through laws and ordinances or by reaching agreements with the Swedish Association of Local Authorities and Regions (SALAR), which represents the county councils and municipalities. Responsibility for providing health care is devolved to the county councils and, in some cases, municipal governments.

History of innovation and strong performance Sweden's healthcare system has an international reputation for strong performance, equity and innovation and was among the first countries to recognize the limits of hospital care and to make a national commitment to primary care and preventive services (Glenngård et al. 2005). Sweden compares very favourably internationally with regard to access and medical outcomes with moderate resource and cost levels (Organisation for Economic Co-operation and Development 2005). Rooted in a social ethic of participation and partnership, the Swedish system is highly decentralized and aims to achieve its objectives through public ownership as well as local and regional democracy, operation and accountability.

The county councils have been in existence since 1982. Members are elected to the council every 4 years at the time of general elections. County councils, which typically include several municipalities, fund, plan and deliver healthcare services. There are 20 county councils in Sweden for a population of 9.5 million. Healthcare is a dominant focus for county councils, comprising over 70% of their resources (other responsibilities include cultural activities, public transportation and regional development). County councils finance their healthcare expenditures by income taxes (in addition to taxation revenue, healthcare financing is supplemented by state grants and user charges). They plan and allocate resources to healthcare, dental care, education and research for their jurisdictions, own and operate all their healthcare facilities and contract with healthcare providers. The councils employ salaried, community-based primary care physicians. Hospitals, which are owned and operated by the county councils, employ salaried, hospital-based physicians (Glenngård et al. 2005).

Other national organizations that influence healthcare in Sweden include the National Board of Health and Welfare, which sets standards for patient safety, performance assessment and practitioner licensing. The Swedish Association for Local Authorities and Regions (SALAR), a result of a recent merger of the Federations of County Councils and Local Authorities, is the county council’s membership organization. The SALAR advocates for county councils and regions in government and reports publicly on their performance, supports quality improvement and oversees relations with labour unions.

Jönköping County Council The remainder of the analysis focus on the experience of Health Service integration at Jönköping County Council (Baker et al 2008).

Healthcare System Jönköping Jönköping County is located 330 km southwest of Stockholm in the southern province of Småland. It has three hospitals and 34 care centres (including primary care clinics, specialized medical services, rehabilitation facilities and pharmacies), with a combined workforce of over 9,900 across 13 municipalities (Bojestig, Henriks and Karlsson 2006). It serves a population of around 340,000.

Jönköping has gained a reputation as a centre of excellence for healthcare improvement and a model of health care system transformation.

Two initiatives stand out among Jönköping County Council's achievements in health and social care integration:

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1) Esther Care for the elderly is a critical issue in Sweden, a country that has the world's oldest population (19% 65). **Esther is an 88 year old fictional patient invented by clinicians in Jönköping to help them improve patient flow and coordination for seniors in six of the county's 13 municipalities.

Esther lives alone in the community but has a chronic condition and occasional acute health care need. In the late 1990’s Jönköping clinicians and leaders came together to map Esther's movements through the complex network of care settings and providers. In addition, interviews were conducted with patients like Esther and clinicians who provide care across the system.

The collaboration tried to simplify the journey for the patient through the complex health care system and improve health service integration.

Changes included a redesigned intake and transfer process across the continuum of care, open access scheduling, team-based telephone consultation, integrated documentation and communication processes and an explicit strategy to educate patients in self-management skills.

The “Esther project” yielded impressive improvements over a three- to five-year period, including an overall reduction in hospital admissions by over 20% (9,300 to 7,300) and a redeployment of resources to the community, a reduction in hospital days for heart failure by 30% (from 3,500 days per year to 2,500) and a reduction by more than 30 days of wait times for referral appointments with specialists such as neurologists (Institute for Healthcare Improvement 2006). **(Similar to Mrs Smith in Torbay)

2) Pursuing Perfection Jönköping participated with other international health systems in an Initiative called “Pursuing Perfection” aimed at system transformation across all major healthcare processes. The project was directed by the Institute for Healthcare Improvement (IHI) in the United States (US).

Involvement in this project led to a systems thinking approach to healthcare and new ways of working and resulted in substantial streamlining of processes and cost savings across the system.

As part of this initiative all providers and resources for children with asthma in the county were brought together resulting in care mapping and process improvement. Jönköping reduced the number of hospitalizations for paediatric asthma to 7 per 10,000 (Jönköping formerly had 22 hospitalizations per 10,000; (the US national average is 30 hospitalizations per 10,000).

Another outcome was the increase in Jönköping’s rate of influenza vaccination by 30% (over four years), translating into substantial reductions in acute care hospital admission as well as in morbidity and mortality among the elderly population.

If the example in Jönköping could be spread to other county councils this would obviously result in considerable national health cost savings.

Further projects to improve integration and continuity of care were undertaken as a consequence of the success of these projects. This is reported to have led to a longer term focus on data to inform strategic and budget planning within the Council.

Governance of the Council at Jönköping County Council CEO Board of directors-Assembly with a chair and 81 elected members (4 yearly) Enablers of success for Jönköping x

Vision

x

Continuous and effective leadership and governance ¾ Period of stability with sustained leadership from the same CEO of the county council for 18 years, & the same elected chair ¾ Long standing key senior team members - physician leader and learning & innovation leader ¾ Stability regarding the majority of the council’s assembly of 81 politicians

x

Board interference in day-to-day operations is virtually non-existent in Jönköping.

x

Culture of financial discipline coupled with CQI approach

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x

Education of all staff in frameworks and tools for audit measurement and Total Quality Management (TQM) & CQI Establishing Qulturum - a centralized "quality" house for training and education & open dialogue. Supported by Qulturum, Jönköping County Council reports having made over 800 measurable improvements

x

Government initiatives complimented local Jönköping projects e.g. CQI initiatives

x

Performance measurement and communicating objective information on performance to board members for comparison

x

Including clinicians and staff in the process

x

Strategic guidance, support and coordination of initiatives.

x

Management and front-line staff - oriented toward process and systems thinking in their everyday work

x

Small scale changes then spread to other areas-“pilot projects” “Results across the small parts of the system create big results for the system ... and lots of winners. ... Big, high-risk projects and changing structures in a traditional way, buying and selling and depending on the market, creates losers”. Karlsson County council CEO.

x

Use of tools for change e.g. Action-Oriented learning / the Model for Improvement. Plan-DoStudy-Act (PDSA) type cycle that guides the testing and implementation of changes in a real work setting and accelerates improvement (Langley et al. 1996).

x

Facilitating and enabling changeCollaborative team projects towards common goal of improvement –facilitated/supported by Swedish Association for Local Authorities and Regions annual Quality Conference, the QUL award and Breakthrough Series modelled after the IHI's approach. Funding projects Management restructuring to align with this learning. Managers and clinicians who were working on improving common or linked processes across the council came together regularly

x

Leadership Development Network for CEOs and other decision-makers, & investment locally in leadership development and education across various council levels.

Strategic appointments to the leadership team of chief of learning and innovation & a chief medical officer and planning director.

Widespread learning about how to change and improve processes for patients

x

Open to looking for best practice elsewhere and adapt for the context E.g. United Kingdom's National Primary Care Development Trust to engage patients in selfmanagement using improvement methods-adapted this to launch the “Passion for Life” initiative.

E.g. Learned from experts in the US about ways of transforming care by working at the level of clinical microsystems (i.e., teams working at the front line of service delivery) (Nelson et al.

2002).

Integrating improvement knowledge and skills into clinical education- Partnership with medical school and other health professions

x Putting quality at the centre of strategic and business planning at the county council.

Called Big Group Healthcare, all executive, clinical and quality leaders and managers across the system meet over five days throughout the year- Expose the good and the bad in the current system, discuss how quality improvement initiatives are (or are not) contributing to these in measurable ways. A “whole systems approach”- co-designing improved plans x

Provide Incentives and Removing disincentives for improvement In conjunction with Big Group Healthcare, the three hospital CEOs began to receive limited incentives (5% of salary) for demonstrating Baldrige-type values in their leadership.

Instead of reclaiming cost savings in the global budget, organizations and units are able to reinvest all of these funds.

x

Constancy of purpose

x

The Chief Planning Officer is in charge of the new electronic health record and information system. Collection of data on performance and outcomes measurement is prioritised.

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h. Israelâ&#x20AC;&#x2122;s Experience of Integrated Care Demography The population of Israel is circa 8 million ( Israel Central Bureau of Statistics, 2013) with a population density of 377 people per km2. Life expectancy is 81.8 years (78.9 for males and 83.5 for females), well above the OECD average (80.1 years). The majority of the population are aged between 15-64 years (62.2%), 27.3 % are aged 0-14 years and 10.5% are aged 65 and over. Similar to the countries studied in the report, Israel has a growing elderly population and rate of chronic diseases. Obesity rates have increased in recent decades in all OECD countries, including Israel heralding increases in the occurrence of health problems (such as diabetes and cardiovascular diseases), and higher health care costs in the future.

There are a number of ethnic groups residing in Israel but the majority of the population are either Jews (75%) or Arabs (20%).

Healthcare System Israelâ&#x20AC;&#x2122;s primary care health service has a history of significant improvement in recent years. In the 1980s competition between the health plan market led to improvement in facilities, service to patients and physician satisfaction and retention. The creation of family medicine residency programmes offered by the health plans is attracting doctors into the field of primary care. Since 1995, and the passing of the National health Insurance (NHI) Law, participation in a medical insurance plan with one of the four national HMOs is compulsory for all Israeli citizens. The plans provide universal access to a comprehensive package of healthcare services including primary care. Residents are free to choose from among the 4 non-profit health plans regardless of factors such as age, gender, or pre-existing conditions.

Financing of Healthcare The state is responsible for providing health services to all residents of the country, registered with one of the four health service funds. To be eligible, a citizen must pay a health insurance tax.

Coverage with the Uniform Benefits Package is extensive and includes medical diagnosis and treatment, preventive medicine, hospitalization (general, maternity, psychiatric and chronic), surgery and transplants, preventive dental care for children, first aid and transportation to a hospital or clinic, medical services at the workplace, treatment for drug abuse and alcoholism, medical equipment and appliances, obstetrics and fertility treatment, medication, treatment of chronic diseases and paramedical services such as physiotherapy and occupational therapy.

Health care is funded by means of a progressive health tax, or the National Insurance Institute, Israel's social security organization, which transfers funding to the Health Maintenance Organizations according to a certain formula based on the number of members in each fund, the age distribution of members, and a number of other indices. The Health Maintenance Organizations also receive direct financing from the stateâ&#x20AC;&#x2122;s money. The 1995 law also imposed a system of financial and medical oversight of HMOs by the State.

However, availability of services differs by location, as each of the organizations operate their own medical facilities, including private hospitals. In addition, they also operate their own supplementary health insurance programs, under which non-essential health services are funded for an extra (reportedly modest) fee. In addition, non-essential services can also be funded by a citizen sharing the cost with their employer.

There are also private health insurance plans which citizens may pay for in addition to compulsory participation in the national health insurance initiatives. They provide coverage for additional options for treatments. For example, in the area of elective surgery, a participant in a private insurance plan may choose the surgeon, anaesthetist, and hospital anywhere in Israel or around the world. In the area of transplants, unlimited funding is available to ensure a donor is found and the procedure is done without the need for government approval. In the area of medications for serious illnesses, while the "basket of medications" which are funded by the national HMOs is large and updated regularly, private insurance companies give access to a wider range. In comparison with health insurance in other countries, private health insurance in Israel is considered comparatively cheap, but premiums are based on age, gender, and previous medical history.

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In Israel, 60.8% of health spending was funded by public sources in 2011, well below the average of 72.2% for OECD countries. In 2011, the share of public spending among OECD countries was the lowest (less than 50%) in the United States, Mexico and Chile, and relatively high (over 80%) in several Nordic countries (Denmark, Iceland, Norway and Sweden) and Japan (OECD Health Data 2013).

Access to Primary care is reported to be good with between 7.6 and 5.9 community based physicians per 10,000 of the population. Financially only one of the 4 health plans has a system of co-payments for primary care visits and this is reported to be nominal, the remaining 3 are free although the OECD does comment on some inequalities in service provision and rising cost of co-payments.

All of the plans provide continuing care/home care units in every region and there are over 100 such units nationally. These units provide short term assistance to patients in the community after discharge from hospital and care for patients over longer periods in the home setting.

A big factor of the system of care is the development of Information technology in the primary care setting providing universal access to electronic medical records in the primary care facilitating information sharing on a number of levels. Clalit, the insurance provider with the largest market share (54%) is the only plan with an IT system sharing information across the community hospital divide.

The health plans offer a 24 hour telephone hotline staffed by experienced RNs, there are evening care centres available in all major cities, independent urgent care centres and medical home visit services.

Primary care services in Israel rate highly and have been described as â&#x20AC;&#x153;world classâ&#x20AC;? by the OECD (2012). Israel has reportedly maintained tight control on healthcare costs at circa 8% of GDP (7.7% in 2011) below the average of 9.3% in OECD countries amidst a background of rising health care costs.

Israel also ranks below the OECD average in terms of health spending per capita, with spending of 2239 USD in 2011 (adjusted for purchasing power parity), compared with an OECD average of 3339 USD. Despite the relatively low level of health expenditure in Israel, there are more physicians per capita than in many OECD countries. In 2011, Israel had 3.3 practising physicians per 1000 population, just above the OECD average of 3.2. On the other hand, there were only 4.8 nurses per 1000 population in Israel in 2011, much less than the OECD average of 8.7 (OECD Health Data 2013). As was the case for most OECD countries, the number of hospital beds per capita in Israel has fallen over time.

This decline has coincided with a reduction of average length of stays in hospitals and an increase in the number of day surgeries. The number of hospital beds in Israel was 3.3 per 1000 population in 2011, much lower than the OECD average (4.8 beds).

Community based medical teams provide access to abroad range of expertise aimed at avoiding unnecessary hospital admission. An example of the success of his approach is the reported low level of hospitalisation for poorly controlled diabetes in Israel despite a comparable incidence of the disease (6.5.%) in the adult population. Patient satisfaction surveys report most Israelis are very satisfied with the care they receive in Primary care setting (Gros et al., 2009). In addition the clinical quality of Israeli primary care rated highly with similar levels to the US despite a much higher level of per capita spend in the US (Rosen et al 2011) .

This plan Clalit insurance group uses EMR to identify members of the elderly population that are at most risk of deteriorating health based on economic, socio-demographic and clinical information and adopt a proactive approach to their care. A similar system is in operation for the management of chronic disease states. The group has reportedly eased the role of the PCPs as gatekeepers to specialists care yet at the same time the PCP is retaining its role in integrating care of its patients.

Enablers for the success of the primary care system Enablers for the success of the primary care system in Israel are the reliance of remuneration systems other than fee for service thus reducing financial incentives for overuse of services. Sophisticated EMR is thought to contribute to quality of care and cost containment. Physicians generally work for only one plan allowing for the development of consistency between physicians and the health plan goals The existence of a strong foundation in the area of primary care prior to the introduction of the NHI initiatives is credited with facilitating effective change.

The health plan groups actively recruited physicians to work in peripheral locations so as to meet the healthcare needs of their members of the population living in these areas. The health plans provided

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organised systems of care and physicians working therein could be encouraged to provide care in keeping with this broader vision.

The hospital and community sector are not sufficiently integrated Quality of care monitoring in Primary care is easier due to the well-developed EMR system. In addition the health plans compete with each other for market share and need to provide information and accountability data to attract and retain members.

The health plans work effectively with the community physicians and are thought to contribute greatly to the success of primary care in Israel. Some physicians split their time between hospitals and clinics and some community based specialists are physicians whose primary appointment is in a hospital fostering a spirit of co-ordination and continuity of care.

External quality control is monitored rough the Quality Indicators in Community Health Care Programmes which tracks performance across 35 key measures. The health plans help primary care clinics by showing them what they are not doing well and how they can improve their performance.

This is in contrast to a number of other countries (UK, Australia) where financial incentives are offered to providers who meet their performance targets.

Performance monitoring and information on the hospital system is sparse by comparison with the primary care sector and co-ordination between primary and acute care is reported to be poor (OECD 2012). The lack of a single electronic data system to track and share patient information has been felt to compound this chiasm. In addition, communication between the health sector and the related educational and social services sectors are reported to be inadequate.

Additionally, certain services were brought under the direct administration of the State, usually by means of the Health Ministry impeding possible integration and collaboration.

i.

Netherlands Experience of Integrated Care

Demography The population in the Netherlands is circa 16.77 million. It is the 24th most densely populated country in the world, with 404.6 inhabitants per square kilometre (1,048 /sq mi)â&#x20AC;&#x201D;or 497 inhabitants per square kilometre (1,287 /sq mi) if only the land area is counted. The Randstad is the country's largest conurbation located in the west of the country and contains the four largest cities: Amsterdam in the province North Holland, Rotterdam and The Hague in the province South Holland, and Utrecht in the province Utrecht. The Randstad has a population of 7 million inhabitants and is the 6th largest metropolitan area in Europe (OECD Health Data 2013).

The Netherlands is divided into twelve provinces, each under a Commissioner of the King (Commissaris van de Koning), except for Limburg province where the position is named Governor (Gouverneur). All provinces are divided into municipalities of which there are 408.

The number of physicians per capita in the Netherlands was 3.0 per 1000 population in 2010, slightly less than the OECD average of 3.2. On the other hand, there were 11.8 nurses per 1000 population in the Netherlands in 2010, a number above the OECD average of 8.7. The number of hospital beds in the Netherlands was 4.7 per 1000 population in 2009, very close to the OECD average of 4.8 beds. As in most OECD countries, the number of hospital beds per capita in the Netherlands has fallen over time(OECD Health Data 2013)..

In 2011, life expectancy at birth in the Netherlands stood at 81.3 years, more than one year higher than the OECD average of 80.1 years. Obesity rates have increased in recent decades in the Netherlands, up from 6.0 in 1990 to 11.4% in 2011, heralding the occurrence of health problems (such as diabetes and cardiovascular diseases), and higher health care costs in the future.

Total health spending accounted for 11.9% of GDP in the Netherlands in 2011, the second highest share among OECD countries and well above the OECD average of 9.3%. The Netherlands also ranks well above the OECD average in terms of health spending per capita, with spending of 5099 USD in 2011 (adjusted for purchasing power parity), compared with an OECD average of 3339 USD. Health spending per capita in the Netherlands was fourth highest among OECD countries, behind the United States (which spent 8508 USD per capita in 2011), Norway and Switzerland.

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In the Netherlands, it is not possible to distinguish clearly the public and private share for the part of health expenditures related to capital expenditure.

The public sector is the main source of health funding in the Netherlands, 85.6% of current health spending was funded by public sources in 2011, well above the average of 72.2% in OECD countries (OECD Health Data 2013).

Overview of the Dutch healthcare system Major reforms have recently taken place in the Dutch healthcare system. A new single healthcare insurance system was introduced at the beginning of 2006, replacing the old two-tier system. All residents (except those with temporary permits or student permits) are now legally required to hold the same basic health insurance package, which can be supplemented by additional optional packages.

The coverage provided by the basic insurance package is subject to ongoing review and change by the government. It generally includes most general healthcare costs, but does not currently cover the cost of dental treatment for adults, some maternity and post-natal care and physiotherapy. Children under the age of 18 are automatically covered by their parents’ basic health insurance package, and also receive coverage for dental care.

Individuals can buy their basic insurance policy from any of a number of insurance companies who all legally have to offer the same basic package, and which also offer additional supplementary cover at higher cost. The annual premium for the basic cover is in the region of €1,115 to €1,250, and a tax allowance is available against this for people on low-incomes. Residents can choose between three types of insurance policies: 1. Policy in kind: the insurance company concludes sufficient contracts with health care suppliers in order to deliver health care. The insurance company pays the bill directly to the health care supplier.

2. Restitution policy: residents choose the health care supplier and pay the bills, after which the health insurance company reimburses.

3. Combination policy: part of the bill is paid by the insurance company and the rest is paid by the resident.

It is possible to take out additional health insurance but, unlike the basic insurance policy, the insurance companies are not obliged to accept residents for this additional insurance. The additional health insurance can cover physiotherapy, spectacles, and dental help for persons of 22 years and older as well as alternative medicine such as homeopathy and acupuncture. The contents and premium differ per insurance company. Insured persons can, except when the issue centres on ’treatment’ or ’residence’, choose between care in kind or a personal budget. A personal budget is a sum of money that residents can use to purchase care, help and support themselves.

The medical care that is available in the Netherlands is generally reported to be of a very high standard with excellent facilities and advanced specialist treatments available.

Alternative treatments, such as homeopathy and acupuncture, are very popular in the Netherlands and the cost of these can sometimes be covered by health insurance.

General Practitioners (GPs) and Specialists Primary healthcare in the Netherlands is provided by GPs. Residents are free to choose a GP in their area.

Some GPs and specialist require their patients to pay at the time of the consultation and will provide a receipt with which to reclaim the money from their insurance company; others will send a regular invoice to patients which can be forwarded to the insurers for payment, or will send this to the insurance company direct. The majority of specialists work within hospitals; there are very few private specialist clinics.

Specialists require a letter of referral from a GP and as such the GP acts as a gatekeeper, preventing unnecessary activity in the acute sector. A copy of the referral note from the GP will also usually be required by the insurance company for reimbursement.

All dental services in the Netherlands are provided by private clinics, most of which consist of a single dentist and their assistant, although there are some joint dental practices which also include dental hygienists. Dental charges are relatively high in the Netherlands, and cannot be reclaimed under the

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basic insurance package, except for children under the age of 18. Dental services are tightly regulated by the government, which sets the charges for different dental procedures and ensures that the standards of dental care are consistently high. Dental specialists such as oral surgeons, periodontists and orthodontists generally work within hospitals in the Netherlands, and a referral from a dentist is usually required in order to see a specialist.

Hospitals The Netherlands has a large number of hospitals including eight university hospitals, as well as a number of hospitals which are run by community or religious organisations. Traditionally, all hospitals in the Netherlands have offered the same range of specialist services, but under the new reformed healthcare system, the government is encouraging hospitals to specialise in particular areas of treatment. Although all hospitals generally offer the same high standards of care, the University hospitals, where medical research is conducted, often have the most up-to-date facilities and use the most advanced medical techniques.

Pregnancy and Ante-Natal Care The Dutch have a very natural approach to childbirth; around 30% of babies are delivered at home, reportedly the highest percentage in the western world. The costs are fully covered by every medical insurance company. In the Netherlands, midwives are the mostly commonly used primary carers for women throughout pregnancy, childbirth and the post-natal period. It is fairly uncommon for gynaecologists or GPs to provide this service, although this can be requested if the pregnant woman has strong preference for this type of care. GPs also look after women during pregnancy in some remote areas where no midwife is available.

Childbirth and Aftercare There is an excellent aftercare programme in the Netherlands, in which insurance cover provides for a maternity assistant to visit the home of a new-born baby every day for up to a week after the delivery, whether or not it was a home-birth or hospital delivery, to help look after mother and baby, teach new parents how to look after their child, and even carry out light housekeeping duties, cooking or shopping for the family.

The GP Cooperative Around the millennium, out-of-hours primary care was reorganized from small-scale call rotations into large-scale GP cooperatives, with generally 40 to 120 GPs taking care of populations ranging from 50,000 to 500,000 inhabitants (van Uden Giesen et al., 2006). In 2005, more than 120 GP cooperatives in the Netherlands were set up covering more than 90% of the population.

Most GP cooperatives are situated near or within a hospital but have not formally regulated patient flow in conjunction with the hospital or its emergency department. This means that patients with a medical problem during out-of-hours times can choose either to attend the GP cooperative or the hospital emergency department. There are no financial incentives for any particular behaviour.

In the Netherlands, there are 60 GPs for every 100 000 inhabitants, which is quite moderate by international comparison.

GP networks For research and education purposes, departments of family medicine of most Dutch universities have primary care networks consisting of GPs from different practices in the region. There are currently 11 GP networks in the Netherlands which do not overlap. The networks are independent and there is no routine dataflow to a national database. These GP networks collect computer based information about patient care using uniform data collection and registration methods. At regular intervals the information from local registration systems is fed into a central database. On the national level, two GP networks exist that collect data on morbidity, prescriptions and referrals. The aim of regional and national networks is to collect data about primary care in a standardized way, suitable for scientific evaluation.

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GPs administer primary health care 24 hours a day, 7˺days a week. Most GPs in the Netherlands work in private practices and are self-employed, although a growing number of GPs are being contracted by community health centres. Many GP practices are solo practices, but support each other through ‘cooperatives’ to provide out-of-hours care, usually within one of the 105 regionally distributed out-of-hours centres. However, some insurers, such as Menzis, are beginning to open their own primary-care centres to serve the patients it insures in order to lower costs.

In the Netherlands, the government has been implementing components of the Chronic Care Model for at least 10 years (before the model was formally conceptualised). Their Transmural Care Programme aims to bridge the gap between hospital and community care.

Secondary and tertiary care: As in the NHS, patients reach secondary and tertiary care through A&E or with a GP referral. More than 90% of Dutch hospitals are owned and managed on a private not-for-profit basis, with specialists working on a self-employed basis.

Willcox et al., (2011) report on reforms and achievements in Australia, the UK, the Netherlands (Table 1). They report that, similar to the UK and Australia, the Netherlands have been striving to implement integrated care. One of the strategies has been the implementation of midlevel primary care organizations both to coordinate primary care health services and to serve other functions, such as population health planning. Better coordination of primary health care services is also the objective driving the use of patient enrolment in a single general practice. Dutch payment reform has stressed financial incentives for better management of chronic disease.

The Netherlands is recognised as having a well-developed primary care infrastructure and a track record of strong performance. Primary healthcare is provided free of charge to all through universal access. General practitioners (GPs) provide primary care services and act as “gatekeepers” for patients’ access to most specialist services and hospitals. This gatekeeper requirement places primary care at the centre of the health system, effectively ensuring that almost all patients have a regular primary care doctor or GP group. General practices in the Netherlands are effectively small private businesses providing a range of family medicine services. Funding is through universally mandated private insurance coverage in the Netherlands.

One notable difference in primary care provision between the UK, Australia and the Netherlands is the average size of GP practices (Table 1). Dutch practices tend to be smaller than their English and Australian counterparts, with 40 percent of Dutch GPs operating solo. In contrast, the share of GPs in solo practices in Australia has halved over the decade from 2000–01 to 2009–10, with about six of every 10 practices now employing five or more GPs. Another significant organizational change has been the growing presence of practice nurses, who now are part of the general-practice landscape in all three countries.

The is evidence for improved access to primary care, after hours care and team based care in the Netherlands (and the UK and Australia) since the introduction of health care reforms.

One of the approaches to enhancing coordination of care is the requirement for patient enrolment with a local GP which has been mandatory in the Netherlands since 2006 coupled with the creation of regional GP co-operatives.

Primary care organisations in the Netherlands (regional GP co-operatives) are directly involved in providing patient care. They were initially set up to provide afterhours care but have evolved to support GP practices and may offer a range of administrative, IT, data collection and professional services to practices. GP co-operatives have recently entered into contracts with health insurers to provide disease management services to patients. These cooperatives were incentivised by government through financial reimbursements covering organisational and material costs.

Payment methods to GPs have been changing and in recent times, a ”blended payment approach” has been brought in, whereby incentives for desired behaviours amongst practitioners are funded alongside the usual capitation based system. The challenge has been to find the right balance between capitation and fee –for service.

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Table 1. Primary Care Organisations UK, Netherlands, Australia Country

Population size (avg)

Roles

Funding

Australia: divisions of general practice (replaced by Medicare Locals 20112012, see below)

200,000

Provide GP services, support GPs IT, education, projects to improve service integration

Core provided by Australian government-additional project funding

Australia Medicare Locals Since 2011/12

380,000

Co-ordination of primary care ,local health planning, address gaps in service

Core funding from Government

UK Primary Care trusts (replaced by commission consortia April 2013, see below)

300,000

Population health focus.

Contract funds for services for population servedâ&#x20AC;&#x201C;moving to commissioning consortia April 2013

80% of total NHS budget

UK GP commissioning consortia

Range from 18,900 (3 practice GPs) to 672,000 (83 GPs).

Avg. 35 GPs serving 239,000

Commissioning NHS services acute and community sectors

Netherlands GP Co-operatives

National Commissioning Board according to person-based risk adjusted formula.

After hours care is funded under the basic care package. GP coops get extra payments for disease management under contracts with health insurers.

100,000-500,000

The Chronic Care Model in the management of chronic disease states sees tasks delegated to practice nurses covered by additional fees paid for by health insurers. GPs are required to provide performance indicators. The government determines the maximum budget for primary care services and most prices for primary care.

Evidence for improved care is suggested by reported low rates of avoidable admissions in hospitals.

Overall satisfaction amongst the Dutch for their health system is reported to be high. The out of hours service is characterised by a single regional telephone number for each co-op with most services situated close to hospitals-a significant 45% of after hour consultations are telephone only. The shared electronic health records between the coops and the patientâ&#x20AC;&#x2122;s usual GP practice facilitates continuity of care. The phones are serviced by triage nurses who have access to national evidence based clinical guidelines (especially in the Netherlands) to enhance standardisation of care, transparency and performance measurement.

In the Netherlands, as in the UK and Australia, a robust primary care infrastructure has been key to service integration with patient enrolment being a key feature of health systems in both the UK and the Netherlands. The use of IT for out of hourâ&#x20AC;&#x2122;s continuity of care is important. The focus on chronic disease management including mental health has seen investment for better coordination of such care in the Netherlands.

The GP co-operatives having been set up voluntarily have the advantage of professional ownership.

Different countries have adopted different approaches to governance and influence. The role of the professional is well recognised in the Netherlands approach as well as a focus on local provision of care.

Willcox et al., (2011), recognise that there is no single solution that can strengthen primary care and initiatives include changes in organisation & governance and influencing norms and behaviours amongst healthcare professionals, changing roles and engaging consumers in their care. Regulation is important to improve quality of care and is encouraged through vocational training of GPs, accreditation of practices and the use of clinical guidelines.

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3. Critical Review Papers on Successful Health Systems Integration The following section is based on 2 critical reviews of successful health systems integration. Both reviews were undertaken to guide decision makers and others to plan for and implement integrated health systems.

1. The first publication by Suter et al., (2009), is the result of a systematic literature review of organisations where 10 universal principles of successfully integrated healthcare system were identified. Below is a summary of the findings.

An important finding from the literature review is that one size does not fit all, in the bid toward integration, allowing organizational flexibility and adaptation of models and processes to local context.

Suter et al. (2009) found 10 frequently and consistently presented principles associated with successful integration regardless of the type of integration model, healthcare context or patient population served. The authors’ findings are listed below.

Ten key principles for successful integration I Comprehensive services across the care continuum •Co-operation between health and social care organizations.

•Access to care continuum with multiple points of access.

•Emphasis on wellness, health promotion and primary care.

II. Patient focus •Patient-centred philosophy; focusing on patients' needs.

•Patient engagement and participation.

•Population-based needs assessment; focus on defined population.

III. Geographic coverage and rostering •Maximize patient accessibility and minimize duplication of services.

•Roster: responsibility for identified population; right of patient to choose and exit.

IV. Standardized care delivery through inter-professional teams •Inter-professional teams across the continuum of care.

•Provider-developed, evidence-based care guidelines and protocols to enforce one standard of care, regardless of where patients are treated.

V. Performance management •Committed to quality of services, evaluation and continuous care improvement.

•Diagnosis, treatment and care interventions linked to clinical outcomes.

VI. Information systems •State of the art information systems to collect, track and report activities.

•Efficient information systems that enhance communication and information flow across the continuum of care.

VII. Organizational culture and leadership •Organizational support with demonstration of commitment.

•Leaders with vision who are able to instil a strong, cohesive culture.

VIII. Physician integration •Physicians are the gateway to integrated healthcare delivery systems.

•Pivotal in the creation and maintenance of the single-point-of-entry or universal electronic patient record.

•Engage physicians in leading role, participation on Board to promote buy-in.

IX. Governance structure •Strong, focused, diverse governance represented by a comprehensive membership from all stakeholder groups.

•Organizational structure that promotes coordination across settings and levels of care.

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X. Financial management •Aligning service funding to ensure equitable funding distribution for different services or levels of services.

•Funding mechanisms must promote inter-professional teamwork and health promotion.

•Sufficient funding to ensure adequate resources for sustainable change.

2. The second publication by Grant (2010), is based on information obtained by speaking with healthcare organisations (either individually or in panels) who have succeeded in implementing integrated care.

Grant (2010) states that regardless of the approach to health care integration, successful organisations share a common trait, they design all stages of care delivery around what is best for patients. She suggests the approaches used can be grouped into three broad categories: 1) Integration between primary care and secondary care. The author gives the example of Polikum, the largest provider of integrated outpatient health services in Germany to exemplify this approach. “Its guiding philosophy is that patients should be able to obtain all types of outpatient care under one roof. At its polyclinics in Berlin, patients can consult primary care physicians, specialists, nutritionists, and other health professionals; they can also undergo diagnostic tests and have prescriptions filled. Polikum executives have estimated that within a year of adopting this approach, the company’s hospitalization costs were reduced by about half.”

2) Integration between health care and community care. These efforts coordinate a wider range of services, including social services and community nursing services. The author gives Sweden as the country exemplifying this approach in the care of elderly or disabled patient.

Regarding discharge home or to a step down facility, a physician from the hospital and a case worker from the municipal social services agency must jointly develop a plan to ensure appropriate follow-up services. This results in faster discharge and means patients were not kept in an acute bed for longer than necessary.

3) Integration between payors and providers. This results in better co-ordination of planning, commissioning, and delivery of healthcare. The organisation chosen to exemplify this approach is Kaiser Permanente in acute coronary event management.

Grant (2010) advises that “Even the organizations that are best at providing integrated care did not attempt initially to integrate every aspect of health and social care”.

She advises that an organisation must; x

be clear about why it is conducting the pilot

x

know what it hopes to accomplish

x

be realistic about what it can achieve in any one pilot

x

focus on where it can have the greatest impact.

Grant (2010) advises that decisions around integrated care “should be based on the needs of the community and the context within which the organization is operating”.

Grant ( 2010) then asks the following questions to help organisations piloting integrated care.

1. Which patients and clinical pathways should be integrated?

The answer to this question can be narrow, expansive, or somewhere in between.

An example of a narrow focus would be a single clinical pathway. The author recommends this approach if the goal is to optimize health outcomes in a specific patient population. E.g. Bolton Primary Care Trust in the United Kingdom built a diabetes network to address the region’s high prevalence of that disease. The network, which includes primary care, secondary care, social services, volunteer groups, and patient representatives, has enabled Bolton to ensure that diabetes patients get high-quality care from well-trained local teams. Another example listed is in Germany,

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where integrated disease-management programs are being used by payers to improve care delivery to patients with specific conditions (diabetes, heart disease, and asthma, for example).

A broad focus might include all patients in need of long-term care or like Geisinger Health System in the United States all patients with chronic conditions..

A mid- sized focus might consider all patients who use specific types of services (for example, home nursing care).

2. How many people should be included?

The scale of the effort will depend on the clinical pathways selected for the pilot, the financial (Return on Investment, ROI) and clinical viability. Thus, the population included can be anywhere from a few thousand people to hundreds of thousands.

Consider collaborating/contracting with other regions/organisations to achieve adequate numbers for cost effectiveness and viability with an integrated care initiative.

3. Which services should be included?

The answers to the two previous questions determine which professionals need to be involved.

The author suggest that a key consideration is whether payors should also be involved and suggests that involvement can help ensure that all incentives are appropriately aligned. In Germany, for example, the public payor AOK has used incentives to strengthen coordination among GPs, hospitals, and nursing homes and thereby improve the services delivered to elderly patients.

4. Which model of integration should be used?

Here, there are basically two choices: structural and virtual. Structural integration requires that different organizations either be merged or have some sort of formal partnership or joint-venture arrangement. Virtual integration requires only that the organizations work closely together. In both cases, the best results are achieved when effective governance mechanisms, including strong performance management, are in place.

The Veterans Health Administration (VHA) is a good example of the value of structural integration.

VHA, the largest integrated health care organization in the United States, delivers a wide range of health services to retired military personnel. It outranks many other US providers in the quality of care it delivers, the outcomes it achieves, and the efficiency of its care delivery.

However, full integration into a single organization is not a necessity. In some countries, physicians in private practice have banded together to form independent practice associations (IPAs) e.g. in Canterbury New Zealand . These associations help physicians in their negotiations with payors; in addition, they encourage collaboration and increased efficiency in care delivery. The physicians remain autonomous, but the IPAs give them incentives to coordinate care.

As structural integration is not always possible the author suggests that the organization should put other governance mechanisms in place to ensure that care is coordinated.

5. What other organizational enablers are needed?

The author proposes Five factors that can help maximize the results obtained with integrated care: 1. Patient self-care. Integrated care achieves best results when patients take control of their own health.

2. Team responsibilities and accountability (the “panel approach”). Integrated care is provided by a team of professionals who must work together to deliver the necessary services. For the team to function effectively there must be clarity about who is responsible for what.

Grant (2010) suggests that If possible, a single person should have ultimate accountability for each patient; this helps ensure that all appropriate services are delivered without duplicate or wastage. However, a single point of accountability may not always be possible, especially when integration is virtual. In such cases, all care providers need to understand what they are accountable for, develop and then agree to follow protocols for how care will be delivered, and communicate regularly with other team members.

3. Information infrastructure (a “registry”). All care providers need easy access to up-to-date patient records through a strong information system.

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Electronic patient records improve care during individual patient visits; make it easier to plan for future care needs, with more accurate risk profiling and facilitate more robust performance management.

4. Clinical leadership. The author suggests that it is crucial that clinicians (especially physicians) play a prominent role. as partners in—and, ideally, leaders of—the change effort.

Those who want to assume leadership roles should be given appropriate training and additional compensation.

5. Governance and provider incentives. An integrated-care pilot must be predicated on a strong vision. The author stresses the importance of a clear governance structure; either a single board should be in charge of the effort or the involved organizations should have an agreedupon plan for how decisions will be made. x x

Clearly communicated responsibilities for all involved and an emphasis on performance measurement (individual and collective).

Incentives (both financial and non-financial) should be offered to all participants to encourage improved care quality and increased productivity.

Ideally, all of these factors should be in place if the integration effort is to maximize its ability to improve outcomes and reduce costs. However, which of these factors are most important to the success of the effort will depend on the pilot being conducted and the setting in which that pilot takes place.

The author gives the example of Knappschaft, Bahn, See, a German payor and hospital system, focusing first on getting physicians’ support by having them help develop the clinical pathways and on developing the IT infrastructure needed to support the pathways’ use.

Making integrated care work The author points out that most change programs fail, and “most of those failures arise from cultural factors—either senior managers are not supportive of the change or employees are resistant to it.”

If an integrated-care pilot is to succeed, therefore, strong support for it must be developed among all participants, which is part of the reason that appropriate incentives and clinical leadership are so important. A good communication program can also help in this regard. E.g. Torbay experience of integrating community care and health care providers in 2005. The trust began by communicating a clear and concise vision to all staff members of how they—and their patients—would benefit from integrated care. In addition, they also physically co-located the health and social care professionals to signal that they would collaborate from then on.

The author points out that enthusiasm alone is not enough for successful care integration. A deep transformation of attitudes and behaviours is required of all participants. The author suggests that the conviction among Kaiser Permanente’s physicians and nurses that hospital admissions often represent a failure of care as central to its successful integration of care. This belief unites the staff around the common goal of keeping patients healthy.

4. Summary of Key Themes and Learning from International Experience with Integrated Care ¾

Integrated Care is a Journey. Many countries recognised as having made significant advances in the area of Integrated Care have been working on the concept for 2 decades or longer.

¾

One size and approach to Integrated Healthcare does not fit all circumstances ¾ Successful integration has followed different paths and approaches in different healthcare systems ¾ It is important to be cognisant of the local context, and inherent challenges

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¾

It is neither possible nor advisable to attempt to introduce Integrated Care across all areas in one step ¾ A number of countries have adopted a pilot type approach introducing integrated care in pockets of service with a view to expansion o E.g. Healthpathways in Canterbury DHB integrating care around disease states/conditions o E.g. Care Programmes in elderly care & Mental Health in Northern Ireland o E.g. Pursuing Perfection in Jönköping Sweden for childhood asthma

¾

Focus on the patient need and journey through the healthcare continuum rather than focusing on the service providers perspective e.g. Mrs Smith (Torbay) and Esther (Jönköping Sweden) ¾ A named person to co-ordinate patient care ¾ Single point of patient contact, co-ordinating care across the continuum ¾ Focus on collaboration between health and social services and acute and community sectors rather than competition- CQI in patient care ¾ Care in Community wherever possible-Shift focus from Acute sector

¾

Leadership ¾ Strong leadership from the top and at various levels in the process-consider leadership development ¾ Buy-in from clinicians is essential-clinicians to act as leaders ¾ Political commitment

¾

A firm foundation ¾ A robust Primary Care System acts as a firm foundation for integrated Care ¾ A history of successful collaboration between health and social care may facilitate further integration ¾ Structural and organisational stability facilitates the change

¾

Synergy regarding drivers for integration is advisable e.g. National Policies support local initiatives, legislation, policy and structures facilitate the process

¾

Staff ¾ ¾ ¾ ¾ ¾

Must be included in the decision making process Must be enabled and supported throughout the process Must be trained in the knowledge & skills required to make integration a success.

Systems thinking approach may be beneficial Commitment of staff necessary for success Multidisciplinary/Interdisciplinary staff training and development-can help break down barriers and smooth cultural differences and facilitate a unified approach to patient care

¾

Governance ¾ Representatives from community , health and patient on the governing bodies

¾

A clear Vision regarding the purpose and outcome of integrated care is essential and this needs to be communicated to all stakeholders

¾

Capturing robust evidence of improved healthcare outcomes as a result of integration is important ¾

Recognise difficulties around definition of Integrated Care. Is it Primary and secondary, primary, secondary and community any or all of these with social care?

Important to define what to measure.

¾

Performance Management Systems are important to capture meaningful data on improvements in patient care and efficiency/cost savings.

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¾

Information Technology plays a key role in communicating and sharing information regarding patients within the system, avoiding duplication etc. and in evaluating the impact of any changes in outcomes by capturing data.

¾

Funding ¾ A unified Health and Social Care system with a unified budget ¾ Flexible sustainable financial mechanisms - enable funding to follow the patient ¾ Provide a system of shared resources & mutual accountability for service delivery and patient outcome

¾

Introduce incentives and remove disincentives where possible

¾

Accountability ¾ Be clear on roles and responsibility of all team members. Have a clear line of accountability ¾ All providers need to understand what aspect of care they are responsible for and develop and agree protocols for how care is to be delivered. Regular communication between team members is essential. ¾ Different systems appear to have different systems of Accountability ¾ In Canterbury New Zealand, responsibility for operational and management duties are delegated to the CEO of the Health Board. The CEO has an executive team. A clinical board provides clinical leadership and clinical governance. ¾ Joint accountability from providers of services for outcomes is proposed to be a factor in enabling integrated care in Scotland (Ham et al 2013). ¾ A named Non-healthcare) person co-ordinates patient care in Torbay trust. It is not clear if the co-ordinator is accountable for patient care.

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APPENDIX E REVIEW OF PRINCIPLES OF GOOD GOVERNANCE

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PRINCIPLES FOR GOOD GOVERNANCE IN PUBLIC SERVICES

NOVEMBER 2013 DR KATHERINE GAVIN

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Table of contents Page 1. Independent Commission on Good Governance in Public Services ................................ 152 -6 core principles of good governance

2. Perspective of the Chartered Institute of Public Finance & ............................................... 152 Accountancy International Federation of Accountants

3. Perspective of the Institutional Development Division (GIDD) .......................................... 153 Commonwealth Secretariat

4. Other Perspectives on â&#x20AC;&#x153;Principles of Best Corporate Governance Practice ..................... 153 5. International Committee of Sports for the Deaf (ICSD) (2012) .......................................... 154 â&#x20AC;&#x201C; Key Principles of an Effective Board for Good Governance

6. References ......................................................................................................................... 154

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1. Six Core Principles of Good governance The Independent Commission on Good Governance in Public Services identified 6 core principles of good governance (CIPFA/OPM 2004); 1. Focusing on the organisation’s purpose and on outcomes for citizens and service users ¾ e.g. Clear purpose and outcomes 2. Developing the capacity and capability of the governing body to be effective ¾ Ensuring “governor’s” have knowledge , skills and experience to perform effectively ¾ Develop capability of people and evaluate performance as individuals and as part of team 3. Engaging Stakeholders and making accountability real ¾ Understanding formal and informal accountability relationships 4. Performing effectively in clearly defined functions and roles ¾ Being clear about functions of governing body and various responsibilities 5. Promoting values for the whole organisation and demonstrating good governance through behaviour 6. Taking informed, transparent decisions and managing risk ¾ Having and using good quality information, advice and support

2. Perspective of the Chartered Institute of Public Finance &

Accountancy International Federation of Accountants(CIPFA/IFAC)

CIPFA/IFAC describes a governing body as “a group of one or more individuals that is explicitly responsible for providing strategic direction and accountability” (CIPFA/IFAC 2013).

The composition of the group can vary and may include; ¾

Independent and non-independent members and various subcommittees.

¾

Executive members.

¾

Separate governing and management functions with a non-executive governing body overseeing an executive management group. The non-executive division contributes to strategic decision making, ensuring management arrangements and teams are in place.

They hold the executive to account for performance in fulfilling the responsibilities delegated to it by the governing body.

¾

A two tiered structure including a top elected supervisory tier with similar roles to the non-executive board.

¾

State owned enterprises have governing bodies with a mix of executive and nonexecutive members commonly appointed by ministers of state. In such organisations, transparency over ministerial involvement is thought to be crucial to good governance.

CIPFA/IFAC state that the function of good governance in the public sector is to ensure entities act in the public interest at all times This requires; ¾ Strong commitment to integrity, ethical values and the rule of law ¾

Openness and comprehensive stakeholder engagement

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In addition, they state that good governance in the public sector also requires the following; ¾ Defining outcomes in terms of sustainable economic, social and environmental benefits ¾ Determining the interventions necessary to optimise the achievement of intended outcomes ¾ Developing the capacity of the entity, including the capability of its leadership and the individuals within it ¾ Managing risks and performance through robust internal control and strong public financial management ¾ Implementing good practices in transparency and reporting to deliver effective accountability

3. Perspective of the Institutional Development Division (GIDD)

Commonwealth Secretariat

Menocal A. R. (2011) describes 6 Key Principles of “Good Governance”; ¾ Effectiveness-performing key functions and delivering basic services ¾ Transparency-clarity and openness of decision making. ¾ Efficiency-government effective and responsive regulatory framework in place. ¾ Participation and inclusiveness-participation and ownership by a broad range of stakeholders. ¾ Accountability-decision makers responsible for their actions. ¾ Respect for institutions and laws.

4. Other Perspectives on “Principles of Best Corporate Governance

Practice” (www.best-practice.com) ¾ Ethical approach. ¾ Balanced objectives.

¾ Each party plays his/her part-roles of key players. ¾ Decision making process in place and reflects principles 1-3, gives weight to all stakeholders. ¾ Equal concern for all stakeholders-some have greater weight than others. ¾ Accountability and transparency- to all stakeholders.

Five Golden Rules ¾ Ethics-having a clear ethical basis (for the business) ¾

Align (business) goals-clear and achievable & arrived at through creation of suitable stakeholder decision making model

¾

Strategic Management-an effective strategic process to achieve goals, incorporating stakeholder value

¾

Organisation structure suitable to effect good corporate governance

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¾

Reporting systems structured to provide transparency and accountability

They describe the essence of success (in business); o Having clear and achievable goal(s) o Having a feasible strategy to achieve the goal(s) o Creating an organisation appropriate to deliver the goal(s) o Having a reporting system to guide progress

5. Key Principles of an Effective Board The International Committee of Sports for the Deaf (ICSD) (2012) describes the Key Principles of an Effective Board for Good Governance. An effective board; ¾ Understands its role ¾ Ensures the delivery of the organisations vision and purpose ¾ Is Effective as individuals and as a team ¾ Can exercise control ¾ Behaves with integrity ¾ Is open and accountability

6. References CIPFA/OPM (2004), ‘The Good Governance Standard for Public Services’ (CIPFA, London). Available at www.coe.int/t/dghl/standardsetting/media/doc/Good_Gov_StandardPS_en.pdf CIPFA/IFAC (2013), Good Governance in the Public Sector-Consultation Draft for an International Framework The Chartered Institute of Public Finance & Accountancy International Federation of Accountants. www.ifac.org/sites/default/files/publications/files/Good-Governance-in -the Public-Sector.pdf Menocal A. R. (2011) “The Good Governance Agenda and its Discontents” Development Day Governance and Institutional Development Division (GIDD) Commonwealth Secretariat. Available at www.odi.org/uk/events/presentation/934.pdf Principles of Good Governance for the International Committee of Sports for the Deaf (ICSD) (2012). Available at www.icsd.dialogue-app.com/what-principles-should-be-followed-b-icsd-within-its-governance/principles-of-goodgovernance www.best-practice.com/compliance-best-practices/golden-principles-of-effective-corporate-governance14042012/

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APPENDIX F - REVIEW OF GOVERNANCE AND CLINICAL SUPERVISION

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HEALTH SERVICE GOVERNANCE AND CLINICAL SUPERVISION aA REVIEW a

NOVEMBER 2013 DR KATHERINE GAVIN

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Table of contents Page 1. Health Service Governance-Clinical Governance ............................................................... 157 1.1. Key Features of Clinical Governance and Guidelines for Implementation........................ 157 1.2. Examples of Clinical Governance Systems in Practice...................................................... 158 1.2.1.NHS Scotland ............................................................................................................ 158 1.2.2.NHS England............................................................................................................. 160 (a) Torbay Care Trust......................................................................................... 160 (b) NHS Knowlsey.............................................................................................. 161 (c) North East Lincolnshire Care Trust............................................................... 161 1.2.3. Australia-New South Wales .................................................................................. 161 1.2.4.

New Zealand......................................................................................................... 162

1.2.5.

Canadian Mental Health ....................................................................................... 164

2. Clinical Supervision................................................................................................................ 165 3. References............................................................................................................................... 167

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1. Health Service Governance - Clinical Governance Section 1.1 provides general information on Clinical Governance. Section 1.2 reports on the practical experience of healthcare systems implementing clinical governance and lessons learnt. Section 2 looks at Clinical Supervision and its role within Clinical Governance.

1.1 Key Features of Clinical Governance and Guidelines for Implementation Clinical governance: principles into practice mea.elsevierhealth.com, provides a useful overview of clinical governance in a Trust setting. The author suggests that there is no simple recipe for clinical governance and no easy to assemble model of clinical governance, but offers guidelines that may facilitate its introduction.

Structure and chain of responsibility The Chief executive officer (CEO) of a hospital or primary care trust has ultimate responsibility for assuring quality of care. The CEO has a subcommittee to oversee clinical governance in the trust.

Non-executive directors on the sub-committee may act as useful independent advisors to the Board.

Recommended membership of the sub-committee includes the CEO, non-executive directors and senior clinicians.

The subcommittee is responsible for the strategic development of clinical governance. The presence of the CEO on the subcommittee provides evidence of the importance of clinical governance to the organisation. Clinical governance should be led by a clinician as it concerns clinical practice and a clinical governance lead be established /appointed to be responsible for co-ordinating and monitoring care, providing support to staff and reviewing progress against specified objectives (Clinical governance : principles into practice mea.elsevierhealth.com.) The author suggests the clinical lead can be a doctor often medical director, senior nurse or other senior clinician. The clinical lead should in turn set up a multidisciplinary team of clinicians to steer/monitor the day to day development of clinical governance and to provide staff with the necessary support to make this a reality.

Due to the fragmented nature of health care in the community, the establishing of clinical governance is reported to be more challenging. Staff involvement, development and support in this process are seen as key success factors. Within primary care one suggested structure is; a Primary Care Board and Executive to whom a Clinical Governance and Education Team would report. A number of other groups and teams would report to the Clinical Governance and Education Team including specialist working groups, doctors, nurses and practice managers. These teams would in turn get input from a Practice Quality Team. Staff and practices would receive personal development plans and monitoring systems would capture individual and collective performance across established standards and objectives.

The author puts forward the following principles to change healthcare delivery and improve quality of patient care; x x

x x x x x

Clinical governance should be mainstream-integral to everyday practice of all healthcare professionals Effective Teamwork o clinical governance must be a multidisciplinary activity, o collaboration across disciplines but also interdisciplinary to standardise care for the same patients/disease groups Management support o needed from senior management to enable required changes in organisational development as result of clinical governance endeavours/evidence based suggestions Leadership by Senior Clinicians Collaborative approach/ Collaboration and partnership o Patient involvement o Link primary with secondary care Monitor progress against objectives and plans- Monitoring of progress should be routine Resources o Staff roles and skill mix to deliver requirements, protected time, IT, training o Available resources should be used to maximum effect.

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Carter K., et al. (2011), suggest 3 sets of elements which help support successful integrated care; x x x

Addressing patient needs in a pathway Working in multidisciplinary systems Establishing key enablers for support.

Accountability and shared decision making are put forward as elements to support service integration.

The authors suggest that accountability begins at the top level with the executive board demonstrating strong support for the integration effort. It notes that primary care physicians are responsible for the delivery of care but that all team members are accountable for patient well-being. The authors recognise the need for appropriate clinical governance mechanisms and standing agreements to support the process. They recommend joint decision making to achieve alignment and “a partnership” approach with all stakeholders having an equal role in decision making.

In addition, clinical leadership is identified as essential for integrated care. Clinical leaders are seen as key figures in the development and updating of evidence based best practice protocols and in facilitating and supporting their implementation in the workplace.

1.2 Examples of Clinical Governance Systems in Practice 1.2.1 NHS Scotland The Chain of Responsibility in NHS Scotland states; “Clinical governance is the system through which NHS organisations are accountable for continuously monitoring and improving the quality of their care and services, and safeguarding high standards of care and services (NHS Quality Improvement Scotland 2005).

NHS Scotland states that “whilst it is each individual clinician’s and employee’s responsibility to ensure their practice is safe, it is the Chief Executive who carries ultimate accountability for the quality of care provided within each NHS Health Board (NHS Scotland Healthcare Quality Strategy 2010).

IN NHS Scotland there is a recognition that clinical governance is about the culture and attitude of staff working in the health service as well as specific activities.

NHS Scotland outlines 3 principles that need to be in place to achieve effective clinical governance (Governance NHS Scotland, 2013); ¾ ¾ ¾

Clear , robust national and local systems and structures that help identify and report on quality improvement Involving staff, patients and the public Establishing a supportive, inclusive learning culture

Staff Governance Each NHS Board must operate within the Governance Framework (Clinical Governance, Financial Governance and Staff Governance). Staff governance focuses on how NHS Scotland staff is managed, and feel they are managed. NHS Scotland is striving to be an exemplary employer. Staff Governance is a central aspect of this endeavour.

Employment practices are evolving in NHS Scotland based on the concept of Partnership working.

Organisations involved in the partnership are: x

Trade Unions

x

Professional Organisations

x

NHS employers

x

The Scottish Government Health Directorates

The NHS Reform (Scotland) Act 2004 saw the commitment to staff governance being reinforced by legislation and supported by the introduction of the Staff Governance Standard which requires certain obligations from employing organisations and the staff working there-in.

NHS Boards must ensure that staff is; x

well informed;

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x

appropriately trained and developed;

x

involved in decisions;

x

treated fairly and consistently, with dignity and respect, in an environment where diversity is valued; and

x

provided with a continuously improving and safe working environment, promoting the health and wellbeing of staff, patients and the wider community.

Staff are required to: x

keep themselves up to date with developments relevant to their job within the organisation;

x

commit to continuous personal and professional development;

x

adhere to the standards set by their regulatory bodies;

x

actively participate in discussions on issues that affect them either directly or via their trade union/professional organisation;

x

treat all staff and patients with dignity and respect while valuing diversity; and ensure that their actions maintain and promote the health, safety and wellbeing of all staff, patients and carers.

In Scotland the Staff Governance Standard continues to evolve and NHS employers are required to demonstrate that they are striving to both achieve and maintain exemplary employer status. In order to be able to do this, they will be expected to have systems in place to identify areas that require improvement and to develop action plans that will describe how improvements will be made Staff governance and its underpinning in legislation was a major achievement for NHS Scotland and a first for the United Kingdom. The development and implementation of this Framework demonstrates the proactive approach of trade unions and professional organisations, NHS employers and the Scottish Government to modernising employment practices based on the concept of partnership working. This approach has received critical acclaim from independent research by Nottingham University.

An important development within this version of the Framework is the recognition that a responsible organisation that ensures that its employees are fairly and effectively managed within a specified framework of staff governance can reasonably expect these staff to ensure that they take responsibility for their actions in relation to the organisation, fellow staff, patients, their carers and the general public. Active engagement of all parties with the principles of good staff governance is essential for NHS Scotland to achieve continuous improvements in service quality which deliver the best possible outcomes for the people of Scotland.

In recent years the NHS Scotland has been developing the concept of a Partnership Approach to working with Trade Unions (Tus). This partnership working has been recognised in NHS Scotland as a critical success factor in achieving the aspiration of a world-class health service designed from a patient's viewpoint conducted so as to facilitate this aspiration. Since 1998, and the establishment of the Scottish Partnership Forum (SPF) all stakeholders were to be involved in formulating policy.

Current National Partnership Structures There are two key bodies the Scottish Partnership Forum (SPF) and The Scottish Workforce and Staff Governance Committee (SWAG) representing partnership working at a national level. Both bodies are tri-partite, taking their membership from representatives of the Health and Wellbeing Directorate, NHS Scotland Employers and TUs, are co-chaired and have formal constitutions.

The Scottish Partnership Forum exists to provide the Scottish Government, NHS Scotland employers and trade unions/professional organisations an opportunity to work together to improve health services for the people of Scotland. It also provides a forum for all national key policy leads to engage with key stakeholders to inform thinking around national policies on health issues.

Topics discussed at the SPF are shared with the local Area Partnership Forums to ensure that local systems are aware of what is being discussed at National Level.

The SWAG addresses workforce issues that require Scottish-wide solutions, working in conjunction with the SPF to ensure that NHS Scotland operates as an exemplary employer.

Community Health Partnerships (CHP) have been set up across Scotland to provide a wide range of community based health services delivered in homes, health centres and clinics. The CHP have a document which sets out some principles and guidance around governing across partnerships

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describing key principles for governance arrangements for joint services (Governance for Joint Services, Principles and Advice 2007).

These include; ¾ ¾ ¾ ¾

how partners address the issue of accountability for delivery of joint services, how accountability is preserved across different management structures , good financial governance for budgets for joint services, issues regarding risk management for joint services

The Scottish Borders CHCP offers an example of the Governance Arrangements in Community Health Partnerships in Scotland (Scottish Borders Community Health and Care Partnership-NHS Borders, 2009).

The Board of the Scottish Borders CHCP is a Strategic Committee accountable to NHS Borders and Scottish Borders Council (SBC). The key functions delegated from NHS Borders Board and the Scottish Borders Council to the CHCP include all governance arrangements relating to services delivered in partnership between the organisation and other stakeholders for adults and older people, mental health, learning disabilities and children’s services. This includes joint planning, service redesign, performance monitoring, including Single Outcome Agreement (SOA) and Health Improvement, Efficiency and Access to Services and Treatments (HEAT) targets and commissioning of services. Health Improvement, Drugs and Alcohol Services and Prevention Strategies, Housing and Data Sharing also come under the remit of the CHCP. The role of the Partnership Board is to: x

to set the strategic vision

x

to agree a Strategic Plan for Community Health Partnership working

x

to monitor overall progress against joint HEAT targets, Community Health Partnership (CHP) objectives and joint outcomes within the SOA including those for Health Improvement

x

ensure structural and cultural barriers to joint working are minimised so that patients and the public experience seamless care and enhanced services

x

to hold the Joint Planning and Delivery Committee to account in delivering all the above

Joint Planning & Delivery Committee The committee’s role is “to deliver the CHCP Strategic Plan, monitor governance arrangements, plan, Commission and redesign jointly delivered services, hold Joint Boards and Joint Commissioning Teams to account and drive forward health improvement”. A number of key groups are responsible for achieving this for specific patient / client groups, including the Primary & Community Care Interface Group, the Mental Health & Wellbeing Partnership Board, the Joint Learning Disabilities Board and the Children & Young People’s Planning Partnership.

There are joint appointments on boards to encourage alignment of services. The Chairs of the Joint Health Improvement Team (JHIT), the Drug and Alcohol Action Team (DAAT), the Housing Strategy Group and the Data Sharing Partnership are members of the Joint Planning & Delivery Group.

1.2.2 NHS England (a) Torbay Care Trust (Torbay and South Devon Health and Care NHS Trust In Torbay, Primary Care Teams and Local Authorities had a history of joint working and decided to set up a care trust. Five integrated health and social care teams are aligned with general practices seeking to manage vulnerable service users using single patient-held records. The service model is based on integrated multidisciplinary teams working closely with primary care and specialist health services to deliver care for the target population. Governance is based on a formal agreement between Torbay Council and Torbay Primary Care team. The Local Authority retains accountability for adult social care and an Annual Agreement allows the Council to outline the resources available for social care and performance monitoring agreements. There are capitated budgets for health services.

Local teams manage integrated budgets. There is general management across integrated and colocated health and social care teams. A Heath and Social Care Co-ordinator role was introduced to have a single point of contact co-ordinating health and social care for patients. Multidisciplinary teams work across zones. There is a systems based approach to care with hospitals, primary care and

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community services encouraged to work in partnership. Senior management at the trust advise the early engagement of senior and middle management to avoid separate arrangements for different professions.

(b) NHS Knowlsey (NHS Knowsley Primary Care Trust) Knowsley Primary Care Trust serves a population of 161,000 (based on GP practice registration). In NHS Knowlsey, efforts are being made to bring together PCT and the council’s health responsibilities into a strategic arrangement. A Health and Wellbeing Partnership Board oversees the outcomes, and day to day responsibility is with a partnership management board. The chair is the PCT Chief Executive/Council Executive Director. There is a Partnership Agreement which provides for single accountability with dual governance. In developing the partnership agreement, development days were scheduled and included employment law and a “dignity and respect agenda”. There is a Joint Negotiating Consultative Committee (JNCC) which meets monthly and focuses on organisational developments and their implications for staff and the development of the HR/employment strategy. A joint policy and procedure group which develops, reviews and equality impact assesses all human resource policies and procedures and passes these to the JNCC for ratification. Governance staff is represented on the trust board and provider board. The joint policy and procedure group includes 2 experienced union representatives. Trade union representatives contribute to corporate inductions and management development programmes. Widespread involvement of staff representatives and service managers ensures partnership working outside JNCC membership. There is one executive leadership team and commissioning is organised through five executive leads.

1.2.3

(c) NHS North East (NHS Lincolnshire Care Trust)

The North East Lincolnshire Care Trust Plus commissions adult health and social care services for a population of circa 170,000 served by 28 GP practices. The trust is described as the first of its type in the country commissioning health and social care together allowing for greater integration between health and social care of services and includes potential for consideration of education, employment, and housing. The trust functions under a Governance Framework and Partnership Agreement. The community care group delivers 7 programmes of care each supported by a unique leadership model; a clinical leader is at the heart of each model and is supported by a community member and service manager. The projects areas are; disability, older people & dementia, planned care, unscheduled care, women & children, prescribing and wellbeing and prevention.

1.2.4 Australia (New South Wales) Governance in New South Wales Health (Australia) Report of the director general reviewed the functions, responsibilities, structure and relationships of each of the main components of NSW Health (Governance of NSW Health Report of the Director-General 2011). Major considerations were the alignment of each component with Government policy particularly devolution to Local Health Districts, transparency and accountability, and strengthening clinical engagement. The guiding principle was that “every decision and every person” working within NSW Health is focussed on the “best outcome” for patients.

Each Local Health District (LHD) and Speciality Network assumed responsibility for all aspects of hospital and health service delivery for their district under a “Service Agreement” between the Department of Health and the Board of the LHD. Boards established a Performance Agreement with their CEO. A key element of the Government’s health policy is the devolution of the management and governance of the State’s public healthcare services to LHD governed by LHD Boards. NSW recently reorganised its public health service from 8 large area health services into 17 Local Health Networks. In the restructuring, the government were conscious to avoid unnecessary administrative layers of bureaucracy.

Devolution of functions to LHD was encouraged to occur “unless a clear and compelling reason for delivery on a state wide or other basis” was found. There are 2 Ministers of Health in Australia, one for Health and Medical Research and another Minister for Mental Health and Healthy Lifestyles.

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Within the governance framework there is provision for clear allocation of responsibilities, transparency in accountability and linkages and processes between all NSW healthcare providers.

A Governance Review Team was set up to provide expert advice and supports to the Director-General in the conduct of the review. A consultation process with other key stakeholders was held.

The NSW Government Policy is to devolve management and governance of the State’s public hospitals and healthcare delivery services to LHD (Speciality Health Networks). It is proposed that each LHD will negotiate a service Agreement with the Department of Health specifying which services will be purchased or funded.

A number of “Pillars” were established to focus on particular aspects of function. The Pillars are in the areas of Clinical Excellence Commission (CEC), Innovation, Health Information and Education/Training. The CEC for example will take responsibility for quality and safety and providing leadership in clinical governance with LHDs. The Governance approach proposed in NSW seeks to empower local health services, build a sense of joint ownership across the system, improve transparency, accountability and responsiveness within the system.

The review details responsibilities, accountabilities and working relationships of the various entities within NSW Health, emphasising clear delineation and non-duplication of roles and a collaborative approach. It is stated that all entities would have a joint governance responsibility for health services.

The review speaks of a number of critical design factors which are needed in the governance model to support clinicians and patients to achieve effective care x Local flexibility and responsiveness requirement of the health services to engage with patients and best meet patient needs and to build linkages across the hospital community sectors. x Clinician engagement in designing models of care and decision making for local and system wide policies. x Evidence based policy & effective information systems to support best practice, system management and performance. x Transparency in funding and decision making. x Accountability at all levels for performance against validated standards and benchmarks. x Capable & adaptive work force focused on teamwork and cooperation. x Effective information and communication technologies to support service delivery and empower patients.

It describes both clearly delineated system wide governance combined with local governance flexibility and accountability in keeping with a “localise where possible, centralise where necessary” philosophy.

1.2.5 New Zealand A report by the Ministerial Task Group on Clinical Leadership in New Zealand states that decisions around planning and healthcare “demand a balance between clinical, community and corporate governance” (In Good Hands. Transforming Clinical Governance in New Zealand, 2009).

The report states that much effort was being put into corporate governance, the reporting of corporate outcomes, and establishing processes for community governance. However, clinical governance and reporting of clinical outcomes had not been the prime focus of District Health Boards (DHBs) and especially their hospitals.

The report suggests that successful governance within Primary Care Networks requires distributed leadership (at practice, network and national levels) which is happening and that the challenge now is to transform clinical governance into an everyday reality at every level.

The report proposes 6 principles upon which Clinical Governance should be based; 1. Quality and safety will be the goal of every clinical and administrative initiative.

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2. The most effective use of resources occurs when clinical leadership is embedded at every level of the system.

3. Clinical decisions at the closest point of contact will be encouraged.

4. Clinical review of administrative decisions will be enabled.

5. Clinical governance will build on successful initiatives.

6. Clinical governance will embed a transformative new partnership which will be an enabler for better outcomes for patients The Ministerial Task Group recommends that DHBs establish governance structures which ensure effective partnership of clinical and corporate management and that the Chief Executive enables strong clinical leadership and decision making. In addition, clinical governance must cover the whole patient journey, including horizontal integration across the sector and across primary and secondary/tertiary services.

The Task Group puts forward a series of tangible examples of clinical governance, which DHBs must report on including: a) Clinicians on the Executive Management Team as full active participants in all decision making b) Effective partnership between clinicians and management at all levels of the organisation with shared decision making, responsibility and accountability. c) Decisions and trust devolved to the most appropriate clinical units or teams. d) Clinical leadership must include the whole spectrum from inherent (e.g. bedside, clinical) through peer-elect (e.g. practice, department arrangements) to clinician - management appointment (e.g. clinical directors, clinical board). DHBs must report on the establishment, and effectiveness, of clinical leadership across the spectrum of activities, aligning management to clinical activities.

The report states that empowerment of clinicians is the best means of realising effective clinical governance, and that this must be accompanied by a willingness to accept responsibility and accountability, including for best use of resources.

The Task Group recommends that, at a minimum, DHBs must: 1.

Report on clinical outcomes and clinical effectiveness, in a nationally consistent manner.

2.

Ensure that quality and safety are at the top of every agenda of every Board meeting and Board report.

3.

Assess their own and Chief Executive performance on measures that include clinical outcomes and the establishment of clinical governance.

4.

Report on clinical leadership and clinical governance through their District Annual Plans and scorecard reports to the Ministry.

5.

Demonstrate clinician involvement at all levels of the organisation including the Executive Management team.**

6.

Demonstrate devolvement of decision making and responsibility to the most appropriate clinical unit or team.**

**The mechanisms for reporting on 5. and 6. must include clinicians themselves. **An example is existing Joint Consultative Committees.

7.

Identify actual and potential clinical leaders, and foster and support the development of clinical leadership at all levels.

8.

Coordinate funding, access to internal and external training, and support for coaching and mentoring of leadership at all levels.

The Group recognises the importance of performance measures to drive change and recommends applying the existing well established and validated international leadership metrics to the New Zealand healthcare industry. In addition, they suggest that â&#x20AC;&#x153;a small group be tasked with developing

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an initial national framework for reporting on clinical outcomes, clinical effectiveness, and clinical leadership within DHBs. This evidence-based framework should be part of existing reporting mechanisms such as “balanced scorecards” to the Ministry, and should be validated for accuracy by clinician groups within DHBs”. The framework would be subject to regular review and updated accordingly as part of a national process to improve the quality and safety of health and disability services. The Task Group recommends sharing successes to encourage others to get involved in the transformation process.

The philosophy is apparent in the following statement by Lord Darzi “If clinicians are to be held to account for the quality outcomes of the care that they deliver, then they can reasonably expect that they will have the powers to affect those outcomes. This means they must be empowered to set the direction for the services they deliver, to make decisions on resources, and to make decisions on people.” - Professor of Surgery, the Lord Darzi, Parliamentary Under Secretary of State, Department of health UK. NHS Next Stage Review Final Report, 2008.

1.2.6 Canadian Mental Health Wiktorowicz et al., (2010), compared models of governance across 10 local mental health networks in diverse contexts (rural/urban and regionalised /non-regionalised). The aim of the project was to clarify the governance processes that foster inter-organisational collaboration and to identify the conditions that support these processes.

In Canada, as elsewhere, there is a shift of mental health care to the community setting. In addition, the Canadian health care system is introducing Regional Health Authorities (RHA) charged with the delivery of care to target populations in their location/area. Networks act as sub-regional governance structures below RHAs. A number of networks have been established in Canada in the areas of cancer, AIDS, elderly chronic care in a bid to bring about a systems approach to health care. These Networks are built around a philosophy of co-operation. Networks require participating organisations to translate their values into a common vision for care and negotiate provision of services and fill service gaps.

For this research, 10 Canadian Mental Health Service Networks, across a mix of diverse contexts, agreed to participate. Mental health networks were set up to provide a means to deliver co-ordinated care to target populations on a regional basis. The goal of the network is to co-ordinate care across primary, secondary, tertiary and social services and to simplify the patient journey.

Governance is coordinated between the RHA and the local networks through their respective executive committees. Governance is described as overseeing the collective action of organisations contracted to provide services and encompasses strategic direction, policy, management and resource utilisation to ensure accountability for performance. Co-ordination of care is assumed under the governance function.

Local mental health networks adopted one of 3 approaches to govern inter-organisational collaboration; 1) corporate structure, 2) mutual adjustment or 3) alliance.

In regionalised provinces, RHAs integrated organisations boards through a corporate structure. The researchers found the most co-ordinated networks adopted corporate-governed models. In one such network, an initial lack of co-ordination was facilitated by the appointment of director to oversee hospital and community services and committees from both sectors were set-up to facilitate coordination.

In small and mid-sized urban networks, governance occurred through an alliance of organisations forming an executive team that mediated service coordination. In this approach, organisations retained their autonomy. This form of governance would appear to work best in small and mid –sized urban networks. Due to size, working relationships were developed easier in addition to a stronger sense of accountability.

Large urban networks reported the highest level of coordination through a corporate governance type model, and executive committee. Resources were deployed as needed and these networks reported that union contracts did not prevent shifting of care to the community.

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In Ontario’s large urban networks the governance model adopted was mutual adjustment. This model relied on co-ordination through voluntary exchange without formal co-ordination mechanisms.

A Community Investment Fund acts as a financial incentive, encouraging co-ordination of care as programs wishing to expand required a memorandum of understanding with the other organisations in the network to coordinate the service.

If a region had a psychiatric hospital, its involvement in network governance was described as pivotal to ensuring coordination. Corporate governed networks in regionalised provinces were held accountable for ensuring mental health service coordination. One key feature of successful integration was the central patient intake registry which was proposed to act as a “governance lever” in corporate governance networks.

If networks had budget authority and service planning authority this alignment supported governance capacity prompting organisational coordination/cooperation. Conversely if a province holds budgets for organisations while networks oversee service planning, the key lever is removed and governance was reported to be less well supported. Misalignment was evident where a mental health service was planned by the network while secondary and tertiary facilities were funded by and reported to the province. This divided authority meant hospitals were not held accountable when their care was not co-ordinated with community based organisations (Networks).

Conversely, Network governance was most supported when planning and budget decisions resided at the regional or network level. Provincial control of network budgets was less likely to support governance due to lack of local insight and the lack of a shared vision.

An important governance strategy in Canadian mental health was the formation of sub-networks to address the needs of certain sub-populations e.g. addiction.

The importance of strong leadership in the networks was noted. A team of executives representing the participating organisations assessed needs, decided on resource allocation, etc. Networks reporting successful co-ordination, had governance structures consisting of a network executive committee with representation from all local organisations. Where sub-committees existed, these ensured the executive committee’s decisions were carried through into action. An executive forum of governance enabled the advance of shared understanding of goals, roles etc. in a co-ordinated regional manner.

Large metropolitan networks relying on mutual voluntary adjustment were unlikely to achieve coordinated care. Overly large organisations were seen not to be conductive to community building. In addition, an absence of clear goals and trust amongst organisations hampers integrated care.

Incentives may be used to encourage inter-organisational collaboration. The concept of shared governance of network members-a committee of executive directors is proposed. A director across primary and hospital care can be effective where conditions for collaboration are not favourable. A corporate structure with oversight by a regional health authority can lead to inter-organisational collaboration. Sometimes an external brokered form of governance is needed to facilitate the process.

2 Clinical Supervision There is a difference between the day to day supervision of clinical practice within specific health disciplines and clinical governance. Clinical practice is the monitoring of professional standards of care and practice, which may best be supervised by appropriately skilled superiors in the discipline.

Clinical governance has a wider remit. This section looks at the practical experience of clinical supervision in diverse healthcare disciplines and systems.

Clinical Supervision has been defined as “the formal process of professional support and learning that addresses practitioner’s development needs in a non-judgemental way. To enable practitioners to deliver an appropriate standard of care and to keep abreast of developments in care, clinical supervision is seen as an integral part of clinical governance. Continuous professional development of staff to maintain high standards of clinical care in a supportive environment is the essence of clinical supervision. The importance of involving clinicians in the supervision process is obvious as is ensuring that those charged with this responsibility have the required knowledge and expertise to carry out the role effectively. Training may be required across the various healthcare disciplines to ensure staff is competent and confident to act as supervisors. Management commitment to the process is seen as a key element in successful clinical supervision along with a bottom up approach and involving a wide range of disciplines (Clifton 2002).

165

Carpenter and Webb (2012), look principally at the role of supervision from a staff satisfaction and retention perspective, they also consider the practice of supervision in integrated multi-professional teams. They emphasise the essential role of supervision of clinical practice in education and training and suggest that the positive aspects of supervision such as personal development and reflection may be lost if it is viewed purely as part of a system of surveillance. They report on the experiences of supervision in integrated multidisciplinary teams in the UK, Canada and the USA where supervision has been provided by staff from a different discipline. The authors remark on the paucity of evidence regarding the impact of the practice of supervision on service user outcomes.

In the UK clinical supervision usually involves a 1 to 1 meeting with a line manager but could be provided by a senior practitioner or external consultant in the case of reflective practice or professional development. In some cases group supervision takes place. In order for clinical supervision to have the desired principle effect, i.e. to support staff according to the organisations responsibilities and to be accountable to professional standards, Carpenter and Webb (2012), argue that staff need to be “skilful, knowledgeable and clear about their roles and assisted in their practice by sound advice and emotional support from a supervisor with whom they have a good professional relationship”.

Reports of a merger of Toronto on Mental health and addiction, (Bogo et al 2011a and b), reported on a merger of 2 addiction services and 2 mental health services where supervision was no longer necessarily provided by someone from staffs’ own professional background. Mixed reactions were reported. Some staff reported that their supervisors would not discuss clinical issues but focused on performance management, others were more positive. Safety and trust were rated more important by staff than whether supervision was provide by a member of their own disciple. This project reported that in the area of supervision, job satisfaction and professional development was related to the following components of supervision regardless of whether respondents shared the same professional background; that the supervision was regular, provided by those with expert knowledge and clinical intervention skills for the specific client population, able to teach new and effective treatment methods and that the supervisee was actively involved in the process. Almost all participants agreed, the key elements of an effective supervisor were clinical expertise and an ability to provide new relevant practice knowledge and promote learning in a respectful and safe way and that these factors were more important than professional affiliation. Some employees did comment that meeting with others from within one’s own profession was important for profession specific work. A safe confidential space was important in helping staff process the personal aspects of practice experience in contrast to a focus on purely administrative and performance management issues which might be perceived in a negative way by the supervisee Kavanagh et al., (2003) looked at supervision practices in allied mental health in Australia. and suggests that supervision from one’s own professional discipline may be important to performance.

The study reported a positive relationship between frequency of contact with supervisors from staffs’ own discipline and perceived impact on practice. This was not recorded when supervision was from outside staff’ own discipline. They further reported that supervision which prioritised discipline specific skills was strongly associated with impact on practice but time spent on generic skills was not.

Kavanagh et al., (2003) suggest that supervision may contribute to better patient care and suggest a targeted approach to skill acquisition and a discipline specific focus may be needed. A positive relationship between supervisor and supervisee emerged as a key feature in terms of job satisfaction and perceived impact on practice.

These findings suggest that supervision by one’s own discipline may be important for certain aspects of professional clinical practice. Direct instruction and skills acquisition may only be possible if supervision is provided in a uni-disciplinary fashion.

In a study of home health social workers in the USA, a supervisor’s authority in facilitating staff access to resources to meet patient needs was given greater importance compared with professional development and staff mentoring (Egan M. & Kadushin G. 2004). Supervision was viewed as a means of ensuring safe practice and providing learning and development opportunities and enabling staff to represent their discipline in joint and integrated work practice.

The overview of the evidence reported by Carpenter & Webb (2012), suggests that in social work, the overriding priority of supervision is to ensure that work is completed and conforms to acceptable standards. As such, supervision which focused on task assistance may improve performance. The authors believe that supervisors are in a key position to communicate the organisations duties, priorities and goals to the worker and to bring back workers comments to the wider organisation.

166

3 References Bogo M., Paterson J., Tufford L., and King R., “Interprofessional clinical supervision in mental health and addiction: toward identifying common elements”, The Clinical Supervisor, 2011a; vol. 30, no 1, pp 124-140 Bogo M., Paterson J., Tufford L., and King R., “ Supporting front-line practitioners’ professional development and job satisfaction in mental health and addiction” Journal of Interprofessional Care, 2011b; vol. 25, no 3, pp 209-214), Marion Bogo1 Carpenter J, Webb C., Effective supervision in social work and social care. Social Care Institute for Excellence –Research Briefing no. 43, Oct 2012. Available at www.scie.org.uk/publicatios/briefings/files/briefing43.pdf Carter K., Chalouhi E., Mc Kenna S & Richardson B. “What it takes to make integrated care work” Mc Kinsey & Company. Health International 2011; Number 11. www.mckinsey.com Clifton E. Implementing Clinical Supervision. Nursing Times 2002; vol:98, Issue 09, page no: 36.

Available at www.nursingtimes.net/implementing-clinical-supervision/200410.article Clinical governance: principles into practice. Available at www.us.elsevierhealth.com/media/us/samplechapters/9780443071263/9780443071263.pdf Egan M. & Kadushin G. 2004 “ Job satisfaction of home health social workers in the environment of cost containment” Health and Social Work, vol. 29, no 4, pp 287-296) Governance for Joint Services, Principles and Advice (2007). Audit Scotland, COSLA, Healthier Scotland. Available at www.chp.scot.nhs.uk/wp-content/for-joint-services.pdf Governance in New South Wales Health (Australia) Report of the director general “Future Arrangements for Governance of NSW Health Report of the Director-General (2011). Available at www.health.nsw.gov.au/resources/govreview/governance_report.pdf Governance NHS Scotland, (2013). Available at www.staffgovernance.scot.nhs.uk/what-is-staffgovernance/overview In Good Hands Transforming Clinical Governance in New Zealand. Ministerial Task Group on Clinical Leadership, February 2009. Available at www.aemh.org/pdf/Ingoodhandsreport.pdf Kavanagh D.J., Spence S.H., Strong J., Wilson J., Sturk H., Crow N., “Supervision practices in allied mental health: relationships of supervision characteristics to perceived impact and job satisfaction” Mental Health Services Research, 2003; vol 5, issue 4, pp 187-195 NHS Knowsley Primary Care Trust. Available at www.knowsley.nhs.uk NHS Quality Improvement Scotland, (2005). Available at www.healthcareimprovementscotland.org/previous_resources/standards/cgrm_standards.aspx NHS Scotland Healthcare Quality Strategy, (2010). Available at www.scotland.gov.uk/publications/2010/05/10102307/0 NHS Reform (Scotland) Act, (2004). Available at www.legislation.gov.uk/asp/2004/7/contents North East Lincolnshire Care Trust. Available at www.northeastlincolnshireccg.nhs.uk Scottish Borders Community Health and Care Partnership-NHS Borders, (2009). Available at www.nhsborders.orguk/_data/...CHCP-Gov-Arr-May-2009-3.pdf Torbay and South Devon Health and Care NHS Trust. Available at www.tsdhc.nhs.uk/ Wiktorowicz M.E.,et al. Experience and analysis of “Mental health network governance: a comparative analysis across Canadian regions “International Journal of Integrated Care. Vol 10, October 2010, ISSN 1568-4156

167

APPENDIX G

MANAGED CLINICAL NETWORKS SCOTLAND

How to set up a managed clinical network – getting started There are several key stages in the development process for an MCN. Box 1 sets out these stages – from gaining agreement for development to launching the MCN. The development process is likely to take around 12 months; remember that it will be focused on more than one area at a time (Figure 2, overleaf).

Project plan: key development areas Area of development 1. Secure agreement for MCN development and outline funding from board 2. Identify and appoint project leader and manager Secure administrative/secretarial support and a base or office 3. Identify the key clinicians in the area Secure the involvement of a project team 4. Draft a development plan and timetable Appoint project leader and project manager 5. Hold first meeting of project team to: lAgree development plan and timetable l Discuss use of allocated budget and identify any potential shortfall lAgree number and remit of working groups l Discuss possible membership of working groups l Identify obstacles to progress and key clinical issues to focus on in development lAgree responsibilities 6. Establish working groups and: lAgree work programme and working methods for each lAgree timetable and key outcomes l Undertake development work 7. Arrange regular project team meetings to review, co-ordinate and guide working groups’ progress Produce regular newsletters 8. Hold open meetings to consult on and refine: l Quality assurance programme and standards l Care pathways and protocols lAny core documents, e.g. referral and discharge documents 9. Finalise and agree quality assurance programme with CSBS 10. Appoint lead clinician(not necessarily the same as project leader) and ratify transfer of project manager and support staff to MCN 11. Launch MCN = Managed clinical network CSBS = Clinical Standards Board for Scotland

168

169

APPENDIX H Appendix H.1 â&#x20AC;&#x201C; Hospitals and Hospital Groupings for Each Option

Option 1 Area (1)

1

2

3

4

5

6

Hospital Mayo General Roscommon County University Hospital Merlin Park Letterkenny General Portiuncula Sligo General Mid Western Regional Ennis General Nenagh General Limerick Maternity Croom St John's Cork University Mercy University Waterford Regional Bantry General Kerry General South Infirmary Tipperary General Mallow General Lourdes Orthopaedic Wexford General St Lukes St Michaels St Vincents St Colmcilles Mullingar Holles street Royal Victoria Eye and Ear Naas General Coombe Portlaoise Tullamore St James Adelaide and Meath Cavan General Our Lady of Lourdes, Drogheda Rotunda Beaumont Connolly Hospital Louth County Monaghan Our Lady's Hospital, Navan Cappagh Orthopaedic Mater Misericordiae

Hospital Group West/North West West/North West West/North West West/North West West/North West West/North West West/North West Midwest Midwest Midwest Midwest Midwest Midwest South/South West South/South West South/South West South/South West South/South West South/South West South/South West South/South West South/South West Dublin East Dublin East Dublin East Dublin East Dublin East Dublin East Dublin East Dublin East Dublin Midlands Dublin Midlands Dublin Midlands Dublin Midlands Dublin Midlands Dublin Midlands Dublin North East Dublin North East Dublin North East Dublin North East Dublin North East Dublin North East Dublin North East Dublin East Dublin East Dublin East

Colour coding has been used in the above table to identify instances where Hospital Groups cross the boundaries of areas identified in this option.

170

Option 2A Area (2A) 1

2

3

4

5

6 7

8

9

Hospital Letterkenny General Sligo General Cavan General Monaghan Mayo General Roscommon County University Hospital Portiuncula Merlin Park Mid Western Regional Ennis General Nenagh General Limerick Maternity Croom St John's Cork University Mercy University Bantry General Kerry General South Infirmary Mallow General Waterford Regional Tipperary General Lourdes Orthopaedic St Lukes Wexford General St Michaels St Vincents St Colmcilles Naas General St James Adelaide and Meath Our Lady of Lourdes, Drogheda Louth County Our Lady's Hospital, Navan Mullingar Holles street Royal Victoria Eye and Ear Coombe Portlaoise Tullamore Rotunda Beaumont Connolly Hospital Cappagh Orthopaedic Mater Misericordiae

Hospital Group West/North West West/North West Dublin North East Dublin North East West/North West West/North West West/North West West/North West West/North West Midwest Midwest Midwest Midwest Midwest Midwest South/South West South/South West South/South West South/South West South/South West South/South West South/South West South/South West South/South West Dublin East Dublin East Dublin East Dublin East Dublin East Dublin Midlands Dublin Midlands Dublin Midlands Dublin North East Dublin North East Dublin East Dublin East Dublin East Dublin East Dublin Midlands Dublin Midlands Dublin Midlands Dublin North East Dublin North East Dublin North East Dublin East Dublin East

Colour coding has been used in the above table to identify instances where Hospital Groups cross the boundaries of areas identified in this option.

171

Option 2B Area (2B)

1

2

3

4

5

6

Hospital Mayo General Roscommon County University Hospital Portiuncula Merlin Park Letterkenny General Sligo General Cavan General Monaghan Mid Western Regional Ennis General Nenagh General Limerick Maternity Croom St John's Cork University Mercy University Bantry General Kerry General South Infirmary Mallow General Waterford Regional Tipperary General Lourdes Orthopaedic St Lukes Wexford General St Michaels St Vincents St Colmcilles Our Lady of Lourdes, Drogheda Louth County Our Lady's Hospital, Navan Mullingar Holles street Royal Victoria Eye and Ear Coombe Portlaoise Tullamore Naas General St James Adelaide and Meath Rotunda Beaumont Connolly Hospital Cappagh Orthopaedic Mater Misericordiae

Hospital Group West/North West West/North West West/North West West/North West West/North West West/North West West/North West Dublin North East Dublin North East Midwest Midwest Midwest Midwest Midwest Midwest South/South West South/South West South/South West South/South West South/South West South/South West South/South West South/South West South/South West Dublin East Dublin East Dublin East Dublin East Dublin East Dublin North East Dublin North East Dublin East Dublin East Dublin East Dublin East Dublin Midlands Dublin Midlands Dublin Midlands Dublin Midlands Dublin Midlands Dublin Midlands Dublin North East Dublin North East Dublin North East Dublin East Dublin East

Colour coding has been used in the above table to identify instances where Hospital Groups cross the boundaries of areas identified in this option.

172

Option 3 Area (3)

1

2

3

4

5

6 7

8

9

Hospital Letterkenny General Sligo General Cavan General Monaghan Mayo General Roscommon County University Hospital Portiuncula Merlin Park Mid Western Regional Ennis General Nenagh General Limerick Maternity Croom St John's Cork University Mercy University Bantry General Kerry General South Infirmary Mallow General Waterford Regional Tipperary General Lourdes Orthopaedic St Lukes Wexford General St Michaels St Vincents St Colmcilles Holles street Royal Victoria Eye and Ear St James Coombe Naas General Adelaide and Meath Our Lady of Lourdes, Drogheda Louth County Our Lady's Hospital, Navan Mullingar Portlaoise Tullamore Rotunda Beaumont Connolly Hospital Cappagh Orthopaedic Mater Misericordiae

Hospital Group West/North West West/North West Dublin North East Dublin North East West/North West West/North West West/North West West/North West West/North West Midwest Midwest Midwest Midwest Midwest Midwest South/South West South/South West South/South West South/South West South/South West South/South West South/South West South/South West South/South West Dublin East Dublin East Dublin East Dublin East Dublin East Dublin East Dublin East Dublin Midlands Dublin Midlands Dublin Midlands Dublin Midlands Dublin North East Dublin North East Dublin East Dublin East Dublin Midlands Dublin Midlands Dublin North East Dublin North East Dublin North East Dublin East Dublin East

Colour coding has been used in the above table to identify instances where Hospital Groups cross the boundaries of areas identified in this option.

173

Option 4A Area (4A)

1

2

3

4

Hospital

Hospital Group West/North West West/North West West/North West West/North West West/North West West/North West West/North West Dublin North East Dublin North East Midwest Midwest Midwest Midwest Midwest Midwest South/South West South/South West South/South West South/South West South/South West South/South West South/South West South/South West South/South West Dublin East Dublin East Dublin Midlands Dublin Midlands Dublin North East Dublin North East Dublin East Dublin East Dublin Midlands Dublin Midlands Dublin North East Dublin North East Dublin North East Dublin East Dublin East Dublin East Dublin East Dublin East Dublin East Dublin East Dublin Midlands Dublin Midlands

Mayo General Roscommon County University Hospital Portiuncula Merlin Park Letterkenny General Sligo General Cavan General Monaghan Mid Western Regional Ennis General Nenagh General Limerick Maternity Croom St John's Cork University Mercy University Bantry General Kerry General South Infirmary Mallow General Waterford Regional Tipperary General Lourdes Orthopaedic St Lukes Wexford General Naas General Adelaide and Meath Our Lady of Lourdes, Drogheda Louth County Our Lady's Hospital, Navan Mullingar Portlaoise Tullamore Rotunda Beaumont Connolly Hospital Cappagh Orthopaedic Mater Misericordiae St Michaels St Vincents St Colmcilles Holles street Royal Victoria Eye and Ear Coombe St James

Colour coding has been used in the above table to identify instances where Hospital Groups cross the boundaries of areas identified in this option.

174

Option 4B Area (4B) 1

2

3

4

5 6

7

8

Hospital Letterkenny General Sligo General Cavan General Monaghan Mayo General Roscommon County University Hospital Portiuncula Merlin Park Mid Western Regional Ennis General Nenagh General Limerick Maternity Croom St John's Cork University Mercy University Bantry General Kerry General South Infirmary Mallow General Waterford Regional Tipperary General Lourdes Orthopaedic St Lukes Wexford General Naas General Our Lady of Lourdes, Drogheda Louth County Our Lady's Hospital, Navan Mullingar Holles street Royal Victoria Eye and Ear Coombe Portlaoise Tullamore Rotunda Beaumont Connolly Hospital Cappagh Orthopaedic Mater Misericordiae St Michaels St Vincents St Colmcilles St James Adelaide and Meath

Hospital Group West/North West West/North West Dublin North East Dublin North East West/North West West/North West West/North West West/North West West/North West Midwest Midwest Midwest Midwest Midwest Midwest South/South West South/South West South/South West South/South West South/South West South/South West South/South West South/South West South/South West Dublin East Dublin East Dublin Midlands Dublin North East Dublin North East Dublin East Dublin East Dublin East Dublin East Dublin Midlands Dublin Midlands Dublin Midlands Dublin North East Dublin North East Dublin North East Dublin East Dublin East Dublin East Dublin East Dublin East Dublin Midlands Dublin Midlands

Colour coding has been used in the above table to identify instances where Hospital Groups cross the boundaries of areas identified in this option.

175

Option 4Câ&#x20AC;&#x201C;Dublin Divided into 4 Local Authorities, Remaining Country as 4B Area (4C) 1

2

3

4

5 6

7

Dublin City

Fingal Dun Laoghaire South Dublin

Hospital Letterkenny General Sligo General Cavan General Monaghan Mayo General Roscommon County University Hospital Portiuncula Merlin Park Mid Western Regional Ennis General Nenagh General Limerick Maternity Croom St John's Cork University Mercy University Bantry General Kerry General South Infirmary Mallow General Waterford Regional Tipperary General Lourdes Orthopaedic St Lukes Wexford General Naas General Our Lady of Lourdes, Drogheda Louth County Our Lady's Hospital, Navan Mullingar Holles street Royal Victoria Eye and Ear Coombe Portlaoise Tullamore Rotunda Beaumont Cappagh Orthopaedic Mater Misericordiae St Vincents St James Connolly Hospital St Michaels St Colmcilles Adelaide and Meath

Hospital Group West/North West West/North West Dublin North East Dublin North East West/North West West/North West West/North West West/North West West/North West Midwest Midwest Midwest Midwest Midwest Midwest South/South West South/South West South/South West South/South West South/South West South/South West South/South West South/South West South/South West Dublin East Dublin East Dublin Midlands Dublin North East Dublin North East Dublin East Dublin East Dublin East Dublin East Dublin Midlands Dublin Midlands Dublin Midlands Dublin North East Dublin North East Dublin East Dublin East Dublin East Dublin Midlands Dublin North East Dublin East Dublin East Dublin Midlands

Colour coding has been used in the above table to identify instances where Hospital Groups cross the boundaries of areas identified in this option.

176

Appendix H.2 – Integrated Service Area – Proposals Identified

Map of Proposed ISA Boundaries Louth Meath Dublin North

Dublin City North Dublin City South

Donegal

Dublin South East Dublin South West Kildare

Sligo/Leitrim/West Cavan Cavan/Monaghan Mayo

Louth/Meath Dublin North Galway/Roscommon

Dublin North City Dublin South Central

Midlands

Dublin South West/Kildare/West Wickl Dublin South East/Wicklow

Mid West Carlow/Kilkenny/South Tipperary

Waterford/Wexford Kerry Cork

Produced by: National Programme Office Children and Family Services Holland Rd., Limerick.

OSI Licence HSE 030601 June 2013

177

Appendix H.3 â&#x20AC;&#x201C; LHO populations LHO Donegal Sligo/Leitrim/West Cavan Galway Mayo Roscommon Clare Limerick Tipp/East Limerick Kerry North Cork North Lee South Lee West Cork Tipperary South Waterford Wexford Dublin South East Dun Laoghaire Wicklow Carlow/Kilkenny Dublin South City Dublin South West Dublin West Kildare/West Wicklow Laois/Offaly Longford/Westmeath Cavan/Monaghan Louth Meath Dublin North Dublin North Central Dublin North West

2011 164023 95598 250653 130638 64065 103364 169631 106332 145501 89531 181802 191169 56530 94136 127807 145320 115359 130563 118542 130315 144858 154471 146332 228410 157246 125164 129427 122098 187880 244362 143584 193540

178

Appendix H.4 - Hospital Groupings Category

Name

Hospital Group

County Tertiary County County County Maternity County County County Maternity Tertiary County County Tertiary Orthopaedic County Maternity Tertiary County County County Orthopaedic County Tertiary Tertiary County County Maternity Orthopaedic County County County County Other County County County Tertiary County County County Tertiary Tertiary County County County

Cavan General Cork University Mayo General Mercy University Naas General Holles Street Our Lady of Lourdes Our Lady's Hospital Roscommon County Rotunda Waterford Regional Wexford General Bantry General Beaumont Cappagh Orthopaedic Connolly Hospital Coombe University Hospital Merlin Park Kerry General Letterkenny General Lourdes Orthopaedic Louth County Mater Misericordiae Mid Western Regional Ennis General Nenagh General Limerick Maternity Croom Mullingar Portlaoise Tullamore Portiuncula Royal Victoria Eye and Ear Sligo General South Infirmary Tipperary General St James St John's St Lukes St Michaels St Vincents Adelaide and Meath Mallow General St Colmcilles Monaghan

Dublin North East South/South West West/North West South/South West Dublin Midlands Dublin East Dublin North East Dublin East West/North West Dublin North East South/South West Dublin East South/South West Dublin North East Dublin East Dublin North East Dublin Midlands West/North West West/North West South/South West West/North West South/South West Dublin North East Dublin East Midwest Midwest Midwest Midwest Midwest Dublin East Dublin Midlands Dublin Midlands West/North West Dublin East West/North West South/South West South/South West Dublin Midlands Midwest Dublin East Dublin East Dublin East Dublin Midlands South/South West Dublin East Dublin North East

179

Appendix H.5 â&#x20AC;&#x201C; Options with Mental Health Boundaries Overlaid Option 1

DN

Louth/Meath

DN

Meath

DNW

DNW/DNCDNC

Legend Mental Health

DNC

option_1

Donegal DW

Donegal

DSC

DSW

DSE

Area 3 - pop 886,476

DL

Area 4 - pop 640,099 Area 5 - pop 956,481

Wicklow

Kildare/W Wicklow

Area 1 - pop 704,977 Area 2 - pop 379,327

DW/DSW/DSC

Area 6 - pop 1,020,891

DSE/DL/Wicklow

Sligo/Leitrim

Sligo/Leitrim Cavan Monaghan Cavan/Monaghan

Mayo

Mayo

Louth

Roscommon

Meath

Louth/Meath

Longford/Westmeath

DN

DN

DNWDNC

Galway

DNW/DNCDNC

Galway/Roscommon Midlands/Kildare WW

DW/DSW/DSC DWDSW DL DSE

Kildare/W Wicklow Laois/Offaly

DSE/DL/Wicklow Wicklow

Clare

North Tipp/East Limerick

Mid West Carlow/Kilkenny

S Tipp/Carlow Kilkenny

Limerick

Tipperary SR

Wexford

Waterford/Wexford

Kerry

North Cork

Kerry

North Lee

Waterford

Cork

South Lee West Cork

SRG Projects Office, Limerick Produced Under OSI License HSE 030601

180

Option 2A

Area 8

DN

Meath

Area 9

Legend NEW Mental Health Areas Option 2A v2 Option_2A

DNW

DW

DNC

Area 1 - pop 389,048 Area 2 - pop 445,356

DNC

Area 3 - pop 379,327

Area 7

DSW

Kildare/W Wicklow

Area 4 - pop 664,533

Donegal

DSC DSE

Area 5 - pop 497,578 Area 6 - pop 364,464

DL

Area 7 - pop 674,071

Area 6

Area 8 - pop 592,388 Area 9 - pop 581,486

Wicklow

Sligo/Leitrim

Area 1

Mayo

Roscommon

Area 2

Meath Longford/Westmeath

DN

Area 9

Area 8

Galway

DNWDNC

DW DSE DSC DSW DL

Area 7

Kildare/W Wicklow

Laois/Offaly

Area 6 Wicklow

Clare

Area 3

Limerick

North Tipp/East Limerick Carlow/Kilkenny

Tipperary SR

North Cork

Kerry

Louth

Cavan/Monaghan

Area 5

Wexford

Waterford

Area 4

North Lee

South Lee West Cork

SRG Projects Office, Limerick Produced Under OSI License HSE 030601

181

Option 2B

Meath

Area 4

DN

DN

Louth/Meath

Area 6 Legend

DNW

DNW/DNCDNC

Mental Health

DNC

Option 2B v2

DW

Donegal

DW/DSW/DSCDSC

Area 5

DSW

Option_2B

Area 1 - pop 834,404

Donegal

DSE

Area 2 - pop 1,043,860 Area 3 - pop 862,042

DL

Area 4 - pop 671,071

Area 3

Area 5 - pop 592,388

Wicklow

Kildare/W Wicklow

Area 6 - pop 581,486

DSE/DL/Wicklow

Sligo/Leitrim

Sligo/Leitrim

Mayo

Cavan Monaghan

Area 1

Mayo

Cavan/Monaghan Louth

Roscommon

Meath

Louth/Meath

DNDN

Longford/Westmeath

Galway

Area 6

Area 4

Galway/Roscommon

DNW/DNC

Midlands/Kildare WW

DW/DSW/DSC

Area 5

DW DSE DL DSW

Kildare/W Wicklow

Laois/Offaly

DSE/DL/Wicklow Wicklow

Clare

North Tipp/East Limerick

Mid West

S Tipp/Carlow Kilkenny Carlow/Kilkenny

Limerick

Tipperary SR

Area 3

Wexford

Waterford/Wexford

Kerry

Kerry

North Cork

Area 2

North Lee

Waterford

Cork

South Lee West Cork

SRG Projects Office, Limerick Produced Under OSI License HSE 030601

182

Option 3

Area 8

DN

Meath

Area 9

Legend Mental Health Option 3

DNW

option_3 DNC

Area 1 - pop 389,408 Area 2 - pop 445,356

DNC

Area 3 - pop 379,327

Donegal DW

Area 4 - pop 664,533

DSC

Area 7

DSW

Kildare/W Wicklow

Area 5 - pop 497,578

DSE

Area 6 - pop 509,322

DL

Area 6

Area 7 - pop 529,213 Area 8 - pop 592,388 Area 9 - pop 581,486

Wicklow

Sligo/Leitrim

Cavan/Monaghan

Area 1

Mayo

Louth

Roscommon

Area 2

Meath Longford/Westmeath

DN

Area 9

Area 8

Galway

DNWDNC

DW DSEDSC DSW DL

Area 7

Kildare/W Wicklow

Laois/Offaly

Area 6 Wicklow

Clare

Area 3

North Tipp/East Limerick Carlow/Kilkenny

Limerick

Tipperary SR

North Cork

Kerry

Area 4

Area 5

Wexford

Waterford

North Lee

South Lee West Cork

SRG Projects Office, Limerick Produced Under OSI License HSE 030601

183

Option 4A

DN

Meath

Area 3 DNW

Area 4 DNC

Legend

DNC

Mental Health

Donegal DW

Option 4a

DSC

DSW

option_4a

DSE

Area 1 - pop 704,977

DL

Area 2 - pop 1,265,803 Area 3 - pop 1,3444,402

Kildare/W Wicklow

Area 4 - pop 1,273,069

Wicklow

Sligo/Leitrim Cavan/Monaghan

Area 1

Mayo

Louth

Roscommon Meath Longford/Westmeath DN

Area 4

Galway

DW DSEDSC DSW DL

Area 3

Kildare/W Wicklow Laois/Offaly Wicklow Clare North Tipp/East Limerick Carlow/Kilkenny

Limerick

Kerry

North Cork

Tipperary SR

Area 2

Wexford

Waterford

North Lee

South Lee West Cork

SRG Projects Office, Limerick Produced Under OSI License HSE 030601

184

Option 4B

Area 7

DN

Meath

Legend

DNW

Mental Health

Area 8 DNC

Option 4b option_4b

DNC

Area 1 - pop 389,048 Area 2 - pop 445,356

Donegal DW

DSW

Area 6

Area 3 - pop 379,327

DSC DSE

Area 4 - pop 664,533 Area 5 - pop 497,578

DL

Area 6 - pop 346,952 Area 7 - pop 592,388

Kildare/W Wicklow Wicklow

Area 8 - pop 1,273,069

Sligo/Leitrim

Cavan/Monaghan

Area 1

Mayo

Louth

Roscommon

Area 2

Meath Longford/Westmeath DN

Area 7

Galway

Area 8

DW DSEDSC DSW DL Kildare/W Wicklow

Area 6

Laois/Offaly

Wicklow Clare

Area 3

North Tipp/East Limerick Carlow/Kilkenny

Limerick

Tipperary SR

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Area 4

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