A FUTURE DIRECTION FOR IRISH HEALTHCARE

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Table of contents About Towards 2026

About Towards 2026 03

A message from Prof Frank Murray, President Royal College of Physicians of Ireland 06

Foreword from Dr Tom Keane, Chair, Towards 2026 07

Recommendations 08

A healthcare system in crisis 11

Towards 2026 - the vision 14

References 33

Towards2026participants 36

 

Towards 2026 is a policy forum established in 2016 by the Royal College of Physicians of Ireland to provide an opportunity for open dialogue between various healthcare stakeholders on the future direction of hospital careA in Ireland.

Asaprofessionaleducationandtrainingbody,RCPIisresponsibleforproducingclinicalleadersacrossarangeofspecialties.Addressing the complex challenges endemic in our health system requires strong clinical leadership in which the responsibility ofdoctorsextendsbeyondindividualpatientstotheentirehealthcaresystem.

Towards 2026 is about understanding the future needs of patients,highlightingthegapsincurrenthealthcareservicesandclarifying the new role of the doctor in a more responsive and dynamichealthcaresystem.

ThisreportpresentsafuturedirectionforhospitalcareandtheroleofthedoctorinIrelandbasedonaconsultationprocesswith over 100 stakeholders from across the spectrum of the Irish healthcareserviceincludingpatients,carers,doctors,nurses,health and social care professionals, GPs, and healthcare policy-makersandmanagers.

Aseriesofmeetingsandfacilitatedworkshopswasheldwiththese key stakeholders from May to October 2016, and the recommendationsofthisreportarebaseduponthesediscussions.

Towards 2026 was chaired by Dr Tom Keane, former Director oftheNationalCancerControlProgramme.

“Towards2026hasthepotentialtobeablueprintforatrulyinclusivehealthserviceforallcitizens.HavingthevoiceoftherecipientsofserviceslistenedtoduringtheentireTowards2026processwas,forme,hugelysignificant. The inclusiveness of the process is one of the key messages forme.Toooftenpatientsandthosecaringforthemarestillbeingtoldwhatisgoodfortheminsteadofbeingaskedwhattheyneed.IwashonouredtobeinvitedtoparticipateintheTowards2026PatientandCarerForum.”

Hazel Luskin-Glennon, Towards2026Patientand Carer Forum

A ThemainfocusoftheTowards2026forumwasacuteadulthospitalcare.

Towards 2026 patient and carer forumStanding L-R:ThomasBergin,HazelLuskin-Glennon,ClareDuffy,MervynTaylor,MarieCregan,LeoKearnsRCPI,MichaelDrohan,BrianHartnett,MilaWhelan,TomClifford,DrSiobhánKennelly,KatharineO’Leary,BettinaKorn,AlisonHarnett, AnnaClarke,ProfFrankMurrayRCPI.

Seated L-R:DrTomKeane,ElisaCosgrave,ProfRisteardO’Laoide,MarianMackle

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My health service in 2026

“Healthcare is about me”

“Professional, caring, accessible

and safe”

“I am a valued person, not just an illness. I am listened to”

“I can get care when I need it!

“They really care”

“I don’t think it could come quickly.

What a change!”

“My care is coordinated,

personalised and enabling”

“The patient journey is

convenient, efficient, caring

and safe” “An accessible, quality and

compassionate service”

“It’s better now for my family”

“These days my doctor actually listens to me”

“I am treated with dignity, respect and kindness”

“A responsive, innovative system

with a focus on health rather than

just disease”

“I felt that I was treated as a valued customer”

“Easily accessible,

safe, quality care” “I got looked

after quickly when I

needed it”

“Accessible, makes sense, good quality”

“There is an equal partnership. I have the opportunity to ask questions and

make the call” “They know who I am and they

know I am here! I know them”

“I am not afraid of going

to hospital”“I feel safe”

“I am managing very well. The health

system allows me to self-manage”

“I feel listened to. I matter”

“Somebody listened”

“It’s where I’m cared

for”

“I am given time to make up my mind”

“It was easy to move through

the system” “Reliable, accessible, excellent quality,

respectful, focused on me, the patient”

“A coherent, connected and compassionate

experience”

“I know who is looking

after my care throughout my

journey”

“I trust that the country I live in will meet my

care needs when I or my family no longer can”

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ForewordDr Tom KeaneChair, Towards 2026

A message fromProf Frank MurrayPresident, Royal College of Physicians of Ireland

Many of the challenges facing the Irish healthcare system are common across the developed world – the increasing demand, rising numbers of people living with chronic diseases, and ageing populations.

Ascitizensandpatients,weneedtoequipourselveswiththeskills and knowledge to take responsibility for our health and, wherepossible,forourhealthcare.

Weneedtocreateahealthcaresystemthatsupportsandrespondstothecomplexneedsofcommunitiesandindividuals,boththepatientswhoreceivecareandthestaffprovidingthatcare.Andweneedtotrainourdoctorsinnewwaysofworking:in teams, in the community, in leadership roles, in governance andinentrepreneurship.

The Royal College of Physicians of Ireland has a long and proud traditionofadvocatingforstandardsofpatientcare,toinformandinfluencenationalhealthpolicy,andtoengageinthecontinuingimprovementofhealthinIreland.

This College is also a leading advocate for evidence-based legislation,suchasthePublicHealth(Alcohol)Billandataxonsugarsweeteneddrinksandinitiativestosupportpeopletobehealthier.Theselegislativemeasuresareessentialandwecallonceagainfortheirimplementation.

LedbyouresteemedChair,DrTomKeane,Towards2026aimstoprovideaneutralspaceforpatients,clinicians,healthand social care professionals, academics, policy-makers and managerstoidentifytheirshareddesiredcharacteristicsofthefuturehospitalandhealthcaresystem.

As part of the Towards 2026 process we sought to understand theneedsofthefuturepatient;todescribetheacutecareservicesthatwillbestmeettheirneeds;andtore-examinetheroleofthedoctorinthisnewenvironment.

There is no perfect formula to create the ideal healthcare

systemforthefuture.Butitisclearthatourhealthsystemmustrevolvearoundpatients’needstoensurethedeliveryofhighqualityhealthcare.Thisreportcaninformatransitiontoapatient-centredhealthcaresystem.

Weneedaplanforthefutureofourhealthcaresystemandthatplanrequiresfullpublicandpoliticalsupporttoensure itsucceeds.

Withapoliticalcommitmenttosupportlong-termchange,theRoyal College of Physicians of Ireland will support and lead the transitiontobuildinganewmodelofpatientcare.ItwilldothisthroughtheNationalClinicalCareProgrammes,bysupportingpublichealthinitiatives,throughitspostgraduatetrainingofdoctorsandwillplayitspartinhelpingtoattractandretainhighqualitydoctorsinIreland.

Wewillalsoplayasignificantpartindevelopingclinicalleaderswhowilldriveandfacilitatethisstructuralshift.WewillprioritiseleadershipineducationandtrainingandensureourtrainingprogrammesaredesignedtocultivatetheskillsdoctorsrequiretomeettheclinicalneedsofallIrishpatients.

Iamconfidentthatbyworkingcollaboratively,wewillcomethroughthemanysectoral,socio-politicalandeconomicchallengesstrongerthanbefore.

WefullysupporttheworkoftheOireachtasCommitteeontheFutureofHealthcarewhichisseekingtosetalong-termplanfor the health service, and hope that this report will assist them inthatendeavour.

Wehaveahugeopportunitytosetthecourseofourhealthcaresystem so that it survives to meet the needs of future generations.Thereisastrongdesireandwillingnesstomakeithappen.Itrustwecanmakeithappen.

I would like to thank all those who contributed and who are listedattheendofthisreport,especiallyDrTomKeane.

Our duty is to build a system of patient care and develop health services that meet the needs of the entire population. Everyone has a role to play in reaching this goal. There has never been a complete system change; only particular improvements have been made. Our existing system has pockets of excellence, but until we address the many systemic problems caused by a lack of process and transparency, we will remain anchored in the past. There is a danger in thinking through the lens of the current system; that is why we need to set our sights firmly on the future. This process is less about ‘fixing’ existing hospitals as it is about imagining a different way.

This report focuses on hospitals and how they can become more aligned with changes in the broader system, such as increased care in the community and greater emphasis on prevention.Weconsultedwithpatients,doctorsandotherhealthcare professionals, hospital managers, academics, health and social care professionals, clinicians, trainees and policyspecialists,andconsideredthevariousperspectivesputforthduringaseriesofworkshops.Thisreportisasynopsisoftherichcontentgleanedfromthoseexperts.Thehigh-levelrecommendationsoutlinedhererepresentthestrongideasthatemergedfromthosesessions.

Thisisnotadefinitiveblueprintforthefuturehealthsystem.Rather,itisastatementofdirectionforchange,which,Ihope,willhelppatients,thepublicandhealthcareprofessionalstothinkdifferentlyaboutthehealthsystemandtorecogniseopportunitiesforimprovement.Inthesechallengingtimes,theneedforabold,ambitiousvisionforhealthcareforeveryoneinIrelandhasneverbeengreater.Someofthosechallenges,suchas tackling the known causes of chronic diseases, cannot be overcome by individuals or health services alone, but require Governmentandallsectorstoplaytheirpart.

Weknowoursystemcanfunctionmoreeffectivelyandproducebetteroutcomesforpeople.Asasociety,weneedtoconsider

what type of healthcare system we want, whom it should serve andhowitshouldbepaidfor.Theprocessoflearningtoworktogethertowardssharedaspirationsofabetterhealthsystemhasbegun.Wemustmaketheverybestofthisopportunity.Wehopethisreportwillprovokediscussionandleadtosustained improvement in the healthcare system and the human relationshipsthatunderpinit.

Iwouldliketoextendmygratitudetoallofthepatientsandcarerswhosecontributionsguidedourwork.Mysincerethanksalsototheworkshopparticipants,ourhealthcareleaders,whogenerouslygavetheirenergyandexpertiseand,mostimportantly,thetimetolistentooneanotherandreachacommonunderstanding.Ihavebeengreatlysupportedinmyworkbyourresearchandthematicleads,DrSiobhánKennelly,ProfRisteárdO’Laoide,ProfGarryCourtneyandProfCharlesNormand.Finally,IcommendtheRoyalCollegeofPhysiciansofIrelandforhavingthevisiontoundertakethisambitiousbutnecessarywork.

 

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Recommendations

1 Healthcare is about meA truly patient-centred system

Thefuturehealthsystemmustputpeopleandpatientsatitscentreinameaningfulway.

Thismeanslisteningtothepatientvoiceintheplanning,designandimplementationofservices;supportingopenandhonestpublicdebateonhowservicesareprovided;and building a sense of partnership between the people whouseservicesandthosewhoprovidethem.

Italsomeansunderstandingpopulationneedandtheneedsofgroupswithspecificvulnerabilities,anddesigningservicestorespondtothatneed.Inthecomingyearsthiswillmeanaparticularfocusontheneedsofanincreasingpopulationofolderpeople.

Wemustchampionthefundamentalprinciplethatthehealthcaresystemisownedbythepatientandisaccountabletothepeopleitserves.

2 Keeping people wellStemming the tide of preventable health conditions

Unlessactionistakentokeeppeoplewell,ourhealthsystem will be overwhelmed by the rise in long-term diseases,suchasdiabetes.Theremustbesustainedcross-governmental and cross- societal commitment to reduce ill-health through addressing lifestyle trends and inequalitiesinhealthoutcomes.

3 Funding and expectationsTime for public dialogue

Clarity is needed on what can reasonably be expected from the health service, what funding is to be allocated tomeetthoseexpectations,andhowdecisionsaremadetobenefitthegreatestnumberofpeopleinafairandtransparentway.

Fundamentally, we must support the principle that people should be able to access healthcare on the basis of clinical need,notabilitytopay.Centraltothisdebatewillbetheissueofwhatsocietyispreparedtoinvestinitshealthservice.

4 Using data to planJoining the dots between population needs and frontline decisions

Healthcarepolicies,strategiesandplansshoulduseresearch evidence and relevant data to make clear connectionsbetweenpopulationneedsassessmentandfrontlineplanningdecisions.Ofcrucialimportanceis the alignment of capacity with demand through the useofdataandevidence.Muchofthecurrentvisibledysfunctioninthesystemisaresultofdemandgrosslyexceedingcapacity.

5 Joined up careDelivering seamless care across various settings

Care pathways should be built around the needs of the patient,notthesystem.Weneedtoprovidecarethatisjoinedupfromthepatientperspective,throughthedesignandimplementationofpatient-centred,clinicallyled,evidence-informedintegratedmodelsofcare.Patientoutcomeandsafetymeasures,costingandfundingmodels,workforce plans and data and system requirements must allbebuiltintotheseintegratedmodelsofcare.Fundingmustbeallocatedtofacilitateandincentivisejoinedupcare,andtoavoidfragmentedcare.

6 Hospital without walls ‘Hospital’ services in the community

Servicedeliveryshouldbeorientedaroundtheserviceitselfratherthanbuildingsandinstitutionsorlegacyarrangements.Thisincludestheconceptofa‘hospitalwithoutwalls’,wheremanyservicesdeliveredinhospitalscan and should be delivered in the community, with greatercollaborationacrosshospital,primarycareandcommunitycaresettings.Strengtheningcapacityinprimary and community care will be crucial to achieve this.Thereshouldbelessfocusonthe‘place’andmoreonthe‘service.’

7 Building for accountabilityResponsibility, authority and accountability from the ground up

Weneedagovernancesystemthatappliesateverylevel,from service delivery upwards, and is grounded in the principle that the healthcare system is owned by and accountabletothepeople.Thisrequiresclearlyidentifiedresponsibility, authority and accountability at all levels of the health service from ward level right up to the DepartmentofHealth.

8 Supporting healthcare staffWithout people, there is no healthcare system.

Major, sustained emphasis is needed on strengthening andsupportingthepeoplewhodelivercare,andonrebuildingtrustandconfidenceamongtheworkforce.Successfulorganisationsrecognisetheimportanceofthepeoplewhoworkforthem;theytrytorecruitthebest;ensuretheyareenabledtoperformtotheirbest;areinvolvedappropriatelyindecision-making;aretrusted;andareprovidedwithdevelopmentopportunities.Thisiswhatweshouldaspiretoforourhealthservice.

9 e-Health now!e-Health supporting and enabling joined-up care

Theindividualhealthidentifierandelectronichealthrecordmustbeimplemented.TheadventoftheeHealthStrategyprovidesanopportunitytoadoptalong-termstrategy to underpin joined-up care across community, primary care, acute hospitals, and mental health, andtosimultaneouslyenableeffectivepopulationneeds analysis, planning, outcome measurement, and performanceaccountabilityatlocalandnationallevels.

10 Developing healthcare leadersGreat leaders bring about great change

Onlystrongleadershipatlocal,regional,nationalandinstitutionallevelscanovercomethelackoftrustinthesystem and bring about the kind of change needed to return thehealthsystemtoitscorepurpose.Itmustberecognisedthat there is a crisis in leadership at all levels, and that there hasbeenalackofsupportforleadershipdevelopment.

Clinical leadership roles and managerial leadership capability shouldbedevelopedandsupportedatalllevelsinthesystem.

11 Shared vision and political consensusLong term vision, and the political drive and courage to deliver it.

A shared vision and long-term strategic plan with cross- partypoliticalsupportisessential.Frequentchangesindirectionarefundamentallydestabilisingandunderminingforthehealthservice.

Crucially, it must be recognised that to have a meaningful impact,theremustbesustainedpoliticalcommitmenttolong-termpoliciesandstrategies.Cross-partypoliticalconsensusandlonger-termcollaborativeplanningarenecessarytosupportacommitmentthatspansmultiplegovernmenttermsandcomposition.

The establishment of the cross-party Oireachtas committeein2016isanecessaryandpracticalpoliticaldevelopmenttosetadirectionforthehealthservice.Thechallenge to all stakeholders will be to support the output ofthecommittee.Thechallengeforthecommitteewillbetooutlineadirectionthatallstakeholderscancommitto.

12 Implementing changeA major implementation strategy to deliver change

Theserecommendationsrepresentanenormouschallenge.Failure to successfully implement change has been a recurrentanddebilitatingfeatureofthehealthserviceformanyyears.Theremustbesignificant,targetedandsustainedinvestmentintomakingthesechangeshappen.This will require a high level expert group that reports to the Oireachtas on progress and that has the mandate and authority to hold all parts of the system to account for makingthechangehappen.Changewillnothappenwithoutaplan.Neitherwillithappenwithoutdeterminedandconsistentleadership,fromthehighestlevelofgovernment.

“ If older people are afraid of going to hospitals then theservicesarewrongandtheyneedtochange.”Patient and carer forum, Towards 2026

“InthefutureIdon’tthinkpatientswillbeasfocusedon‘theHospital’.Peoplewillacceptanyalternativeifitsavesyoutime”Patient and carer forum, Towards 2026

“Supportingdoctorsandhealthprofessionalsintheirrolesisapatientsafetyissue.”Patient and carer forum, Towards 2026

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A healthcare system in crisis

Despite two major reports recommending radical and rational reorganisation of Irish hospitals (the 1968 Fitzgerald report1 and the 2003 Hanly report2), and many other policy and strategic reports, the location, structure and services of hospitals in Ireland today still reflect a largely organic and unplanned evolution, although some progress has been made in rationalising services such as cancer and emergency interventional cardiology. Despite the fact that medical care and therapies have changed radically in recent years, the structures to deliver these modern therapies has altered little.

Joined-uphealthcareinthiscontextisnotpossible.Infact,we have by default designed a system where disjointed, fragmentedcareisinevitableandwherereactive,crisismanagementhasbecomethenorm.

Irish hospitals are charged with what appears to be an impossible task;demandforservicesexceedscapacitytodeliver.

ThepublichealthcaresysteminIrelandisinacriticalstate.Excessivelylongwaitinglists,recurrentandworseningtrolleywaits in emergency departments and ongoing problems in recruitingcoremedicalandnursingstaffpaintapictureofahealthserviceindeepcrisis.

Despitepositivehealthoutcomessuchasafive-yearincreasein life expectancy in the last 20 years, and the improvement in outcomesforpatientswithcancer,itisclearthatIrishhospitalsarechargedwithwhatappearstobeanimpossibletask;thedemandforservicesexceedscapacitytodeliver.

Concern exists that much of this demand may relate to the extenttowhichpatientsarereferredintosecondaryandtertiarycarewithproblemsthatwouldbebetterresolvedintheprimaryandcommunitycaresetting,orspendprotractedperiodsinhospitalsaftertheyarefitfordischarge.Withknowndemographictrendsindicatingcontinuedgrowthindemand,hospital services as currently structured simply cannot deliver appropriatecarewithoutradicalchange.

Manyofthesolutionstotheproblems of the hospital lie beyond the hospital itself, and it is clear that building capacity and capability within the primary and community settingisoftheutmostimportance.

Thereisapressingneedtoredefinethepurpose,roleandfunctioningofhospitalsandhospitalcareinthecontextof a modern healthcare system, while learning from the proposals,andbarrierstotheirimplementation,identified bypreviousreports.

Notwithstanding the many major problems facing the Irish health service, there is an opportunity to radically improve thepatientexperienceandoutcomesinIrishhospitalsandtodefinetheirfutureroleinacohesiveIrishhealthservice.WhilethefocusofthisTowards2026initiativeisprimarilythe hospital, it is clearly understood that the hospital can only functionasanintegratedcomponentofthewiderhealthcaresystem.Manyofthesolutionstotheproblemsofthehospitallie beyond the hospital itself, and it is clear that building capacity and capability within the primary and community settingisoftheutmostimportance.

Failure to recruit and retain healthcare staff

Whiletrolleywaitsinemergencydepartmentsandextralongwaitinglistsarevisibleindicatorsof a system in crisis, what is not so obvious, but potentiallymuchmoreseriousandlong-lasting, isthefactthatIreland’shealthserviceisfinding itverydifficultandoftenimpossibletorecruitdoctorsandnurses.

• In 2016, approximately 20% of approved permanent hospital consultant posts were either vacant or filled on a temporary basis.4

• In 2016 there were almost 4,000 less Nursing and Midwifery posts in the health service than in 20085

• By 2025, the predicted shortage of GPs in Ireland will range from 493 to 1,380 depending on increased levels of access to free GP care.6

Without doctors, nurses and health and social care professionals, we cannot deliver healthcare. Addressing this recruitment crisis must be of the highest priority as we face the next 10 years.

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Irelandisnotaloneinfacingthesechallenges.Thesamedifficultiesarefacedbyhealthsystemsacrossthedevelopedworld.Healthcare,oneofthegreatestofhumanachievements, is also one of its most complex and is becoming increasinglydifficulttomanage.Afundamentalproblemisthechallengeofmeetingever-increasingdemandwithconstrainedresources.Ourgoalmustnotbetofinallyresolvetheproblemsofthehealthservice,assuchanaspirationisunachievable.Ratherweshouldendeavourtocreateasystemthathaswithinitselfthecapabilitytocontinuallydevelopandimprovetomeetthechangingneedsofthepopulation,andthatsitswithinasocietythathasreasonableexpectationsofthesystemitself.

Anumberofpolicyreportsonthefuturedirectionofhealthcarehave been published in the past 15 years, including the ‘HanlyReport’-ReportoftheNationalTaskForceonMedicalStaffing(2003)2,QualityandFairnessHealthStrategy(2001)7, FutureHealthStrategy(2012)8andtheHealthyIrelandFramework(2014)9.Manyoftheirrecommendationsremainrelevant.Asfarbackas1968,theFitzgeraldreport1, and the HospitalsCommissionreportsofthe1930s10, contain many recommendationsthatareappositetoday.

Manyofthekeyrecommendationsfordeliveringintegratedcare and developing a cross-sectoral approach to health and wellbeinghavenotbeenimplemented.SinceplansfortheimplementationofUniversalHealthInsurance(UHI)11 were shelved in 2015, there is a policy vacuum on the fundamental questionofhowtofundourhealthsystemtoensureitsviabilityintothefuture.Atcurrentlevelsoffundinganddemand12, the public healthcare system is unsustainable and thecracksareclearlyvisible.Inthefaceofcontinuingeconomicuncertainty, more than ever a clear vision for the future model ofhealthcareisrequired.

Dearthofpolicyisnottheprimaryissue;rather,thereisaproblemofimplementationandtranslation.Toomanyprevious

healthcareinitiativeshavefailed,andtheirfailureaddstothecomplexityofthechallengenowfaced.Theenormityofthe crisis that now prevails within the Irish healthcare system issuchthatwecannotaffordanotherfailuretodesignandimplementtheradicalandfundamentalchangerequired.

TherehavebeenmanypositivehealthoutcomesinIrelandwhichcangiveusreasonforsomeoptimism.Theadvanceofmedicineandtheapplicationofnewtechnologiesandresearchareonaparwithmostdevelopedhealthsystemsintheworld.OurmedicaleducationsysteminIrelandhasbeeneffectiveintheproductionofahighlyskilledworkforce,althoughthebenefitsofeffectiveeducationarenegatedtoalargedegreebyafailuretoretaininIrelandgraduatesacrossalldisciplines.

Clarity and honesty is needed about thedeficienciesinoursystem,asitisthesedeficienciesthatmust be overcome if fundamental improvementistobeachieved.

There are some encouraging developments at all levels of the healthservicethatprovideindicationsthatthehealthserviceismovingintherightdirectioninareassuchasmodelsofcare,qualityimprovement,trainingandarenewedfocusonstaff.Thedevelopment of the Integrated Care Programmes, while at a very early stage, present another indicator of movement in the rightdirection.

Atthesametime,clarityandhonestyisneededonthedeficienciesinoursystem,asitisthesedeficienciesthatmustbeovercomeiffundamentalimprovementistobeachieved.

Moreofthesamewillnotdo.WeneedanewdirectionfortheIrishhealthservice.Therecommendationsofthisreportindicatethedirectionthesystemmusttaketoovercomethemanybarrierstodeliveryofappropriate,effectiveandsafecare.

The crisis that is so obvious in Emergency Departments is a microcosm of the deep problems that exist right across the health service.

TheEDcrisisisnotdueto,orsolvableintheED.TheEmergency Department has become the default place of lastresortwithinthehealthservice.Whennothingelseisavailableoraccessible,peoplewillgototheED.Thereforewhiletheproblemmanifestsasan‘EDproblem’,generally

speaking the problem is usually caused elsewhere and needstobesolvedelsewhere.

ResolvingtheEDcrisisisessential,notjustbecauseoftheimmenseandutterlyunacceptablesufferingcausedtosomanypatientsandtheirfamilies,andthesafetyissues that arise from such extreme overcrowding, but also because of the destabilising impact it has on the rest ofthehealthservice.

Figure 1: Trolley crisis January 2017As this report was being finalised in January 2017, the latest instance of crisis was making the news: on January 4th, 2017, the number of patients on trolleys waiting for admission hit an all-time high of 612.13

These are people assessed by healthcare staff as being sufficiently ill to require admission to hospital for further treatment.

Not included in the 612:—Peoplewaitingin

ambulances—Peoplewaitingtobe

assessed

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WE’VE BEEN HERE

BEFORE

Over 10 years ago, the then Minister for Health described the trolley crisis in ED as ‘a national emergency’ and determined to resolve the problem within 12 months. Each year, the same crisis occurs, and each year the crisis is managed in the same way, and emergencyfundingallocated,untilthepeakpasses,andthemajorcrisisbecomesasmallercrisisthatdoesn’thittheheadlines,untilinevitablythecyclebeginsagain.

From2006-2015,over-65populationincreasedby29.5%,whileacuteinpatienthospitalbedsdecreasedby13%.24,25

Crisis management will not and cannot resolve the fundamental problem. If underlying causes are not understood and dealt with, it is inevitable that the crisis will return and be worse each time.

The result is: — Suffering and distress for patients and families.

— Safety risks for patients and staff

— Extreme stress and frustration for doctors, nurses, health and social care professionals and administrators

Emergency Department Crisis

PATIENTS ON TROLLEYS IN HOSPITAL EMERGENCY DEPARTMENTS— ALL TIME HIGH

*INMOTrolleyWatch/WardWatchFiguresbelowforFebruary10th2017

Things we need to understand and approach differently:

• Thereisinsufficientbedcapacitytomeetdemandinbothhospitalsandnursinghomes• TheproblemmanifestsinEDbutthesolutionmaybeelsewhere• Inadequatecapacityinprimary,communityandoutpatientsservicesincreasesdemandinED• Anunacceptableexperienceforpatientsandstaffhasbeenculturallynormalised

A more coherent approach:

• Joinedup,longtermplanningforemergencycareatnationalandregionallevel• Dynamicmanagementofunscheduledpatientflowatlocallevel• Integrated pathways for unscheduled care across community, primary, mental health and acute care• Data,includingdemographicdata,toproperlyplan.Underpinnedbysystems• Awilltofaceuptoreorganisationofhospitalssothattheycanprovidetheemergencyservicethatpeoplerequire

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The core purpose of the health service, and the main reason most people aspire to work in the sector, is to provide appropriate care to the people of this country when and where they need it.

Unfortunately, for many who work in the health service, itappearsthatoverthepastfewyears,financialcontrolhasbeentheoverridingandindeedprimaryobjectiveofthehealthservice.Whileprudentfinancialmanagementiscriticaltotheeffectivefunctioningofthehealthservice,tomanythereisastrongsensethatthefocusonpatientcare as the primary purpose has been lost at a system level.Whileitcanbearguedthatthenationalfinancialcrisisof2007/2008requiredanintensefinancialfocus,itisessentialtounderstandthatsuchanapproachhassignificantlydamagedthehealthcaresystem18, and has hadsignificantnegativeconsequences.

In order to seriously embark on a re-engagement of people acrossthenationandwithinthehealthservice,wemustbeginwithadeclarationthatthecoreandprimarypurposeof the health service is to provide the care that people need, within the context of what is reasonable to expect from the health service, and what society is prepared to pay for theservice.Allthosewhoworkintheservice,andthoseatgovernmentalandpoliticallevelwhocreatethefinancialandpolicy framework within which the health service operates, mustcommittothis.

Someofthemostdifficultpublicandmedianarrativesaboutthehealthservicerelatetoinequalitiesinaccesstocareanddemand/capacitymismatch.Theseconcerns,whichperpetuateasenseofinjustice,raisefearsinrelationtoequity,queue-jumpingandprioritisationbasedonabilitytopayratherthanonmedicalneed.Peoplewhomustrelyonthehealthsystemshouldbeconfidentthattheiraccesstoessentialservicesisbasedonmedicalneedratherthantheirabilitytoaffordprivatehealthcare.

Priority Prevention Measures

• Public Health Alcohol Bill• Introduction of tax on sugar sweetened drinks

1 “Healthcare is about me” The future health system must put people and patients at its centre in a meaningful way. This means listening to the patient voice in planning, design and implementation of services; supporting open and honest public debate around how services are provided; and building a sense of partnership between the people who use services and those who provide them.

Wemustchampionthefundamentalprinciplethatthehealthcaresystemisownedbythepatientandisaccountabletothepeopleitserves.

People want high quality care and to feel a sense of partnershipwiththepeopledeliveringtheircare.Theywant their voice to be heard in planning, design and implementationoftheservicesthattheyandtheirfamilieswilluse.Theywanttobeabletoaccesssystemsofpeersupportforpatients,carersandfamilies.

Whenconsideringpopulationperspectives,itisnecessaryto acknowledge the increased number of older people who will be served by the hospital and the health system andtoensureappropriateconsiderationisgiventotheirhealthneeds.Toaddressthisandtoeffectivelymeettheneeds of an older demographic, we will need to deliver moreservicesinhospitals,incommunityclinicsettings,incommunitiesandinhomes.Italsomeansdesigningservicesthatreflecttheneedsofpatientswithspecificvulnerabilitiessuchasthosewithdisabilities.

OurreflectionsduringTowards2026clearlyindicatethatmoreeffectiveuseofleadingtechnologies,andshiftingfromapredominantlypaper-drivenadministrativesystemin our hospitals to a universal electronic system with appropriate use of smart data management, will assist in successfullyandequitablyrisingtothischallenge.

2 Keeping people wellThere must be sustained cross-governmental and cross-societal commitment to reduce ill-health through addressing lifestyle trends and inequalities in health outcomes.

Keeping people well and reducing ill-health as far as possible by modifying lifestyle and reducing health harmsmusthaveasustainedandsignificantfocus intothefuture.

If ill-health due to tobacco, alcohol, obesity and physical

inactivityisnotreduced,thehealthservicewillbeunabletocopewiththeinevitableriseindemand.Thiswillrequirethathealthpromotionisplacedasacoreresponsibilityofallsectionsofgovernmentandsociety,andnotlaidatthedoorofthehealthservicealone.

Individuals play an important role in maintaining their ownhealth;thehealthserviceshouldbebuiltuponthephilosophythatitistheretofacilitatethemtodoso.

Evidence shows that poverty is a strong determinant in healthoutcomes.9 No health policy or strategy will be trulyeffectivewithoutastronganddeterminedefforttoreducepovertyandsocialinequalities,includinginequitableaccesstoessentialhealthservicesbasedonabilitytopayratherthanmedicalneed.

Towards 2026 – The vision

Reaffirming the purpose of the health service

Figure 2: Preventable health conditions in Ireland

160,221 hospital bed-days used for alcohol related illness in 201214

27,540 inpatient admissions each year due to smoking.

Physical inactivity is responsible for 9% of coronary heart disease; 11% of type 2 diabetes; 15% of breast cancers and 16% of colon cancers16

56% increase in the number of obese men and 70% increase in obese women between 2007-201517

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3 Funding and expectations

Clarity is needed about what is reasonable to expect from the health service, what funding is to be allocated to meet those expectations, and what decisions need to be made to benefit the greatest number of people in a fair and transparent way. Central to this debate will be the issue of what society is prepared to invest in its health service

Asanationweacceptthatwecontinuetofaceintouncertaineconomictimes.Wealsoacceptthatthe healthcare economics are trending towards ever-increasing demand and cost, most likely on an unsustainablescale.

There must be radical change to the philosophy and methodsweusetofundourhealthservice.Clearalignment, based on transparency and fairness, must be establishedbetweenthefundingallocationandwhatthehealthserviceisexpectedtodeliverforthatfunding.

Addressing the issue of funding is a fundamental challenge.Manyhealthsystemsarefacinganexistentialcrisisinrelationtoincreasingdemand,costs,andanever-increasingfundingdeficit.DrDonBerwick,founderoftheInstituteforHealthcareImprovement,hasspokenaboutthepotentialofhealthcaresystemstobankruptnationsif current demographic, disease, cost, and waste trends continue.Itisthereforeallthemoreessentialtoensurethat the resources allocated to the health service by the Governmentareusedtothegreatestbenefit.19

Thisisaresponsibilitythatallshare,includingdoctors.Dr Berwick has referred to the ethical responsibility of doctors to ensure that available resources are allocated to thegreatestbenefitofpatients,andthattheallocationoffundingisnotsimplyamatterforotherstodecide.20 21

Equitymustplayasignificantroleinfundingdecisions–bothintermsofensuringequityofaccessforpatients,butalsoequityintermsofresourceallocationacrossthecountry.Wemustconsiderallresourcesavailable,bothpublic and private, and how best use may be made of these resourcesforthebenefitofpatients.Allchangemustbetransparenttoensurethegreatestbenefitaccruestothegreatestnumberofpeople.Difficultiesexperiencedbyspecificgroupsinaccessingservices,forexampleinremoteorless-populatedareas,mustbeconsidered.

Fundamentally,thefundingallocationmustbealignedwithpopulationneedatbothlocalandnationallevel.This can only happen if we have the accurate data and processesnecessarytoaccuratelydefinepopulationneed;toprioritiseneed;todesignandimplementintegratedmodelsofcare;andtoallocatefundinginwaysthatarealignedtoneedandmodelsofcare.Thisrequiresarigourandtransparencythatdoesnotyetexist.Italsorequires fundamental changes to the way the health servicedoesitsbusiness.

Theseobjectiveswillbeattainableonlywithtransparentandmeaningfulfinancialdataavailabletonationalandlocaldecision-makers, who must apply an ethical framework to ensureresourcesareusedforthegreatestimpact.

Towards 2026 – The vision

A funding crisis

TherehasbeenunsatisfactorydebateandmuchuncertaintyregardingthefundingoftheIrishhealthservice.However,theprevailingnarrativeisthatthesystemhasneverhadsuch a high level of funding, and that it is well funded comparedtootherOECDcountries.

Depending on which OECD comparators are used, funding mayappearrelativelyhigh,butifitis,wedonotappeartobederivingthebenefits.Measuressuchasthelengthoftimepeoplehavetowaittobeseenbyaspecialist;orthenumbersandtimespentwaitingonatrolleyinemergencydepartments;oraccesstodiagnosticsincommunityandprimary care clearly indicate that other systems may be derivinggreaterbenefitfromtheirexpenditurethanisthecaseinIreland.Forexample,despitetheincreaseinfunding in the last two budgets, the average annual number ofpeopleontrolleyshasrisenfrom230in2013to326in2016.17

There is a risk that an exclusive focus on a limited set of particularoutcomeswillgiveabiasedviewofahealthsystem that does actually achieve against a range of other important indicators, one of which, for example, includes a progressive lengthening of the expected life span of the Irishcitizenduringtheselastdecades.

The subtext here is that the Irish health service cannot expectmorefundingbecauseitis‘well-funded’.Thismayverywellbethecasewhenfinancialdataareviewedatanaggregatelevel,andwithoutreferencetopatientoutcomesandexperience.However, given that themajority of funding is allocated on a historical basis, a muchmoresophisticatedanalysisisneededifthereistobeameaningfuldiscussionontheredistributionandstrategicallocationoffunding.

Duringthefinancialcrisis,IrelandwasoneofthefewOECDcountrieswheretherewasanabsolutereductioninexpenditureonhealth.However,thiswasachievedthrough relatively simple measures applied crudely across the health service, some of which may have had theperverseimpactofactuallyincreasingcosts,e.g.ofexpensiveagencystafftofillcriticalstaffinggaps.22

There was also no provision for demographic change in this period.Since2009,therehasbeena10%increaseindemandfor acute hospital services based on demographic pressures,

anda24%reductioninhospitalfunding17.Itisnotpossibleto discuss meaningfully an appropriate level of funding for the health service without an explicit alignment of funding toexpectation,need,demandandoutcome.

Thehealthservicealsofacesaseriouscrisisinrelationtocapitalfunding.Almostallavailablecapitalfundingfor the health service for the next number of years has already been allocated to a small number of major capital-intensive, highly visible and worthwhile projects such as theNationalChildren’sHospital.Workingandclinicalconditionsinbothcommunityandhospitalsareverymuchsuboptimalinmanycases,thereisanurgentneedto implement an electronic health record, and to replace ageing equipment and infrastructure in a planned and orderlyfashion.Thisproblemisexacerbatedbythefactthat a burst of capital spending in 2006-2008 has resulted inaspikeinreplacementrequirementsnow.

It is incorrect to say that the healthcare problem in Ireland issolelyduetoinsufficientfunding,andthatadditionalresourceswillresolveeverything.Itisequallyincorrecttocharacterisethehealthserviceasawell-funded‘blackhole’whereanyfurtherinvestmentwillbewasted.Allstakeholdersmustfaceuptotheresponsibilitiestheybearincreatingthissituation,anddeterminetomaketherealchanges that will help improve the alignment between expenditure,patientneedandhealthoutcomes.

Intheabsenceofeffectivejoined-upmodelsofcare,joined-upreal-timeinformation,theabilitytocollectandmakeuseof‘bigdata’,andthelackofjoined-upgovernance, we do not have the tools to properly cost healthprovision,toaccuratelyassesspopulationneed,evaluateresourceallocation,makestrategicandprioritiseddecisions, or translate this into plans and performance acrossthesystematlocalandnationallevels.

18 19

4 Using data to planHealthcare policies, strategies and plans should use research evidence and relevant data to make clear connections between population needs assessment and frontline planning decisions.

Of crucial importance is the alignment of demand with capacitythroughtheuseofdataandevidence.

Weneedtoensurewecanaccuratelyestimatepopulationneed, and design and implement costed models of care to meetthatneedwithfundingallocationalignedwiththeagreedmodelsofcare.Thehealthsectormustcontinuetodevelopexpertiseinthesystematisationofaccessto

adultsaged65andoverwillincreasebyupto21%by2022,whileinthesameperiodthepopulationofthoseaged85andoverwillincreasebyalmost4%.Itisalsonotable that over 600,000 people at the last census reportedatleastonedisability.17

The scale of the surge in demand that this foretells can be appreciated when one considers that in 2015, adults aged65andover,whorepresentedjust13%ofthepopulation,used52%oftotalhospitalin-patientbeddays(See figure 3).2425 Current demand is not being met and, notwithstanding increases for health announced in the 2017 budget, there is no plan outlining how this level of futuredemandcanbeaddressed.

Towards 2026 – The vision

and the appropriate analysis of healthcare-related data to helpinformdecision-makingprocesses.

Muchofthecurrentvisibledysfunctioninthesystemisaresultofdemandgrosslyexceedingcapacity.Thisfailuretoaligncapacityanddemandhascontributedsignificantlytothecurrentcriticalstateofthepublichealthcaresystem.Unacceptablylongwaitinglists,recurrentandintractable trolley waits in emergency departments, andseriousandworseningproblemsinrecruitingcoremedicalandnursingstaffarejustsomeindicatorsofhowvulnerablethesystemiscurrently.

Demographicandhealthprojectionsshowacontinuousupwardtrendindemandforservices.Thenumberof

5 Joined-up careCare pathways should be built around the needs of the patient, not the system. We need to provide care that is joined up from the patient perspective, through design and implementation of patient-centred, clinically led, data-informed integrated models of care. Patient outcome and safety measures, costing and funding models, workforce plans and data and system requirements must all be built in.

Carethatis‘joinedup’andcoordinatedfromthepatient’sperspectiveiswhatpeoplewant.However,formany historical reasons, including the impact of legacy funding mechanisms, ad-hoc service development, siloed policy, poor or absent strategic planning, local politicalimperatives,medicalpolitics26 and fragmented governance,carehasbeenorientedaroundtheentities,places, processes and structures of the system, rather thantheneedsofthepersonrequiringcareservices.

Tobeseriousaboutreaffirmingthepurposeofthehealthservice and the care that people need, the system needs toprovidecarethatisbuiltaroundpatientneedsandthatisjoinedupfromtheperspectiveofthepatient,regardless of where in the system that care is delivered, or bywhom.

All healthcare providers will need to be involved in the deliveryofco-ordinated,continuouscarepackagesacrosssettingsanddisciplinestomeetpatients’needs.Thisform of people-centred care will require a high level of organisation,co-operationandtimeforcommunication.Healthcareprofessionalsandproviderswillneedtosupport each other and demonstrate an evolving spirit of collaborationandknowledge-sharing.

The system needs to provide carethatisbuiltaroundpatientneeds and that is joined up from theperspectiveofthepatient,regardless of where in the system thatcareisdelivered,orbywhom.

Community and hospital budgets that are aligned across theintegratedmodelsofcarewillbeessentialtoaddresstheoverallneedsofasharedpopulationbase.Otherwisetherespectivecommunityandhospitalskillmixes,andthedomainofprevention/healthmaintenance(suchas

Population over 65

700,000

600,000

500,000

400,000

300,000

200,000

100,000

0

Total acute inpatient hospital beds

12,500

12,000

11,500

11,000

10,500

10,000

9,500

9,000

% inpatient hospital bed days used by patients over 65

53%

52%

51%

50%

49%

48%

47%

46%2006 2006 20062015 2015 2015

Source: Health in Ireland – Key trends24, 25

MEDICAL EMERGENCY

2006 2015

The number of acute inpatient

hospital beds has decreased

-13%

12,110 10,473

2006 2015

Even while demographic demand

has been increasing

+29.5%606,000over 65s

467,900over 65s

Figure 3:Mismatch between capacity and demand

The number of hospital beds per 1000 population in Ireland is among the lowest in the OECD 23

2120

HealthyIreland)willremaindivergent,andgenuinesharedcarewillbedifficulttoattain.

Whiletheimplementationofteam-based,joined-upcareacrosssettingsiscritical,absoluteclarityastowhoultimatelybearsclinicalresponsibilityateachstageisequallyimportant.

All of this will require a radical change to the way care is designedanddelivered.WiththeadventoftheNationalClinicalProgrammes,forthefirsttime,thereisinitialdevelopment of models of care and pathways that are oriented towards understanding the needs of the person andnotthesystem.Buildingonthisbase,modelsofcarethat are integrated across community, primary, acute, social and mental health care can now be developed, and anumberareatanearlystageofdevelopment.

However,joined-up,safeandeffectivecarecannotbeprovidedtopatientsunlessthereisdeliberatedesignof integrated models of care, with alignment of funding models, workforce plans, clarity in ownership of tasks andresponsibilities,performancemeasuresanddata,andsystemstoenableimplementationofthosemodels.

6 Hospital without wallsHealthcare delivery should be oriented around the service itself rather than buildings and institutions or legacy arrangements. This includes the concept of a ‘hospital without walls’, where many services delivered in hospitals can and should be delivered in the community, with greater collaboration across hospital, primary care and community care settings.

Hospitalcaretodayincorporatesacomplexmixofservices, some of which should be consolidated within the hospitalandsomedeliveredinthecommunity.Hospitalscannot be a one-stop-shop for all care services but rather areonecomponentofthehealthcaresystemconsistingofa network of providers working closely together to deliver joined-upcareforpatients.Throughoutthisexercisetherewastherecurrentobservationthatoursecondaryandtertiarycaresectorarecongestedwithworkwhichshould be carried out in the primary sector, which, unless addressed, will fatally compromise the ability of the secondaryandtertiarycaresectorstodeliver.

‘Hospital’asabuildingisnolongeranappropriateconcept.Thereshouldbelessfocusonthe‘place’andmoreonthe‘service.’Thevisionofthehospitalin2026isofa‘hospitalwithoutwalls’.Thisrepresentsashiftawayfromtheconceptofahospitalassimplya‘place’,totheidea of a hospital as a package of acute, specialist and emergencyservicesavailabletoapopulation.

People must be able to access care in the most appropriatecaresetting,includingspecialistopinion,someofwhichmaybedeliveredoutsidethetraditionalacutehospitalsetting,perhapsusingtelemedicineorbyelectronicallyengagingwiththegeneralpractitioner.

Strengtheningcapacityinprimaryandcommunitycarewillbecrucialtoachievethis.Equallyimportantwillbe the appropriate mapping of hospital services for complex,specialisedcareand24-houremergencycare.Someserviceswillcontinuetorequireaggregationinaspecificplace.Althoughmuchcarecanandshouldbedevolved locally, this can only work if relevant secondary andtertiaryservicesarealsosupported.Criticalmassand adequate clinical throughput with specialised infrastructurewillbenecessarytoensureretentionofskills, safety and quality in the delivery of those secondary andtertiaryservices.

Towards 2026 – The visionFigure 4: Patient flowTo effectively manage the flow of patients through ED and to resolve the longstanding trolley crisis, we must understand that this ‘flow’ begins long before the ED and continues long after.

Servicesprovidedwithin the community to enable people to live at home and manageconditionsthemselves with support in the community if necessary

GP’senabledwithresources and diagnosticstominimise referrals to acute services to those who need them

Expertiseandresources within EDtoeffectivelymanage those presentingandtodischarge and admit appropriately

Sufficientacutehospital beds with all related resources, therapies anddiagnostics,tomeetdemand.

Community services and capacity to enablepatientsto move from acute bed to a more appropriate rehabilitation,nursing home or homesetting

Mental health services to meet demand in the community and othersettings.

Itisessentialtohavegovernancearrangementsthatallowfortransparency,oversight,integrationandmanagementofpatientflowacrosscommunity,primaryandacuteservices.

AcapacitydeficitatanypointalongtheflowwillusuallymanifestasaproblemintheED,whichisoftentheplace oflastresort.

The system must be able to adapt to address capacity and demandissuesatanypointalongthepatientflow.Forthisweneedto:

Manage flow

continuously

Haveauthoritytomakedecisions across the

flow

Usereal-timedatatoknowwhat’s

happening

Plan for contingencies

Usesciencerelatingtomanagementofflowfromotherindustries/healthcaresystems

Ifthepatientflowpathwayis…

thentheincidenceofpeoplewaitingontrolleyswillbeminimised.

Mapped out

Demand predicted

Resources lined up in

community, primary care

Diagnosticsavailablein community and acutesettingsatthe

timerequired

Patientsdischarged as soon as acute

care completed

Rehabilitationand nursing home beds

available

Homesupports allocated

Thisalsorequires…

Agreement with stafftomoveresources to

where they are needed

Workingpatterns

changed to meet demand

May require agreements with private providers to meet spikes in

demand

Dynamic management of patientflowappliedwith

authorityacrossthecontinuumof home, community, primary

and acute care

Skilledcliniciansandmanagersworking together with

responsibility for managing patientflowacrossboundariesinrealtime,atalocallevel

Patientflowislocal.Aggregatingdatatonationallevelisinterestingandsupportsnationalplanning,butwillnothelptomanagetheflowofpatientsthroughaspecificED.

Funding Workforce Performance Measurement Systems and Data

areallcriticalenablersofthissystemicapproach

If a systemic approach is taken, we should expect all local services to be able to deal with episodic spikes in demand, but no system can deal with sustained and gross mismatch between demand and capacity

22 23

7 Building for accountabilityWe need a governance system that applies at every level, from service delivery upwards, and is grounded in the principle that the healthcare system is owned by and accountable to the people. It must identify responsibility clearly at every level, provide authority and capability as required, and be held to account for doing so. Service delivery must be aligned with national frameworks and policy.

Itisessentialthatrobustandintelligentmodelsofclinicalgovernance are in place and aligned across service domains.Theyshouldalsobeintegratedacrossnon-clinicaldomainssuchashumanresources,finance,andinformationtechnologyandfullyembeddedwithinthegovernanceoftherelevantserviceorganisation.

Effectivegovernancemustbebuiltfromthegroundupandnot,assooftenhappens,fromthetopdown.Itmustbeginwiththeservicetobeprovidedtopatients,asdefinedinmodelsofcare;andinthecontextoftheoutcomes,quality,performanceandfinancialframeworkswhichthesemodelsdefineandrequire.Clinical governance should be a core concern of the board andCEOofahealthcareorganisation.Itshouldalignseamlesslyacrossprimary,secondaryandtertiarycare.

Governance must become an integral part of clinical andhealthcaretrainingandpracticetofacilitategreaterunderstandingamonghealthcareprofessionals,patientsandhealthcaremanagers.Governanceframeworksmustapply at every level of the health service, including at DepartmentofHealthandgovernmentallevel,andmustberigorouslyapplied.

Goodgovernanceensuresthatanorganisationissetupoptimallytoachieveitspurpose;thatallwhoworkinthatorganisationunderstandtheirpersonalandteamresponsibility;haveallrelevantcompetenciesandauthoritiesnecessarytofulfilthoseresponsibilities;andareappropriatelyandconsistentlyheldtoaccountforthat.

Whilestructuresareimportantandcanenableorimpedegood governance, resolving the governance crisis is notprimarilyanissueofstructure.Changingstructureswithout addressing the fundamental system issues is akin to adding extra storeys to a building while leaving the foundationsunchanged.Itmaygivetheimpressionofprogressandactivityintheshorttermbutultimatelyitisprofoundlyunsafeand,underpressure,willfail.

Muchofthedysfunctionwithinthehealthsystemflowsfrompoororunclear,ornon-existentgovernance.WehavepreviouslydiscussedthenegativeimpactoffragmentedgovernanceacrosstheflowofpatientsthroughtheED.Withoutaddressinginameaningfulandradical way the problems of governance within the health service, including clinical governance, no real progress will bemadeintermsofimprovingthehealthservice.

RCPI therefore welcomes the changes that are happening, albeit slowly, to devolve responsibility and authority to servicedeliveryorganisationssuchasCommunityHealthOrganisationsandHospitalGroupswhileatthesametimereimaginingthefunctionofthenationalcentreofthehealth service to develop much more relevant and strategic nationalfunctionssuchaspopulationneedsassessment;servicedesignandcommissioning-typeactivities.

Itisessentialthatthis‘nationalcentre’becoherentandalignednotjustwithintheHSE,butalsowithintheDepartmentofHealthandotherrelevantgovernmentdepartments, including the Department of Public ExpenditureandReform.Itisnotpossibletodelivercleardirectionandanintegratedapproachtothewiderhealthserviceifthereisn’talignmentbetweenthepolicyfunctionoftheGovernmentandthehealthdeliverysystemitself.

This is a rare and important opportunity to build governancesystemsfromthegroundup.

Towards 2026 – The vision

Governance – the foundation stone

Governance is the framework of processes, systems and structures that enable the health service to deliver on itscorepurposeanditskeygoals.Clinicalgovernancedefinestheculture,values,processesandproceduresrequired to achieve sustained quality of care in healthcare organisations.Itinvolvesmovingtowardsaculturewheresafe,high-quality,patient-centredcareisensuredbyallthoseinvolvedinthepatientjourney.Thisissignificantlymorecomplexinthenot-for-profithealthsectors,andinhospitalsinparticular,thaninthecorporateworld,asdescribed in Belgian28 and Irish29research.

Allpatientexperience,patientoutcomes,quality,safetyand cost derive from the point at which care is delivered to thepatient.Yetanextremeformofcentralisedcommand-and-control governance has evolved in the Irish health system.Thishasbeenlargelydrivenbythedesiretohaveasingle point of accountability for the health service, which isneitherachievablenoroptimal.Itdestroysthesenseof ownership and decision-making at local level that is essentialtoenablehigh-qualityandeffectivecaretobeplanned,organisedandprovided.Italsodivertsfocusawayfromcriticalmattersthatrequirenationalleadershipandattention,suchasstrategicplanningfortheentirehealthservice,populationneedsassessment,servicedesignandperformanceaccountability.

Not only has governance been overly centralised, it has alsobeenfragmentedandsiloed–notjustinrelationtoservice areas such as acute, primary care, social care and mentalhealth,butalsoinrespectofcriticalenablersofthesystemsuchasworkforce,financeandinformationandcommunicationtechnology(ICT).Thisfragmentationhas fatally undermined the ability of the system to act in a co-ordinatedwayatlocal,regionalandnationallevels,yetthere is almost no instance of care that does not require ajoined-upapproach.

Nosuccessfulorganisationwouldapproachthetaskofserviceplanninganddeliveryinthisway.Theproblemhereisnotamenabletoexhortationsforpeopletoworkharder or smarter, but rather that at a fundamental level the health service has evolved a governance system that makesitimpossibleforthehealthservicetofunctioninaneffectiveandsafeway,andforthosewhoworkwithinittoeffectivelycarryouttheirduties.Thoseresponsiblefordeliveringservicehavebeendisempowered;andthoseresponsibleforsettingandassuringstrategicdirectionhavebeenequallydisempowered.InthewordsofW.EdwardsDeming,‘abadsystemwillbeatagoodpersoneverytime’.30

Wehavetodayasystemthatcandolittlemorethandealwiththelatestcrisis,possessinglittleabilitytoaddressthe underlying causes, with the result that the same problems and crises recur repeatedly, and when they do, theyaredealtwithinthesamemannerwhileadifferentresultisexpected.Itmustbeacknowledgedthattherearefundamental problems within our healthcare system which canonlybeaddressedinafundamentalway.

24 25

Towards 2026 – The vision

Accountability, not blame

In this dysfunctional governance model, while there is much talk about accountability, what is often actually created is a blame culture, where in reality there can be little accountability. Accountability is only meaningful if the person or entity being held accountable has been provided with:

1 Clarityaboutwhattheyareresponsiblefor;

2 Theauthorityandresourcestheyrequiretofulfilthatresponsibility;and

3 Clarity about how they are to be held to account andbywhom.

Itisessentialthatnopersonorentitywithauthoritytomakeadecisionthathasamaterialimpactonthefunctioningofthehealthserviceliesoutsideanaccountabilityframework.If authority is assumed, then accountability must go with it.Oftenapersonorentitymaybeheldtoaccountfora responsibility where they were denied the authority orresourcestheyneedtomeetthatresponsibility.Thiscreatesablameculture.Equallydamaging,andlessoftenspoken about, is where an individual wields authority without being held accountable themselves for any adverseoutcomesoftheirdecisions;butothersare.Thisleadstodysfunctionality,andfundamentallyunderminesanysenseofrealaccountability,andindeedtrust.

Given that the purpose of the health service is to provide care, accountability must start at the point at which care isdelivered.Anyaccountabilityframeworkthatdoesnotbeginatthislevel–intheward,oremergencyoroutpatients’department,orlaboratory,orinprimarycare–isultimatelyirrelevanttothecorepurposeofthehealthservice,andwillfail.Buildingfromthislevel,accountabilitymust then be aligned through the layers of the health system,rightthroughtotheMinisterforHealthandtotheGovernment.

Sadly,whatthe Irishhealthservicehasevolved isagovernance system that is applied from the top down, not from the ground up, and where at every level, including at nationallevelsoftheDepartmentofHealthandtheHSE,appropriate responsibility is not aligned with authority, nor withaccountability.Mostdamaging,governanceisnotalignedwiththeservicetobeprovidedtopatients,leadingto a fragmented approach to planning and delivering care, whichforpatientsultimatelyresultsinanexperienceofdisjointedandsometimesunsafecare.

Whilewecanallunderstandandsupporttheconceptofproviding care that is centred around the needs of the patientwhetherathome,inthecommunity,inprimarycare, or in hospital, the system has been set up to work in almosttotaloppositiontothatconcept,intermsofhowtheserviceisgoverned,managed,fundedandmeasured.This is why nothing less than fundamental, systemic changeisneeded.

“Youareresponsibleandaccountable for things over whichyouhavenocontrol”.31

Hospital Groups and Community Healthcare OrganisationsAre Hospital Groups and Community Healthcare Organisations a good idea and will they work?

In principle the concept of devolving responsibility, authority and accountability for the delivery of services as close to the patient as possible is not only good, but essential.

A weakness of the envisaged structures is that they are notclearlyalignedtothepopulationtheyserveacrosscommunityandacuteservices.Neitherisityetclearhowintegrated care will be governed and managed across the boundariesthatwillexist.

Amajormistakeistofocusexclusivelyonthe‘structures’beingcreated.Newstructuresarealmostcertaintohaveno discernible impact, and more changes to structures is likelyonlytocausemoreconfusionanddelay.Whatwillmakeadifferenceishownewpatient-orientedwaysofdeliveringintegratedcarecanbeimplemented.

ThefocusforbothHospitalGroupsandCHOsshouldbeonhowtheyaresettinguptheprocessesandaligningresources to be able to deliver joined-up coordinated care tothepopulationtheyserve.

WhetherHospitalGroupswillbecomeindependentHospitalTrusts,isanissuefortheGovernmenttoaddress,but it is highly unlikely that Ireland has the scale to warrantsuchanapproach.

TheGovernmenthasaresponsibilitytosetthedirectionoftravelinthisregard–ideallytowardspopulation-based,integrated healthcare services, but should understand that thiswilltakeconsiderabletime,andwillnotbecreatedthrough structure but through changed ways of working at local,regionalandnationallevel.

AnotherpointtonoteisthatthewhiletheHigginsReport27

envisages autonomous hospital trusts, this has not yet been implemented, and it is unclear whether this goal is achievable.Thefuturestatutorybasisforhospitalgroupsmustbeclarified.Thelackofclarityonthisissuehasbeenadestabilisingfactorwithinthehealthservice.Itisalsoimportantthatthesenewservicedeliveryorganisationsbeorientedaroundprovidingservicestoadefinedpopulation;and that governance arrangements and processes between themaresuchthatanintegrated,patient-centredapproachtoservicedeliverybythoseorganisationsisbothenabledandmandated.Otherwiseourexistingsiloedapproachtoservicedeliverywillendure.

Inthiscontextitiscriticalthatservicedeliveryorganisationsareestablishedinsuchawaythattheyarebothaccountabletothelocalpopulationtheyserve,andaccountableataregionalornationallevelinrelationtoperformanceagainstframeworksandstandards.

2726

8 Supporting healthcare staff

Major, sustained emphasis is needed on strengthening and supporting the people who deliver care, and on rebuilding trust and confidence among the workforce.

Successfulorganisationsrecognisetheimportanceofthepeoplewhoworkforthem;theytrytorecruitthebest;ensuretheyareenabledtoperformtotheirbest;areinvolvedappropriatelyindecision-making;aretrusted;andareprovidedwithdevelopmentopportunities.Thisiswhatweshouldaspiretoforourhealthservice.

Withoutpeople,thereisnohealthcaresystem.Clinicalteamscannotfunctionwithouthigh-calibreadministratorsandmanagerswhomanagethelogisticsandsupportfortheteam.Doctorscannotdeliver

high-qualitycaretopatientswithouthighlyskilledand professional nurses and health and social care professionals.Hospitalscannotfunctionwithouthighlyablefinancialmanagers;norcantheyfunctionwithoutthededicationofporters,cleaners,cateringstaffandthemany others who contribute to the day-to-day life of the hospital.High-calibreCEOshaveaprofoundinfluenceontheeffectivenessandefficienciesofahospital.Hospitalscannotprovidequalitycaretopatientswithouthigh-qualityGPsdeliveringexcellentprimarycare.Insuchacomplexsystem,multipletalentsareneededforthesystem to perform, and we should acknowledge and supporttheessentialrolesplayedbyallthesestaff.

Thereisalsoaresponsibilityonstafftoplaytheirroleinleadingandsupportingchange.Manyofthoseworkingintheservice,farfromresistingprogress,areeagerandwillingtopromotechangethatresultsinbettercareandimprovedmorale.32

Workforceplanningthatisbasedonhealthcaredemandwillensurethattheworkforcecapacityissufficientandappropriately skilled to meet future needs will ensure thattheworkforcecapacityissufficientandappropriatelyskilledtomeetfutureneeds.Newandexpandedroles,basedoninternationalmodelsofbestpractice,willbea feature of the healthcare workforce in the future, requiringnewprofessionalcontractswithnewdefinitionsofrolesandresponsibilities.

Retentionofthebeststaffwillbeimprovedwhentheyaresupportedtofulfiltheirrolesandresponsibilitieswith appropriate equipment, training, structured and flexiblecareerpathways,asafe,comfortableandeffectivephysical working environment, and a prevailing culture in whichallstaffarevalued.

ItisencouragingtonotethattheHSE’sPeopleStrategy33

recognises the central importance of high-quality, motivatedstafftothedeliveryofcare,andseekstochange the experience of people working in the health service.Thisisanindicatorthatanewapproachtopeopleis being led from the very top of the health service, and isverymuchtobewelcomedandsupported.Weshouldbeoptimisticthatthevastmajorityofstaffacrossthehealthservicewillrespondpositivelytoanewphilosophyandapproach,iftheytrustthatthisnewdirectionwillbe meaningfully supported and sustained at all levels of leadership,withintheHSE,theDepartmentofHealthandotherrelevantgovernmentdepartments.

Towards 2026 – The vision

Crisis of staff retention and morale

1in5medicaltraineesintendtoeitherdefinitelynot,orprobablynotpractisemedicineinIrelandintheforeseeablefuture.

Atatimewhentheworldisfacingintoaglobalshortageofhigh-qualityclinicalstaff,Ireland’sstrategytowardsthepeoplewhoworkinthehealthserviceisunclear.Overthepastnumberofyears,itappearstohavebeenoneofalienation.WeknowfromaMedicalCouncilsurveythat1in5medicaltraineesintendtoeitherdefinitelynot,orprobablynotpracticemedicineinIrelandintheforeseeablefuture.34

“Emigrationisamatterofself-preservation. Theworkingconditions…arekillingusslowly’35

Thereisacrisisofmoralewithinthehealthservice,andacrisisofretentionandrecruitmentamongmany criticalclinicalandmanagementstaff.Whilethereisnodoubtthatpayhasbecomeacrucialissuewithmanystaff,andthatIrelandisnowcompetingwithinternationalhealthservicesforthebestmedicalandnursingstaff,theproblemisalsofundamentallylinkedtoaperceivedlackofrespectforstaff,andindeedthesensethatworkers areincreasinglyregardedasacommodity,whichwasparticularlyandmostdamaginglyexacerbatedduringthe financialcrisis18.Engagementwithstaffhasbeenunnecessarilyanddamaginglyadversarial.

Healthprofessionalswhohaveemigratedhavereportedthatimprovedworkingconditionsinthedestinationcountryappearedtoproviderespondentswiththeopportunitytorediscoverthejoyofpractisingtheirprofessionwithouthavingtocontendwithadifficultworkenvironment

Thissituationmustberecovered.Staffwanttoplaytheirpartinafunctionalhealthcaresystemwheresustainedfocusisondeliveringoptimalpatientcare.Achievingsomesenseofprofessionalfulfilmentinahealthsystemthatisinalmostcontinuouscrisismodeisextremelydifficult,ifnotimpossible.Healthprofessionalswhohaveemigratedhavereportedthatimprovedworkingconditionsinthedestinationcountryappearedtoproviderespondentswiththeopportunitytorediscoverthejoyofpractisingtheirprofessionwithouthavingtocontendwithadifficultworkenvironment.35

“Wearenotafraidofhardworkbutthedailydemandissuchthatyoudon’tevengettoavailofsimplehumanneedslikelunchorthebathroombecauseofstaffshortages.”31

ThealmostconstantnegativepublicandmedianarrativeaboutthehealthserviceinIrelandhasalsohadanegativeimpact.Despitethemillionsofpositiveinteractionsandgoodpatientoutcomeseachyear,tomanystaffinthehealthserviceitappearsthattheprimarypublicnarrativeisoneoffailure.Thiscreatesadamagingcontextforpeopleinwhichtowork.Whilethesystemmusttakeitsshareofresponsibilityforcreatingthisenvironment,ata societal level it must be recognised that the health service is a human system, subject to human frailty and the limitsoftechnologyandsystems.Inthebestsystemsintheworlderrorsdohappen.Inasystemwithfundamentalflawsingovernance,errorswillcertainlyoccur.Ouremphasisshouldbeonminimisingerroranditsimpactthroughappropriatesystems.

28 29

paper-baseddocuments;andwherethetransitionofapatientfromonecaresettingtoanotherisbywayofpaperfiles.However,persistentlackofstrategyandunderinvestment over the last number of years has led to afragmentedandnotfit-for-purposeapproachtoICT.

WhilethereisamultiplicityofITsystemswithinthehealthservice,thereisverylittleinteroperabilitybetweenthem.Almost all are in the acute sector while community systems arelargelyabsent.

It is not possible to deliver safe,qualityandeffectivecaretopatientswhenimportantpatientdatainthesecondaryandtertiarycaresettingsiscontainedinmultiple,oftenpaper-baseddocuments.

Withoutsignificant,strategicandlong-terminvestmentineHealth,thevisionofcaringforpeopleinthecommunity,asclosetohomeaspossible,willremainapipedream.

ThepublishedeHealthstrategyforIrelandprovidesadirectionforustotakeinthisregard.36

10 Developing healthcare leaders Clinical leadership roles and managerial capability should be developed and supported at all points in the system

Onlystrongleadershipatlocal,regional,nationalandinstitutionallevelscanovercomethelackoftrustinthe system and bring about the kind of change needed to return the health system to its core purpose and deliveronit.Itmustberecognisedthatthereisacrisisin leadership at all levels, and that there has been lack of supportforleadershipdevelopment.

Clinicians should be represented in all governance structures and an environment should be created whereby leadership and governance roles are seen as desirableandattractive.Thisisofparticularimportancefor doctors, as historically their involvement in leadership andmanagementroleshasbeenlimited.

Among clinicians, management and leadership should beseenascareertracksthatareasvalidaseducation,researchandclinicalexcellence.Rolesshouldbecreatedforclinician-managers,andclinicalleadershipeducationandtrainingshouldbeprovidedthroughoutclinicians’professionalcareers,startingatundergraduatelevel.Coaching and mentoring support should be provided for thoseappointedtoclinicalleadershiproles.

9 eHealth The individual health identifier and electronic health record must be implemented. The advent of the eHealth Strategy provides an opportunity to adopt a long-term strategy to underpin joined-up care across community, primary care, acute hospitals, and mental health; and to simultaneously enable effective population needs analysis, prioritisation, planning, outcome measurement, and performance accountability at local and national levels.

Movingtoasinglenationalpatientidentifierandelectronic health record is a prerequisite to the success of anydevelopmentofintegratedcare.SustainedinvestmentineHealthpromisesprofoundpotentialbenefits,andcannolongerbeignored.Irelandhasanopportunityheretoleverage its historical underdevelopment in this area by learningfromwhathasnotworkedwellinternationallyandensuringwedesignasystembasedontheselessons.

Healthcareisacomplexsystem,andtheneedforInformationandCommunicationsTechnology(ICT)systemsanddatatosupportandenableeffectiveandjoined-upmodelsofcareisclear.

Itisnotpossibletodeliversafe,qualityandeffectivecaretopatientswhenimportantpatientdatainthesecondaryandtertiarycaresettingsiscontainedinmultiple,often

Clinicians should play a leadership role in guiding and informing public discussion and policy-making on major issuesrelatingtopublichealth(suchasprioritisationoffundingandthetransitiontoapreventivehealthcaremodel)throughadvocacyandcollaborationwithotherstakeholders.

The advocacy role of clinicians should include leading improvement in their work environment through identifyingandpromotingexamplesofgoodpractice,ensuringthevoiceoffrontlinestaffisheard,andadvocatingonbehalfofpatients.

The need for e-health - the physician’s perspective

“We’reusingleverarchfilesandpost-itnotes.Patientfilesaremissingvitalpiecesofinformationsuchasreferralletters.Wecannotimplementthecarewearestrivingforinthisoutdatedenvironment”

- Consultant in an Irish Hospital

Towards 2026 – The vision

30 31

11 Shared vision and political consensusA shared vision and long-term strategic plan with cross-party political support is essential. Frequent changes in direction are fundamentally destabilising and undermining for the health service.

Theremustbesustainedpoliticalandinter-professionalcommitmenttolong-termpoliciesandstrategies.Cross-politicalconsensusisnecessarytosupportacommitmentthatspansmultiplegovernmenttermsandcomposition.

Asaconsequenceofdysfunctionalgovernance,theextreme austerity experienced by the health service in recent years18, and the inexorable rise in demand for health services38 there has been a default towards crisis management,andadistinctlackofstrategicplanningatnationalandlocallevels.Theonlyoutcomeofsuchanapproachiscontinuedself-perpetuatingcrisisandunderperformance.

Forexample,sincethefoundationoftheHSEin2005,therehavebeenfiveMinistersofHealth,eachwithaparticularpolicyfocus.DuringthistimewehaveseentheformationoftheHSEastheaccountablebody;theabolitionoftheboardoftheHSEastheaccountablebody;thecreationofnationaldirectorates;integratedserviceareas;regionaloperationalareas;hospitalgroupsandcommunityhealthcareorganisations.Policiesregarding co-locationofpublicandprivatehospitalsandaprogramme of universal health insurance have comeandgone.

Thelackofacleardirectionforthehealthsystemwithgeneraland sustained all-stakeholder support is extraordinarily debilitatingfortheservice.ItistheresponsibilityoftheGovernmentandpoliticianstoprovidepolicyframeworksand to enable those frameworks to be implemented, through legislationandfunding

Theappropriateroleofpoliticsinthehealthservicemustbeconsidered.TheHSEwassetupwithasensethatitwouldallowfor‘removingpoliticsfromhealth’.Thiswasneverrealisticashealthwillalwaysbeapoliticalissuegiventhatpoliticiansrepresentandareaccountabletothepeople,whoareultimatelytheownersandusersofthehealthsystem.However,themannerinwhichpoliticsengageswiththehealthsystemneedstochange.

Themannerinwhichpoliticsengages with the health systemneedstochange.

Itistheresponsibilityofthepoliticalsystemtoestablisheffectiveandrobustgovernancearrangementsforthehealthsystem;toleadthepublicdebateonwhatisreasonabletoexpectfromthesystem;todefinewhatfundingistobeallocatedtomeetthoseexpectations; to set out the high-level measures to which the system isheldlocallyandnationallyaccountableonbehalfofthepopulation;andtoputinplacethepolicyandlegislativerequirements to enable the health service deliver on itsresponsibilities.

12 Implementing change Failure to successfully implement change has been a recurrent and debilitating feature of the health service for many years. There must be significant, targeted and sustained investment into making these changes happen.

There is no shortage of strategic reports and policy documentsdescribingouraspirationsforthehealthservice.Butthereisaproblemwithimplementation.TheQualityandFairnessHealthStrategy(2001)calledforashiftofcareintothecommunity.Adecadeandahalflater,wearestillpursuingthesametarget.Thisisunacceptable.ThehealthserviceinIrelandisonaprecipice and crisis management will not draw us back fromtheedge.Thoseinleadershippositionsatalllevelsof the health service and in Government have a clear duty toinformthepublicandtoeffectivelyadvocateandleadchangeonbehalfofthepeople.

Learningfrompastexperienceiscrucial.OneofthefewrecentexamplesofsuccessfulimplementationofradicalchangewastheNationalCancerProgramme.Lessonslearnedwereontheimportanceofpoliticalandclinicalleadership;thedevelopmentofalong-termvisionandplan;changebasedonevidence,appropriateauthorityandresources;andcontinuouscommunicationwithallstakeholders.

Change is not possible without a vision that resonates withthosewhoneedtomakeithappen.Butneitherisitpossiblewithoutaconcreteplanwithobjectives,milestones,management,expertiseandresources.

Policyaloneisnotaplan.Legislationisnotaplan.Aco-ordinated,programmaticapproachwithcross-sectoralengagementisessential.

Thefocusmustshiftfromshort-term, recurring crisis management to strategic change management

Changeisdifficultandrequiresasustainedandconsistentapproach.Itwillfailiftheplanisn’tgoodenough;itwillalso fail if the plan itself is open to frequent change of direction,oriftheexecutionoftheplanisnotreliablyinformedbytimelyanalysisofreal-timedata.Thefocusmustshiftfromshort-term,recurringcrisismanagementtostrategicchangemanagement.Simplyandnaivelyassertingthat‘changeisneeded’isnotchange.Unlessthe pursuit of real change becomes the primary focus,itwillnothappen.Iftheprimaryfocusremainscrisis management, this will always win out against implementingrealandconstructivechangeasithasdoneforthepastfewyears.

Political leadership for changeThe Oireachtas and the Government must become guardians ofthetransformationofthehealthservice

Whilehealthcarewillalwaysbeapoliticalissue,nomeaningfulimprovementwillbedeliveredunlessthereisasustainedagreementacrossthepoliticaldivideonafuturepathforthehealthservice.TheGovernmentneedstoprovidea10to15yearundertakinganddirectionforthehealthservicematchedbyinvestmenttocreateanewpatient-centredsystemofhealthcareinIreland.

TheOireachtasandtheGovernmentmustbecomeguardiansofthetransformationofthehealthservice,andprovidethenecessarypolicyandlegislativeframeworktoenabletheimprovementplan.Theestablishmentofthecross-partyOireachtascommitteein2016isanecessaryandpracticalpoliticaldevelopmenttosetadirectionforthehealthservice.Thechallengetoallstakeholderswillbetosupporttheoutputofthecommittee.Thechallengeforthecommitteewillbetooutlineadirectionthatallstakeholderscancommitto.Evenwiththiscross-partysupportitisessentialthattheGovernment establish a high level expert group that reports to the Oireachtas on progress and that has the mandate andauthoritytoholdallpartsofthesystemtoaccountformakingthechangehappen.Intheabsenceofsuchabody,thereisnopossibilityofmeaningfulchangeemergingfromwithinthehealthsystem.

Towards 2026 – The vision

3332

Change that focuses on symptoms and not on underlying causeswillfail.Thefocusmustbeonchanginghowthe system is governed and operates, its ways of working,culture,capabilitiesandprocesses.Tomakeeffectivechangesintheseareas,theremustfirstbeanunderstandingastowhythesystemisfailing.Structuralchangemustcomeafterthis.Structuralchangealoneisnotchange.

Change requires transparency, honesty and adherence tocommitmentsandtothevaluesandspiritoftheplan.Lackoftrustisamajorbarrierthatonlyleadershipofgreatvisionandintegritycanovercome.

Makingchangehappenrequiresinvestment.Withoutadditionalresourcesitwillbeimpossibleforchangetooccuronanymeaningfulscale.Anyassumptionthatsignificantimprovementcanbeachievedwithoutspecificinvestmenttomakechangehappenisnotfeasible.Theremust be deliberate, targeted and sustained investment in makingchangehappen.Long-terminvestmentisneededtoenablechangesovertime.

Making change happen requiresinvestment.Withoutadditionalresourcesitwillbeimpossible for change to occur onanymeaningfulscale.

From our discussions in Towards 2026, there is a real sense thatchangeisnotonlynecessary,butthatitisachievable.

There is support for fundamental, meaningful change from those working in the health service and those receiving care.Therewillbeaneedtomobilisepublicsupportforchange, and many stakeholders are willing to help in this regard.Inthesamewaythatthefutureofhealthcareservicesreliesoneffectivecollaborationandpartnershipbetweenmultiplestakeholders,aradicalplanforourfuturehealthcaresystemwillalsodependonthiscollaborationandpartnership.

Toputtherecommendationsofthisreportintoaction,amajorimplementationstrategyisrequiredencompassingpolicyimplementationwithinandoutsidethehealthsector.

All stakeholders must be involved in making change happenandshouldhaveaclearlydefinedroleintheimplementationofthisvision.Withouttheiractiveinvolvement,changewillbeimpossible.Inparticular,

thevoiceofpatientsandcarersmustbeprominentintheprocess.

Meaningful change is impossible without strong leadership atalllevelsofthehealthserviceandtheGovernment.Allthoseinleadershippositionsmustreflectontheirvisionandcapacitytodothejobrequired.Theultimategovernance of this change must reach the top level of the GovernmentandtheOireachtas.

Thiswillrequireanimplementationgroupthatismandatedand given the authority and resources necessary to drive and support change throughout all aspects and levels of thehealthservice.

Finally, there must be an understanding and acceptance thatthisjourneywillneverend.Allstakeholdersmustforeverseektoimprovethehealthofthenationandthehealthcareserviceprovidedtothepeopleofthenation.The challenge is to build a system that, within itself, has thecapacity,capabilityanddrivetocontinuetoimprove.

Towards 2026 – The vision

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11.DepartmentofHealth.ThePathtoUniversalHealthcare:WhitePaperonUniversalHealthInsurance’.Dublin,Ireland:DepartmentofHealth;2014.

12.HealthServicesExecutive.HSENationalServicePlanfor2016.Dublin;2015.Availablefrom:http://www.hse.ie/eng/services/publications/serviceplans/nsp16.pdf

13.INMO.TrolleyWatch/WardWatchforFebruary10th2017.www.inmo.ie

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References

34 35

1 Healthcare is about me

2 Keeping people well

3 Funding and expectations

4 Using data to plan

5 Joined-up care

6 Hospital without walls

7 Building for accountability

8 Supporting healthcare staff

9 eHealth

10 Developing healthcare leaders

11 Shared vision and political consensus

12 Implementing change

2016 2026

• 1 in 5 medical trainees intend to eitherdefinitelynot, or probably not practicemedicinein Ireland in the foreseeablefuture.

• In 2016, approximately20%ofapproved permanent hospital consultant posts were either vacantorfilledonatemporarybasis.

• In 2016 there werealmost4,000less Nursing and Midwifery posts, in the health service, thanin2008(INMO).

• By 2025, the predicted shortage of GPs in Ireland will rangefrom493to1,380dependingonincreased levels of access to free GP care.(HSE).

Our recommendations

Patientssupported to live at home

People have confidenceintheirhealthcare system

Joined-up care is the norm

Lesspeoplesmoking,lower alcohol

consumption,lesspeople overweight,

more people physicallyactive

Nowaitingforspecialist care

Happyhealthcarestaff

Whenyouneedspecialist care, it’sworldclass

Nobody waits for a bed on a trolley for morethan4hours

A healthcare system that is

always improving

Most care in community and

primary care

“ I didn’t think it could come so far so quickly. What a change!”

“ I feel listened to. I matter”

“ The patient journey is convenient, efficient, caring and safe”

“ I am not afraid of going to hospital”

“Easy accessible, safe quality care”

Preventable Health Conditions in Ireland

160,221 hospital bed-days used for alcohol related illness in 2012

27,450 inpatient admissions per year due to smoking

Physical inactivity is responsible for 9% of coronary heart disease; 11% of type 2 diabetes; 15% of breast cancers and 16% of colon cancers

56% increase in the number of obese men and 70% increase in obese women between 2007-2015

Trolley Crisis

Jan 2017

612Patients on trolleys(all time high)

2014Emergency department taskforce convened

2011The Minister for Health stated “never again” would trolley numbers getso high

Population over 65

700,000

600,000

500,000

400,000

300,000

200,000

100,000

0

Total acute inpatient beds

12,500

12,000

11,500

11,000

10,500

10,000

9,500

9,000

% inpatient bed days usedby patients over 65

53%

52%

51%

50%

49%

48%

47%

46%2006 2006 20062015 2015 2015

Source: Health in Ireland – Key trends (2016 and 2016)

Mismatch between capacity and demand

Figure 5: Towards 2026

36 37

Chair, Towards 2026Dr Tom Keane,

Thematic Leads, Towards 2026Dr Siobhán Kennelly,ConsultantGeriatricianandNationalClinicalAdvisorandGroupLeadSocialCare

Dr Garry Courtney, Consultant Physician and Gastroenterologist&ClinicalDirector,St.Luke'sHospital,Kilkenny

Prof Risteard O’Laoide, Consultant Radiologist

Prof Charles Normand,EdwardKennedyProfessorofHealthPolicy & Management, Trinity College Dublin

Participants, Towards 2026Siobhán Creaton,HeadofPublicAffairs,RCPI

*Dr John Barragry, Consultant Endocrinologist and Member of the Irish Medical Council

Dr Sarah Barry, Research Fellow, Trinity College Dublin

Mr Thomas Bergin,PatientnominatedbytheIrishHeartFoundation

*Prof Peter Boylan, Consultant Obstetrician and Gynaecologist attheNationalMaternityHospitalandChairofInstituteofObstetricians and Gynaecologists

Ms Mary Brosnan,DirectorofMidwifery&Nursing,NationalMaternityHospital

*Mr David Byrne,SC,Co-ChairoftheEuropeanAllianceforPersonalisedMedicine(EAPM),FormerEUHealthCommissioner, Member of RCPI Council

Dr Declan Byrne, Consultant Physician in Geriatric and GeneralMedicine,StJames’sHospital

Mr Tony Canavan,CHOChiefOfficer

*Dr Áine Carroll,NationalDirector,ClinicalStrategyandProgrammes Division

*Dr Geoff Chadwick, Consultant Respiratory and General Physician,St.Columcille'sHospital

Dr Anna Clarke,HealthPromotionManagerwiththeDiabetesFederationofIreland

Mr Tom Clifford,Carerandformerco-chairofLimerickRegionalHospitalPatientForumnominatedbyFamilyCarersIreland

Ms Heather Coetzee,SpeechandLanguageTherapyManager,MaterMisericordiaeUniversityHospital

Ms Aileen Colley,CHOChiefOfficer

Tracey Conroy,AssistantSecretary,AcuteHospitalsDivision,DepartmentofHealth

Ms Eliza Cosgrave,DevelopmentOfficer,IrishHospiceFoundation

Ms Marie Cregan,LecturerinUniversityCollegeCorkandPatientAdvocate

*Dr Philip Crowley,NationalDirector,QualityImprovementDivision,HSE

Dr Gerry Cummins, ICGP President

Ms Carol de Wilde,PrincipalMedicalSocialWorker,StColumcille'sHospital

*Dr John Donohoe, Past-President of the Royal College of Physicians of Ireland

Ms Trina Doran,ExecutiveBusinessManager,South/SouthWestHospitalsGroup

Mr Michael Drohan,COPDSupportIreland

Ms Mary Duff, Registered nurse and midwife, Board of Medical Council of Ireland

Ms Karen Egan,PatientAdvocate

Dr Una Fallon,PublicHealthMedicine

Dr Martin Fellenz,AssociateProfessorinBusinessStudies(Business&AdministrativeStudies),TCD

Maebh Ní Fhallúin,PolicySpecialistRCPI(Towards2026)

Dr John Fitzsimons, Consultant Paediatrician and Clinical Director for Quality Improvement

*Dr Catherine Fleming,ConsultantinInfectiousDiseases,GalwayUniversityHospital

Ms Rhona Gaynor,DepartmentofHealth

Dr Karena Hanley,ICGPNationalDirectorofSpecialistTraininginGeneralPractice

Dr David Hanlon,NationalClinicalAdvisorandGroupLeadPrimary Care

Ms Eilish Hardiman,CEOChildren’sHospitalGroup

Ms Alison Harnett,NationalFederationofVoluntaryBodies

Mr Brian Hartnett,Patient

Dr Blánaid Hayes,ConsultantOccupationalPhysician

Ms Ita Hegarty (representing Mr Ollie Plunkett,NationalOutpatientLead,HSE)

Mairéad Heffron ,PolicySpecialistRCPI

Dr Colm Henry,NationalClinicalAdvisorandGroupLeadforAcuteHospitals

*Prof Hilary Hoey, Director of Professional Competence, RCPI

*Dr Mary Holohan, Consultant Obstetrician and Gynaecologist, RotundaMaternityHospital

Dr Tony Holohan,ChiefMedicalOfficer,DepartmentofHealthand Children

*Prof Mary Horgan, Dean of the Council of Deans & UCC SchoolofMedicine

*Prof Hilary Humphreys, Dean, Faculty of Pathology

Prof Alan Irwine,ProfessorofDermatology(ClinicalMedicine),Trinity College Dublin

Dr Howard Johnson,ClinicalLead,KnowledgeManagement(incorporatingHealthIntelligence),HSE

*Prof Elizabeth Keane,DeanoftheFacultyofPublicHealthMedicine

Prof Frank Keane, Past President of the Royal College of SurgeonsIrelandandClinicalLead,NationalClinicalProgrammeforSurgery

Leo Kearns, CEO RCPI

Ciara Kirke,PharmacistandClinicalLead,MedicationSafetyProgramme, Quality Improvement Directorate

Dr Peter Lachman,ISQuaCEO

Ms Jill Long,PresidentoftheISCP&ChairpersonofHSCPA(previously)PBAI

Ms Hazel Luskin Glennon,PatientAdvocateandCarer

Mr Matthew Lynch,RoyalCollegeofSurgeonsinIrelandSchoolofPharmacy

Ms Marian Mackle,PatientNominee,IrishHeartFoundatio

*Dr James Mahon (HST),CollegiateMembersCommittee,RCPI

Dr Ann Manley,SpRRepresentative,FacultyofOccupationalMedicine

Ms Rosarii Mannion,NationalDirectorofHumanResources,HSE

Dr Gerard Mansfield,ICGPNationalDirectorofSpecialistTraining

Dr Sara McAleese,NationalDoctorsTrainingandPlanningUnit,HSE

Mr Damien McCallion,HSEAreaManager,Sligo/Leitrim/WestCavan(NationalDirectorforNationalAmbulanceService)

Dr Gerry McCarthy,ClinicalLead,EmergencyMedicine,CorkUniversityHospital

Dr Julie McCarthy,LeadClinicalDirector,Histopathology

Prof Eilis McGovern,DirectorNationalDoctorsTrainingandPlanning,HSE

*Dr T. Joseph McKenna, Former President of RCPI

Dr Mary McMahon,ConsultantOccupationalHealthPhysician

Dr Michelle Monahan, Radiographer

Dr Carmel Moore,Traineerepresentative,Paediatrics

Prof Frank Murray, President RCPI

Roisin Neary,CorporateAffairsExecutiveRCPI

Ms Colette Nugent (representing Mr Ollie Plunkett,NationalOutpatientLead,HSE)

Prof Alf Nicholson, Consultant Paediatrician

Prof Charles Normand,EdwardKennedyProfessorofHealthPolicy & Management, Trinity College Dublin

Mr Simon Nugent,ChiefExecutive,PrivateHospitalsAssociation

Dr Sorca O'Brien, Trainee

Ms Olive O’Connor,FounderofMedistori.comandIrishPatientsAssociationRepresentative

Dr Paul O'Hara (BST),CollegiateMembersCommittee,RCPI

Mr Brendan O'Hara, Programme Manager at All Ireland InstituteofHospiceandPalliativeCare

*Prof Conor O'Keane,ConsultantHistopathologist,MaterMisericordiaeUniversityHospital

Dr Stephanie O’Keefe,NationalDirectorofHealthandWellbeing,HSE

Towards 2026 – Participants

* indicates member of RCPI council

38 39

Mr Pat O’Mahony,DeputySecretaryGeneral,DepartmentofHealth

*Prof Des O'Neill,ConsultantGeriatrician,TallaghtHospital

Prof Anthony O'Regan, Consultant Respiratory Physician

Dr Orlaith O’Reilly,NationalClinicalAdvisorandGroupProgrammeLead,Health&WellbeingDivision

Dr Susan O'Reilly CEO,Dublin-MidlandsHospitalsGroup

Dr Brendan O'Shea,GeneralPractitionerandClinicalAssistantProfessorinPrimaryCare,SchoolofMedicine,TrinityCollegeDublin

Dr Diarmuid O’Shea, Registrar RCPI

Prof Donal O'Shea, Co-Chair, RCPI Policy Group on Obesity

Prof Ellen O’Sullivan,ConsultantAnaesthetist,StJames'sHospital

Leah O’Toole,HeadofCorporateAffairsRCPI

Dr Naomi Petty-Saphon,Traineerepresentative

*Dr Donal Reddan, Consultant Nephrologist and Clinical DirectorforMedicine,SAOLTA

*Patricia Rickard Clarke,Solicitor&RCPICouncilMember

Dr Eve Robinson,TraineeRepresentative,FacultyofPublicHealthMedicine

Mr Joe Ryan,ActingHeadofSystemReformGroup

Dr Karen Ryan,ConsultantinPalliativeMedicine

Dr Emer Ryan,FacultyofPaediatricsSpecialistRegistrar

Dr Rupak Sarkar,TraineerepresentativeIOG

Dr Tony Shannon,CCIOLeedsNHSandFounderofFrectalLtd

Dr Keshav Sharma,ForumTraineeSubcommittee

Prof Emer Shelley,ConsultantinPublicHealthMedicineandRCSILecturer

Dr Diarmuid Smith, Consultant Endocrinologist

Dr Breda Smyth,ConsultantinPublicHealthMedicine,HSEWest

Dr Yvonne Smyth,Traineerepresentative

Mr Eddie Staddon,BusinessManager–NationalDoctorsTraining&Planning(NDTP)

Mr Mervyn Taylor,ManagerofSAGE(ThirdAge)

Dr David Vaughan,DirectorofQualityandPatientSafetyatChildren’sHospitalsGroup

Dr Catherine Wall, Consultant Nephrologist

Ms Mila Whelan,NationalAdvocacyUnit,QualityandPatientSafetyDirectorate,HSE

Dr Barry White,ConsultantHaematologist,StJames’sHospitalandformerNationalDirectorforNationalClinicalProgrammes

Prof Freddie Wood, President, Medical Council

Mr Liam Woods,InterimNationalDirector,AcuteServices

Dr Margo Wrigley,ConsultantPsychiatrist,NationalClinicalAdvisorandClinicalProgrammeGroupLead–MentalHealth

Mary Wynne,InterimNursingandMidwiferyServicesDirector,HSEClinicalStrategyandProgrammesDivision

Many thanks to MCO Projects for facilitation of the Towards 2026 workshops, to Walker Communications Limited for report design and to the RCPI policy and public affairs staff for their contributions towards this report.

* indicates member of RCPI council

Towards 2026 – Participants

Royal College of Physicians of Ireland,FrederickHouse, 19SouthFrederickStreet, Dublin 2, IrelandPhone: +35318639700Fax: +35316724707

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