Dr. Tony O'Connell:

The special report from the Comptroller and Auditor covers in detail many of the aspects to the development and deployment of elective surgery capacity. I will, therefore, confine my opening statement to highlight a number of key issues for the HSE. I welcome the report and the HSE is well under way to implement its recommendations. Staff from the HSE worked closely with the Comptroller and Auditor General to provide much of the information contained in the report and to share with his staff examples of the current work we are already engaged in this area.

The key recommendations of the report are to improve and to reduce variation in day surgery rates, to drive more standardised approaches, to improve information for patients, to optimise the locations for day surgery, to streamline business processes, improve funding arrangements and to better manage hospital performance with regard to surgery services. It is important to note the HSE had a specific focus on both elective and day surgery rates for several years with each successive improvement approach adding to impacts seen. For example, we have seen day case activity rise from 675,162 to 838,922 discharges between 2009 and 2013, a rise of 24% in activity volumes which translates into an additional 163,760 patients seen on a day case basis. During this time, most of the additional patients seen came as a result of specific improvements in the utilisation of resources and capacity by hospitals.

As part of our service planning process, the HSE sets a range of access and performance targets. Each year, the one area where the HSE has consistently exceeded its target is in the provision of day case treatments. However, in parallel to focusing on improvements in the areas of day case, the HSE has also focused on ensuring overall elective surgery services are improved. It is important to note our surgical inpatient activity rates increased from 417,846 in 2010 to 484,167 in 2013, an increase of almost 16% or 66,321 cases. At the same time, we have reduced the number of bed days for this group meaning that the length of stay of patients has significantly reduced while utilising our surgery resources more efficiently. Our current target length of stay is 5.3 days and in 2014 it is 5.2 days. We intend to target further reductions in 2015.

We are making overall surgery more efficient with a shorter inpatient stay and not just focusing on day case procedures alone.

Nevertheless, we have also seen improvements in our day of surgery admission, DOSA, rate which currently stands at 64%. We have further work to reach our target of 85% across all hospitals and we will talk further about that during our session this morning.

To give committee members a summary of how the HSE has and will be targeting improvements in the area of elective day surgery, I will highlight some examples from our overall approach. That approach has been in three broad areas: redesigning surgery service delivery, which is an important element of a larger reform programme; facilitating numerous initiatives at a local level; and implementing performance monitoring and management systems to consistently track and drive improvements in the key surgical areas. I will briefly highlight a number of elements and key initiatives in each of these domains to illustrate the important work that is ongoing.

From a redesign and reform perspective, we see optimising utilisation of surgery resources and providing clarity for hospitals about their roles as key deliverables in our overarching reform agenda. Our approach seeks to provide consistency across regions in the standards for surgery and to deliver efficiencies through networking the delivery of surgery between hospitals in the new hospital groups. Improvement in surgery services and other areas of activity in acute hospitals will be significantly facilitated by the changes that come with the establishment of hospital groups and subsequently trusts. This is because hospital group boards and executives will be able to be more responsive to local demands while being accountable for a much more manageable size of entity. We have already quite successfully targeted a number of smaller hospitals to increase elective and day surgery activity volumes within them. The national clinical programmes are also working within the HSE to address acute and elective surgery efficiency and effectiveness. The relevant programmes in this respect are surgery, anaesthesia, major trauma and orthopaedics.

The surgery clinical programme has prepared and launched two special reports on the appropriate models of care for acute and elective surgery in Ireland. I am very pleased to have Professor Frank Keane with me today, because in his role as lead of the surgery program he has been instrumental in driving the majority of the improvements we have seen. The HSE is also working closely with the anaesthetics clinical programme on a pre-admission model of care, which will be launched in December. Our new approach to funding episodes of care, called Money Follows the Patient, or activity-based funding, will also provide an opportunity to better incentivise day case models.

With regard to facilitating improvements at the front line, we are rolling out a range of surgery-related improvement initiatives. The productive operating theatre, TPOT, programme is a joint quality improvement initiative between the HSE, the Royal College of Surgeons, RCSI, and the College of Anaesthetists, CAI. TPOT is now operational in 17 hospitals nationally. The TPOT programme is designed to enable hospitals to continuously improve across four quality domains, which include patient experience and outcomes, safety and reliability of care, team performance and staff well-being and value and efficiency. In conjunction with the anaesthetic clinical programme, the HSE will be implementing a range of pre-admission clinics across hospitals nationally. Currently about 90% have anaesthetic pre-admission clinics. Pre-admission encompasses the entire process around the peri-operative management of a patient scheduled for surgery, be it a day case or an inpatient being admitted on the day of their operation.

Importantly, we have recently started rolling out a web-enabled interactive reporting tool called NQAIS that uses a hospital's own surgery data to present information in a user-friendly way. This encourages better management by surgeons, clinical directors and hospital managers of their local surgery resources. We have commenced work with the primary care sector to improve standardisation of GP referral pathways and thresholds for referral. We will also be driving better compliance with the recommendations which arise from the various HIQA health technology assessments so that surgery is only performed when there is an appropriate evidence base.

We are more rigorously managing surgery performance at hospital and hospital group levels. Targets have been set globally and individually for each hospital in respect of day case rates and DOSA rates. These are regularly monitored in the HSE and the subject of on-going discussions with hospitals. The HSE has developed and expanded its range of surgery indicators and will include these in its 2015 national service plan, which we are currently finalising. This is all being done within a performance framework for hospital groups in which I meet with each of the individual hospital group executives monthly to analyse their recent performance across a balanced scorecard and we agree improvement strategies.

There remain challenges to the HSE to successfully implement our goals. We acknowledge that there is a need to focus on continuing to move minor surgical cases and less complex care to less intensive environments such as out-patient departments and the community. This requires changes to practice and infrastructure and the alignment of payment approaches with these goals. Similarly, despite the significant efforts of hospitals and clinicians, there continues to be pressure on waiting lists for scheduled care as unscheduled care demands continue to rise and hospitals struggle to discharge patients ready for placement in the community to nursing homes and other supported community settings.