Professor David Keegan:

I thank the Cathaoirleach and members of the committee for the opportunity to present the work of the NERIECS teams. As members are no doubt acutely aware, the delivery of eye care services in Ireland has been challenging for many years and now stands as the longest waiting list in the country with nearly 45,000 patients awaiting on outpatient appointments. Within the NERIECS network, there are in excess of 18,000 patients awaiting their first outpatient appointments, with 6,000 of these on the Mater waiting list and a further 6,000 to 10,000 on community waiting lists. The demographic demand for eye care is set to increase exponentially in the coming years, with an estimated doubling of the number of patients requiring eye care in the next 30 years. This situation has been further compounded following the global pandemic, with a latent demand for services now starting to manifest in the six-month to 12-month category of waiting lists.

Of concern to the ophthalmology clinical community is the growing support for patients to access care for routine cataract care outside our jurisdiction, such as in North Ireland, while other ophthalmic patients wait an unacceptable length of time, outside of clinically acceptable intervals, and are being harmed with resultant irreversible sight loss for conditions such as glaucoma and age related macular degeneration. The vision for better eye care in Ireland has been clearly articulated in the primary care eye services review and the HSE national model of eye care.

Sláintecare advocates for the development of a more integrated health service, centred on a comprehensive community-based care model and provides the framework within which our health services will develop over the coming decade. While these documents outline the what, they do not support the how and the when of this initiative. This has been the work that the NERIECS team has been road mapping, making sense of and implementing for the past 12 months. We have extensively collaborated with all stakeholders to understand how to fully integrate and deliver eye care locally, to quality standards with optimal outcomes for patients. We have also worked to understand how current hospital-centric services need to be redesigned and integrated with community and primary care, how to support this with information and data, and how current funding models and mechanisms need to change.

The current service provision model is unsustainable and will require transformational change to deliver the required paradigm shift in care delivery models. To achieve this ambition, which incremental change will not deliver, we accept that we must transform our eye care delivery across the region. We are committed that the pace and scale of this transformation must deliver sustainable change. The north-east region comprises north Dublin, Meath, Louth, Cavan, Monaghan, Westmeath and Longford, with a combined estimated population of 1.2 million to care for. Demographic modelling shows a significant projected increase in the population of those over 65 years of age in this area. Eye care is delivered by six healthcare organisations in the region, namely: Ireland East Hospital Group via the Mater; RCSI Hospitals Group, Children's Health Ireland at Temple Street; CHO 1; CHO 8; and CHO 9. These are six distinct legal entities delivering care that is anchored in the Mater and at Temple Street from where the clinical governance is provided. These areas are soon to be restructured into regional health authorities and we await that with interest.

The challenge was how best we delivered care for all patients in this region to reduce and eliminate our wait list, which at the beginning of Covid numbered 9,000 for the Mater alone and approximately 15,000 for the entire region. There were also approximately 2,500 patients on a wait list for cataract surgery at this time. Through collaboration between CHO 9 and the Mater hospital, a hub and spoke model for service integration was tested and has to date delivered substantive improvements to waiting lists, with a near 85% reduction in the adult long-waits through our Ashgrove House initiative. My colleague, Dr. Rogers, will talk about the similar reduction in the paediatric amblyopia via the initiative between Temple Street and Grangegorman, which has nearly totally reduced in spite of the pandemic.

The model of eye care we are implementing across the NERIECS region holds to a hub-and-spoke concept of three-level integration that is based on: geography; the level of care required, be it primary, secondary or tertiary; and a specific care pathway that patients need focusing first on the largest volume care pathways, such as cataract, glaucoma, paediatric amblyopia and age related macular degeneration.

In the absence of a formal legislative framework, we accepted that governance and co-ordination of six organisations, while maintaining clear clinical and corporate governance in this structure, would be challenging, and it has proved so. We set out to innovate to solve this problem in the interests of our staff and patients through the adoption of lean principles and a management system for process improvement and implementation of our strategy. This is novel to the Irish healthcare system. We are happy to lead from the front to test the reality of delivering system-level specialty integration.

The methodology provides a mechanism to eliminate waste in system and deliver managed, co-ordinated structural change, while keeping what is of value to our patients and staff to the fore. In June 2021, 12 months ago, the eye care teams in the region enabled and empowered more than 100 staff and our patients to participate in a system-level enterprise value stream analysis, EVSA. This week-long event empowered staff to clearly understand the current state and reality of eye care delivery in this region and to collectively agree on a vision and roadmap to improve and redesign eye care in the next five years. It also afforded them a sound methodology to deliver on this.

The gap as to how we would deliver on accountability, clinical governance and ownership for the transformation was proposed through our facilitators in IBM Simpler, Mr. Richard Carr and Mr. Dave Jones-Lofting, through the design concept of a virtual accountable care organisation, VACO. This structure has been deployed in healthcare in the US since 2014, and more recently in the UK, but this will be the first deployment of this structure in Ireland. The VACO provides a mechanism to co-ordinate the function of the six healthcare organisations. It is responsible for devising and deploying the strategy to improve eye care. The VACO co-ordinating group comprises stakeholders from all the sub-specialties working in eye care in the region such as medics, nurses, optometrists, orthoptists, GPs, finance officers and information technology teams. There is also broader representation across the six healthcare organisations.

That value stream analysis also looked specifically at the four high-volume care pathways - cataract, glaucoma, paediatric amblyopia and age-related macular generation - to develop best practice pathways, including, specifically, a shift to community-based care, where appropriate, and templates for rationalisation of standardised referral, enhanced triage and more accurate demographic data capture. Crucially, the VACO also puts targeted design teams in place to support all its activity. These are our foundations.

All participants in the community integration team, information technology team, training, education research and innovation team and finance team are taking this on as part of other normal roles in the HSE, save for a core team of three; giving extra to this project in which they believe. These staff and teams are the bedrock of this co-ordinated effort. We held 11 planning events over the 12-month period since that initial value stream analysis and we have now created the infrastructure and processes where we can deploy integrated care across the region. We still need to finalise the financial pathways, but discussions have been positive with the chief finance officer of the HSE, and it is interested in this model that we are developing. The chief finance officer has given us a clear set of rules that need to be respected as we seek to deploy this in providing a roadmap.

Our goal would be a core regional account for funds that can be deployed to the area of need to best serve the patients and improve efficiency based on the principle of our purpose pyramid, which is to reduce the burden of blindness and vision impairment while improving quality of life for those affected. The IT team is looking specifically at how we introduce an integrated electronic patient record along with harmonised patient administration systems so we can reduce the need for patients to travel between the different sites, with an expert opinion given more efficiently and patients just needing to travel to clinics and-or diagnostic hubs close to their home. This feeds directly to the principles of Sláintecare and will be advanced with regional health authorities' centralised scheduling with a clear clinical governance line.

We have achieved a significant amount through the goodwill and willingness of all those working in eye care across the region in all different disciplines coming together to tackle the problem in eye care delivery. To date, the transformation has already delivered significant outcomes including a decrease in both adult and paediatric waiting lists across the region; a reduction in surgical waiting lists of 21% for more than 12 months; standardised regional referral for both cataract and glaucoma; right-first-time referral improved from 20% to 95%; improved patient and staff satisfaction with cataract pathway experience; and conversion rate to surgery for patients referred for cataract now at 95% - improved from where it was previously at 75%.

We are patient-focused, and our purpose pyramid sets the reduction of vision impairment and blindness and access to support services as the core driving goal of this group. The improved access to care, reduction of wait lists and transformation efforts are all to support this goal. We have identified our funding gap for the next three years and we are confident that, if supported, we have the mechanism, structures and, most importantly, the buy-in of all involved in eye care delivery to eliminate our wait lists in the north east in three years. This is a bold ambition as we look to reduce the wait list for outpatients from approximately 14,000 currently to zero, and the cataract wait list, which has grown to 3,000, also to zero. This data is all validated by Mr. Gerry Kelleher and the data team in the HSE. This is greatly aided by the recent approval of funding for staffing for the new eye cataract theatre at the Mater hospital, which, based on projections, will eliminate its surgical wait list in three years based on current levels. We should be able to assist with cataract wait lists in other parts of the country from that date.

The issues we still need to tackle are finalising the funding stream and pathway, which is very close, and integrating the information technology systems in order that we can create a web of interconnectivity between the six healthcare organisations. This will give us visibility on patients’ records across the system thus reducing their need to travel. We also feel strongly that the VACO provides a model for eye care delivery in other parts of the country that may not have that co-ordinated effort in place just yet. The VACO will also provide a model for the improved community care delivery of other medical specialties such as an ear, nose and throat, ENT, dermatology and neurology.

I encourage members to read our submitted slide presentation and look in particular at our strategy deployment tool, the level zero X matrix, which has all our aims and metrics summarised on one page. Our ask of them today is to support the virtual accountable care organisation as a governance structure to manage care across different organisations in our health service, and support the initial funding gap for staffing, equipment and transformation costs, which will be at €3.9 million for 2023, €3 million for 2024 and €2.72 million for 2025, with just index-linked costs required thereafter. In return, under the principle of accessibility through innovation, we will provide the delivery of accessible, integrated, equitable and optimal eye care across our entire community while eliminating resource waste within our system. We commit to return to the committee with all the data it requires in 12 months to demonstrate our progress. I am happy to take any questions. I thank members for letting me present today on behalf of the broader NERIECS team.