Oireachtas Joint and Select Committees
Thursday, 6 November 2014
Public Accounts Committee
Special Report No. 83 of the Comptroller and Auditor General: Managing Elective Day Surgery
10:30 am
John McGuinness (Carlow-Kilkenny, Fianna Fail)
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I welcome the witnesses and apologise for the delay. We had some housekeeping to sort out. Before we begin I remind members and witnesses to turn off their mobile telephones as interference affects the sound quality and transmission of the meeting. I advise witnesses that they are protected by absolute privilege in respect of the evidence they are to give to the committee. However, if they are directed by it to cease giving evidence on a particular matter and continue to do so, they are entitled thereafter only to qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against a Member of either House, a person outside the Houses or an official by name or in such a way as to make him or her identifiable. Members are reminded of the provisions within Standing Order 163 that the committee shall refrain from inquiring into the merits of a policy or policies of the Government or a Minister or the merits or objectives of such policy or policies.
I welcome Dr. Tony O'Connell of the Health Service Executive, HSE, and ask him to introduce his officials.
Dr. Tony O'Connell:
I thank the Chair and members for inviting us here today. On my left is Professor Frank Keane, clinical programme lead for the surgery programme. On my right is Dr. Áine Carroll, national director of clinical strategy and programmes, and to her right is Ms Jenny Hogan of the National Treatment Purchase Fund.
John McGuinness (Carlow-Kilkenny, Fianna Fail)
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Mr. Paddy Howard is here from the Department of Public Expenditure and Reform.
John McGuinness (Carlow-Kilkenny, Fianna Fail)
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I ask Mr. McCarthy to introduce the special report.
Mr. Seamus McCarthy:
Irish acute hospitals report that in 2012 they carried out surgical procedures on almost a quarter of a million admitted patients. Around 50,000 of these admissions occurred after emergency presentation for treatment. The bulk of the surgical procedures, 80%, or just under 200,000 cases, were elective or planned surgery cases, and two thirds of these were treated on a day surgery basis.
Day surgery refers to surgical treatment provided in hospital, generally under anaesthetic, where the patient is expected to return home on the same day. It requires formal admission of the patient to the hospital and is different to minor surgical treatment provided in an outpatient clinic. Day surgery has a number of benefits over the same procedure provided on an inpatient basis, where the patient occupies a hospital bed for one or more nights. These benefits include reduced risk for patients of contracting a hospital-acquired infection and reduced costs for hospitals. Properly managed, day surgery should also lead to a reduction in waiting time for elective procedures because of improved throughput of cases.
Since 2006, the HSE has required acute hospitals to provide details of the total number of admissions and the number carried out as day surgery for 24 targeted surgical procedures. The target procedures range across all the major specialties and accounted for 31% of all elective surgical procedures in 2012. Appendix A lists the target procedures, together with a layman's description of each one.
The examination was carried out to establish the extent to which there had been progress in switching the delivery of treatment from an inpatient to a day surgery basis, to identify factors that assist in that switch or that might be impeding it and to assess if there was scope for the use of day surgery to be extended. In view of the specialist medical knowledge required regarding the nature of surgical procedures and hospital processes, we contracted in two experienced medical consultants based in the UK to assist the examination team drawn from my office.
The examination report is presented in two main parts. Chapter 2 presents an analysis of the available data on elective surgical procedures designed to identify key trends and outcomes at individual hospital and procedure level over the period since 2006. Chapter 3 is a review of procedures adopted by hospitals in planning and delivering day surgery treatment and supporting patients after discharge. It includes recommendations aimed at ensuring hospitals are in a position to deliver elective surgery in the most appropriate and effective setting.
Figure 2.1 indicates that the volume of elective surgery reported by hospitals increased by around a quarter between 2006 and 2012. There was a small reduction in the volume of elective surgery carried out on an inpatient basis. This contrasts with a big increase in the volume of day surgery. As a result, the proportion of elective surgery carried out on a day surgery basis increased from 55% to 69%.
For the years 2009 to 2012, the HSE set all acute hospitals a target of achieving an overall day surgery rate of 75% for the set of 24 procedures. In 2012, the rate achieved across all hospitals was 74%, just below the target. However, there was significant variation in performance between the different acute hospitals that have a significant surgical case load. In 2012, the day surgery rate for the target procedures in individual hospitals varied from 50% to 92%.
The HSE specified only a single day surgery target rate even though existing practice varied widely for the different types of procedures. The mix of surgical procedures varies between hospitals and this influences the overall hospital day surgery rate relative to the target.
Figure 2.5 shows how treatment delivery has changed regarding each of the target procedures since 2006. The diagram can be seen on the screens. The darker bands indicate the balance between inpatient and day surgery in 2006, while the lighter bands show the 2012 balance. Overall, the relative shift to the right of the lighter bands reflects a trend towards delivery of more treatment via day surgery.
For some procedures there was little change over time in the balance between inpatient and day surgery.
For example, more than 75% of operations for correction of a squint were carried out on an inpatient basis in 2006. By 2012, the balance had reversed with 75% of squint correction carried out on a day surgery basis. There have also been considerable shifts towards day surgery for removal of cataracts and to relieve a condition that results in contraction in the hand. In contrast, there were only minor changes in the day surgery rates for tonsil removals and removal of bladder tumours.
It is notable that across hospitals several of the procedures targeted by the HSE for improvement in day surgery rates were already at or above the 75% day surgery level in 2006. This included cases involving post-fracture removal of pins or plates, internal examinations of joints, treatment of glue ear and treatment for nasal fracture.
Some clinicians expressed the view to the examination team that several of the 24 target procedures monitored by the HSE are not suitable for day surgery. This viewpoint may be reflected in very low day surgery rates for some high volume procedures, such as removal of tonsils, 5,200 cases in 2012, with an 8% day surgery rate and gall bladder removal, 3,700 cases in 2012 with a 27% rate. The examination found that in three hospitals, the day surgery rate for gall bladder removal increased from 1% in 2006 to between 56% and 70% in 2012. In other hospitals, the day surgery rate for gall bladder removal remained low at around 1%. Figure 2.7 in my circulated paper indicates the very considerable variation that existed between hospitals in two other high-volume target procedures, namely laparoscopy and repair of hernia. We found that across all hospitals, the day surgery rate increased for both procedures between 2006 and 2012 while the gap in performance between hospitals narrowed.
The overall conclusion from the data analysis is there has been a significant increase in the day surgery rate for many of the targeted procedures but that scope exists for further improvement. We recommended the HSE should seek to identify the factors associated with increased day surgery rates and transferable good practices. We also recommended that instead of a single global target, appropriate targets should be set for different procedures and that targets should be set for a wider range of elective procedures. It is important to acknowledge that setting a target rate for day surgery for a category of procedure cannot override the professional judgment of the relevant clinicians in deciding on the appropriate delivery setting in any individual case which must take account of all factors, including the patient’s condition and circumstances.
The HSE estimates day care surgery is, on average, almost 60% less costly than performing the same procedure on an inpatient basis. However, both the HSE and the Department of Health have pointed out that because a high proportion of hospital costs are fixed in the short term, the full potential savings of a significant shift from inpatient to day surgery will not accrue immediately. Related measures to reduce cost are also needed to achieve the potential cash savings.
The primary focus of the examination was on the procedures targeted by the HSE for monitoring and target setting. However, we also looked at the trends in elective surgery that were not subject to targeting. Figure 2.10 in my circulated paper presents a comparison of the numbers of targeted and non-targeted procedures reported which indicates a significant difference. The total number of elective procedures carried out in the target categories increased by only 3% over the seven years. Within the targeted procedures, it is evident the increase in day surgery admissions was broadly offset by a corresponding decrease in inpatient admissions. This suggests a strong substitution effect which over time should yield savings or free up resources for other activity. In marked contrast, the total number of elective procedures in non-target categories increased by 39% over the same period. There was little change in the number of inpatient admissions for those procedures but a very striking 74% increase in day surgery admissions. Underlying demographic changes such as an aging population are highly unlikely to explain a trend shift of that order of magnitude in one category without apparently affecting other categories.
The HSE concluded that an increasing number of minor surgical procedures are being carried out as day surgery cases when it would be more economical to carry them out in outpatient clinics or in primary care settings. It estimates it would be more appropriate to carry out as many as three in five of the non-target day surgery treatments in other settings and at less cost. It attributes this shift to the incentive effect of the current method of funding of hospitals under which the payment rate for a procedure performed in a day surgery setting is higher than if the same procedure is performed, appropriately, in an outpatient setting. This is an inefficient outcome and I have recommended the HSE should closely monitor cases currently classified as day surgery with a view to ensuring that all hospitals direct surgical cases to the most appropriate and economical settings.
The examination included a survey of hospitals and site visits to a number of hospitals where the medical consultants examined the processes around management and delivery of day surgery. The results were measured against criteria identified by the medical consultants based on established good practice for day surgery is UK hospitals. Procedures were examined at each stage of the day surgery pathway which is outlined in figure 3.1 in my report. Recommendations are presented in the report aimed at achieving improvements in the way day surgery is managed in hospitals. The HSE has agreed to implement the recommendations. It remains to be seen what impact this will have on efficiency and cost in the delivery of elective surgery, as well as on the quality of the service provided to patients.
10:40 am
John McGuinness (Carlow-Kilkenny, Fianna Fail)
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Thank you Mr. McCarthy. I invite Dr. Tony O’Connell to make his opening statement.
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.
10:50 am
John McGuinness (Carlow-Kilkenny, Fianna Fail)
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I thank Mr. O'Connell for his statement. May we publish this statement?
Derek Nolan (Galway West, Labour)
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I welcome Dr. O'Connell and Dr. Carroll and their officials. In going through the report I wish to compliment them on the Comptroller and Auditor General's observation that from 2009 to 2012, the HSE set a 75% target day surgery rate for all acute hospitals for the 24 procedures and reached a rate of 74%. It is rare that we see targets actually being reached, so I compliment the witnesses on that. However, the next sentence says that there is a significant variation in performance rates between the individual hospitals. This variation can be dramatic, ranging from 50% to 92%. Reading between the lines of the report, some clinicians expressed the view that the 24 target procedures are not suitable for day surgery. Another one mentions that consultants and so forth were possibly objecting. Is it the case that the variance is due to individual consultants in individual hospitals who have a different view to the HSE on how certain day case procedures should be treated and that they would rather these procedures were treated as in-patient surgeries?
Dr. Tony O'Connell:
I can give Deputy Nolan the latest figures. We have the year-to date 2014 figures on that basket of 24 procedures to which he referred. For the 41,500 cases this year to date the day case rate is now up to 77%, so we are continuing to improve. However, Deputy Nolan is correct, there is a variance between the rates for individual procedures. I might just quote a handful of them to give an example. Procedures which everyone is quite comfortable doing as day cases have quite high rates. For example, removing a ganglion, which is a swelling in a tendon in the hand, or orchiopexy, or repairing a nasal fracture. Each of these have rates of day case procedures that are well in the 90s. The four that are lowest are tonsillectomy at only 10%, 18% for bunions, 34% for transurethral resection of the prostate and 34% for laparoscopic cholecystectomy. I think bunions are an aberration, but tonsillectomy is a good example of the answer to the question the Deputy is raising, namely whether consultants are comfortable with doing these procedures as day cases.
Tonsillectomy is something which ENT surgeons and anaesthetists have been quite uncomfortable about doing as a day case procedure. It has taken many years across the globe for practice to change in this regard, because they all remember cases of a bleeding that first night after the tonsillectomy which was horrendous, which was in the airway and which threatened the life of the patient, requiring them to come in from home to almost repeat the tonsillectomy in order to get the bleeding under control. They are plagued by the memory of these cases from the past, which make them uncomfortable saying that they are going to change their entire practice to doing every tonsillectomy as a day case. They will change over time and that rate will increase, but they must be reassured that there are systems in place where a patient can come in from home rapidly, where their entry to the hospital's emergency department will be accelerated and where the time between leaving home and getting to the operating theatre is not so long that they expire from the haemorrhage. It is uncommon for a haemorrhage to occur on that first night after the operation but it is such a worrying event that it has swayed the opinions of doctors.
I was pleased that, in his opening statement, the Comptroller and Auditor General mentioned that we cannot have metrics overriding professional judgement. Ultimately, we have to convince our surgeons that their practice needs to change, and convincing independent, strong-willed people like competent surgeons is a challenge. This is the reason there will always be some variation. The other reason there will be variation is that there is a different range of numbers of cases in each of those 24 procedures in the various hospitals.
11:00 am
Derek Nolan (Galway West, Labour)
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Could Dr. O'Connell repeat that line?
Dr. Tony O'Connell:
There will be a range of numbers of cases in each of those 24. For example, if there is a strong orthopaedic and general surgery service, there might be a preponderance of minor orthopaedic work, or of ganglions, which could be done as day cases. If there is no ear, nose and throat service, nasal fracture reduction surgeries will not necessarily be taking place. Each individual hospital will have a different profile of the numbers and percentage of cases that contribute to the total 24 which are in this nominal basket of indicative procedures.
Derek Nolan (Galway West, Labour)
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If I may interrupt Dr. O'Connell, I only have limited time and want to focus on the tonsillectomy which he raised as an example. We were at 8% in 2012, are we at 10% now?
Derek Nolan (Galway West, Labour)
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That compares with 40% in the UK, according to the Comptroller and Auditor General's report. This has been listed as one of the day-case surgery target routines since 2006. We are eight years into it; it seems a long time to be trying to win over and sympathise with consultants and to assure, coax and cajole them into believing it can be done as a day-case procedure.
Dr. Tony O'Connell:
It is a long time and it is a slow process. We are attempting to convince individual surgeons that they need to improve their rates, but ultimately they will make the decisions. Over a period of time we hope there will be a number of prominent clinical champions for these new ways of doing business who will drive a change in behaviour. There will be an opportunity to incentivise through different funding arrangements. We could quite artificially alter the reimbursements in the new activity-based funding arrangements, for example, by preferentially rewarding hospitals for doing day cases. In other words, we would pay them above cost to carry out a procedure as a day case, and below cost for in-patient care of equivalent procedures. There would then be much more local pressure from the hospital managers, who have to deal with the budget, on people they bump into every day in the hospital.
Derek Nolan (Galway West, Labour)
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Does it not contradict Dr. O'Connell's argument that it is to do with health and safety issues, when he tells me that we could influence behaviours by changing the funding structure?
Dr. Tony O'Connell:
It is clearly both. The individual surgeons would articulate the quality and safety perspectives louder, but the whole environment is clearly at issue. They need to feel comfortable about the nurses who would be discharging the patient from the ward and about the referral pathways back to the hospital, as I said. The whole environment in which surgeons are working needs to be conducive to this significant change in behaviour for what is ultimately 90% of tonsillectomies.
Derek Nolan (Galway West, Labour)
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That is the point. Is there another contradiction in that the HSE has labelled this as a day-case surgery, as something that should be targeted and promoted and resources put into treating as a day-case surgery, when only 10% of surgical activity actually agrees with this? In 90% of the procedures, the consultant does not agree with the HSE's analysis that it is a day-case surgery. Is it the HSE that is wrong rather than the consultants?
Dr. Tony O'Connell:
I will defer to Professor Keane in a moment, but I am sure that the people who decided which procedures would be in the 24-case basket did consider tonsillectomy to be an aspirational member of that group. It is evident from the NHS figures the Deputy cited that there is a similar disquiet across the water, where a minority, only 40%, of tonsillectomies are done as day cases. There is varying comfort with each of those 24 procedures as to whether we can achieve the goal. I ask Professor Keane to comment.
Professor Frank Keane:
I agree with everything that has been said. It is difficult and quite slow, and it is not unique. The English rate of 40% is quite high in terms of national figures for tonsillectomies and it took them a long time to get to that point. It has been difficult to persuade hearts and minds that the systems are in place for people to manage these patients safely. A combination of coaxing and persuasion of hearts and minds is required.
I have been in surgical practice for 30 years. When I started out we did absolutely nothing as day cases. If someone came in for a laparoscopic cholecystectomy they came in for two weeks and that was it. We have changed hugely over the years and in my practice we now do the majority of laparoscopic cholecystectomies as day cases.
The other issue is that for clinicians - and I am just articulating the truth behind it, without necessarily answering the Deputy's question satisfactorily - there is a comfort factor in having one's patients in hospital the night after they have been operated on. There is an intuitive comfort factor in knowing they are in safe hands. For the first while doing them as day cases, the surgeon goes home and thinks, "My God, what is happening to my patient tonight, how are they?" Returning to what Dr. O'Connell said about tonsils, it is very emotive on a practice basis. Many of the patients are children and people are very uneasy about the prospect of a child being put at risk because they bleed torrentially after they go home and something terrible happens to them. It is quite a significant risk, in other words.
When we try to encourage people to do day cases, the constant response is, "What will happen if I send somebody home and they bleed to death? Where will I be then? I can see it all over the newspapers". It is difficult to persuade people. It takes leaders and we can see that there are some places that are now doing much more, up to 20% or 25% of tonsillectomies being carried out as day cases. It is usually those people, the pathfinders, who show that it is safe and then it gradually trickles into the system.
Dr. Tony O'Connell:
If I could add another aspect of variance to the answer to Deputy Nolan's question. Hospitals do not have the same degree of complexity in the cases they are dealing with. If we stick with the tonsillectomy example, if a child is severely obese and has obstructive sleep apnoea exacerbated by large tonsils in their upper airway, that is a case where the clinician is going to be less comfortable. If a hospital tends to attract large numbers of that kind of case - children with obstructive sleep apnoea - it is going to be different to the practice of a hospital where the majority of tonsillectomies are just done on the indication of a few episodes of tonsillitis.
Derek Nolan (Galway West, Labour)
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We are talking about if there is a specific surgeon in that hospital who specialises in, for instance, complicated cases. Is that what Dr. O'Connell means?
Dr. Tony O'Connell:
That is partly it but it is also clear that the children's hospitals tend to attract the more complicated, high-risk cases. We would not expect to see the same rates of day-case surgery for the same procedure, even by the same surgeon, when he operates in one small hospital compared to when he operates in a large teaching hospital.
Derek Nolan (Galway West, Labour)
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I thank Dr. O'Connell for being very honest with me. His answer puts a lot of stock in the national clinical programme for surgery and how this is changing.
While acknowledging the bona fide nature of the witnesses' contribution, it does not give me much confidence in the programme if eight years after introducing tonsillectomy as day case surgery, we have gone from approximately 8% to 10% and the goal is still a long way off. It is difficult to say the programme will be really successful if ten years into it we have not made progress. It is a different culture from the one I understand. We spoke previously about the private sector. If a business decides to do a procedure, it develops a business model and follows it. Everyone signs up to it. If a business had to spend ten years coaxing and cajoling its managers to follow the business model, it would not survive. I accept I am introducing a business element but it is a difficult to have faith in a programme when it takes so long to get change.
11:10 am
Derek Nolan (Galway West, Labour)
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I beg Professor Keane’s pardon. I use the case of tonsillectomy as an example.
Professor Frank Keane:
I absolutely take Deputy Nolan’s point, but the programmes which were formed as a joint partnership between the Royal College of Surgeons, as it happens, and the HSE to reform the process, began three years ago because it was realised that the situation had to be expedited and there had to be better knowledge of what was going on.
In terms of what the programmes are doing, they are dealing with a whole lot of issues such as understanding the data, making real time data available to consultants and doctors within hospitals and administration in order that people know what is going on. That connection of trying to understand in a granular manner what individual people and services are doing has only come about since the programmes have started engaging in the whole inquiry into the data so that we have become more familiar with what is going on.
Part of the programmatic activity is not only writing models of care but also interrogating the data of what is going on and visiting hospitals. We visited all the hospitals in the country on a number of occasions, presented their data to them and also showed them how their performance compared with other hospitals and with the best performing hospitals in the country. That is a relatively new process and it has had significant gains in that period, in particular in a time which has been difficult because of financial and staffing cutbacks and other factors.
Derek Nolan (Galway West, Labour)
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Looking at some of the figures from the 2012 report, which is akin to being a million years ago in terms of where the health service is currently, we have an issue with Cork University Hospital, which was one of the lowest scoring of the major teaching hospitals. Its percentages were dragged down dramatically by, for example, the extraction of cataracts. Is it a case of there being a difficulty with people getting comfortable with the idea of moving to a different way of doing things?
Professor Frank Keane:
No, in that particular situation the outcome related to the set-up and resources necessary to provide an efficient cataract service as a day service. That is in the process of being corrected. We are aware the hospital is behind the line on cataract outcomes. It has come down to the fact that the hospital did not have the set-up to do such operations as day cases. That might sound peculiar but part of the process of day case activity is having the resources to carry out the activity. It is rather like what we have been talking about with tonsils in that not only does one have to be careful about how one assesses people beforehand and do all the work-out before they come in, but that has to be done very close to the time they have their operation. The reason for that is in order for it to be within a safety span of having been seen and worked out, and then having one’s procedure and having systems set up in order that people are managed after they go home. If one does not have all the bits and pieces one needs to deliver the service set-up, it is not safe to carry out the procedure and one will continue to do some as day cases. That has been the situation with Cork University Hospital.
Derek Nolan (Galway West, Labour)
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Is the situation being remedied?
Derek Nolan (Galway West, Labour)
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Could I ask Professor Keane about figure 2.10 in the report of the Comptroller and Auditor General where there is a large increase in the number of non-targeted procedures? It is estimated that just two out of five of the cases examined were true surgical day cases. Paragraph 2.8 says that based on a review of day cases admitted under surgeons in 2011, the Accounting Officer estimated that just two out of five of the cases examined were true surgical day cases. In other words, what we are seeing is incorrect headings attaching to statistics that were reported. Could someone update me on the cause of that and where the HSE is now in terms of remedying the situation of incorrect allocations?
Dr. Tony O'Connell:
There is no denying that at the time, and even to some extent currently, there is an over-counting of procedures which should probably not be counted as true day case procedures based on the definition used by the Comptroller and Auditor General in the opening statement in the sense of there being an anaesthetic and one has something cut out. That is a short way of saying it. Some procedures are just done under local anaesthetic. What we heard in the opening statement from the Comptroller and Auditor General is that there is a perverse incentive because of the funding arrangement to count as much as one can as something that is happening within the hospital. That is something we must resist and we will do that much more forcefully as we introduce the money follows the patient activity-based funding arrangements. We will be able to financially reward much more appropriately something that is good clinically, which is good for the hospital.
There are some perverse financial incentives which are currently running in the system. There is also an incentive because of changes in the recent reimbursements to count cases as overnight cases rather than day cases.
Derek Nolan (Galway West, Labour)
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Is that even when the cases are day cases?
Dr. Tony O'Connell:
Not necessarily. A number of hospitals have an embarrassment in their financial situation. A component of the embarrassment is attributable to the fact that if they continue to do cases appropriately as day cases rather than overnight, they would effectively be penalised in terms of their income. We must overcome the perverse financial incentives to ensure that what is clinically right for the patient is reflected in an appropriate financial reimbursement. Perhaps Professor Keane has something to add to what I said.
Derek Nolan (Galway West, Labour)
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I would be happy for Professor Keane to respond as he can deal with an additional point. He mentioned in the surgical programme about analysing and sharing the data and having the data as key, but in one particular example we have seen that 40% of the data are inaccurate. How does that play into his need for true data in the programme?
Dr. Tony O'Connell:
We will be doing audits. Our case mix people are commencing audits to make sure we get on top of the issue. It is very important for the successful implementation of activity-based funding that the documentation is accurate and that the financial incentives drive the appropriate behaviour.
Derek Nolan (Galway West, Labour)
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Does it give rise to questions of honesty on the part of hospitals?
Professor Frank Keane:
No. If one is a surgeon and one has a minor procedure to carry out, one can either do it on an outpatient basis, or in a minor operations room or bring the patient into a day surgery unit. Strictly, a day surgery unit is an equipped operating theatre that gives a general anaesthetic in which one does substantive day case work, not the relatively trivial operations which Deputy Nolan identified. There is no question that because of facilities and the number of operating theatres in certain hospitals that they are having to carry out all their inpatient work and their outpatient or day case work within the same resource.
That is an historical fact because that is what we are dealing with. A county hospital with four operating theatres will be providing a range of inpatient treatments in a number of different surgical specialties such as orthopaedics, obstetrics, gynaecology, paediatrics and ENT from those four operating theatres. One must fit that into a week's work. One must also carry out the day stuff through there. The best way to do day surgery is to run it in effect as a factory in order that there is a set-up that allows one to process patients through dedicated admission wards and dedicated operating theatres and then out the other end. Processing patients sounds a bit callous because it makes it sound like an industry, but to a certain extent it works best like that.
There is a process of transition within the groups of hospitals becoming dedicated day centres where this kind of process works much more efficiently. The way a majority of surgeons work their operating time in the theatre is often to do two day cases at the beginning of the list and then do the rest of the inpatient operations. I have done this for a long period. That is fine but it does not work the day case system as efficiently as it should be worked. It does not work the beds so it is better if it is isolated. It will take time for that system to evolve, especially at this particular moment. This does create efficiencies.
Certainly there are things being done as day cases in day theatres that are inappropriate because they do not require a general anaesthetic and that needs to be sorted. Part of the problem with that and the reason it did not happen up to this point is because people are not incentivised to perform these things, even in the outpatient department. The reason is because one does not get a coded procedure. The hospital, and nobody else, gets funded for that activity if it is done in the outpatients department because outpatient procedures are not coded. In many cases, patients in minor operation rooms that hospitals operate do not get coded so they are missing out. Clearly, that needs to be gradually corrected, and the money follows the patient exercises will do that. These things must become coded activities in order that they start being done in the right place.
11:20 am
Derek Nolan (Galway West, Labour)
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Are activities with no coding that are taking place in hospitals being coded as something else? We have activities taking place in hospitals that are not coded but they are showing up under day case surgery. Are they being coded as something else?
Professor Frank Keane:
They are because everything that comes in as a day case is hype coded, even a little cyst that would be taken off. If that happens to be brought in as a day case, it will be coded as a day case. There are a number of those. We reckon that something like 25% or 30% or up to that are possibly things that can done on a lesser site.
Derek Nolan (Galway West, Labour)
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Is it the case that there is almost an incentive to bring them in as a day case?
Derek Nolan (Galway West, Labour)
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The argument is that this activity should not be done in hospitals but in GP surgeries or outpatients.
Derek Nolan (Galway West, Labour)
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By paying for it when it is brought in as a day case, we are incentivising that activity at the moment.
Professor Frank Keane:
I think that has to be looked at. My remit is not to look at primary care but I have been liaising with primary care doctors and asking how we can move some of this work out of the acute hospitals in order that it is done in primary care settings. There are issues in primary care. Again, it comes back to reimbursement because part of the reimbursement for doing substantial procedures is insufficient to pay for the actual equipment with which they do the procedure. I am talking about the local anaesthetic, the sutures and everything necessary to do that work. Those are all things that must be looked at.
Dr. Tony O'Connell:
We are already moving activity out of the bigger, busier hospitals and making much greater use of the smaller hospitals, so we are increasing our rates of things like endoscopy and day care procedures in hospitals like Ennis, Nenagh, Roscommon, Louth and Bantry. As the first step, it is addressing the issue that Professor Keane referred to. In an ideal world, day case procedures would be done in a quarantined separated procedure - a cold surgery factory, so to speak, where there is no pressure on beds and where the business is very much attuned to churning through people, getting them ready to be sent home and providing them with standard information packages, etc. That is the first step.
The next step of getting the GPs to do the procedures involves a much higher level of difficulty because it requires the GP to be somehow financially incentivised to do that because GPs are not my direct employees. We need to cajole and pay them in a way which makes it worth their while to do these minor procedures when they are under a lot of pressure to churn through cases every 15 to 20 minutes from non-surgical procedures.
Professor Frank Keane:
We have started that liaison process with GPs. There is a national association of general practitioners practising surgery which has 66 members, so that is quite a substantial membership of people who are keen and enthusiastic. They are doing things. They are very keen to get into that space. That process of persuading has started.
Derek Nolan (Galway West, Labour)
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It seems that much of Professor Keane's and Dr. O'Connell's job involves cajoling, persuading, coaxing and almost dangling things in front of people. Why did the HSE stop monitoring the 24 target procedures in 2013 and 2014?
Professor Frank Keane:
We can do so but we do not do so. The Deputy asks why we do not do so. One must realise that every hospital in the country is different. Let us take a big volume thing. A hospital might provide ophthalmic surgeons and surgery and do a considerable amount of cataract surgery. We know that 95% of cataract surgery is done as a day case, so that will skew that hospital which will find it much easier to reach that target of 75%, 80% or whatever it is. If a hospital only carries out laparoscopic cholecystectomies and tonsillectomies, about which we have been talking, it will find it very hard to reach that 75%. Different hospitals have very different specialty mixes and using that 75% figure to compare hospitals in terms of their performance is not terribly effective. What is much more effective is looking at individual procedures. This is what we are doing now with the nursing instrument for quality assurance, NIQA, system described by Dr. O'Connell where we are feeding back to clinicians data that are now as close as three months old. One must remember that this has only just come about because, before that, we were showing them data that were a year to a year and a half old, which is not meaningful for a practising clinician in terms of changing their practice. We have this system that looks at individual procedures. Not only does it tell individuals or individual specialty units what their performance is, it sets them a target for each of those procedures and compares them with national targets, national activities relating to what is going on and the best in class, so to speak. That is designed to stimulate and cajole change and make sure that people understand their performance.
Derek Nolan (Galway West, Labour)
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However, it is the case that if a consultant really does not feel comfortable with a surgery, it is their clinical decision as to whether something is done as a day case or an inpatient case.
11:30 am
Professor Frank Keane:
One has to respect that, because patients are individuals. One of the difficulties of grouping everything is that one is assuming the case mix and complexity of each patient is precisely the same. There are some hospitals which attract patients with a particular type of case mix, in terms of what they are like themselves, their age, their level of infirmity and how complex a procedure is. Comparing hospitals and patients is a complex process. If there is a hospital dealing with very complex and very sick patients, clearly it is going to have a different performance picture from hospitals which are dealing with very healthy patients who have no and low complexities.
Derek Nolan (Galway West, Labour)
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Is it possible to compare, on a national scale, consultants in specialties?
Professor Frank Keane:
The system that we are introducing looks right down to individual specialties. Clearly, it is necessary to be careful in terms of people's access to it. It is a web based system so people actually can get into it, but clearly they have to use passwords and all that sort of thing. This is being rolled out and every clinician will be able to look at his or her own data; one's last three months, one's last six months, one's year, how one's last year compared to the year before - all that information is going to be provided for them.
Dr. Tony O'Connell:
What we are getting to here is this issue of how does one improve performance in a sustainable way. The way to do this is to do it at a local level. This requires clarity about what the targets are, what the metrics are, and an audit approach to check on them. In the end, especially when we have a health system - as we do in every Western democracy - where individual clinicians are making patient-by-patient decisions, a better way to change their behaviour in a sustainable way is to do it much more at a local level. This is why the movement towards hospital groups is so important. We have clinical directors who are now responsible for only a handful of hospitals rather than, for instance, me being responsible for all 50 of them. It is not possible for me to dive down into the individual performance and check the clinical indication for day case versus inpatient case by individual surgeons without doing an enormous amount of work. Having a clinical director for just a handful of hospitals with sub-clinical directors in each individual hospital is a much better way to get a mindset and an approach and a consensus change in practice rather than doing it on a national level. They have to be complementary, but the sustainable change comes from much more local implementation of the principles and the clinical champions.
John McGuinness (Carlow-Kilkenny, Fianna Fail)
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Before I call Deputy Fleming, how does one apply the code or why is the code not applied to some procedures? Professor Keane said the code has to be applied or each procedure has to have a code in order to get paid. Is that correct?
John McGuinness (Carlow-Kilkenny, Fianna Fail)
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Not very long.
Professor Frank Keane:
The coding system used in the hospital inpatient inquiry system is an Australian system of coding. When patients come into hospital, basic demographics such as age and address and all that sort of stuff is obtained. Then they are coded by diagnosis, in other words, pneumonia, heart attack, cancer or whatever is their code. That is one of the coding systems. The other coding system is for whatever procedure they have. Every procedure for which a person comes into hospital is given a code, from a scan to an operative procedure. All those codes are different. It is possible to interrogate that to find out how many cases of a specific procedure were carried out. That is all fed into a system that creates what we call DRGs. These are diagnostic related groups. That is how the system is funded. There are about 690 diagnostics groups. That is what is used for the funding process.
John McGuinness (Carlow-Kilkenny, Fianna Fail)
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These other procedures are not included in those diagnostic groups.
Professor Frank Keane:
All procedures that are done in the hospital as inpatient or day cases are coded. What was said to you before is that if a procedure is carried out in the outpatients department or sometimes in minor operations rooms, which are usually in the outpatients department, they do not get coded.
John McGuinness (Carlow-Kilkenny, Fianna Fail)
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If they do not get coded, the hospital does not get paid.
John McGuinness (Carlow-Kilkenny, Fianna Fail)
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Who suffers then because of that? Who is out of pocket because of it? Is it the hospital administration? The consultant? Who is it that suffers?
John McGuinness (Carlow-Kilkenny, Fianna Fail)
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The person carrying out the procedure gets paid anyway. Is that right?
John McGuinness (Carlow-Kilkenny, Fianna Fail)
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Yes. They get paid anyway?
John McGuinness (Carlow-Kilkenny, Fianna Fail)
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They are not doing it for free.
John McGuinness (Carlow-Kilkenny, Fianna Fail)
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They get paid their salary anyway. Therefore, for these non-coded procedures, it is the hospital that loses out.
John McGuinness (Carlow-Kilkenny, Fianna Fail)
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Why are the hospitals not complaining about this, from a business perspective, and saying, "We are sorry, we are doing this, and not only are we not getting paid for it, but we are not being incentivised to carry out the procedure"? Is the hospital itself not conscious of the fact that there is a business loss?
John McGuinness (Carlow-Kilkenny, Fianna Fail)
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Am I right in saying that you said some 30% of those type of procedures are not coded and therefore not funded?
John McGuinness (Carlow-Kilkenny, Fianna Fail)
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If one did introduce the coding system, for all of those minor procedures that currently are not in the system, it is going to cost a lot more in terms of the allocation from the Department of Health and the HSE.
Dr. Tony O'Connell:
At the moment, outpatient activity is funded in a block way. There is an expectation that hospitals will do so many thousand outpatient visits every year. Therefore, they are funded for that. That funding does take into account the range of procedures, interviews and interactions which occur in an outpatient setting. In a sense, the block funding for outpatient activity has already taken into account the fact that some of those patients who attend an outpatients department would, for example, have been having some local anaesthetic and a small mole on the back of their hand taken off. The issue is the difference between the reimbursement for that in block funding form and the reimbursement for calling it a day case activity.
Mr. Seamus McCarthy:
Chairman, can I make an observation in relation to that? I would also have a concern at this kind of movement from procedures that really should be categorised and treated and monitored as outpatient attendances and, if one likes, transferring them into the admissions side. It has a potentially distorting effect on the waiting lists for both sides as well. I would be quite concerned that there would be proper categorisation of the procedures. It is something I have recommended as needing to be addressed by the HSE.
John McGuinness (Carlow-Kilkenny, Fianna Fail)
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I call Deputy Fleming.
Seán Fleming (Laois-Offaly, Fianna Fail)
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I thank the witnesses for attending. I am looking at the documentation we have, including the Comptroller and Auditor General's report, and I thank the witnesses for the briefing note they furnished also. We also have our own summary. I am trying to understand the big picture before we get into the little picture.
We have been told that there were 247,000 surgical procedures in 2012, the year of the report. Accident and emergency services accounted for 49,000 of these or approximately 20%, with inpatient services accounting for 61,000 or 25% and day surgeries accounting for 137,000 or 55%. This is the summary of the chart received by the committee. I presume these are the ballpark figures.
11:40 am
Seán Fleming (Laois-Offaly, Fianna Fail)
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That is fine. Paragraph 1.2 of the HSE's briefing note reads: "There are currently 2,102 day case places nationally. Of these, 1,530 are public, 293 private and the remainder are non-designated". I will not hone in on the last point. The 293 cases represent 14% of day case places. I hope Dr. O'Connell is following me.
Seán Fleming (Laois-Offaly, Fianna Fail)
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Of the 61,000 inpatient cases, what percentage are private? The HSE claims it has the exact numbers in respect of day case places, but what is the comparison between public and private inpatient places?
Seán Fleming (Laois-Offaly, Fianna Fail)
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That is interesting.
Seán Fleming (Laois-Offaly, Fianna Fail)
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That was my hunch. Some 14% of people who opt for day surgery are private patients, but the comparable percentage opting for inpatient treatments is much higher. Does this have anything to do with the operation of the private health industry? If someone needs a day case procedure, he or she may need to pay for it and reclaim the cost from a private health insurer at a later date. If someone is an inpatient and is kept overnight, though, the VHI, Laya or so on pays for everything and the client will not have to write a cheque. The consultant, the anaesthetist, the hospital's bed manager and so on send a bill to the insurer. As such, there is an incentive for private patients to have procedures done on an inpatient basis. This is borne out by the HSE's figures. A higher percentage of private patients opt for overnight treatment. Does Dr. O'Connell follow my point?
Seán Fleming (Laois-Offaly, Fianna Fail)
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Am I right? That was my instinct about how Irish society and hospitals worked and the HSE's figures verify it. What can we do about this situation?
Kieran O'Donnell (Limerick City, Fine Gael)
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And consultants.
Seán Fleming (Laois-Offaly, Fianna Fail)
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Does Dr. O'Connell take my point? It was a valid, if not empirically proven, observation, but even the HSE's figures demonstrate that more private patients want to be kept in overnight. That approach might suit the surgeon, but it certainly suits the client, as the bills go straight to the VHI, Laya or another insurer. Convenience is a factor.
I have not seen particular information in the reports of the HSE or the Comptroller and Auditor General. We are meant to be considering the breakdown of the 24 selected day surgery procedures that account for 137,000 separate cases. Does anyone in the Comptroller and Auditor General's office, the HSE or the Department have that figure? We have a report on day surgery in which 24 items have been measured, but we do not have a breakdown of how many tonsillectomies, submucous resections, laparoscopies, nasal fracture treatments and the like were carried out. Has that information been prepared by the HSE?
Seán Fleming (Laois-Offaly, Fianna Fail)
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Will the HSE provide it? The Comptroller and Auditor General's report runs to 50 pages, but it is the first one I have seen that does not contain a single euro symbol. We are the Committee of Public Accounts. We might discuss health, outcomes and so forth, but this is a discussion of numbers, percentages of targets, percentages of the 24 procedures, percentages of pre-operative assessments and discharge assessments, etc. In a curious way, this discussion would probably be better held by the health committee, but from this committee's point of view-----
John McGuinness (Carlow-Kilkenny, Fianna Fail)
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It would not. This matter is not the health committee's remit. Our remit is governance as well as-----
Seán Fleming (Laois-Offaly, Fianna Fail)
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To follow the report. I am gently saying that I would like to see a few money-----
John McGuinness (Carlow-Kilkenny, Fianna Fail)
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Do not give up your turf.
Seán Fleming (Laois-Offaly, Fianna Fail)
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Like the consultant, I will not. However, nothing I have read so far gives any indication of the savings to be achieved by the HSE's targets. If the HSE reached a 75% target - I am pleased to hear that it has reached 77% on average this year - how much would it save? I cannot find even a single sentence on this issue. Does the HSE know? Is it a financial target or a procedures, numbers or percentage target?
Seán Fleming (Laois-Offaly, Fianna Fail)
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What about outpatient procedures?
Dr. Tony O'Connell:
The cost of a bed day is €825 on average. Clearly, the first few days cost more than subsequent days. A theoretical calculation could be made whereby the difference between the current performance and the ideal performance is multiplied by these monetary numbers. It is a significant amount. Comparing 2010 with 2013, bed day savings amounted to 66,160, representing a marginal cost saving of approximately €12.5 million. They are appreciable savings.
Seán Fleming (Laois-Offaly, Fianna Fail)
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Is that €12.5 million an annual figure?
Seán Fleming (Laois-Offaly, Fianna Fail)
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Some €4 million per annum. If an inpatient procedure costs €4,000 or so and staying in the bed overnight costs an extra €800, every inpatient case that is moved to a day case surgery results in a saving of at least €4,000.
Seán Fleming (Laois-Offaly, Fianna Fail)
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I accept that, but I am trying to get some sense of the money.
Dr. Tony O'Connell:
It will vary procedure by procedure. Historically, there has been a tendency to leave some procedures overnight. As Professor Keane mentioned, some procedures saw patients stay for up to a week 20 years ago but can now be handled as day stay procedures. The situation varies depending on procedure and historical practice.
Seán Fleming (Laois-Offaly, Fianna Fail)
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We all know that everything that is involved is complex, but if the average saving per case of moving a procedure from inpatient to day case surgery was €4,000, there would be a saving of €4 million for every thousand such switches. Mr. Hardy is nodding in disagreement.
Mr. Charlie Hardy:
A day case is normally a less complex one. Therefore, the inpatient case that it replaces will be a less complex case. One would expect the inpatient case that is replaced to be of lesser value than the average inpatient case because one normally expects the less complex inpatients to move to day cases.
11:50 am
Seán Fleming (Laois-Offaly, Fianna Fail)
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We are being told that the day case rate was 60% in 2010, 63% the following year, 65% in 2012, 67% last year and 77% today. I do not accept for one moment that the medical cases presenting in hospitals have become so much less complex that we can go from a day case rate of 60% four years ago to 77% now. That represents a phenomenal number of patients being dealt with on a day surgery basis who, four years ago, would have been treated as inpatients. If, as I accept, procedures and patients are not being compromised, then it means that this volume of day cases should have been happening all along. It is good that we are catching up and getting more out of the procedures. The delegates might say that some of the complex ones are left, but they never were going to be part of the day surgery comparison.
On the question of medical outcomes, we have been told there is a 2% return rate, where patients need to return for further treatment or a procedure was not right. The delegates' submission states that the HSE's target surgical readmission rate is less than 3% and the actual figure is currently 2%. Does that figure refer to day cases only and, if so, what is the figure for inpatients and how does it compare internationally?
Professor Frank Keane:
That figure relates to the readmission rate for all surgery. It oscillates between 2% and 3% for individual hospitals. Looking at hospitals and their readmission rate is not especially useful. We are on a journey and readmission rates are one of the outcome measures. The other measures are process measures. If all of one's day cases are running into complications and being admitted the next day because of those complications, one is clearly not doing a very good job. It is important to monitor the readmission rate. When one looks at a list of different procedures, one usually gets a really low figure. We find it sits at around 2% to 3% for all hospitals. It is only when one becomes more granular in terms of looking at either specialties or individuals' procedures that differences begin to show.
Another issue is that readmission rates can be difficult to quantity because we do not have a system of unique patient identifiers. Patients who run into complications after a procedure might then present at a different hospital, in which case one does not have that-----
Seán Fleming (Laois-Offaly, Fianna Fail)
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To clarify, is Professor Keane saying that we do not, in 2014, have a system of unique identifiers for patients?
Seán Fleming (Laois-Offaly, Fianna Fail)
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Irish Water seems to have no problems in this regard when it comes to charging for water, but the HSE has not figured it out yet. Did the delegates never hear of PPS numbers? I am shocked to discover there is no system of patient ID numbers. I am thinking of a case, for example, where an elderly person is treated in Portlaoise, returns to his or her nursing home and is readmitted to Naas the following week. My understanding is that there will be no match-up in this case because there is no unique identifier for the patient. I hope it is not as bad as it seems.
Dr. Tony O'Connell:
There is no system of unique patient identifiers at the moment but there will be. The cost of implementing such a system is quite significant. It is not just a matter of asking for a PPS number; we will have to change thousands of databases to accept the number. It is a huge cost, but it is absolutely within the programme of work of the HSE's IT programme. It is seen as very important. Unfortunately, we are limited as to the budget available to us for information technology. However, it is something that will be done in the next few years.
Seán Fleming (Laois-Offaly, Fianna Fail)
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We will have to make a recommendation in this regard, Chairman, because the situation is unacceptable in 2014. Public service cards, complete with photographic ID, are being issued to people for use in their dealings with social welfare offices and Revenue. We are being told today that the HSE is not part of that system and, for some reason, patients cannot use the public service cards that have been issued across the board. When the property tax was introduced last year, it was possible to match every home in the country with the relevant PPS numbers. As I said already, there has been no difficulty with Irish Water accessing PPS numbers. Yet patients cannot be identified in this way. It is a bizarre situation.
Will the delegates speak to Revenue or the Department of Social Protection and ask one of them to design a system for the HSE? The HSE should not be spending its money on this; it is a public service issue. I have a list a mile long of organisations that can share PPS numbers across the public service, including Revenue, local authority housing departments and social welfare offices. That system should be extended to include the HSE. I am amazed that the delegates are apparently determined to reinvent the wheel. The submission tells us there were 838,922 day case discharges in 2013. On that basis, I would estimate that 1.2 million or 1.3 million people go through the hospital system every year, including inpatients, outpatients and day patients. All of those people have PPS numbers, but the delegates want to spend time and money developing a whole new system. The HSE's resources are simply too valuable to be spent in this way. We look to it to care for the health of the nation. This type of administrative function should be outsourced to some other public body that has already done it several times.
Ms Tracey Conroy:
From the Department's point of view, we are in complete agreement that a unique patient identifier system is a key component of health reform. Indeed, it is integral to much of what we want to do from a health reform perspective. The issue is being deal with in the health information Bill we are currently working on. It is a complex, resource-intensive issue and we have been working on it for some time.
Seán Fleming (Laois-Offaly, Fianna Fail)
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I am even more shocked to hear that a Bill is being introduced to deal with this issue. Legislation is not required. Every one of the 1.2 million people who went through the door of a hospital last year has a PPS number. We do not need to waste time drafting legislation to identify them. It would amount to another PPARS if we were to use resources to design a system that is already operating in other Departments and offices. There should be no money spent in the Department of Health or the HSE on this issue. The delegates' job is to deliver health services; several Departments could sort out this administrative issue for them. I do not accept the need for legislation to be drafted to cope with this. If that is the mindset in the Department, then it is a classic example of the silo approach, with each Department or body going off and doing its own thing instead of working together to serve the public. If we are to achieve anything in terms of public efficiency, we will have to break down this silo mentality and tell whomever is drafting that legislation to concentrate on health and let somebody else do the administration. I am shocked at this situation.
John McGuinness (Carlow-Kilkenny, Fianna Fail)
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Will the departmental officials provide a note on the funding issues relevant to the IT solutions that are proposed and indicating a timeframe for implementation?
John McGuinness (Carlow-Kilkenny, Fianna Fail)
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Yes.
John McGuinness (Carlow-Kilkenny, Fianna Fail)
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It would be helpful to know if there is a shortfall in the budget or if funding for this has been refused. It would be useful to know where the blockage is.
Seán Fleming (Laois-Offaly, Fianna Fail)
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I apologise for going off on a tangent with this issue.
We must look at the direction in which we will be moving if we are obliged to track the records of the people with whom we are dealing. Appendix A tracks the 24 procedures but there is no list provided as to the number of people covered by those procedures. Will somebody forward the relevant information in this regard to the committee? I am sure it is in the system and that it was just not included in the documentation provided. It was stated that a number of other procedures are not included on the list. What are the most common procedures carried out on an outpatient or day case basis which are not included on the list of 24? I am seeking to discover what might be missing.
12:00 pm
Professor Frank Keane:
There would be many. In my own area of specialty as a colorectal surgeon, there would be a lot of anal procedures which would be done. I refer to procedures involving dealing with, for example, perianal haematomas and pilonoidal sinuses and a range of orthopaedic procedures, the names of which I can supply.
Seán Fleming (Laois-Offaly, Fianna Fail)
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Will Professor Keane state whether they relate to people's hips, noses or toes as opposed to providing the official medical names?
Seán Fleming (Laois-Offaly, Fianna Fail)
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Perhaps Professor Keane might forward to us a list of those other procedures which are not included among the 24 to which I refer.
Kieran O'Donnell (Limerick City, Fine Gael)
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Professor Keane is providing the Deputy with some wide-ranging information.
Seán Fleming (Laois-Offaly, Fianna Fail)
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Perhaps that information could be forwarded to the committee in written form in due course.
Seán Fleming (Laois-Offaly, Fianna Fail)
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The list of 24 procedures was drawn up some time ago. If it were being drawn up now, would the same 24 procedures be included or would there be different ones listed?
Seán Fleming (Laois-Offaly, Fianna Fail)
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They are no longer being used.
Seán Fleming (Laois-Offaly, Fianna Fail)
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Will the Comptroller and Auditor General indicate why his report is based on a list of 24 procedures which is no longer in use?
Mr. Seamus McCarthy:
At the time we decided to compile the report, these were the procedures that were being targeted. Deputy Nolan inquired earlier as to why we are not monitoring the data for the period after 2012. In fact, the monitoring is ongoing but the position with regard to target setting has changed. There are now targets for more procedures than the 24 listed, which was one of the recommendations we made.
Seán Fleming (Laois-Offaly, Fianna Fail)
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With regard to figure 2.4 - elective surgery rates for target procedures in specialist hospitals, 2012 - on page 20, I can understand why paediatric day surgery rates are somewhat lower, especially in light of the need for extreme care to be taken. I presume paediatric procedures are carried out in the main hospitals. The rate for paediatric day cases stands at 75%, which is the lowest in the group. People will be happy that fewer day case procedures are performed on children, particularly as they require additional aftercare.
Seán Fleming (Laois-Offaly, Fianna Fail)
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Figure 3.1 relates to the day surgery patient pathway and it is stated that post-discharge treatment is 50% nurse led. Should the figure in this regard be higher? I am concerned that people were not given details regarding the accident and emergency departments they should attend if they required aftercare. It appears that patients seem to be discharged on a somewhat perfunctory basis. It is stated that they are not given adequate information regarding which accident and emergency department to attend should they need to return. What level of post-discharge care would Professor Keane like to be nurse led?
Seán Fleming (Laois-Offaly, Fianna Fail)
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Are consultants obliged to return after a couple of hours and discharge patients?
Seán Fleming (Laois-Offaly, Fianna Fail)
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Of the 49,000 emergency procedures dealt with through accident and emergency departments, how many would be day cases? If there is an emergency involved, would they by definition be classed as inpatient cases? We are really only considering elective procedures on a day surgery and inpatient basis, but there were 49,000 other emergency procedures in respect of which we have not received the same breakdown. Is Professor Keane in a position to provide an indication of the position in this regard?
Professor Frank Keane:
That is a much more difficult matter with which to deal. What we are talking about here is someone coming in with an injury, such as a fractured arm, and being taken to theatre to be operated on under general anaesthetic or to have a cast put on. That is happening in many places. We have not reached the stage of adopting a programmatic approach to identifying specific common conditions which should go through a day case process. Again, it is a difficult one because people are often running their elective practices and dealing with acute admissions concurrently. So it comes down to the availability of staff. If a person comes in with a condition which could be dealt with on an acute day patient basis, it is a matter of having an individual of sufficient seniority available to carry out the relevant procedure. We are moving forward very quickly in this regard and we have written a model of care for elective surgery, which is mainly what we have been discussing at this meeting, and a model of care for acute surgery. What we are recommending is that we try to create situations in hospitals where there will be a surgeon on call to deal specifically with emergencies. Such surgeons will be taken away from their duties relating to their elective practices in order that they will be available to both assess and treat patients. We refer to them as senior decision-makers and patients will be seen sooner by them and given appropriate treatment.
Seán Fleming (Laois-Offaly, Fianna Fail)
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I wish our guests the best of luck with that. I visited the accident and emergency department in Naas yesterday and I could hardly gain physical entry as a result of the line of trolleys on both sides of the corridor. This is a very difficult matter with which to deal but deal with it we must. There is no doubt that some emergency procedures could be done on a day case basis if the necessary systems, resources and personnel were in place.
Kieran O'Donnell (Limerick City, Fine Gael)
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I thank the witnesses for coming before the committee. In the context of personal identification, has consideration been given to the budget that will be required and how long it will take to put the system in place?
Ms Tracey Conroy:
The Health Identifiers Act 2014 passed by the Houses provides the legislative framework for a national system of unique identifiers. I just wanted to provide some reassurances to the committee in that regard. If memory serves, the unique identifier element was removed from the Health Information Bill, as it was then titled, last year because there was a recognition within the Department that it needed to be prioritised as a result of the fact that it forms such a key part of the reforms we have been discussing at this meeting. My understanding is that the HSE is working to establish the individual health identifier registers that will be required across the board to manage the operation of the identifier system. No doubt a budget has been allocated in respect of this matter.
Dr. Tony O'Connell:
Yes, there is such a budget. It would be fair to say that this has been a challenge for all public hospital systems throughout the world, especially those in western democracies. The implementation of a system of unique health identifiers for the millions of people who use services has always taken years to complete.
It is costly because it requires changes to the thousands of individual applications used to manage the various processes within the hospitals.
12:10 pm
Kieran O'Donnell (Limerick City, Fine Gael)
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If, for example, a patient presented to the accident and emergency department in St. Vincent's hospital in Dublin after previously attending the university hospital in Limerick, what would typically happen? Would the doctor on duty pick up the phone to ask the Limerick hospital to provide the notes?
Dr. Tony O'Connell:
The doctor would seek information from the patient about his or her history. If the doctor was comfortable that the information was adequate to inform the decisions he or she needed to make at that point in time, that would be all that happened. If it was necessary to get more information, such as the results of pathology tests, the doctor would consult the medical records held in Limerick.
Kieran O'Donnell (Limerick City, Fine Gael)
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How long would that typically take?
Kieran O'Donnell (Limerick City, Fine Gael)
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Would the patient be waiting in the accident and emergency department until the notes were provided?
Dr. Tony O'Connell:
It would be very unusual for access to historical information from another hospital admission to be a predicated step in a patient moving out of the emergency department. The patient would go to a ward if he or she required admission and that information would come across. The short cut is, of course, to ask the patient the name of the doctor or surgeon who dealt with him or her in Limerick and then contact that individual directly.
Kieran O'Donnell (Limerick City, Fine Gael)
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If the ordinary person whose medical card has been pulled goes to a GP or local pharmacist, he or she will be told on the spot that the card is no longer valid because a computer system is already in place to gather this information. I am considering this matter in terms of beds, and the case study for me is Limerick, with which Dr. O'Connell will be familiar, and the mid-west hospital network. We have a major problem in terms of accident and emergency services and the big issue is beds. In terms of discharge policies and everything else, we are currently discussing elective procedures. If someone comes in for a day procedure, he or she would not take up a bed but an overnight inpatient would take up a bed. As Dr. O'Connell will be aware, one of the problems facing accident and emergency services in Limerick is the availability of beds through the system. If someone moves from inpatient to day procedure status, how many bed days are typically freed up?
Kieran O'Donnell (Limerick City, Fine Gael)
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In respect of 2013 and 2014, how many procedures might have been moved from inpatient to day patient status and how many beds did this free up? Reference was made to a figure of 66,000 but I do not know the relevant period.
Kieran O'Donnell (Limerick City, Fine Gael)
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I know that.
Kieran O'Donnell (Limerick City, Fine Gael)
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I am looking at the issue in the context of freeing up beds. Has the HSE been able to come up with a measure that calculates the number of bed days freed up by promoting the day patient option?
Professor Frank Keane:
We have given the committee a total figure for the bed days freed up based on a number of different measures, including shortened length of stay of inpatients as well as doing more day cases and transferring patients from inpatient to day case status. We can break the figures down, although I cannot provide them off the top of my head.
John McGuinness (Carlow-Kilkenny, Fianna Fail)
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That would be useful.
Dr. Tony O'Connell:
To provide a higher level comment, it has only been possible for us to deal with the €4 billion reduction in our funding and the loss of 15,000 staff over the last seven years in the face of increasing activity by becoming more efficient through the measures that Professor Keane outlined. That is a major driver for our move to day cases. There is no lack of incentive to move to day cases.
John McGuinness (Carlow-Kilkenny, Fianna Fail)
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How many staff were lost?
Dr. Tony O'Connell:
We lost more than 15,000 staff over the past seven years in the austerity programme, as well as €4 billion in funding. This is in the face of attendances increasing by 3% in the last year, unscheduled admissions through emergency department portals increasing by 2% and the total number of inpatient bed days increasing by 2.3%. There is a significant increase in what we are doing alongside an almost unprecedented - around the world - reduction in funding for the system.
Kieran O'Donnell (Limerick City, Fine Gael)
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As matters stand, if a patient presents for consultation, is there any incentive for the consultant to deal with him or her as a day patient? If the same case was done as a day case rather than on an inpatient basis, would the health insurer pay a different fee to the consultant?
Kieran O'Donnell (Limerick City, Fine Gael)
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A procedure, yes.
Kieran O'Donnell (Limerick City, Fine Gael)
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The figure for a day case is €590, compared to €4,230 for a procedure which is inpatient and €825 for a bed day. Is that the public cost?
Kieran O'Donnell (Limerick City, Fine Gael)
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If a patient stays in overnight, does the figure of €4,230 include the bed or is it just the procedure?
Kieran O'Donnell (Limerick City, Fine Gael)
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It includes the bed.
Kieran O'Donnell (Limerick City, Fine Gael)
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It is an average.
Kieran O'Donnell (Limerick City, Fine Gael)
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In terms of changing behaviour and attitudes of consultants towards patients, it appears that inpatient numbers have remained steady while the number of day cases has increased. The inpatient figure has decreased but not to the level one would like. In the system as it currently operates, what is the incentive for a consultant to treat somebody as a day patient?
Dr. Tony O'Connell:
The incentive is knowing that it is clinically better for the patient because the shorter the stay in hospital, the lower the chance of encountering the side effects of being in hospital. Patients often request that they be allowed to go home that night because they do not want to stay in hospital overnight. It is a more efficient system for the hospital and if the consultant is altruistic, he or she will be very interested in the overall efficiency in the running of the hospital and its ability to stay within budget. The Deputy implied that there are incentives which work in the opposite direction.
Kieran O'Donnell (Limerick City, Fine Gael)
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I am questioning whether that is the case.
Dr. Tony O'Connell:
We have already articulated a number of those. The consultant might have a sense of reassurance that the patient is safer being looked after by nurses. Occasionally, a patient wants a night away from home and does not want to leave if there is a risk that his or her pain might not be as well managed outside the hospital setting. There is also a potential financial incentive for the hospital from an inpatient stay. There are a number of incentives, and we are dealing with a balance between the two sides. That is why it is such a complicated change of practice.
12:20 pm
Kieran O'Donnell (Limerick City, Fine Gael)
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In the limited time I have, can Dr. O'Connell share with me his observations on St. John's Hospital and the hospitals in Ennis and Nenagh, which are now mainly doing elective work? I have raised the issue of the accident and emergency service in the past. The new emergency department that is under construction in Limerick is very welcome. It appears that it will not be up and running until 2016. Could more be done to free up beds in the regional hospital in Limerick? I am aware that people have been transferred from that hospital to St. John's Hospital. We need to take the pressure off the accident and emergency department in the regional hospital in Limerick until the new emergency department is opened. HIQA said recently that the existing department is not fit for purpose. We need to do something to bridge the gap over the next year - this coming winter and the following winter. Dr. O'Connell is probably aware of the proposals that have been made. The medical assessment unit that is operating at the hospital is, in effect, a day facility. If it were to be converted into a temporary inpatient facility adjacent to the accident and emergency department, perhaps it could relieve some of the current problems. Dr. O'Connell is familiar with the ongoing pressures that have resulted from the reconfiguration within the region. I refer, for example, to the decrease in the number of beds. The emergency department at the regional hospital in Limerick is now the only such department in the mid-west region. There is no other level 3 hospital in the region. Everything is being funnelled into one hospital. Dr. O'Connell might give me his overall perspective. I suppose I am trying to be constructive. This is an ongoing issue in Limerick and the mid-west as a whole. I supported the proposal to move the existing 30-bed medical assessment unit to another part of the hospital to allow an area that is beside the current accident and emergency department to be used as an inpatient facility - a type of a spillover from the accident and emergency department - for the next year until the new emergency department is up and running.
Kieran O'Donnell (Limerick City, Fine Gael)
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I am aware of that.
Dr. Tony O'Connell:
I intend to have the same conversations with the new chief executive officer of the group, Ms Colette Cowan. There is a clear need to ensure the balance of activity between each of the four hospitals is appropriate. There is more opportunity to divest the lower-acuity work that involves a shorter length of stay to Ennis and Nenagh hospitals and, to some extent, St. John's Hospital.
Kieran O'Donnell (Limerick City, Fine Gael)
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Yes.
Dr. Tony O'Connell:
At the moment, the level of bed occupancy in Ennis and Nenagh is slightly lower than the level in Limerick. I think that is a palpable reason to make more use of those hospitals. That would require a more aggressive approach to how we move patients. There is an opportunity for a kind of step-down, back-transfer way of approaching patients. After they have had their more complicated procedures in the largest hospital, they could move back to a hospital closer to home for the lower-acuity end of their stay in hospital. We have already started to provide for much more use of Ennis and Nenagh hospitals along these lines. I referred earlier to the increase in day cases and things like endoscopies, etc. The Deputy also raised the separate issue of how to make more appropriate use of the beds that are available. I am disinclined to promote use of the medical assessment unit because I think its advantage lies in its ability to churn patients through rapidly. It makes sure they are given a kind of holistic assessment with a level of clinical input. They are then moved to an appropriate place in the community, if that is reasonable, hopefully with minimal double handling.
Kieran O'Donnell (Limerick City, Fine Gael)
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The people who use the medical assessment unit are day patients, in the main.
Kieran O'Donnell (Limerick City, Fine Gael)
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I will put it in simple terms. As a Deputy who represents the constituency of Limerick City, I regularly get telephone calls very late at night telling me about people, many of whom are elderly, who are on trolleys. I am acting on this purely because that is my role. I am bringing it to Dr. O'Connell's attention that the number of people who are on trolleys on an ongoing basis is a major issue. There is a factual reason for it. A number of years ago - not too long ago - there were 35 accident and emergency beds between Ennis and Nenagh hospitals, St. John's Hospital and the regional hospital in Limerick. Seventeen of these beds were in the regional hospital. Ennis, Nenagh and St. John's hospitals had six beds each. The 18 beds in those three hospitals are gone. They no longer have 24-hour, functioning accident and emergency departments. The regional hospital continues to have just 17 beds. The number of beds has been halved. It is a major problem as we come into the real winter months, when the weather gets very bad. We have already had some problems even though the weather has been relatively mild. What can be done to ensure I no longer receive telephone calls at 11 p.m. or 12 midnight from people who have been on trolleys for many hours? The staff in the regional hospital are excellent. When one rings them, they deal with it. People are working within very difficult confines.
We have a unique set of circumstances. HIQA, which is an independent body, has said it is not fit for purpose. It is clear that the reconfiguration has resulted in a reduction in the number of accident and emergency beds. Obviously, this falls directly under Dr. O'Connell's remit. I appreciate that he is here for another purpose today. Given that this is about beds, I think it falls within the same context. What can be done? I acknowledge that a new accident and emergency department is being built. I would have liked to have seen it being developed more quickly. We are now being told that it will be in place in early 2016 and that it will be a state-of-the-art facility when the physical structure is there and is fitted. What can the HSE do to ensure additional bed capacity is available for people who are coming through the accident and emergency department at the regional hospital in Limerick over the period until the new emergency department is up and running in 2016?
John McGuinness (Carlow-Kilkenny, Fianna Fail)
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I ask Deputy O'Donnell to conclude after this reply.
Kieran O'Donnell (Limerick City, Fine Gael)
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I will. I thank the Chairman.
Dr. Tony O'Connell:
It is clear that a more robust reconfiguration, which makes better use of the beds in all four institutions, needs to occur. That can happen quite quickly. As the Deputy said, we may have to do certain things during surges in demand like those we expect to see in winter. For example, we may have to convert wards that currently accept patients for just 12 hours a day and start using them 24 hours a day.
Kieran O'Donnell (Limerick City, Fine Gael)
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Like the medical assessment unit.
Kieran O'Donnell (Limerick City, Fine Gael)
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Okay, as a short-term measure.
Kieran O'Donnell (Limerick City, Fine Gael)
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Okay, but-----
Dr. Tony O'Connell:
However, this is a decision for the individual group executive, which has a much better idea of what the relationship between the four hospitals is. I think there is much more opportunity for better utilisation of the four sites. I totally agree with the Deputy that it is unacceptable to have patients on trolleys in Limerick.
Kieran O'Donnell (Limerick City, Fine Gael)
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The members of staff do a great job. It is a question of the particular circumstances that arose coming out of the reconfiguration. I will put it this way. While Dr. O'Connell would like everything to be explored, he is not averse to the medical assessment unit being made available on a short-term-basis, subject to discussions with local management, if extreme pressures arise. He is willing to explore the use of a ward that is currently being operated on a 12-hour basis.
John McGuinness (Carlow-Kilkenny, Fianna Fail)
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I thank Deputy O'Donnell. Can we dispose of the-----
Mr. Seamus McCarthy:
I would like to make a quick point. Deputy Sean Fleming made the astute observation that cost figures are not included in the report. It was something that we looked at. In effect, the costing of the activity and the models for that just were not strong enough.
We would have been in a situation of speculative figures which I did not feel comfortable with putting into the report, so we concentrated on the performance end of the thing.
12:30 pm
John McGuinness (Carlow-Kilkenny, Fianna Fail)
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We will accept the special report.
Ms Tracey Conroy:
I wish to finish on that matter, from a policy perspective. That is where money follows the patient comes in. That is where the huge opportunity is in terms of diagnosis related group-based, DRG, costing. If one were to do a similar report again, that funding model would be in place and there would be euro signs.
John McGuinness (Carlow-Kilkenny, Fianna Fail)
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I thank the witnesses for coming along and they are free to go. The committee will deal with other matters but we appreciate the information that they gave us. We have now disposed of special report No. 83.