The HSE's clinical chief is departing, pleased with the new acute early warning sysytem, writes DR MUIRIS HOUSTON
THE HEALTH service remains in the eye of the storm. With a projected budget overrun by year-end of about €500 million and with the smoke of junior health minister Róisín Shortall’s acrimonious departure still in the air, both the Taoiseach, Enda Kenny, and Minister for Health James Reilly remain under considerable political pressure.
The continuing drama coincides with HSE national director of clinical strategy and programmes, Dr Barry White’s, last weeks in office.
In agreeing to an exclusive interview with The Irish Times he says he cannot answer any questions about political events. But it is impossible to consider his comments about clinical matters outside the context of recent political drama.
Last Wednesday in the Dáil at leaders questions, Kenny name-checked Tallaght hospital when yet again defending the public health system. Tallaght hospital was “transforming itself into what we want it to be”, he said, pointing out the hospital had achieved significant savings in 2012 despite a 5 per cent increase in patient numbers and a 9 per cent cut in funding.
White’s news about Tallaght comes in relation to one of the principal successes of his tenure – the acute medicine programme. “Ireland aims to be the first country in the world to have standardised early warning score across the entire hospital system,” he says.
“In simple terms it is a standardised [scoring] process for managing a deteriorating patient, very similar to how pilots manage an emergency situation. Over 3,000 staff have been trained and 25 sites have commenced implementation. Tallaght hospital is one of the early adopter sites and preliminary data suggests that one less death may be occurring per week since its introduction there.” (See panel, right.)
Some 50 fewer avoidable deaths a year in just one hospital in the State is significant progress, but it is the sort of good news about our public health service that often struggles to get publicity. White points also to Cork University Hospital where there has been a 60-70 per cent reduction in the number of patients waiting on trolleys despite an increase in attendances and bed closures at the emergency unit.
But will it be possible to continue to offer a minimum level of frontline services as long as health budgets continue to be cut? “We are facing a serious challenge in delivering healthcare in the current economic environment. While we know we can make improvements in care and save money, time will tell whether we can do it at a rate that prevents more cuts. This is influenced by external factors well beyond us.
“However, I have been hugely encouraged by the willingness of frontline staff to step up to this enormous challenge,” White says.
A national obstetric programme is noteworthy because it started shortly before the miscarriage misdiagnosis scandal that first emerged at Our Lady’s Hospital, Drogheda. The programme implemented the Ledger report that followed in full, including ensuring high specification ultrasound machines and software and national clinical guidelines were in place in all obstetric units.
“The clinical programme together with the State clinical indemnity scheme identified 18 cases of missed miscarriage in the previous five years; however, to date they have identified no cases since the introduction of the new guidelines in 2011,” White says.
Another success story is the creation of an audiology programme he says is making significant progress on the introduction of a universal neonatal hearing screening. The target is to significantly reduce speech and language disability by detecting hearing problems within the first few days of life, thereby allowing early intervention.
“This will have a major impact on the two babies born every week with moderate to severe hearing defects. Twenty thousand babies have been tested to date and all newborns will be tested by the middle of next year.”
What about primary care? Has he any good news for the perennial runt of the health service litter?
“GPs have been keen to drive improvements in chronic disease management. However, there are legitimate issues around the scale of resourcing required,” he says. Taking diabetes as an example, international best practice suggests that people with diabetes in the Republic will require over 400,000 structured GP visits per year.
White says: “In light of our economic situation, the challenge for us is to accelerate short-term savings to fund necessary resources. The recruitment of the first wave of 17 diabetes nurse specialists to support integrated care [with the main focus on primary care] has commenced this week. However, a lot of work needs to be done in the coming months to resolve outstanding issues.”
Does he see any possibility of reversing cuts to home care packages and home help hours?
“While home care packages [unlike home help hours] were protected earlier on in the year when the budgets of other services were reduced, the unprecedented financial pressure has resulted in a recent reduction in home care packages . . . However, everyone buys into the concept that home care services will need to be enhanced rather than reduced in the future.”
Asked where he sees the health service in 10 years’ time, the departing clinical chief of the HSE says that as a patient he would like to see a service where he can continue to get the excellent access that is currently provided by GPs in Ireland, and that if he were to develop a chronic disease it would be primarily managed by his GP as part of an agreed and structured programme of care.
“I would like to think that the work of the national clinical programmes has started the journey to that future.” Doctor’s diagnosis?: A case of some solid progress but a lot more to be done for our beleaguered health system.
EARLY WARNING SCORE CAN HELP SAVE LIVES
The introduction of the national early warning score (NEWS) is spearheaded by the clinical leads for the acute medicine programme, consultant physicians Garry Courtney, Shane O’Neill and Eilish Croke. Research suggests that patients who become acutely unwell in hospital may have received suboptimal care and that action taken early can prevent this deterioration progressing to cardiac arrest or even death. International experts recommend a standardised national approach to the way that routine vital signs, such as pulse, blood pressure and breathing rate are monitored using an early warning score system. Staff record the patient’s vital signs, these are allocated points from zero to three, (zero is the best, three the worst); the points are then added together to give an early warning score. Nursing staff then act on this score to ensure the timely arrival of expert help to the patient’s bedside based on pre-determined trigger points.