An Integrated Health System for Ireland

Review recommends Ireland develops fully integrated health services

integrated health system cover imageA review of how public hospitals admit, treat and discharge patients has found that patients would spend less time in hospital and receive a better service if all public hospitals adopted practices that are the norm in other advanced health systems.

The Acute Hospital Bed Capacity Review, carried out by PA Consulting, sets out the choice for Ireland’s public health service;

  1. Continue with the current approach, which it says is over-reliant on acute hospitals to provide care and not in the interest of patients
    or
  2. Move to a community and day case based health system more consistent with best practice in Ireland and internationally and capable of providing better care and better results.

A briefing document and the full report from PA Consulting Group are available to read or download on this page.

To meet the increasing demand for health care and to deliver better quality care, the Review recommends that Ireland develops an Integrated Health System (also known as the Preferred Health System). With this approach, health services (within and between hospital and community) are connected together seamlessly, delays between services are reduced and patients gets a better service.

Some of the practices that the Review recommends should operate in all public hospitals include:

  • Reductions in the average length of time people stay in hospital (Excessively long hospitals stays currently use 900 acute inpatient beds)
  • Increases in the number day cases (The average in Ireland is 12% below the OECD average and ranges between 15% and 69%)
  • More discharge planning (currently no discharge date planned for 83% of patients)
  • Bringing patients into hospital on the day of their surgery – rather than 1-3 days earlier (currently less than 50% are admitted on their day of surgery)
  • Treating patients in more appropriate settings (currently 39% of inpatients could be treated in an alternative to an acute hospital – many in their own homes)

The Review highlights that these practices are already working well in a number of Irish hospitals and introducing them to all public hospitals could be done relatively quickly.

Main Findings
The Review found that many patients are unnecessarily admitted or being kept in hospital for too long. It says that with practice and process changes, existing hospital facilities would be able to deliver care to far more patients – which could reduce waiting times.

It also points out that to meet the 60% increase in demand for health care expected during the next 12 years, Ireland must tackle these process issues and reduce its over-reliance on acute hospitals, which is out of step with best international practice.  Ireland must also rebalance its spending in favour of expanding community based services so that the public can access care more conveniently and closer to home.

Commenting on the Review’s findings, Professor Brendan Drumm, CEO of the HSE, said that modernising hospital practices was essential: “To develop a world class health system we have to replace outdated practices with modern ways of doing things that reflect the needs of patients.”   He said that clinicians (doctors, consultants, nurses and therapists) would play an essential role in leading this change.

“The review tells us that more resources are not the only answer to improving access and reducing waiting times.  Hospitals can reduce waiting times by simply modernising the way staff manage the passage of patients in and through their hospitals, as is consistently achieved in other hospital systems,” he said. 

The Review emphasises that hospital stays should be minimised as they can be disruptive to families, inconvenient for patients, increase the risk of infection, and they can impact on important social networks and delay recovery, especially for elderly people.

Acute Hospital Bed Capacity Review
The HSE commissioned PA Consulting Group to undertake a review of acute hospital bed capacity up to 2020. It involved a comprehensive stakeholder consultation exercise, including over 120 Irish and 20 international health experts.  The Review outlines the options, opportunities and challenges in developing the right balance for patients between inpatient, day case and community based care and sets out what it calls the Integrated Health System.

The concept of the Integrated Health System as set out in the Review is consistent with the HSE’s current strategy to make it easier for people to access services, building up primary, community and long-term care services and developing services for chronic disease management.

One of the authors of the Review, Paul Pierotti, said that the average length of time patients stay in hospitals in Ireland is relatively long.  “In Ireland, many inpatient hospital beds are being used for two types of patients -those who are simply waiting for procedures, access to assessments and test results, and those who are waiting for non acute, long stay and rehabilitation care.  Irish and international evidence shows that services are better provided in the community”, Mr Pierotti said.

With an Integrated Health System patients should get in, through and out of the health service more quickly. The majority of care should be provided through community-based facilities and appropriate day case procedures. People spend less time in hospital and more time being cared for in their communities or in their own homes.   With an Integrated Health System patients are more likely to receive the care they need in the right location provided by the right professional, when they need it.  This approach also promotes greater accountability, transparency and value for money.

Impact of Integrated Health System on bed demand
According to the Review, in addition to delivering better service, better outcomes and better value, the development of a fully Integrated Health System would impact on the demand for public patient beds by 2020.  There are currently 11,660 public beds in public hospitals. In addition there are nearly 4,400 private beds (2,461 in public hospitals and 1,926 in private hospitals).

If the modern hospital practices and processes which already operate in some Irish hospitals, and are the norm in health services around the world, operated in all Irish hospitals, patients could get a better service with less public patient beds than currently exist. For example, countries such as Australia, UK, Finland, Denmark and Canada could treat the same number of patients as Ireland treats today with between 2,000 and 5,000 less public patient beds.

However, because the Integrated Health System does not yet operate universally in Ireland, there are stresses on the existing public health system.  To meet these stresses, based on the current practices and processes, a further 1,118 hospital beds are required today.  The Programme for Government includes a commitment to provide 1,500 extra acute beds over the next few years through the co-location initiative (about 1,000 beds) and the HSE capital plan (about 450 beds).

If current practices and processes continue and there is not the appropriate investment in community based facilities, the demand for public patient hospital beds would reach nearly 20,000 by 2020.  This would require capital investment of around €4bn on new hospitals. Ireland would need to open a new 600 bed hospital (similar in size to some of our largest hospitals such as Tallaght Hospital, University College Hospital Galway and Cork University Hospital) every year for the next 12 years.  Even with this unprecedented investment, patients would not receive the best care or outcomes and taxpayers would not be getting the best return for their health investment.

The Integrated Health System would see an expansion of community services and day cases as standard, with the role of acute hospitals and the configuration of beds adjusting accordingly.  For instance:

  • the number of single bed rooms would increase
  • the number of day case beds would double
  • the number of medical assessment units would triple, and
  • the number of critical care beds would increase by 25%.

There would also be a reduction in acute inpatient beds as patients would be treated in more appropriate settings including their own homes.  The net impact is that Ireland would, if the Integrated Health System was 100% operational, need 8,834 public inpatient acute beds in 2020.

The result would be a much more sophisticated mix in our acute hospital bed stock to better match the increasing complexity of acute care needs, which is likely to continue on into the future.  In addition, a continual programme of refurbishment and modernisation of acute in-patient beds would be needed. Coupled with a significant expansion in the range and volume of community-based services, the demand for additional long term care, continuing care, therapy and rehabilitation beds would reach 10,000.

The Review highlights that:

  • The average length of stay in an Irish hospital is comparatively long – some 37% of total inpatient beds are used by patients who in Australia would no longer be expected to be in hospital
  • Irish hospitals still predominantly operate Monday to Friday, discharging three times more patients on these days rather than on Saturday or Sunday
  • More than half of surgical inpatients are admitted the day before surgery – the practice in most countries is admission on the day of surgery
  • Delays in accessing tests result in bottlenecks throughout the hospitals with many patients admitted for tests that they could have had as outpatients
  • Ireland’s day case rate is 12% below the OECD average and less than half that of Canada.  If Ireland performed as well as Canada, some 338,000 more patients could be treated as day patients
  • The absence of discharge planning in line with normal practice in advanced health care systems unnecessarily extends hospital stays

The Integrated Health System would see:

  • A reduction in the number of Emergency Department admissions as more patients would be treated within the community, in Medical Assessment Units and outpatient clinics
  • An increase in the number of patients treated as day cases
  • A reduction in the average length of stay of inpatients as Ireland moves towards best international practice in terms of length of stay
  • An increase in the number of non-acute, therapy and rehabilitation beds
  • A greater emphasis on hospital discharge planning
  • Better service, better outcomes and better value using less acute beds than exist today