SECONDARY CARE Who gives a damn

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SECONDARY CAREWho gives a damn?

• Death by stealth
• IMO AGM Symposium
• 2008
• Dr Neil Brennan
• Consultant Physician,
• Mercy University Hospital, Cork

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What exactly is secondary care?

• Department of Health
• Executive of Health Service Executive
• Tertiary Level Institutions/Consultants
• Secondary Level Institutions/Consultants
• Primary Care Physicians
• Patients
• Families
• Politicians
• Press

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What is in the mix?

• Small General Acute Hospitals (County)
• Small City Hospitals (/- Teaching)
• Large City Hospitals (Teaching, /- tertiary)
• Private Hospitals
• Private Clinics
• Parallel Polish (Language Based) Services

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My Search for Knowledge
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View from Hospitalwhat patients want

• Patients in crisis well looked after stat
• Quick access to diagnostic services
• Polite and expert care from all they meet
• Continuity of care
• Clean and comfortable surroundings
• A bed and not a trolley

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View from Hospitalwhat the gp wants

• Easy admission for emergencies (?A/E)
• Good communications
• Quick OPD access for problem patients
• Access to diagnostics - lab and imaging
• To be the conductor of the orchestra
• Adequate community services backing

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View from Hospitalwhat the HSE thinks of us

• The Teamwork Management Report on the North East
  HB area is their only published analysis
• Authors acknowledge that the HSE instructed them
  not to carry out full investigation (page 60)
• Transformation Programme 2007-2010
• inappropriate use and over reliance on acute
  hospital services which often create
  inconvenience for patients
• accessing high quality acute hospital care can
  be difficult.

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View from Hospitalwhat we think of ourselves

• We do a reasonably good job given multiple
  constraints
• Trying to mix acute care and elective service
  delivery can be difficult
• Finance is rarely available for innovations
• Burn out is not rare
• Our views dont count for much politically
• Most patients are satisfied with how we care for
  them

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The Hospital Viewexternal reality

• Finance matters more than quality of care
• Private services will continue to expand
• Power politics governs inter-hospital relations
• The cancer juggernaut is a threat to all other
  services
• Staff morale is deteriorating
• The HSE is more a defender of the Dept. of
  Finance than an advocate for hospital care

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The Hospital Viewwhat second level care includes

• A facility for dealing with emergencies
• An out-patient consultation service
• Day care facility/5 Day Ward/Both
• Diagnostic facilities (CT, endoscopy)
• In-patient care for common and/or urgently
  presenting illness not treatable at home
• Level One/Two Intensive Care facility
• Paraclinical - Physio, O/T. Diet. Nurse Sp.
• Audit, CME, teaching

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Secondary Care LevelStrengths

• Based in community
• Ease of access
• Lower unit cost per patient
• Consultants usually on-site in working week
• Rapid care for emergencies
• Many common illnesses can be fully treated

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Respiratory disease admissions and costs - 2006
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Secondary Care LevelWeaknesses

• Poor long-term investment in equipment
• Lack in depth of staffing
• Inability for complex care e.g. cancer
• Lack of Level 2 Intensive Care
• Working Time Directive effects
• No clear vision for future expressed by HSE
• No ability for local management to promote their
  own strategy
• Always at quality disadvantage compared to
  Tertiary

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Secondary Care LevelOpportunities

• To increase existing local links to aid
  development
• Population and Population Age increasing
• The Oil crisis
• Political activism - medical and public
• Internal reorganisation of services (GOYA)
• On-line CME
• Commission our own quality/value report

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Secondary Care LevelThreats

• Any report written by HSE experts or academics
  from Tertiary centres
• Economic recession
• Manpower issues - M/F, Numbers, NCHD/EWTD,
• Demands of infection control
• Knock on effects of cancer strategy-medical/financ
  ial
• Defeatism

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The Future - 1
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The Future - 2
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The Future - 3
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Reaction to Transformation

• The North East is the pilot project
• The rest of us will be governanced anew
• They are blind to the effects of their actions on
  these plans
• Butterflies are fair weather insects who wont be
  flitting around A/E in January
• The pictures would be ideal for parents of young
  children who have projects to do

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Plus ça change

• Ill be judge, Ill be jury, said cunning old
  Fury Ill try the whole cause, and condemn you
  to death.
• Lewis Carroll. Alices Adventures in Wonderland

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Action List

• An active lobby group is needed
• Doctors in second level services and primary care
  need to work and lobby together
• Argue from facts not generalisations
• Any effective lobby needs finance - get it
• Encourage and cooperate with patient support
  groups
• Support those already active in this endeavour

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Dont Forgetwhat second level care includes

• A facility for dealing with emergencies
• An out-patient consultation service
• Day care facility/5 Day Ward/Both
• Diagnostic facilities (CT, endoscopy)
• In-patient care for common and/or urgently
  presenting illness not treatable at home
• Level One/Two Intensive Care facility
• Paraclinical - Physio, O/T. Diet. Nurse Sp.
• Audit, CME, teaching

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A Final Thought

• Only the most intelligent and the most stupid do
  not change
• Confucius. Analects