2.1 Response to Winter Pressures
The Board considered with the CEO and Executive Management Team members, the Board briefing papers which had been circulated in advance of the meeting setting out the HSE response to the pressures in the health system as it continues to manage an exceptional influenza season with rising notifications of cases and hospitalisations.
The Board acknowledged that, in response to the increasing pressures, the National Crisis Management Team (NCMT) was established and held their first meeting on 22 December 2022 which is chaired by the CEO, to ensure that all measures were taken to alleviate pressure and manage patient risk.
The CEO provided an update to the Board on the measures taken to mitigate the impact of the continuing high levels of respiratory illness and the resultant pressures on hospitalisations and patient safety. He confirmed that crisis management continues to be in place to ensure that all required measures, including exceptional escalation actions and supports available through the on-going implementation of the Winter Plan 2022/23, that can be done is being done to improve access for patients and support healthcare workers.
He confirmed that HSE management continue to meet and engage regularly with the Minister for Health and Department of Health (DoH) officials on the ED situation and the EMT members continue to conduct acute site visits to provide support including analysis of key issues and assistance with problem solving to inform immediate actions, future learnings and long-term planning. There continues to be daily meetings of the National Crisis Management Team and the Winter Oversight Group alongside meetings with Hospital Group Chief Executive Officers and CHO Chief Officers (CHOs) to analyse current performance, aid decision-making and facilitate rapid implementation of actions.
The Board noted the escalation actions and arrangements taken by the NCMT, which included:
- Additional 7- day working across both acute and community services since 5 January 2023.
- Extension of participating General Practitioners (GP) clinic hours by up to 8 hours per week per GP, through agreement with the IMO.
- Enhanced funding provided to GP Out of Hours services to enable them to roster additional GPs.
- National Ambulance Service (NAS) engagement of private capacity and voluntary ambulance services to support hospital discharges, and Hospital Liaison Personnel to expedite turnarounds and coordinate care handovers that have been put in place.
- Community First Responder Schemes who are responding to elderly patients and doing welfare checks on patients waiting for emergency ambulances.
- 180 beds accessed from Private Hospitals, and liaison ongoing with private hospitals to secure additional private capacity and ensure that all available contracted private beds are utilised.
- Available nursing home capacity continues to be identified and aligned with hospital need. Community Beds (Public and Private nursing homes) with the help of Nursing Home Ireland, there is greater visibility of available private beds, and teams are actively working to match patients to beds to expedite safe discharge from hospital.
- Ongoing regular and significant engagements continue with key internal and external stakeholders, staff organisations and unions.
- Acute site visits by members of National Management Team took place and are continuing to take place across the country.
The CEO and EMT answered questions and provided clarification to Board members in relation to supports for HSE staff to ensure burnout does not happen, the roles of Clinical Nurse Specialists (CNS's) which has been discussed at previous Board meetings, the uptake of vaccinations in healthcare workers, and communications to the public concerning mask wearing, vaccinations and options other than ED attendance, including GP, Out of Hours, local injury units and the need to ensure appropriate communications if persons who continue to have concerns have the confidence to attend the ED. In response to questions whether the public health advice from the CMO for Covid19 and non-pharmaceutical interventions (NPIs) was appropriately taking into account the negative impact the high wave of infectious diseases was having on the health system, the CCO responded that the HSE members of the Covid Advisory Group (CAG) had proposed stronger measures to protect the health system but that the CAG and CMO had not adopted them in their public health advice to the Minister.
The Board were informed that infectious respiratory diseases are at exceptional levels when compared to the past 5 seasons, with RSV and higher levels of Covid 19 in recent weeks, along with influenza placing significant pressure on general practice and hospitals.
The CEO reported a decrease in attendances and admissions in ED’s in the past week, with 322 patients on trolleys at 8am 13/01/23 compared to a record high of 772 patients trolleys at 8am 03/01/23 and confirmed all measures in place will continue to reduce these numbers down further, in a safe and sustained way. He noted however, that the latest data would suggest that the flu season has not peaked, and that while the pressure from Covid 19 and RSV continues to decline, ongoing pressure on the healthcare system from these viruses is expected for the next number of weeks.
The CEO informed the Board that a review will commence to identify lessons learned as soon as possible, once the services are over the worst, and have agreed to keep track of what has worked well from this crisis to factor into future planning for next winter and for the longer term.
He advised the Board that the longer term elimination of this issue will require a change in the size and shape of the health system by implementing Sláintecare with greater investment in community and hospital capacity and more integrated working facilitated by the implementation of RHAs. The adoption of a formal management method that puts patient safety first and eliminates waste of patient / service user time and skills is required, and a process of engagement with senior leaders is planned which will be communicated to the Board for their input.
The Board discussed the sustained period of unprecedented unscheduled care activity, which has exceeded the most pessimistic modelling, with attendances and admissions at emergency departments across the country at levels higher than ever before. This level of pressure was an unforeseen situation that was being experienced by almost all health systems in Western Europe.
The Board expressed the view and noted that what patients have experienced in many hospitals in recent weeks is simply not acceptable in terms of the time waiting to be treated and the time waiting to be admitted to a bed in a hospital. The Board expressed regret that this has been the case and acknowledged how difficult it was for patients, staff and families.
The Board recommended the need for improved planning and discussed how to accelerate the three-year unscheduled care improvement plan to combine process improvement, expedited infrastructural investment and learning from sites performing well, to ensure the system is prepared to the greatest extend possible if similar situations arise in future years.
The Board welcomed the planned lessons learned exercise to be carried out by management. The Board recommended that this after action review should evaluate the effectiveness of the actions and supports put in place in response to the crisis to capture fully lessons learnt to inform future planning both for next winter and for the longer term.
The Board endorsed the suggestion from the CEO that this review should also address whether the actions undertaken in the recent period could have been undertaken at an earlier point and so mitigated the impact. There must be a focus for future periods on timely measures being in place where spikes in demand and waiting times can be reasonably anticipated. Improvement opportunities to improve modelling was also an area for close examination given that the recent demand levels exceeded the most pessimistic levels.
The Board discussed and recommended that the development of the three-year unscheduled care improvement plan to deliver process improvement, expedited infrastructural investment and learning from sites performing well, be accelerated in 2023. It was agreed the Performance & Delivery Committee will review the progress of the three-year unscheduled care improvement plan at its next meeting and maintain oversight of the development of the plan and also the work being done jointly between the HSE and the DoH to update the 2018 Health Service Capacity Plan.
In conclusion the Board commended all HSE staff across the country in both hospitals and the community in responding to the pressures and their enormous effort and professionalism in what has been extremely difficult circumstances. The Board also acknowledged the work of the CEO and the National Management Team for their continued work and dedication during these past number of weeks. The Board requested that the appropriate planning be put in place now to ensure the system is prepared to the greatest extend possible if similar situations arise next year or in future years.