3. Providing health services effectively
The section on PROVIDING HEALTH SERVICES EFFECTIVELY describes approaches for service delivery planning and patient pathways for suspected COVID-19 cases. It also considers efforts by countries to maintain other essential services during periods of excessive demand for health services.
3.1 Planning services
Update 24 September 2020: HSE winter plan published
On 24 September, the HSE published its Winter Plan (https://www.hse.ie/eng/services/publications/winter-planning-within-the-covid19-pandemic-october-2020-april-2021.pdf). This year’s plan was developed with the intent of delivering essential healthcare in a COVID-19 environment. It details a range of initiatives to enhance community capacity and access and decrease acute hospital demand. The plan prioritises primary and community care, which if delivered will advance the goals of Sláintecare and mitigate the impact of COVID-19.
There is a budget allocation of €600million to support the implementation of the Winter Plan. Key initiatives include additional:
• acute bed capacity;
• home support packages;
• HSE procured private bed capacity;
• intermediate care beds, proposals for acute hospital egress; and
• Community Healthcare Networks, Community Specialist Teams in the areas of Older Persons and Chronic Disease.
Speaking at the launch of the plan, Anne O Connor, HSE Chief Operations Officer said; ‘For the forthcoming winter period, we are focusing on the resumption of health services, while preparing for the expected pressures associated with winter and delivering services in the context of the continuing presence of COVID-19. Guidance, new processes, and infrastructure, will be critical to supporting the resumption of service delivery. In addition, a Community First approach to the delivery of care will be central to delivering safe, efficient and effective services through winter and beyond. Service delivery will be re-oriented towards general practice, primary care and community-based services.’
Key initiatives within The Winter Plan are:
• to open an additional 251 acute beds and 89 Sub Acute beds in Q4 2020 and an additional 232 acute beds in Q1 2021;
• The ongoing provision of COVID-19 Community Assessment Hubs and the extension of these to incorporate the treatment of acute respiratory illness via Acute Respiratory Assessment & Treatment Hubs;
• There are currently seven Community Assessment Hubs operation within 5 Community Healthcare Organisations with a further three on standby to open should demand increase. The plan is to have 20 hubs in total available from January to March
• Three categories of technology solutions encompass 28, large individual projects within the overall programme.
The plan envisages the recruitment of an additional 12,500 staff, however it does not specify which staff types and by when. Other objectives include a 30% reduction in trolley numbers and quicker treatment of patients in Emergency Departments, the completion of 20,000 plus additional elective procedures and a maximum of 450 delayed transfers of care for patients who are well enough to leave hospital.
A new arrangement is being negotiated with private hospitals, so that the HSE has access to capacity in the event of a surge in Covid-19 cases as well as the provision of elective care for public patients experiencing delays given the growth in waiting list during the pandemic.
The 2018 Department of Health Capacity Review and Sláintecare acknowledge the appropriate capacity of the health service in terms of both beds and community based services. This plan is not intended to achieve that level but is intended to be the first major steps towards achieving such a level.
Update 22 July 2020: Plan for return to non-COVID health services
On 22 July 2020, the Health Service Executive (HSE) published a plan outlining the return to health service and social care provision called ‘A Safe Return to Health Services: Restoring health and social care services in a COVID environment’ (https://www.hse.ie/eng/services/news/newsfeatures/covid19-updates/a-safe-return-to-health-services.pdf). The plan outlines a strategic framework for the delivery of services from now until February 2021.
Strict infection prevention measures, including physical distancing, are being implemented across the services resulting in reduced capacity and services being delivered in different ways.
As a result various surgeries, procedures, health screening programmes and outpatient clinics are planned to be running at 50-70 percent of their usual capacity (https://www.independent.ie/irish-news/health/some-services-to-operate-at-half-capacity-as-hse-plans-for-winter-like-no-other-39390013.html). Capacity is envisaged to go up over three phases as outlined in the plan while also allowing for extra capacity potentially needed during the winter months. The main assumption underpinning the plan is the level of illness and health service pressure caused by COVID-19. If later surges present a change, the timelines will change accordingly. The schedule will be regularly monitored and updated as appropriate, dependent on public health guidance and healthcare capacity.
Update 12 June 2020: Waiting lists for hospital treatments growing during COVID-19
Waiting lists in Ireland were long compared to its European counterparts before the COVID-19 crisis but have grown since the virus arrived as hospitals have limited elective care and redeployed staff and resources.
On 12 June 2020, the Irish Hospital Consultants Association (IHCA) warned of unprecedented challenges in the months ahead unless realistic practical plans are developed and implemented urgently to expand public hospital capacity and community step down services to provide care to non-COVID and COVID-19 patients (https://www.irishexaminer.com/breakingnews/ireland/leading-consultant-warns-covid-19-could-push-waiting-lists-up-to-a-million-by-years-end-1003013.html).
A total of 9,137 individuals were added to the public outpatient and inpatient/day case waiting lists in May which now stands at a total of 808,447 meaning around 1 in 5 of the Irish population are currently waiting for public hospital care (https://www.ihca.ie/news-and-publications/ntpf-waiting-lists-could-reach-1-million-as-latest-figures-show-an-additional-11844-people-added-in-may).
Up to early April, GPs are the primary detectors and treaters of COVID-19, linking to hospitals as necessary. While GPs continue to see sick patients, since 16 March, the vast majority of consultations are via telephone, video or other alternative consultation methods.
All Hospitals are to have a COVID-19 plan in place. Measures included in the COVID-19 action plan are:
• Maximise patient flow through hospitals and ensure the most efficient use of existing resources.
• Hospitals receiving infected patients will have a multidisciplinary COVID-19 preparedness committee in place.
• Facilitate patients suitable for discharge who are currently delayed in acute hospitals.
• On an ongoing basis, accelerate appropriate discharge of patients to appropriate facilities, or with homecare support.
• Source and deploy additional step-down beds in nursing homes, hotels etc. to facilitate early discharge. Enhance Minor Injury Unit service provision to reduce pressure on EDs.
• Implement major surge plan.
• Restrict elective & OPD activity, essential clinical services will be maintained.
• Provide telephone triage and support to patients in the community to avoid healthcare attendance.
• Transfer certain essential hospital activity to private hospitals; move certain essential OPD activity to community settings where feasible; source additional step-down beds in nursing homes, hotels etc.
• Reconfigure physical infrastructure in acute hospitals to facilitate separate treatment pathways for COVID-19
• Expand capacity at National Isolation Unit in Mater Hospital
• Maximise single room usage for essential treatment of patients at higher risk, such as immunosuppressed, CF etc
• Use certain specialist non-ED hospitals and/or private hospitals for treating infected patients
• Facilitate National Ambulance Service (NAS) to provide home / community testing services
• Harness additional clinical support from the Defence Forces, voluntary and private ambulance providers
• Expand NAS clinical hub, COVID-19 and mental health support desks i.e. significantly expand staff, including clinical advisors, retired GPs and others to provide clinical advice at the support desks within the National Emergency Operations Centre of NAS
• Continue to enhance paramedic led mobile medical services
• Provide accommodation for patients receiving daily treatment (e.g. Radiotherapy) to minimise risk of infection
• Expand acute & critical care bed capacity
• Expand community care capacity
• Supporting wider capacity
• ICT support: Support for home/self-management for diagnosed well patients and remote management of diagnosed patients who become unwell
• Provide additional beds for patients with moderate, acute and critical care needs
• Open all available beds in acute hospitals, maintain additional beds opened for Winter Action Plan, commission additional critical care and isolation beds
• Secure additional beds in private hospitals
• Maintain current level of short term, transitional and long stay beds
• Continue to deliver additional short term, transitional and long stay beds and training for care staff
• Progress cocooning and cohorting of at risk patients and vulnerable people in accordance with evolving public health advice
• Increase and deliver short term, transitional and long stay beds to manage patient impacted by COVID-19.
By 05/04/2020, figures released at the HSE briefing outlined the increase in hospital beds (from approximately 10,000 hospital beds) by 7,500; this included 2,500 from the private sector, 1,100 isolation beds in a new facility in City West Dublin, 450 overflow beds in same facility, and other increases in beds in health and other facilities around the country. The critical care capacity has increased from approximately 225 ICU beds pre-crisis to 800 critical care beds the week of 05/04/2020. New ventilators are arriving which will increase the numbers of ventilators from 1,100 to 2,400 across the system. HSE CEO Paul Reid outlined how the key issue with delivering critical care is having the skilled staff to provide the care, not the physical capacity that is escalating.
There are plans for up to 40 clinical community assessment hubs are to be put in place, these will start the week of 06/04/2020. They will take referrals from GPs for the treatment of COVID-19 patients or those suspected with COVID-19 outside of hospital. New models of care are being put in place for these community hubs. There are also plans for telehealth so that people can manage their mild COVID-19 symptoms and others at home.
Press releases, Agendas and minutes of the meetings of the National Public Health Emergency Team: https://www.gov.ie/en/collection/691330-national-public-health-emergency-team-covid-19-coronavirus/
Government of Ireland. COVID-19 Action plan for Ireland: https://www.gov.ie/en/publication/47b727-government-publishes-national-action-plan-on-covid-19/