Study of the Impact of Reconfiguration on Emergency and Urgent Care Networks
Emergency and urgent care in Ireland is changing under the Health Service Executive (HSE) Transformation Programme which aims to implement a 'systems-based' approach for discrete geographical regions. The aim of the SIREN project is to describe and evaluate the development and performance of different emergency and urgent care systems (EUCS) in Ireland and produce a framework for the future evaluation of EUCS in this country. Ultimately our research will facilitate the dissemination of quality improvement strategies across the country which will lead to population wide improvements in patient experience and health outcomes. The programme, led by Professor John Browne of University College Cork, involves six inter-related work packages to address the following objectives:
To identify geographical networks of emergency and urgent care in Ireland, and describe the model of EUCS configuration planned/implemented in each region.
To analyse the process by which plans for EUCS reconfiguration were developed with a specific focus on the use of evidence and the roles of different internal and external stakeholders.
To analyse the relationship between different EUCS models of governance and provision, and system-level indicators of activity, process and clinical outcome.
To develop, implement and test a comprehensive evaluation framework for EUCS.
This four year programme of research is being undertaken in collaboration with a number of co-applicants; Dr Steve Thomas at the Centre for Health Policy and Management, Trinity College Dublin; Professor Susan Smith in the Department of General Practice at the Royal College of Surgeons Ireland; Professor Ronan O' Sullivan, consultant in emergency medicine and Director of the Paediatric Emergency Research Unit at the National Children's Research Centre; Dr Orla Healy, public health specialist with the HSE South; and Dr Sheena McHugh and Dr Tony Fitzgerald here in the Department of Epidemiology and Public Health, University College Cork (UCC). A number of national and international collaborators are involved in the research including the School of Health and Related Research (ScHARR) at the University of Sheffield; College of Medicine and Health in UCC; Health Information Systems Research Centre (HISRC) in UCC and National Directorate for Quality and Patient Safety in the HSE.
Emergency and urgent care consists of all the services which contribute to the management of people when immediate care is sought for a health concern along with the process in place for referring patients between services. When patients need immediate care they can enter the health system through a range of services and will often use more than one. Services include but are not limited to GP care (including out-of-hours GP co-operatives), ambulance services, emergency departments and urgent care centres.
Hospital configuration has been defined as the "distribution of medical, surgical, diagnostic and ancillary specialties that are available in each hospital or other secondary or tertiary acute care unit in a locality, region or health care administrative area". Reconfiguration has been defined as "a deliberately induced change of some significance in the configuration by managers and policy makers" . In relation to the configuration of emergency and urgent care systems a defining feature is the imposition of greater levels of control and co-ordination such that service providers within discrete geographical regions have clear roles and relationships to each other within a unified model of care.
Reconfiguration in Ireland
The Health Service Executive (HSE) is the public sector body responsible for the delivery of health care in Ireland. The HSE has embarked on a Transformation Programme which promises to radically change the organisation of care delivery. The first priority of the programme is to "develop integrated services across all stages of the care journey" with the goal of increasing efficiency and improving performance. Within the national health policy framework the HSE is working towards the development of distinct EUCS models for discrete geographical regions within Ireland.
All regions in Ireland have undergone some form of EUCS development and integration but the pace and nature of the changes is highly variable. In three regions (South, Mid-West, North-East) the reconfiguration process is at an advanced stage. In the other regions progress has been slowed by concerns among local staff, patients and the wider public over the impact on emergency department services at smaller hospitals. It has also been limited by substantial variations in the resources available in different parts of the country and by long standing difficulties with co-ordinating the work of large acute hospitals in Dublin. The purpose of our research on reconfiguration is not to determine the 'best' model of care or policy development that can be generalised to all geographical regions but rather to understand better the process of reconfiguration in each region and whether or not reconfiguration leads to a better service for the population affected by it.
1. Spurgeon P, Cooke M, Fulop N, Walters R, West P, Perri S, Barwell F, Mazelan P. 2010. Evaluating models of service delivery: Reconfiguration Principles. London. HMSO.
As in many countries, public discourse about EUCS configuration in Ireland is conducted in a confused fashion. Without an overarching framework to guide debate there is little common ground on which different stakeholders can engage with each other. We will develop an evaluative framework that will deal with this problem. The final product can be used to guide future policy making in a transparent fashion.