1. Reconfiguration of Services in the Mid West Future Role of the Local Hospital

2. FitzGerald Report Outline of the future hospital system: report of the Consultative Council on the General Hospital Services Dublin: Stationery Office, 1968History

3. A Changing Ireland! Patient expectation Cancer strategy HIQA HIQA Doctors Expectations

5. TEAMWORK - background risk issues ! TEAMWORK - background risk issues ! 1 inpatient elective case per day 105 surgical “emergencies” in one month (Full theatre on call in 3 local hospitals) (Full theatre on call in 3 local hospitals) 1 in 3 rota (78 rest days) half of all weekends covered by locum! 1 in 3 rota (78 rest days) half of all weekends covered by locum! A/E: Weak clinical governance in local hospitals!

7. TEAMWORK Report Mid West - 2009 Services are too fragmented ! “Unable to sustain safe reliable levels of care on a continuous basis in Trauma, Acute Surgery, and ICU/High Dependency” SAFETY ! “These issues should be rectified immediately” !

8. Limerick: Junction of Mid west ! “ Hub and Spoke” 75% of population live within 25 miles of Limerick ideal area for integrated health service !

9. Project group set up to develop local plan! Clinical Lead – Chairman Executive Lead – national profile Senior Nurse – full time on project HSE Transformation office - Project Manager and Nursing Development Officer Development Officer Senior Nurse (2) Set up a Project Board, Project Board, Project Team, then Project Team, then “Workstreams” in A&E and Surgery. “Workstreams” in A&E and Surgery. Lots of meetings between Project Group and relevant stakeholders

10. The Vision of the Future Teamwork Delivery of care is now being designed around what is best for the patient, not what satisfies the requirements of the service, or an organisation, or its staff. Non-acute care is delivered in local “centres of excellence” ensuring easy access to a wide range of services for management of most ‘routine’ conditions; ensuring easy access to a wide range of services for management of most ‘routine’ conditions; Acute care is delivered in a single, regional centre responsible for managing the more complex conditions..

11. Selling the Vision! Staff Public GP’s Mid West Regional hospital Tertiary Care Centre Major Trauma Unit Cancer Centre Academic/University Centre Ennis / Nenagh/St John Advanced diagnostics Day Surgery Local Emergency Centre Inpatient beds Therapies Primary Care Team Primary Care Team

12. Pre requisites for change Quick Wins ! Pre requisites for change Quick Wins ! Emergency Theatre Capacity to centralise intensive Care Ambulance transport New services in local hospitals - orthopaedics, new endoscopy units Improved Access to Diagnostics (Nimis) Improved Access to Diagnostics (Nimis)

13. Trouble out West !

14. HIQA Report on Ennis Hospital (April’09) “define clear role for the smaller hospital !” “need structured relationship between hospitals” “need structured relationship between hospitals” Outreach Day Surgical Services “Select Basket of medical conditions”

15. HIQA Report – implications ! HIQA Report – implications ! Regionalise A&E Services immediately ! Regionalise A&E Services immediately ! No ventilated patients to be kept in Ennis ! No ventilated patients to be kept in Ennis !

16. Local A&E Close at 8pm. Clinical Governance Established ! More ambulances Advanced Paramedics Direct medical admission access “Bypass Protocols” Trauma, Obstetrics, Paediatrics “Bypass Protocols” Trauma, Obstetrics, Paediatrics

17. Local Public and GPs not happy !

18. Ambulance Activity and Response time Improvement in response times due to more ambulance availability

19. Capacity: New A&E attendances

20. Impact on Admissions from A&E 2 extra patients requiring admission per day

21. Medical inpatient Activity June 2009 vs 2010 Ennis and Nenagh and St Johns continue to provide significant medical inpatient service

22. All hands on Deck ! Reconfiguration of General Surgery

23. Theatre Schedule ”All men are equal but some are-----------!!”

24. Hospitals in the Mid West “ changing the way we work” ! Emergency Services Regional A&E - clinical governance Regional A&E - clinical governance Acute surgery – centralised Trauma Centre – bypass protocol Acute surgery – centralised Trauma Centre – bypass protocol Anaesthesia/ ICU: centralise and expand ! Anaesthesia/ ICU: centralise and expand ! Regional Surgical Service Cancer Centre, Elective and Day surgery in 3 local hospitals Medical Model in Local Hospital : next challenge !

25. Critical Care / Medicine Centralise Critical Care Anaesthetic Resource Impact on Local Hospital?

26. Region wide Medical Model Can local hospitals remain in their current mode? Relationship of Medicine to Anaesthesia ? Bed Capacity for medical patients in Region Role of Acute Medical Assessment Unit

27. Medical inpatient Activity June 2009 vs 2010 Ennis and Nenagh and St Johns continue to provide significant medical inpatient service

28. Shannondoc: 8PM to 8AM

29. Acute Medical Assessment Unit The AMAU will provide a rapid assessment for GP referrals requiring an acute medical assessment Can keep a significant number of patients out of hospital !

30. JEN – The Model Hospital OPD DiagnosticsEndoscopy Day Surgery Inpatients in JEN rapid retrieval NCHD Training Triage Acute MWRH Sub-acute Post Major Surgery Elderly Rehab LOS 21-28 days Up skill clinical staff LOS < 5days Ambulance Service Who will run ? GP or Community Geriatrician rapid response team Pre-Assessment Clinic AMAU

31. Region Wide Diagnostics Region Wide Diagnostics National Integrated Medical Imaging System (NIMIS) Unified imaging system across all Mid West: Q3 2010 ???? Q3 2010 ????

32. Recession vs. Reconfiguration Moratorium preventing the transfer of retired staff WTE ! HSE being limited in its flexibility by Dept Of Finance ! Meaningful reconfiguration is threatened !

33. Progress ! “Changing the order and bringing order to change !” The small hospital does have a vital role to play in a modern Irish health system!