Building an oasis

Brief reflections from the IFIC Study Tour for the Saudi Arabia Ministry of Health to Ireland and Catalunya

Recently I had the privilege and pleasure of working with Dr Nick Goodwin co-hosting a study tour for Optimity Advisors and their Client the Saudi Arabia Ministry of Health looking at the health systems of Ireland and Catalonia in Spain.

The objective of the mission – supporting the development of care pathways for Trauma, Stroke and Acute Coronary Syndrome in the Riyadh Region as part of Saudi Arabia’s Vision 2030.

This was effectively the speed dating of study tours – 1.5-2 days at each site (Dublin and Barcelona) with 3-4 meetings at different locations and settings per day. This traversed the Ambulance Service, Hospital and, in the case of Ireland, the Royal Colleges and Ministry; rounded off with workshops per day and a debrief. Thanks to our local hosts who co-ordinated this logistical feat, Dr Áine Carroll, National Director, Clinical Strategy and Programmes, Health Services Executive, Ireland and Dr Albert Alonso, Innovation Director, Hospital Clinic Barcelona.

Our delegates were incisive with their questions of the specific pathways – and insightful in their desire to understand the core and common (foundational) elements of the systems we saw. Rather than dwell on specifics, it is these fundamental roots that I would like to explore here.

Delegates and team visiting the National Ambulance Service of Ireland


A coalition and a compass
Whilst both Ireland and Catalonia are politically dynamic regions, the momentum and compass bearing of the pathway programmes we witnessed have been steadily progressing – neither redirected nor stopped from their course.

The course they are on is a general compass bearing of improvement being traversed by a community of clinicians, aided by managers and enabled by the political support to let them get on and do it within some agreed goals and boundaries. This is a strong partnership.

It is not a rigid route set by the centre. Neither is it a random trail being blazed by the hacking of blunt blades. Rather it is a set of parallel projects constantly checked and re-calibrated by reflective practice, research and evaluation. Relationships of mutual respect have developed over time and have withstood the changing political landscapes. In Ireland we witnessed the strong dyad between the Health Service Executive (the HSE is effectively their Ministry of Health) and the Royal college of Physicians. In Spain, we saw the combination of hospital and community clinics in effectively managing flow.

Time has no substitute
The journey for these systems has not been fast – in fact it is probably frustratingly slow in the terms of a government or system seeking revolutionary change.

The Irish example has been marching for the last 7 years; elements of the Catalonian system and its reshaped models of care date back to 2000 and have been evolving since then.

However, it is a pace that allows everyone to contribute to the journey and, in so doing, own it. As with the roots of a tree – the activity below the surface – the strong root structure of relationships and evolution determine the health above the surface. You can’t grow a tree from the top down; it needs fertile soil in which to grow – and nurturing from above.

Measure, review and recalibrate
We witnessed a thirst for quality improvement enabled by strong disciplines of project management and measurement. This was not the national ‘targets’ reporting seen in some jurisdictions. Rather, it is a set of measurements agreed and developed by the clinical community alongside the college (in the case of Ireland) and the regional government (in the case of Catalonia). There is a strong sense of needing an evidence-based approach that looks both outward (to international research) but also inward (at local context) at the same time.

This is a discipline that many systems do not do or do not do well – but it appears to have paid dividends in the examples we saw. This has, perhaps, been an element that has allowed time to be well spent and given space to those implementing to continue.

A consistent theme is the project and improvement methodology approach taken to the pathway development rather than steering a steady operational course. This combines the disciplines of quality improvement, programme management, governance and change management. Where the approach differs from a project is that the concept of a beginning, middle and end are absent. For both the Irish and the Catalan systems this is a journey of continuous quality improvement.

In summary – can you transplant the tree of knowledge?
You can try to transplant an entire tree – though it’s highly likely that the process will be fraught, might not take and that the environment is not compatible. It could wither and die or become a weed and choke the surrounding environment.

Local context is critical.

However, you can develop a strong root structure in your own environment – from there combining the growth and shaping of your own approach together with grafting and pruning branches from other places.

The key lies in these roots. Our study tour witnessed great examples of both strong foundational systems and the corresponding fertile branches of pathways that these enabled to flourish and continue to grow today.

It is the combination of these strong roots and the corresponding growing and tending of local pathways that Saudi Arabia has in front of them. If the delegates we met are a reflection of the custodians of this process – then the oasis will be a large and durable one.

Andrew Terris is a senior associate for the International Foundation for Integrated Care where he heads the Solutions service – to assist systems to implement, scale and sustain integration.