· Web viewThe ICS is specifically for inter-hospital transfers, freeing up existing emergency...

Question 1 (Deputy Denis Naughten)

To ask the Minister for Health & the HSE the location of each acute stroke unit which has 24/7 access to thrombolysis; the thrombolysis rate at each acute hospital and the plans to increase this rate in each of the hospitals concerned - Deputy Naughten

Part A – To ask the Minister for Health & the HSE the location of each acute stroke unit which has 24/7 access to thrombolysis;

Response:As stroke thrombolysis has a narrow risk-benefit margin, it requires availability of advanced brain imaging and input from a senior doctor trained in emergency stroke care on a 24/7 basis. Therefore it is not feasible to deliver this service at all hospitals. The populations served by those hospitals where thrombolysis is not performed are provided a service via immediate ambulance transport to hospitals where the service is available, per regional and national protocols.

The following table sets out the location of each of the acute units and which unit has 24/7 access to thrombolysis:

HSE Area Hospital

Provides Stroke

Thrombolysis Service

Stroke Unit

DML

AMNCH, Tallaght YES Combined- Acute/RehabMidland Regional Hospital Mullingar

YES Acute

Naas General Hospital YES Combined- Acute/RehabSt James's Hospital YES AcuteSt Vincent's University Hospital

YES Combined- Acute/Rehab

North East

Beaumont Hospital YES Combined- Acute/RehabCavan General Hospital YES Combined- Acute/RehabConnolly Hospital Blanchardstown

YES Acute

Mater Misericordiae Hospital


Navan General Hospital NO YESOur Lady of Lourdes Hospital, Drogheda


South

Bantry General Hospital YES Combined- Acute/RehabCork University Hospital YES NOKerry General Hospital YES NO

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HSE Area Hospital

Provides Stroke

Thrombolysis Service

Stroke Unit

Mercy University Hospital YES Combined- Acute/RehabSouth Tipperary General Hospital Clonmel

YES Acute

St Lukes' Hospital Kilkenny YES Combined- Acute/RehabWaterford Regional Hospital

YES Acute

Wexford General Hospital YES Combined- Acute/Rehab

West

Letterkenny General Hospital


Mayo General Hospital YES AcuteSligo General Hospital YES AcutePortiuncula Hospital, Ballinasloe

YES Acute

Roscommon General Hospital

NO Rehab

University College Hospital Galway


Mid Western Regional Hospital, Dooradoyle

YES Interim Stroke UnitCombined- Acute/Rehab

The National Stroke Programme is currently evaluating the level of function of stroke units and planning an audit for September/October which will include reviewing the structure, process and outcome of care for stroke patients, including thrombolysis rates.

In relation to the availability of a 24/7 service, the evaluation of the level of function of stroke units referred to in the original response has just been completed and 23/24 hospitals that responded (95.8%) reported that they offered 24/7 thrombolysis. In the hospital where thrombolysis cannot be delivered 24/7 patients are transferred directly to a neighbouring hospital.

Part B - The thrombolysis rate at each acute hospital and the plans to increase this rate in each of the hospitals concerned

Response:Rates can vary substantially from quarter to quarter and from hospital to hospital due to the small number of patients’ eligible and treated in some hospitals, therefore the national rate is the more reliable rate.

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The Quality and Patient Safety Directorate carried out an audit in 2012 and found an overall stroke thrombolysis rate of 9.5%. This rate is similar or better than national rates from other developed countries and the increase from 3.3% in late 2008/2009 is one of the most rapid increases reported internationally.

This success was recently reported at the European Stroke Conference in London and is due in no small part to work of stroke clinicians and specialist nurses around the country. The National Stroke Programme continues to empower local clinicians to increase thrombolysis rates, by providing access to telemedicine, education and national protocols.

Note re: The evaluation of the level of function of stroke unitsThe evaluation of the level of function of stroke units has been completed and the report is being finalised.

Question 2 (Deputy Denis Naughten)

To ask the Minister for Health & the HSE the current response times for ambulance services in each HSE region and each county; the specific steps which are being taken in each region & county to improve these response times

Response:

The HSE National Service Plan 2013 set out performance targets for response times, based on HIQA’s suite of performance indicators.

Life-threatening or potentially life-threatening calls account for approximately 40% of all 112/999 emergency ambulance calls in Ireland. 60% of emergency calls are excluded from response time KPIs, as they are neither life-threatening nor serious.

112/999 emergency calls are classified by clinical status, as follows.

Clinical Status 1 ECHO calls (life-threatening cardiac or respiratory) should have a patient carrying vehicle at the incident within 18 minutes 59 seconds (HIQA target is 85%)

Clinical Status 1 DELTA calls (life-threatening other) should have a patient carrying vehicle at the incident within 18 minutes 59 seconds (HIQA target is 85%)

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The latest available data published in April 2013 is as follows:

Emergency Response TimesNSP

Target 2013

NAS Perform

anceLeinster West South

Clinical Status 1 ECHO incidents responded to by a patient-carrying vehicle in 18 minutes and 59 seconds or less (HIQA target 85%)

70% 62.8% 66.27% 77.50%

81.48%

Clinical Status 1 DELTA incidents responded to by a patient-carrying vehicle in 18 minutes and 59 seconds or less (HIQA target 85%)

68% 61.89% 68.21% 60.97%

63.78%

It is widely recognised that sole reliance on response times is restrictive and a poor measure of ambulance service work. Most jurisdictions are now preparing to move to clinical outcome indicators, as a truer reflection of the work of a modern ambulance service. For Ireland, this means developing a robust suite of clinical outcome KPIs. This work is underway and is expected to be completed by early 2014. The core issue will then be investment in an electronic patient care reporting system, integrated with the National Emergency Operations Centre and with the technical capacity to automatically audit key patient data and generate appropriate reporting.

The ongoing development of the NAS is providing a robust platform to continue to improve performance against response time standards. Coupled with the ongoing development of education and clinical governance, the safety of services to patients continues to improve.

Key challenges in addressing response time targets continue to be reliance on on-call arrangements, geography (eg west of Ireland), road networks, resourcing and the use of emergency ambulances for inter-hospital transfers.

The NAS is taking a number of steps to improve response times where possible.

Performance Improvement Action PlanThe performance improvement action plan is in place and focused on improving response time performance. The plan has 57 action points for improvement. These are being worked through by local managers and include:

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Faster mobilization times for crews Processes around call taking and dispatch Engagement with and development of Community First Responder Schemes

Development of an Intermediate Care Service (ICS)A key issue for the NAS, for effective responses to emergency calls, has been the continued use of emergency vehicles for inter-hospital transfers. The NAS and staff representatives have, under the Public Service Agreement, signed off on a framework agreement for development of an ICS within the ambulance service.

The ICS is specifically for inter-hospital transfers, freeing up existing emergency resources for emergency calls. Almost 50 intermediate care operatives were appointed in 2012, in areas such as Cork, Galway, Sligo, Letterkenny and South Dublin. The National Service Plan 2013 provides for further developments in in Castlebar, Limerick, Drogheda/Dundalk, Tralee, Cork, Limerick, Waterford, Sligo and Bantry, with 78 additional staff. To support the implementation of additional services, the NAS intends to procure 25 vehicles in 2013 at a capital cost of approximately €4m.

Control Centre Reconfiguration ProjectThe NAS is focused on improving its call taking and dispatch functions, for a positive impact on response times. This project will allow the NAS to see all available resources on one system, ensuring that the nearest available resource is dispatched to a call.

The NAS is also rationalising its ambulance control rooms, to one system across 2 sites, Tallaght and Ballyshannon. This project is in line with international best practice, the Mason Report and HIQA recommendations on patient safety. It requires 2 buildings, the Rivers Building in Tallaght and the existing centre in Ballyshannon, Co. Donegal.

The first phase of this project was the move of Naas and Wicklow Control Centres to Townsend St in 2011. The second phase saw the move of Cork and Kerry control operations to Townsend Street in May 2013, with the simultaneous introduction of national digital radio to both areas. In phase 3, Navan Control Centre moved to Townsend Street in July 2013.

The outcome of a tender process for the structural fit out of the 2 buildings is due in August 2013, with a completion date for works in February 2014.

Revenue funding for this project in 2013 is €4.44m with 55 additional WTEs. Capital costs for the project are approximately €10.3m. Up to 2012, €3.3m was spent on ICT development, with the balance to be drawn down by the end of 2014.

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The development of the National Control Centre will also allow the NAS to engage with and utilise First Responder schemes on a more effective basis.

Current arrangements do not allow for effective capture of all data relating to a First Response on scene whereby technologies within the National Control Project will facilitate a more consistent approach.

The training of the first cohort of call takers for the national centre began on 8 July 2013, with a qualification date in October 2013. This training has a full completion date of the week of 10 March 2014.

The move from Townsend Street to Tallaght will be in line with the above.

New TechnologyThis project will deliver improved technology to the NAS, which will assist in improving response times. Technology developments such as national digital radio, national computer aided dispatch system (CAD), mobile data, route planning and electronic patient care reporting, will allow the NAS to deploy resources in a much more effective and efficient manner on a national basis, rather than within small geographic areas. CAD (capital funding €1.4m), mobile data and AVL (vehicle locator) solutions have gone to tender. Successful vendor notification and award of tender is expected by October 2013.

The unified digital integrated command and control system (ICCS) solution (capital funding €3m) is in place in conjunction with An Garda Siochana. This allows for voice communication traffic to be routed through the ICCS and to appear as touch button technology “on screen” in Control.

The national digital radio system (NDRS) TETRA roll out continues (capital funding €3.9m). The system is live in Cork and Kerry and due to go live in the north east from July. This system will roll out to other areas sequentially before year end. Maintenance and support agreements are in place for both the TETRA network and Sepura Terminals.

National Defibrillator Replacement Programme To assist in the roll out of the acute coronary syndrome programme and the implementation of the clinical practice guidelines, as required by PHECC and HIQA, there has been capital investment in 2013 of approximately €2.5m for a national defibrillator replacement programme. Associated with this is a further €2m for mechanical CPR devices to address health and safety issues for staff performing CPR and to improve outcomes for patients.

Pilot Emergency Aeromedical Service (EAS)

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The pilot EAS, which was established in June 2012, involved the Irish Air Corps providing aeromedical support to the HSE National Ambulance Service.

The Air Corps provided a dedicated helicopter and personnel, based in Costume Barracks, Athlone, to fly and maintain the craft. The NAS provided patient care through advanced paramedics. The Irish Coast Guard provided additional support to the primary aircraft.

The pilot has been reviewed and the report on the review is being considered. The service is being continued, pending completion of this consideration

Engagement under the Public Service AgreementThe NAS is engaged with staff representative bodies under the Public Service Agreement on a number of issues. A key area is more effective use of resources in order to improve performance against response time targets.

Additional InvestmentThe HSE and Department of Health have recognised the development of the National Ambulance Service as a key requirement for 2013. In this context, over €8m in additional development funding was provided to the NAS in 2013, an overall increase in budget of 5% against 2012.

Question 3 (Senator Jillian Van Turnhout)

In light of the growing childhood obesity epidemic in Ireland and Government policy as set out in Healthy Ireland-A Framework For Improved Health and Wellbeing 2013-2025, to ask the Minister for Health why under the new Framework for Junior Cycle the status of physical education and SPHE (amongst others) has changed from a subject to a short course, thereby reducing recommended teaching time, and what will now be done under Healthy Ireland to ensure physical education and social, personal and health education in schools gets the priority they need?

Response

I am aware that on 4 October 2012, the Minister for Education and Skills, Ruairí Quinn, TD, published A Framework for Junior Cycle which outlines his plan to reform the junior cycle in post-primary schools. I understand and am supportive of the overall vision being pursued with the framework and my Department will assist the Department of Education and Skills in achieving this vision. We believe that if the reforms are implemented as envisaged, they may increase student engagement with school due to the decreased emphasis on rote-learning and the broadening out of areas in which students can achieve recognition for

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their achievements. This will have a positive impact on health and wellbeing. I am aware that the Department of Education and Skills is supportive of health and wellbeing and I welcome the inclusion of wellbeing as one of the eight principles underpinning the Framework for Junior Cycle.A position paper on Social Personal and Health Education and Physical Education has also recently been developed by a working group of relevant experts in the HSE which has been shared with the Department of Education and Skills. It is worth acknowledging that several health indicators in Ireland demonstrate positive trends in the health and wellbeing of adolescents in the last 10 years. Trends in the Health Behaviour of School-Aged Children Reports (ESPAD), for example, record declines in cigarette use, alcohol use, binge drinking and illicit drug use.

Research evidence from an international perspective points to the need to have comprehensive all-encompassing strategies for health behaviours which involve multiple settings, including the school setting, if progress is to made in improving health and wellbeing. Improvements in the trends on health behaviours are most marked since 2002/2003, the years that the SPHE programme was required in junior cycle. It is likely that the roll-out of the SPHE programme has had a positive influence on the health behaviour of young people.

Healthy Ireland which was launched in March contains a commitment to fully implement SPHE and PE and this was agreed with the Department of Education and Skills. As the Senator will be aware, Healthy Ireland contains a vision of an Ireland where everyone can enjoy physical and mental health and wellbeing to their full potential, where wellbeing is valued and supported at every level of society and is everyone’s responsibility.

Clearly, the creation of healthy generations of children, who can enjoy their lives to the full and reach their full potential as they develop into adults, is critical to the country’s future. Responsibility for prevention programmes cannot rest solely with my Department, the HSE or, indeed, the Department of Education and Skills but must be shared across Government Departments and all of society.

Officials in my Department will continue to meet with officials in the Department of Education and Skills to address issues of concern including these matters.


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What implementation plans are in place for the new National Consent Policy (May, 2013) for use in health and social care, particularly the education and training of staff who are expected to implement and deliver the policy

Response:

The HSE Consent Policy was developed by an advisory group and a wider stakeholder group. These groups included representatives of the staff who will use the policy on a day to day basis and the document reflects the needs of practitioners. The principle of consent and the knowledge of the importance of obtaining consent are expected of all staff employed or contracted by the HSE. Knowledge of the importance of consent is, and has long been, a professional requirement for health and social care professionals. Therefore the main focus of support for the policy is providing guidance rather than training and education of staff. At a local level there is a training requirement for new staff on local protocols and documents/forms used for consent, and this will continue.

The definitive document (HSE National Consent Policy) is in itself a guidance document and has been supplemented by the publication of a brief summary entitled ‘Seeking Consent: A Brief Guide for Health and Social Care Workers’. This provides practitioners’ guidance on how to use the policy in service settings.

To support staff in the hospital services the HSE will review the consent forms that currently exist for common procedures with the view to development of nationally agreed forms/templates. This will reduce variation in information provided and improve the quality of the consent process; and reduce training requirements as staff move around the system.

Children and Family services provide particular challenges in the area of consent. The Children and Families Services are developing an implementation plan to address particular requirements that arise in the delivery of services. The plan is being prepared at the moment.

Two service user guides have also been developed and published to help patients and service users understand the consent process and what they can expect from their healthcare provider and professional.

A log is maintained of all queries raised with the Quality and Patient Safety Directorate in regards to the use of the policy and these will inform the updating of the policy and other guidance as required.


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Given that an estimated 28,500 women in Ireland are diagnosed with perinatal depression, post-natal depression and pregnancy or childbirth related post-traumatic stress disorder each year, to ask the Minister for Health what efforts are being made to tackle delays of 9 months and more for mothers to be seen by a professional counsellor in the public health care system?

Response:

Pregnant women access a range of services including primary care, obstetrics and ante-natal and post-natal services. If the individual herself, or any of the healthcare professionals caring for her during her confinement have a concern, they should first access their GP or Primary Care team in the normal way. Where an individual is assessed as requiring referral for specialist mental health services, their GP would refer to their local General Adult mental health service.

For women with a recognised mental health need, they may discuss the management of their pregnancy with their consultant psychiatrist as it may be necessary to alter their treatment programmes as some medications as contraindicated in pregnancy.

All community mental health teams would have experience of such presentations and collaborate with the obstetric services to ensure a safe delivery and appropriate aftercare.

For women with a previous history of post-natal distress or depression, there is an elevated risk of recurrence and this would be actively managed through high frequency review by the GP who assess when it would be necessary to engage with the specialist mental health services if at all.

Access to counselling for all medical card holders, including pregnant women, is now available through the Counselling in Primary Care Service. The detail of this new service and pathway of referral is attached in Appendix 1.

If an individual is being treated within the specialist secondary care mental health services and counselling is indicated clinically then the appropriate intervention by a trained health professional would be made available.

There are 123 General Adult Community Mental Health Teams nationally. The HSE, in its 2012 Service Plan, prioritised €35m and 414 WTEs for reinvestment in mental health to progress the objectives in the Programme for Government. One of these objectives was to enhance General Adult and Child and Adolescent Community Mental Health Teams.

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The HSE, in its 2013 service plan intends to build on this investment with a further €35m to strengthen General Adult and Child and Adolescent Community Mental Health Teams.

In addition, there are three peri-natal Psychiatrists based at The National Maternity Hospital Holles St, The Coombe and Rotunda Maternity Hospitals reflecting the number of births at these centres each year.

Of the 414 posts allocated in 2012, 389 posts have either been filled, or under offer or awaiting clearance. These posts include multidisciplinary team members across all the health professions.

Of the 477 posts approved in 2013, 133 posts have been accepted by candidates. A further 16 offers have been made from existing panels. The HSE is establishing new panels and other arrangements to fill the remaining posts.

Currently, our mental health data system is a manual system and the information in respect of service users who may be pregnant is not captured nationally.

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APPENDIX 1 – DETAIL ON CIPC SERVICE

What Is The Counselling In Primary Care (CIPC) Service?Counselling in Primary Care (CIPC) is a short-term counselling service that provides up to 8 counselling sessions with a professionally qualified andaccredited Counsellor/Therapist for persons presenting with mild to moderate psychological difficulties. Such difficulties can present as depression, anxiety, panic reactions, relationship problems, loss issues, stress.

Who can refer and how can a referral be made?A referral can be made by a GP or other members of the Primary Care Team (PCT) with the GP’s awareness. A suite of standardised documentation to facilitate the national roll out of the service has been produced which includes a CIPC Referrer Information Leaflet, a CIPC Client Information Leaflet and a CIPC Referral Form. The completed standard CIPC Referral Form should be sent to the CIPC Counselling Co-ordinator for the service in their area.

Who is eligible?A person must be aged 18 years of age or over, be on the GMS list and want help with problems that are appropriate for time limited counselling at a primary care level.CIPC is not a crisis intervention service and such individuals should be referred to other appropriate services.

What types of problems are suitable for CIPC?Problems of recent onset (within the last six months) whichare specific, identifiable and are impacting on the person’squality of life, relationships or their ability to cope.

Problems Suitable for Counselling in Primary Care Mild to moderate psychological problems Depression Anxiety states including mild specific phobias and panic attacks Non-complex loss & bereavement Coping with injury or illness Adjustment problems Life cycle issues Stress and specific trauma Relationship difficulties

Problems not Suitable for Counselling in Primary Care Moderate to severe psychological problems Depressive disorders which are severe and long standing Eating disorders

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Severe anxiety Personality and behaviour disorders Schizophrenia and related disorders Bi-polar disorder Cognitive impairment or dementia Obsessive compulsive disorder Severe Post traumatic stress disorder

A person may not be suitable for CIPC if: they do not meet eligibility criteria for the service (i.e. they are not over 18

and they do not hold a medical card) the problem is not significant enough to warrant professional intervention

(e.g. is a normal emotional reaction to a normal human event and they have supports)

they are engaging in addictive behaviour(s) (alcohol, drugs, gambling etc.). In such cases addiction counselling is more appropriate

they are avoidant or resistant to the change process in counselling and therapy because they perceive responsibility for change to be outside of themselves

they have multiple, complex problems which are severe in nature and long standing

they are currently dealing with a history of severe trauma, abuse or significant early loss

the problems are more appropriate for Secondary Mental Health Services.

CIPC National Referral Protocol and Client Pathway1 The GP or member of PCT will complete the CIPC Referral Form and send it to the Counselling Coordinator (if GP is not the referrer, copy referral to GP).2 The person to be referred will be given a copy of the CIPC Client Information Leaflet with details of how to opt in to the service.3 The GP or PCT member will advise the client to phone the CIPC OPT IN telephone number for the CIPC service in their area and leave a voice message indicating that they wish to attend counselling.4 If the person does not phone within two weeks they will not be contacted and the referral will not proceed any further.5 On receipt of both the Referral Form and the ‘OPT IN’ from the person, the Counselling Co-ordinator will review the referral and, if considered appropriate an assessment interview with a Counsellor/Therapist will be arranged.6 On completion of the assessment, if appropriate, further counselling sessions (up to a maximum of 8) will be scheduled.7 If a need to access Secondary Mental Health Services is indicated, this recommendation will be communicated to the GP or other member of the Primary Care Team.8 The referrer will be informed in writing if the client does not opt into the service.9 Where the client does opt in and counselling proceeds, feedback will be provided at the conclusion of counselling.

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Question 6 (Deputy Billy Kelleher)

What is the timeframe for the implementation of hospital reconfiguration?

Work is ongoing with regard to the implementation of the recommendations of the Higgins Report on Hospital Groups which was accepted by Government and published on 14 May 2013.

A series of information and consultation meetings with hospitals is nearing completion. Professor Higgins has held over 55 meetings so far since the launch of his report and this process will be completed by end July. Separately, the Minister has visited all six hospital group areas accompanied by his Department and by the HSE DG Designate.

To complement implementation of the Report’s recommendations, the Department of Health will now put in place an overarching policy framework to guide overall hospital services reorganisation from a national standpoint. Work on the roll-out of hospital groups will be overseen by the National Strategic Advisory Group and driven by the HSE. The feedback from the consultation meetings with hospitals will inform this work.

Expressions of Interest were invited through the Public Appointments Service for appointment as Chairpersons and members of Hospital Groups Boards, with advertisements published on Friday 5 July 2013 on the www.publicjobs.ie website and in the Irish Times and Sunday Times, as well as on the ‘Board Vacancies’ section of the Department’s website. The closing date for receipt of applications was Thursday 18 July 2013. The Minister intends to be in a position to appoint the Chairpersons by end July and other board members in September. Separately, sanction has been given to the HSE to appoint each Group's management team. The HSE intends to advertise the posts of Hospital Group CEOs shortly.

Initially the groups will be established on a non-statutory administrative basis. In keeping with a recommendation of the Report, within one year of the formation of Hospital Groups, each hospital group will be required to submit a strategic plan which will outline its plans for future services within the group area. These plans must describe how they will provide more efficient and effective patient services; how they will reorganise these services to provide optimal care to the populations they serve; and how they will achieve maximum integration and synergy with other groups and all other health services, particularly primary care and community care services. Each Hospital Group will be rigorously evaluated in line with predetermined criteria to see whether they are in a position to advance to Hospital Trust status after the necessary legislation is put in place.

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Does the government have any new proposals for tackling suicide?

1. BackgroundDealing with the current high levels of suicide and deliberate self-harm is a priority for this Government. Reach Out our National Strategy for Action on Suicide Prevention 2005 – 2014 makes a number of recommendations in relation to fast track referrals to community-based mental health services, effective response to deliberate self-harm, training, stigma reduction, etc.

2. National Office for Suicide PreventionThe National Office for Suicide Prevention (NOSP) was established by the HSE to progress the implementation of the 26 action areas and 96 recommendations in Reach Out in association with pre-existing and emerging partners.

The Office has progressed substantial work on almost every recommendation. Priority initiatives identified for this year include the further development of existing National Mental Health Awareness campaigns to promote help seeking, increased training for GPs and practice staff; building the capacity of communities to respond to suicide; the implementation of the clinical care programme for self-harm and continued investment in voluntary agencies providing frontline services.

2. Increased Funding for Suicide Prevention in 2012 and 2013Funding for suicide prevention is provided to the NOSP by the HSE from its overall budget for mental health. The annual budget for suicide prevention increased this year to €13.1 million. €8.1 million of this is provided to the NOSP to fund voluntary and statutory agencies delivering services in the area of prevention, intervention, postvention and research. The remaining €5 million for suicide prevention is available regionally to fund HSE Resource Officers for Suicide Prevention, Self-Harm Liaison Nurses in Hospital Emergency Departments and local suicide prevention initiatives.

3. Review of NOSP ActivitiesFollowing consultations with Minister of State Lynch, in January 2013, the HSE Assistant National Director for Mental Health and the Director of the NOSP were requested by the Director General Designate of the HSE to review the work of the NOSP and to formulate a new strategic direction for the Office.

The Director and the Assistant National Director consulted with an ‘Expert Advisory Group’ which includes senior lead clinicians in Adult and Child Mental

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Health and HSE Communications Directorate. Since January 2013, this group has completed the following work:-

· Examined and reviewed the national and international evidence on suicide prevention;

· Conferred with lead national and international researchers, policy makers and frontline services working in this area;

· Reviewed other international Government strategies in this area;

· Re-analysed current data on suicide mortality and morbidity;

· Consulted with Regional Suicide Resource Officers.

The Review will ensure that we make the most of available resources, including looking at best practice internationally to inform evidence-based policy decision and will result in a revised strategic approach which will build on work already undertaken under Reach Out. Its aim will be to support population health approaches and interventions that will assist in reducing the loss of life through suicide. The proposed new programme will provide for the coordination and integration of services to ensure that pathways of care for persons at risk of suicide or in suicidal crisis can be accessible, acceptable and available. It is expected that the HSE will approve the revised approach in the very near future.

3. International evidenceInternational evidence suggests that a 10 - 17% reduction in suicide rates can be achieved over a three year period when suicide prevention strategies include the following elements:

Improve the understanding of suicide prevention among the general population, Build individual emotional resilience, Encourage help-seeking and access to self-help within the population and

identified target groups, Integration of primary care and mental health services for people at risk of suicide. Community response plans to suicide thereby preventing suicide. Provision of suicide prevention training to community gatekeepers and

frontline health service providers. Responsible reporting of suicide by media outlets, National programme focused on reducing access to means of suicide, Provision of appropriate treatment responses for persons who engage in self harm. The establishment of a national coordinating body with clear strategic

targets combined with the delivery of regional implementation plans is a key success factor in reducing suicide and self-harm rates. Government policy should also focus on improving the wider determinants of mental health at a population level e.g. promoting individual well-being,

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decreasing alcohol use levels, increasing access to employment and reducing social exclusion and health inequalities.

The implementation of Reach Out has incorporated many of the above evidence based approaches.

4. New Strategic Direction for the NOSPThe Expert Advisory Group is proposing a new strategic direction for the NOSP. It is proposed that a new programme would

take over from the existing strategy when Reach Out concludes in 2014 need to be a minimum of four years in length to have a measurable impact

on reducing suicide rates adopt a population health approach and deliver evidence based, high

quality services and programme have three levels of intervention, support for the all i.e. the whole

population, support for some i.e. those who are identified as vulnerable to suicide i.e. those present with suicidal ideation or self harming , and support for a few i.e. support for those in suicidal crisis

build across four guiding principles including

the promotion of ‘Well-being’ across the whole population : The programme will work collaboratively with internal and external stakeholders to improve the determinants of mental health within the population by delivering health programmes across key settings e.g. schools, workplaces, sports clubs

the promotion of ‘Help Seeking & Self-Help’: The programme will work to improve the understanding and skills of the population to recognise within themselves and others when individuals should seek support for emotional and mental health difficulties

the promotion of ‘Help Taking’: The programme will work to build person’s willingness, readiness and ability to accept support from services that are acceptable and accessible

the promotion of ‘Help Giving’: The programme will work to ensure that health and social care services delivered to service users who are at risk of self-harm/suicide or have been bereaved by suicide are safe, cost effective, high quality and are community based

Implementation of regional suicide prevention plans International evidence demonstrates that a key success factor in reducing

suicide and self-harm rates is regional suicide prevention plans. The

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implementation of regional suicide prevention plans at a HSE/ISA level shall be the differentiating factor in a new suicide prevention strategy.

Successful programmes in local regions shall be identified and replicated on a national level to serve the particular demands of different population groups. These programmes will form part of regional plans.

Improving standards and building evidence across the sector There are concerns surrounding unproven and unsafe practice across the

sector. The development of standards for service providers will improve the quality and safety of funded services and programmes.

The outputs of research funded under new strategy shall be utilised to improve service provision.


What supports is the government putting in place for residential services for people with intellectual disabilities?

Response:

Specialist Disability services are provided to enable each individual with a disability, to achieve his or her full potential and maximise independence, including living as independently as possible. Services are provided in a variety of community and residential settings in partnership with service users, their families and carers and a range of statutory, non-statutory, voluntary and community groups. Services are provided either directly by the HSE or through a range of voluntary service providers. Voluntary agencies provide the majority of services in partnership with and on behalf of the Health Service Executive.

Disability Services is allocated approximately 10.5% of the €13.3 billion health budget. The majority of specialised disability provision (80%) is delivered through non-statutory sector service providers. Funding is provided through section 38 and 39 of the Health Act, 2004. Out of the total budget for disability services of €1,535m in 2013 (€1,554m in 2012; €1,576m in 2011 and €1.582 in 2010), approximately €400m was allocated under section 38 and €700m under section 39. This funding is governed by either Service Arrangements or Grant Agreements, which set out what services and level of service is to be provided by the agency in return for the money being provided to them.

Implementation of the Report “ Time to Move on from Congregated Settings – A strategy for Community Inclusion”

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On June 8th 2011, the HSE published the Report of the working group on Congregated Settings. The report identified that approximately 4,000 people with disabilities live in congregated settings defined in the report as a residential setting where ten more people share a single living unit or are campus based.

The report “Time to Move on from Congregated Settings – A strategy for Community Inclusion” proposes a new model of support for a person with a disability in the community.

It proposes a seven year phased closure of congregated settings with individuals actively supported to live full, inclusive lives at the heart of the family, community and society. The model envisages that people living in congregated settings will move to dispersed forms of housing in ordinary communities, provided mainly by housing authorities. Individuals with disabilities will have the same entitlement to mainstream community health and social services as any other citizen, such as GP services, home help and public health nursing services and access to primary care teams. Persons with disabilities will also have access to specialised services and will get the supports they need to live and be part of their local community.

The implementation of the report poses significant challenges to many stakeholders including clients, families, disability service providers, HSE, various Government departments and statutory bodies and representative organisations.

This radical change is not the sole responsibility of the HSE but rather a collaborative responsibility shared between the person with a disability, their family and carers, a multiplicity of agencies, Government and society as a whole.

The HSE established in October 2011 a National Project Group to oversee the implementation of the recommendations of the report. The overall objective of the group is to ensure that following the implementation of the report, people with disabilities will be actively and effectively supported to live full, inclusive lives at the heart of the family, community and society. They will be able to exercise meaningful choice, equal to that of other citizens when choosing where and with whom they live. People with disabilities will have the right to direct their own live course.

A number of key work elements have been identified and progressed by the group to support the implementation process. Regional and Local implementation teams are being established to support service providers at operational level with project plans and the transition process. Each service user will have a person centred plan with the relevant supports identified for each individual. Work is currently ongoing.

Specific Initiatives Being Undertaken to Support Implementation - Demonstrations Projects

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An important initiative which is being undertaken by the HSE with the support of the DOH is to develop a range of demonstration projects to lead out on the move towards a person-centred model of service and support. These demonstration projects involve the development of new models of service with a view to determining how well they work and these are being established by service providers across the country which will run in parallel with current services.

An important partner in this overall approach is the Genio charity, which is a registered charity that combines public funding via the DoH and HSE with funding from sources such as Atlantic Philanthropies in order To support transition from Institutional to Person Centred Models of Care in Disability and Mental Health Service (Minister John Maloney, 2009). Funding in this area was announced in December 2009 and came on stream in 2010. Funding of €2m was provided in 2011 and €3m in each of 2012 and 2013.

Expressions of interest are received from those agencies providing services or from new service providers and all the applications are evaluated against the criteria by a panel of four assessors; three Genio personnel and an independent assessor who oversees the entire process. Applicants are interviewed in regard to costs, sustainability and capacity to deliver.

To illustrate the position I set out below a number of the initiatives that are being undertaken in the Deputies own area of Cork:

⌐ HSE Service Grove House – Cork City, the project will support 4 clients to move to community settings more appropriate to their individual needs

⌐ HSE Service St Raphaels Centre Youghal – the project supports seven clients to move to community settings more appropriate to their individual needs.

⌐ Brothers of Charity, Cork – the project will work to identify alternative models of respite i.e. host families to provide respite services, and family support services within a community context, to families of children and adults with an intellectual disability.

⌐ COPE foundation the project will work to provide a community based day service for 18 school leavers in line with the recommendations of New Directions policy.

⌐ Irish Autism Action, Cork – Development of the Home Gift programme to help maintain children in the most appropriate setting ( in their home)

⌐ Inclusion Ireland, Cork – the project will support the training of 9 individuals with an intellectual disability to deliver training and information to people with an intellectual disability regarding implementation of the HIQA standards and what they mean for them.

⌐ Headway Ireland, Cork – the project will support the establishment of a programme to build self and pier advocacy and leadership skills in adults with acquired brain injury (ABI)

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Genio Funding in 2013In partnership with the Health Service Executive and the Department of Health, Genio invited online expressions of interest in May 2013 for disability projects (Community living; Alternative respite; and supporting school leavers) by the closing date of Tuesday 21st May at 5pm. Those short listed to proceed to the full application stage were invited to submit a full application by 5pm on 17th June 2013. The final selection process will be on the 5 th July. You will note that the approved projects have gone to Genio Trust Board for final approval.

Apart from the collaboration with Genio the HSE is also progressing with the implementation of other supports as part of it’s own service plan for example in the Cork area it is progressing Implement the new congregated setting policy in collaboration with the COPE

Foundation, complete “assessment of needs” plans for all residents in Grove House and begin the relocation of the first group of 10 clients from Grove House into alternative appropriate community based services under the governance of COPE Foundation.

Open an 8 bedded specialised unit for adults with behaviour challenges based in Cork, which will provide a significant support to all agencies across the Cork and Kerry area.

National Standards for Residential Services for Children and Adults with DisabilitiesAn important support for the system will be the establishment of national standards for residential services for children and adults with disabilities. In this regard significant progress has been made with the publication by HIQA in May 2013, of the national standards. These standards outline to providers what they must do to ensure safe and effective care is provided to people living in, or using, residential and residential respite services. The HSE is currently working with service providers to ensure that they are prepared for the inspection regime which is expected to commence in September.

Question 9 (Senator Colm Burke)Would the Minister for Health and the HSE outline the total cost expended by the HSE in the employment of Junior Doctors under agency contracts for the periods 1st January 2012 – 31st December 2012 and 1st January 2013 – 30th June 2013, in particular in the areas of:

(a.) accident and emergency units(b.) anaesthesia(c.) obstetrics and gynaecology(d.) orthopaedics(e.) all junior doctors employed by the HSE for the above periods

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Response:

Please see below table regarding Agency Costs:

January to December 2012 HSE

January 2013 to present

HSETotal

(a.) accident and emergency units €3,947,073.69 €1,712,741.18 €5,659,814.87

(b.) anaesthesia €1,439,528.34 €729,416.38 €2,168,944.72

(c.) obstetrics and gynaecology €1,196,366.07 €714,759.61 €1,911,125.68

(d.) orthopaedics €396,861.88 €51,083.44 €447,945.32

(a)+(b)+( c)+(d) €6,979,829.98 €3,208,000.61 €10,187,830.59

Total for other specialities €11,393,639.81 €5,357,219.58 €16,750,859.39

(e.) all junior doctors employed by the HSE for the above periods

€18,373,469.79 €8,565,220.19 €26,938,689.98

a) The information supplied in relation to overall cost of NCHDs are payroll costs and include all costs i.e. pay to doctor, employers prsi etc. Figures are also inclusive on overtime, on call and C factor payments. Data was sourced from SAP in relation to DML, DNE and HSE West, HSE South Data was sourced from Management Accounts HSE South. Data in relation to HSE West, DML and DNE was only available for 5 months so the 6 monthly figure was extrapolated out.

b) Agency Costs - The HSE has two contracted agencies for the provision of NCHDs it was possible to ascertain exact data in relation to the spend associated with NCHDs for these agencies - the data is only inclusive of contracted spend - it does not include spend outside the scope of contracts.

c) CRS reports monthly on agency spend - this includes spend with contracted agencies and spend that is off contract. However it is not possible to determine the split between NCHDs and Consultants in relation to this particular spend as it is not recorded. Expenditure on NCHDs accounts for 40% of total spend in

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relation to contracted agencies therefore this figure has been used to extrapolate the total NCHD spend from the spend recorded on CRS.

d) CRS data not available to end of June - data available to end of May therefore extrapolated out for 6 months.

e) The CRS spend is significantly higher than the spend recorded in relation to the agency contracts - this however would be in line with what our sense is in relation to agency doctors purchased off contract.

Question 10 (Senator Colm Burke) Would the Minister and the HSE outline following;

(a.) Total number of consultant posts advertised since 1st June 2012(b.) The average number of applicants per post advertised since 1st June

2012 (c.) The number of posts advertised where there were two or less

applicants since 1st June 2012 (d.) The number of posts filled between the 1st June 2012 and 1st

October 2012 (e.) The number of posts filled since the 1st of October 2012

Response:

Please note the figures in the below table include both HSE hospitals and non HSE hospitals -

Total(a.) Total number of consultant posts advertised since 1st

June 2012117

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(b.) The average number of applicants per post advertised since 1st June 2012

4.5

(c.) The number of posts advertised where there were two or less applicants since 1st June 2012

25

(d.) The number of posts filled between the 1st June 2012 and 1st October 2012

20

(e.) The number of posts filled since the 1st of October 2012

40

Permanent Consultant appointments for HSE hospitals have always been conducted through the offices of the Public Appointments Service previously known as the Local Appointments Commission (LAC). The time to recruit a consultant has traditionally longer than most other recruitment processes. This is mainly due to availability of highly specialised interview board members and the fact that a large number of applicants are overseas.

Question 11 (Senator Colm Burke)

Would the Minister and the HSE furnish the following information in respect of the Fair Deal Scheme which came into operation in 2009, and in particular:

a) Total number of people who have signed up under the Fair Deal Scheme

b) The number of people who have signed up and have died since the Scheme commenced

c) The number who signed up under the Fair Deal Scheme where under the terms of their agreement 5% of their assets per annum (maximum of 15% of their assets) must be refunded to the HSE after their death

d) The amount of money recovered from the estates of the persons set out in paragraph (c.) above

e) The amount of money which has not been recovered and the reasons why recovery has not been successful

Response:

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IntroductionThe Nursing Homes Support Scheme is a scheme which provides financial support for people who need long-term nursing home care. Under the scheme, people make a contribution towards the cost of their care and the State pays the balance. This applies whether the nursing home is public or private.

Applications are made to the local Nursing Homes Support Office on the standard application form. There are three steps to the application process.

Step 1 - Application for a Care Needs Assessment. The Care Needs Assessment identifies whether or not the person needs long-term residential care services.

Step 2 - Application for State Support. This is used to complete the Financial Assessment which determines the person’s contribution to care and determines the level of financial assistance (State support).

Step 3 is an optional step which allows the person to apply for the Nursing Home Loan (Ancillary State Support) to defer part of the person’s contribution to care. It is effectively a loan advanced by the State which can be repaid at any time but will ultimately fall due for repayment upon the person’s death. Its purpose is to ensure that people do not have to sell assets such as their house during their lifetime.

Replies to Questions

a) Total number of people who have signed up under the Fair Deal Scheme

As at the 31st May 2013, a total of 32,634 people have been assigned under the Nursing Homes Support Scheme since its commencement on the 27th October 2009. [Up to the end of May 2013, a total of 34,138 people have been determined for financial support under the scheme]

b) The number of people who have signed up and have died since the Scheme commenced

Of the 32,634 people who have been assigned under the nursing homes support scheme, a total of 12,778 people have died since been assigned under the scheme. [Financial support may also cease where people are discharged to other health services (acute care, disabilities etc.), home etc.]

c) The number who signed up under the Fair Deal Scheme where under

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the terms of their agreement 5% of their assets per annum (maximum of 15% of their assets) must be refunded to the HSE after their death

Under the scheme, the financial assessment calculates the person’s contribution to care which is based on 80% of assessable income and 5% of the value of assets per annum.

The person’s principal residence is only included in the financial assessment for the first 3 years of care. This is known as the 15% or ‘three year’ cap. It means that the person pays a 5% contribution based on his/her principal residence for a maximum of three years. After 3 years in care, the person’s contribution to care is reduced accordingly [State Support paid by HSE consequently increases] and the person does not pay any further contribution based on the principal residence [If the person has other assets, the contribution on such assets continues]. The 15% or ‘three year’ cap applies regardless of whether the person chooses to opt for the loan or not.

Where a person owns land or property in the State, the 5% contribution based on such assets may be deferred and refunded to the State following a relevant event e.g. the death of the person. This is the optional Nursing Home Loan (Ancillary State Support) element of the scheme.

As at the 31st May 2013, the number of persons who have availed of the Nursing Home Loan (Ancillary State Support) since the commencement of the scheme is 3,213 people.

d) The amount of money recovered from the estates of the persons set out in paragraph (c) above

Under Section 26 of the Nursing Homes Support Scheme Act 2009, the collection and recovery of the repayable amount of the loan is a function of the Revenue Commissioners and the Commissioners have the authority to act as they deem necessary for the collecting, receiving and accounting of the repayable amount. As a result, the loan must be repaid to the Revenue Commissioners and the Commissioners may take all steps which they consider appropriate to recover the repayable amount of the loan, including the bringing of legal proceedings in their own name. Such monies received by the Revenue Commissioners must be paid into the Exchequer’s Central Fund.

The HSE has been advised by the Revenue Commissioners that as at the 31st

May 2013, a total of €7.798m has been paid to the Commissioners in respect of 648 persons who availed of the Nursing Home Loan.

e) The amount of money which has not been recovered and the reasons

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why recovery has not been successful

As at the 31st May 2013, there were 477 loans with a value of €7.880m which are in the process of being recouped by the Revenue Commissioners.

The HSE also understands that in certain circumstances the accountable person may experience difficulties in obtaining the repayable amount due to the current economic climate. As the property market has declined it is more difficult to sell property or release equity in same in order to obtain the repayable amount due.

Further in certain cases a time delay in the Probate process can cause extended time periods before estates are administered and hence cause further delay in the repayment process to the Revenue Commissioners.

Question 12 (Deputy Caoimhghín Ó Caoláin)

To ask the Minister for Health if he will ensure that the National Dementia Strategy is published, with an implementation plan; if he will commit to enhancing the provision of education and community based support and services for carers and if he will make a statement on the matter.

It is estimated that there are currently 41,000 people with dementia in Ireland and Alzheimer’s Disease accounts for the majority of cases. Given that the number of people with dementia is expected to rise to between 141,000 and 147,000 by 2041, the Programme for Government contains a commitment to develop a National Alzheimer’s and other Dementias' Strategy by 2013 to;

- increase awareness

- ensure early diagnosis and intervention and

- ensure development of enhanced community based services.

A significant amount of preparatory work has already been completed. A research review funded by the Atlantic Philanthropies to lay the foundations for the Strategy, titled Creating Excellence in Dementia Care, A Research Review for Ireland’s National Dementia Strategy was published in January 2012. A public

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consultation process to inform the development of the Strategy was conducted in 2012 and a report of same published on the Department’s website in February 2013.

A Working Group, representative of key stakeholders from the Department, the HSE, the medical profession and the community and voluntary sector has been established, meetings of which are on-going.

While the development of the Strategy will have to have due regard to the constraints imposed by the budgetary situation, it is intended that it will be a transformative Strategy. It will have a very practical focus, will be action oriented and will focus on what can be done to make a difference to the lives of people with dementia. It is intended that a draft of the Strategy will be completed by the end of 2013.

The National Carers’ Strategy, which was published in July 2012, is a cross-departmental strategy that sets the strategic direction for future policies, services and supports provided by Government Departments and agencies for carers.

It sets out a Vision and an ambitious set of National Goals and Objectives to guide policy development and service delivery. The objective is to ensure that carers feel valued and supported in their caring role and are empowered to have a life of their own outside of caring. The Strategy also contains a Roadmap for Implementation. This Roadmap also outlines the timelines and the Departments with responsibility for the implementation of the Strategy's various elements.

Each Department has appointed a senior official to take responsibility for relevant actions and for the provision of up-dates to the Cabinet Committee on Social Policy. As implementation progresses, the Strategy will be reviewed on a periodic basis to consider whether adjustments or additional actions are appropriate.

Question 13 (Deputy Caoimhghín Ó Caoláin )

To ask the Minister for Health if it is the case that the implementation plan for the national neurorehabilitation policy will not now be developed by his Department; the reason for this decision; if he will immediately review this situation; and if he will make a statement on the matter.

Response:

The National Neurorehabilitation strategy made a number of recommendations for services for people with rehabilitation needs that covered a range of types of

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provision including: clinical, therapeutic, social , vocational and community supports.

The HSE has taken a pragmatic approach to the implementation of the aspects of the strategy that are within it´s area of responsibility. Following development of the report, the HSE as part of it´s commitment to ensure the optimal care pathway for different Clinical needs, established the Rehabilitation Medicine Programme (RMP). The scope of the programme covers the whole of the patient journey from self management and prevention through to primary, secondary and tertiary care. These programmes provide a national, strategic, and coordinated approach to a wide range of clinical services and include the standardization of access to and delivery of, high quality, safe and efficient hospital services nationally as well as better linkages with primary care services. The RMP has almost completed the Model of Care for the provision of specialist rehabilitation services in Ireland which will be the basis for the delivery of services.

Outside of the Clinical Programme, the HSE Disability Services Programme has a role in certain key aspects of Neuro Rehabilitation Services, primarily the provision of community based therapy services, and personal social services, often funded through partner service providing agencies in the non statutory sector. The Disability Services Programme is obliged to implement the recommendations of the Value for Money and Policy Review of Disability Services, and will use the recommendations of the VFM report, to focus on Disability funded rehabilitation services and enable reconfiguration of existing provision through the establishment of demonstration sites. Close links will be maintained with the Rehabilitation Medicine Clinical Programme to ensure that there is no duplication of effort and that all initiatives receive optimal support. The 2013 HSE Operational Plan commitments for Disability Services commits to: Map and develop ISA level rehabilitation networks and to implement the model of care for rehabilitation services within the networks with focus on community rehabilitation teams. This is complemented by the Operational Plan commitments of the RMP to: Commence development of region managed clinical rehabilitation networks, supporting local rehabilitation teams, and guided by associated national guidelines, protocols, pathways and bundles. Develop a set of standards of care for specialist in-patient rehabilitation services. Develop a set of standards of care for specialist community rehabilitation services.

Demonstration sites have been identified by Disability Services and mapping has commenced. The RMP is continuing to work through a national working group, comprised of all stakeholders and has recently had a new Clinical Lead appointed.

Question 14 (Deputy Caoimhghín Ó Caoláin )

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To ask the Minister for Health to advise the anticipated outcome of the consideration being given by the National Immunisation Advisory Board to the introduction of the new European Commission licensed vaccine to protect against meningitis B, the most common form of bacterial meningitis in Ireland; when he believes we will have such a vaccination programme in place; and if he will make a statement on the matter.

The immunisation programme in Ireland is based on the advice of the National Immunisation Advisory Committee (NIAC). NIAC is a committee of the Royal College of Physicians of Ireland comprising of experts in a number of specialties including infectious diseases, paediatrics and public health. The committee's recommendations are informed by public health advice, international best practice and by the National Centre for Pharmacoeconomics (NCPE).

A Health Technology Assessment which includes a cost benefit analysis is carried out prior to any new vaccine being considered. This has a vital role in ensuring that care technologies, including vaccines, are used in a manner appropriate to their ability to maximise health gain and achieve value for money.

It would be inappropriate to comment on any anticipated outcome of the deliberations of the NIAC. However, should NIAC advice recommend the inclusion of a new vaccine into the primary childhood immunisation programme in Ireland, my Department, in association with the Health Service Executive's National Immunisation Office will then examine the issue.

Question 15 (Deputy Jerry Buttimer) To ask the Minister to comment on the effectiveness of the centralised recruitment process operating within the HSE, the time taken from initial application by the service provider to appointment of the successful applicant and to outline the involvement of local service providers in selecting successful applicants.

Response: Prior to the establishment of the HSE health service recruitment was delivered through multiple locations. This process caused significant duplication of applications and as such had a very expensive cost per hire, lengthy times to hire and was highly labour intensive.

In 2009 the National Recruitment Service was established in Manorhamilton, Co. Leitrim to deliver a recruitment service for the HSE. The net effect of this has been a reduction in average cost per hire of 60%, a decrease in time to hire of 50% and has reduced the numbers involved in recruitment activity from 260 WTE's down to 60. This is largely as a result of the pro-active nature of the

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recruitment process with the formation of national processes and panels. The NRS work closely with the service providers to ensure that the needs of the services are met.

Although the National Recruitment Service provide the HR infrastructures for the recruitment processes it hugely depends upon the professional/clinical managers to take a lead role in making recruitment decisions. This includes the development of job descriptions, competency profiles and it is always professional managers who sit on interview boards and make the key recruitment decisions.

Question 16 (Deputy Jerry Buttimer)

To ask the Minister for an update on the development of children’s services at CUH, to provide details of the capital investment being made and the benefits which such changes will deliver.

Response:

Introduction

Paediatrics services in the HSE South are presently delivered in Cork University Hospital (CUH), Mercy University Hospital (MUH) and Kerry General Hospital (KGH). CUH is the paediatric tertiary referral centre for the HSE South, and also, along with some national services, for a supra regional area. Therefore CUH acts as a regional centre for the catchment population of 550,000 served by the HSE South, and as a supra-regional centre for a total a population of 1.1 million. CUH paediatric unit is accredited for postgraduate medical training and some tertiary and national level services exist in CUH.

CUH is the only site in Ireland where paediatrics is co-located with neonatology and adult services. However, the physical facilities do not currently comply with international best practice.

General Description of Project

The existing Paediatric and Child Health Dept at Cork University Hospital is situated at Ground floor level of the hospital campus. Arising out of the reconfiguration plans for the Cork city hospitals it is intended that CUH will become the Paediatric Hospital for the region.

The capacity of the paediatric and child health department at CUH is to be expanded. This will allow a unified regional service to develop and will

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require the commissioning of six additional beds. The relocation of the Mercy University Hospital Paediatric facilities,

including the Haematology / Leukaemia / Oncology treatment facility to CUH is to be provided for at the facility at ground level.

This will be facilitated by the relocation of the existing Day Hospital to first floor level in the proposed development.

In addition to the Day Hospital, a dedicated Paediatric Outpatients Department with 12 clinic rooms, Cystic Fibrosis paediatric treatment rooms and a gymnasium will be provided at first floor level, all of which are inappropriately provided in the hospital at present.

Additional class room space is also planned, for patients within the paediatric unit.

Academic and research accommodation will be provided in cooperation with University College Cork at second floor level.

The new structure will be built over the existing Paediatric Unit on two levels linked to the main hospital concourse via stairs and lift on the ground and 1st

floor.

Benefits

The new development will support the paediatric service in providing:

The highest standards of treatment and care to patients, in accordance with the principles of equity, quality and accountability.

Holistic care including health promotion, disease prevention and patient education.

An encouraging and congenial atmosphere when patients are undergoing treatment.

On-going staff education and regular reviews of procedures and protocols.

The development will provide:

(1) Projected increases in activity and to allow for key staff appointments in accordance with foreseen needs.

(2) A department that will be efficient and economical.(3) A pleasant environment paying due regard to aesthetics, ergonomics and

scale, to include a quiet restful atmosphere free from excess noise. (4) Natural lighting and ventilation will be provided to the maximum extent in

all areas, but particularly in the in-patient areas and where staff are working continuously.

(5) Integration of the department with the main hospital complex, and ease of access to other departments.

The interior décor, artwork, furnishings and fittings will be carefully selected to

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reflect the needs of children and young people. Young children are dependant to a large extent on their carers meeting their daily needs and support their activities safely. Generally parents or other family members remain with their children while they are in hospital and therefore their needs are taken into account in this development.

Partnership with Outside Agencies

Approval for the project has been given by the HSE Capital Steering Group. The HSE Capital Plan includes €5.455m towards the project.

In addition, the following funding partners have given a commitment to provide support funding:

Build 4 Children (Paediatric Cystic Fibrosis facilities), University College Cork (Academic facilities), Children’s Leukaemia Association (Leukaemia facilities) Department of Education (Patient School Facilities) CUH Foundation

The total project cost will be in the region of €8.43m

Project Timescale

Detailed design is currently being finalised and tender documentation will be completed by September. The tender process, including tender evaluation and recommendation, will take approximately 20 weeks from that date. Mobilisation will take a further 8 to 12 weeks.

The accommodation which is being provided will be built over the existing Paediatric Inpatient accommodation. In order to allow construction commence and progress in a safe manner, Paediatric patients will have to be relocated from the current Paediatric inpatient unit for the 18 month duration of the works. Decanting to existing accommodation within the hospital was considered, but due to the current demands on ward accommodation this is not possible. Plans are being developed which will envisage the provision of prefabricated decanting accommodation over the existing Outpatients Department. This decant accommodation would also facilitate General Ward Refurbishment works once the Paediatric development is complete. The impact of this requirement for prefabricated temporary accommodation on the timescale of completion has not yet been finally established.

Other Developments

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Services to children with diabetes have been enhanced with the appointment of two paediatric endocrinologists/paediatricians with special interest in endocrinology over the past two years. This has lead to a significant improvement in access to insulin pumps as an alternative to insulin injection therapy.

Insulin pump therapy is the continuous infusion of insulin to a child or adult with diabetes. An insulin pump is a mini computerised device, about the size of a small mobile phone, which continually infuses insulin under the skin and thereby optimises the blood glucose control. This therapy has evolved considerably in recent years and is now considered the gold standard of treatments as it enables significantly better blood sugar control which allows for better quality of life and mitigation of the potential for long term complications which can include blindness, kidney failure, amputation etc.

In the past children from this area had to travel to Dublin hospitals to access insulin pump therapy. These children are now returning for care to this area and as advised above it is possible to instigate insulin pump therapy in Cork. The service is at an early stage of development but it is a significant advance in our services in Cork.

At the beginning of 2013, there were approximately 40 children using insulin pumps now attending Cork University Hospital of which 20 commenced the therapy at the pump school in Cork since October 2011. It is planned to commence 20 more during 2013.

Question 17 (Deputy Jerry Buttimer)

To ask the Minister for an update on the establishment and operation of a forum of health insurance companies and to outline his efforts to get health insurance companies to reduce their costs.

ResponseThe Minister has consistently raised the issue of managing costs with health insurers and is determined to address rising costs in the sector in the interests of consumers. The Minister wants insurers to address the base cost of each element of claims which they pay. Last year, the Minister established the Consultative Forum on Health Insurance to generate ideas to address health insurance costs, while always respecting the requirements of competition law. Two meetings of the plenary group of the Forum have taken place this year so far. In addition, a number of meetings have been held with the CEO’s of the health insurance companies and Department officials regarding the introduction of private charges legislation which, for the first time, will charge private patients the full cost of their use of public beds.

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The Minister has made it clear to the health insurers, through the above forums, that he believes significant savings can be made, ultimately reducing the impact of rising health costs on health insurance premiums for the consumer.

The Health Insurance (Amendment) Act, 2012 gave effect to a new permanent Risk Equalisation Scheme (RES), effective from 1 January 2013. This new scheme puts in place, for the first time in this country, a permanent and robust system of Risk Equalisation. It supports competition by encouraging insurers to move their focus away from avoiding older, less healthy customers and towards innovation, achieving greater efficiencies and improved customer service. The revised rates for 2013, announced as part of this RES, increase the support levels in respect of older and less healthy customers, so that health insurance will be made more affordable for them. The Department chaired three meetings of the Consultative Forum on Health Insurance in late 2012, at which the central focus was to discuss the details of the (then) draft Health Insurance (Amendment) Bill. These meetings provided insurers with an opportunity to participate in, and directly contribute to, discussions around the planned working of the Scheme and the Department was pleased to be able to use the Consultative Forum to consult with the commercial insurers for this purpose.

Last month, the Minister announced the appointment of an independent Chairperson, Mr Pat McLoughlin, to work with the Department and the insurers under the auspices of the Consultative Forum on Health Insurance. The Chairperson will oversee a process of review to give effect to real cost reductions in the private health insurance market. Specific areas that insurers will be asked to address include:

Audit - of the volume of procedures;

Clinical audit - to determine the appropriateness of procedures being claimed for;

Procedure based payments - in particular with a view to their extension to the public health sector and

Benchmarking - to determine the underlying basis for the cost of specific procedures, with a view to driving costs downwards.

The Minister is strongly of the view that all procedures should be provided at an appropriate setting that is safe and provides value for money for consumers. Mr McLoughlin, working with the insurers and officials from the Department, will be charged with identifying effective cost management strategies that all insurers can adopt, thereby ensuring the long-term sustainability of the private health insurance market.

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The continued participation of younger customers is important in keeping the health insurance market on a sustainable path. In addition to the work of the Forum, the Department established a Subgroup of the Consultative Forum earlier this year to consider regulatory issues relevant to the health insurance market, including proposals to encourage greater participation of younger, healthier people in the market.

The Minister believes that the appointment of an independent Chair to identify cost reductions, and the ongoing work of the Consultative Forum to address costs and promote the participation of younger customers, will have a positive impact on addressing rising health costs and health insurance premiums.

Question 18 (Senator John Crown)

The recent Ipilimumab (“Ipi”) issue has uncovered a number of dysfunctions:some private health insurance companies are not paying for the drug; in justifying the rejection of Ipi, Aviva referred to the NCPE’s assessment of the drug, an assessment which surely should be confidential to the client i.e. the HSE; the possibility of cartel-like activity amongst these health insurance companies. What is the Minister’s view on these dysfunctions?

Response:The Minister is familiar with the drug, Ipilimumab, which is used as a treatment for advanced melanoma in adults and is recognised internationally as a significant advance in the treatment of melanoma.

The National Centre for Pharmacoeconomic’s (NCPE) conducts the health technology assessment of pharmaceutical products for the Health Service Executive (HSE). With regard to the NCPE’s assessment of Ipilimumab, and whether it should be confidential to the client, the Senator will wish to note that, in the interests of transparency, these assessments are a matter of public record and are available on the NCPE's website.

In relation to treatment of patients in the public system, the HSE's National Cancer Control Programme (NCCP) has overall responsibility for providing access to appropriate cancer treatments that meet clinical needs, including emerging drug treatments. Last year the HSE/NCCP announced that Ipilimumab will now be made available for use by eligible patients and the Minister has previously welcomed this development.

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With regard to the treatment of patients in the private system, the main legislative provisions for the regulation of the Irish private health insurance market are included in the Health Insurance Acts 1994 to 2012. Minimum Benefit Regulations, made under the Health Insurance Acts, require insurers to offer a minimum benefit to every insured person. It is not the role of the Minister for Health to become involved in the day-to-day operations of any private health insurance company. Insurers are free to design their own health insurance schemes, within the parameters of the above governing legislation, and to enter into agreements with health service providers regarding the inclusion of particular procedures or treatments for payment, based on commercial and other relevant criteria/considerations.


What is the current status of my bill, Protection of Children’s Health from Tobacco Smoke Bill 2012?

Smoking in cars where children are present Last June the Government approved the principle of prohibiting smoking in cars with children present and approved the drafting of amendments to Senator John Crown's Private Member's Bill "Protection of Children's Health from Tobacco Smoke Bill 2012". The Department is working with the Senators in consultation with the Attorney General’s Office and the Department of Justice in progressing this legislation.


During the Seanad debate on Senator Quinn’s Public Health (Availability of Defibrillators) Bill 2013 you said that a health technology assessment was required for defibrillators. Considering that defibrillators have been in existence for 60years, exactly what type of assessment is planned or needed and how much will it cost?

Evidence suggests that the clinical benefits and cost effectiveness of a public defibrillation programme are strongly related to the likelihood that a cardiac arrest will occur at the location where the defibrillator is sited. There are, therefore, a number of questions that need to be considered when designing such a programme for Ireland including the quantification of clinical benefits, the identification of the appropriate sites for defibrillators and to address other organisational issues including costs. I have sought and received Government approval that the Health Information and Quality Authority undertake a health technology assessment of a public access defibrillator programme for Ireland. The advice from the assessment will inform my subsequent decisions on the design and implementation of a national programme. I also have approval to

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draft a general scheme of a public health availability of a defibrillators bill, subject to the health technology assessment. There is, therefore, a considerable requirement in defining the range of settings and events as well as monitoring and evaluating the provisions of a community defibrillator programme. The health technology assessment will address key issues in determining how we advance this programme.

Question 21 (Deputy Robert Dowds ) To ask the Minister to discuss the issue of day-beds in certain hospitals (e.g. Saint James' in Dublin) being taken up by A&E patients, and how is the issue being addressed?

Response:

The usage of day beds for temporary accommodation of Emergency Department patients requiring admission is only implemented during periods of extreme congestion within the Emergency Department. This action forms part of a structured escalation plan to reduce ED overcrowding, restore functionality and ensure more appropriate temporary patient placement

In relation to SJH, when designated day care facilities have been utilised, some level of day surgery treatment capacity is always maintained:

- 2013 Total Day Surgery treatments for period 3373 (representing 2.5% increase in comparison to 2012)

- 65 cancellations for period arising from temporary patient placements - these have all been rebooked and treated

The last occasion for usage of SJH day surgery facilities in this manner was 12.06.13

As the number of ED patients waiting on trolleys for bed accommodation reduces, so to does the requirement for temporary usage of day care facilities

- in terms of number of ED patients waiting on trolleys for bed accommodation (nationally) January - June 2011 / 2012 / 20131 there has been a significant ‘patient wait’ volume reduction demonstrated:

Period ED Patient Waiting

2011 / 2012 comparison



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Volume2011 46320 (19% reduction)2012 37433 (9% reduction)2013 33900 (27% reduction)

Notes1 - data source IMNO

Question 22 (Deputy Robert Dowds ) To ask the Minister to report on continuing delays with regard to Assessments of Need in Dublin Mid-Leinster and nationally, particularly concerning the psychiatric aspect of the assessment, and is clearance for additional staffing in this area being sought?

Staffing enhancement of Community Mental Health Teams The HSE, in its 2012 Service Plan, prioritised €35m and 414 WTEs for

reinvestment in mental health to progress the objectives in the Programme for Government. One of these objectives was to enhance General Adult and Child and Adolescent Community Mental Health Teams.


Of the 414 posts allocated in 2012, 389 posts have either been filled, or under offer or awaiting clearance. These posts include multidisciplinary team members across all the health professions..


Assessment of Need Process The assessment of need process is complex and the legislation is quite

prescriptive in respect of the definition of disability to be applied to potential applicants. Furthermore, the legislation also sets out clearly what an Assessment Report is expected to include and the time parameters within which the process as a whole is expected to be completed.

The HSE acknowledges that there is significant variation, between the different Local Health Office Areas, in the number of applications for a statutory assessment of need and in the number of these completed within the statutory timeframes. The HSE has placed particular emphasis on tackling the issues involved with a view to ensuring that all applicants for assessment

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under the Act receive their Assessment Report within the statutory time-frames.

There has been a very significant rise in overall activity around the assessment process in recent years in respect of the children now encompassed by the process. The number of assessment reports received in 2012 was 3,505 which is over 400 applications more than in 2010. It is worth noting that in the period 2010-2012, over 8,200 reports were completed.

While the HSE recognises that it faces significant challenges in respect of meeting the statutory time-frames which apply to the assessment of need process given the number and complexity of cases, it is endeavouring to address the issue from available resources.

While any delay in assessment or intervention for any child is not desirable, the assessment process under the Disability Act can take place in parallel with any intervention which is identified as necessary. The HSE has issued guidance to its staff that where there is a delay in the assessment process, this should not affect the delivery of necessary and appropriate interventions identified for a particular child.

In addition, targeted action plans have been put in place since early 2011. Measures have included: prioritising assessments, holding additional clinics, contracting the private sector to conduct assessments and reconfiguring resources to target areas of greatest need. These plans are monitored on a monthly basis by the HSE centrally.

In relation to Dublin Mid Leinster, a number of measures have been implemented to alleviate the position such as:

o support from voluntary partners in accessing assessment;

o enhancing the interview form to assist with the decision making process;

o assistance from other Local Health Officer;.

o use of private assessors, where necessary.

The issue of ensuring the appropriateness of referrals from CAMHs teams, in the context of the AON, is being addressed nationally.

The report commissioned from the National Disability Authority by the Department of Health and the Health Service Executive, endorsed the major emphasis being placed on reconfiguring disability services for children into geographically-based early-intervention and school-aged teams as part of the

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Progressing Disability Services for Children and Young People Programme which is underway.

The HSE is engaged in a reconfiguration of existing disability services for children and young people into geographically-based teams. The project is organised at national, regional and local level and includes representatives from the health and education sectors, service providers (statutory and non-statutory) and parents working together to see how current services can be reorganised. A detailed action plan is being implemented with the following objectives:

o One clear pathway to services for all children with disabilities according to need

o Resources used to the greatest benefit for all children and families o Health and education working together to support children to

achieve their potential

Based on the NDA’s research findings, it is expected that this re-configuration of services will have a significant impact on the HSE’s ability to meet the needs of children and young people in a more efficient, effective and equitable manner and, in particular, on the ability to comply with the statutory time-frames set out in the Disability Act and the accompanying regulations.

The Department of Health, the HSE and the NDA are engaged in discussion on how best to proceed, in light of the findings set out in this NDA Report.

All service developments have to be addressed in the light of the current economic and budgetary pressures, and Government policy to reduce the numbers employed in the public sector. This policy requires that by the end of 2013, the health service achieves a workforce of 98,955 whole-time equivalents. Staff appointments may be made only where an inescapable service need has been identified and which cannot be addressed by other means, such as the redeployment of staff or reorganisation of services.

The recently concluded Haddington Road Agreement has increased the working week of staff employed in the public sector. This will have the effect of increasing the overall staff capacity available to management to deploy in service delivery.

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Question 23 (Deputy Robert Dowds )

To ask the Minister to give an update on progress in securing funding for follow-on services for severely disabled people, so that they can be sure of being allowed to continue their education and development after they finish secondary school?

Response:

HSE Disability Services was allocated €4m full year costs in the National Service Plan 2013, in respect of demography funding. This funding is being allocated to each HSE Region based on the percentage of population.

HSE South 25.59% 1,023,600

HSE West 23.31% 932,400

HSE DNE 22.72% 908,800

HSE DML 28.38% 1,135,200

The recommendations of the National Working Group for the Review of HSE-funded Adult Day Services (New Directions) will guide the reconfiguration and modernization of HSE funded adult day services and will underpin the collaborative action in terms of flexibility and innovation when addressing requirements for school leavers in 2013.

Currently the National Disability Unit is liaising with the Regional Leads for Disability Services in terms of a cohesive and collaborative approach to meeting the needs of school leavers within the resources available.

In order to address this important issue additional targeted funding of €4m has been provided by the DOH to assist the HSE and it’s voluntary sector partners to support the delivery of appropriate places for school leavers and those graduating from training places in 2013. A guidance document was developed in 2012 to support service providers in addressing this issue and the arrangements being put in place in 2013 will again be based on this national guidance.

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Disability Managers across the four regions are engaged in a planning process in conjunction with relevant non statutory providers to address the 2013 school leaver and RT exit Day service needs per LHO/S Area. The main principle underpinning this interface is that the additional €4m funding together with the reconfiguration of services in line with the recommendations of the National Working Group for the Review of HSE-funded Adult Day Services (New Directions) will enable greater flexibility and innovation in addressing requirements for school leavers in 2013.

2013 position as of 17 th July

832 school leavers are presenting for services and 673 have been accommodated to date with 159 requiring a service.

473 individuals are exiting rehabilitative training with 400 accommodated to date and 73 remain to have placements confirmed.

CURRENT POSITION OF INDIVIDUALS ACCOMMODATED OR AWAITING PLACEMENT

NATIONAL TOTAL

DNE WEST SOUTH DML

SCHOOL LEAVERSNumbers of Placements Required 832 121 275 272 164Numbers Accommodated to Date 672.92 106 191 248.92 127Numbers Awaiting Place 159.08 15 84 23.08 37

RT PROGRESSIONSNumbers of Placements Required 473 54 132 173 114Numbers Accommodated to Date 400 50 79 161 110Numbers Awaiting Place 73 4 53 12 4

The National Disability Unit has been advised by the Regional Leads for Disability Services that those accommodated have been placed in line with their needs, which includes a fulltime place where required.

Work is continuing to secure appropriate placements for the remaining clients and every effort will be made to address the needs of the individual within remaining resources.

Funding of €3m has been allocated to Genio projects in 2013 and a process is underway to allocate this money; this will include some service provision to school leavers, however it also needs to address the movement of residents from residential settings and respite provision.

The HSE has agreed to provide briefings on the latest position to the Department of Health for the attention of the Minister of State every two weeks.

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Each HSE Region has identified a communication process subject to local requirements in respect of informing families of the service that will be available from September 2013.

Question 24 (Deputy Sandra McLellan )

To ask the Minister for Health, what actions he intends to take to the increase the number of perinatal psychiatrists, especially in light of the suicide clause in the ‘Protection of Life during Pregnancy Bill 2013’. Currently there are only three perinatal psychiatrists in the country whose combined work roster amounts to less one fulltime position; and if he will make a statement on the matter.

Question 26 (Deputy Sandra McLellan)

To ask the Minister for Health what steps he intends to take to improve perinatal services in the public health care system in light of the introduction of Protection of Life During Pregnancy Bill 2013; and if he will make a statement on the matter.

Response:

The Protection of Life During Pregnancy Bill 2013 provides that in cases where there is a risk to the life of the pregnant woman arising from suicide, three doctors are required to jointly certify the procedure. One of doctors must be an obstetrician/gynaecologist practising at an appropriate institution, and the other two will be psychiatrists, one of whom must practice in an appropriate institution and the other must practice at an approved centre or for, or on behalf of the HSE, or both. Furthermore at least one of the psychiatrists must have experience in providing mental health services to women during pregnancy, childbirth and after delivery.

This last requirement does not specify that one of the psychiatrists must be a perinatal psychiatrist but rather that the psychiatrist in question must have some experience in providing mental health services to women during the prescribed period. Therefore while perinatal psychiatrists meet the criteria to carry out assessments under the legislation other psychiatrists will also meet the requirements set out in the Bill.

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Where an individual with depression is pregnant or who has recently had a baby, they should be encouraged to present to their GP or Primary Care team in the normal way. Where an individual is assessed as requiring referral for specialist mental health services, their GP would refer to their local General Adult mental health service.

Where an individual is acutely ill, this may require them to be admitted to an Adult Acute Inpatient Unit, following which they would return to the care of the Community Mental Health Team and finally their GP.

In addition, there are three peri-natal Psychiatrists based at The National Maternity Hospital Holles St, The Coombe and Rotunda Maternity Hospitals reflecting the number of births at these centres each year.

There are 123 General Adult Community Mental Health Teams nationally. The HSE, in its 2012 Service Plan, prioritised €35m and 414 WTEs for reinvestment in mental health to progress the objectives in the Programme for Government. One of these objectives was to enhance General Adult and Child and Adolescent Community Mental Health Teams.




Question 25 (Deputy Sandra McLellan)To ask the Minister for Health following the Inspector of Mental Health Services comments in the Mental Health Commission’s Report 2012 that overall compliance with regulation, rules and codes of practice in 2012 can only be regarded as fair with no significant improvement on previous years, what steps he intends to take to address this critique; and if he will make a statement on the matter.

Response:

The Inspectorate of Mental Health Services performs an essential function in monitoring compliance with the regulations, rules and codes of practice applying to the conduct of mental health services. On a year to year basis the report of

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the Inspector indicates areas of improvement and areas for improvement on a service by service basis as well as summarising the national picture.

Governance and National DirectionIn his Annual Report for 2012, the Inspector has raised concerns about governance and the national direction for the mental health services.

Mr Stephen Mulvany has been appointed by the HSE as National Director Designate, Mental Health Services. In this role, he will have the management leadership and budgetary responsibility for the HSE’s mental health services.

Each of the HSE’s mental health services have a highly skilled professional workforce operating under the direction of an Executive Clinical Director (ECD). The first ECDs were appointed in 2009 and competitions are currently being held for the appointment of the next group of ECDs throughout the country.

Staffing The Inspector expressed concerns in respect of numbers of nursing staff. A Vision for Change prescribes 3,800 psychiatric nurses for the mental health services nationally and at the end of May 2013 there were 4,642 nurses in the mental health services.

Training and Supervision.The HSE, in its 2012 Service Plan, prioritised €35m and 414 WTEs for reinvestment in mental health to progress the objectives in the Programme for Government. One of these objectives was to enhance General Adult and Child and Adolescent Community Mental Health Teams by recruiting health and social care professionals as recommended in Vision.

The HSE, in its 2013 service plan intends to build on this investment with a further €35m and up to 477 WTEs in 2013, to, among other things, strengthen General Adult and Child and Adolescent Community Mental Health Teams.



To support the development of Community Mental Health Teamworking, significant resource has been provided to maximise the benefits and effects teamworking with the development of the Enhanced Teamworking programme to

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support community mental health teams to maximise effective teamworking. 45 facilitators have been trained from within the HSE to work with community mental health teams in supporting their development.

Risk ManagementAll mental health services maintain a risk register and plan and implement control measures to ameliorate those identified risks. The priorities identified for the investment in the mental health services over the past two years were informed by the content of national mental health risk register.

The HSE shares the Inspector’s view that family members should be actively included in the care process where the service user so permits and have actively worked with service users and family members on a range of initiatives to build capacity. These include:-

1. The co-operative learning leadership programme with DCU which trains the service user, family member and health professional together in leading on a service improvement initiative within their own service,

2. Encouraging the development of the Trialogue model where the service user family member and professional are working together to fully recognise families and their supportive role in the recovery journey.

Geographic variationsThe Inspector has noted geographic variations in mental health services. Historically, there were 40 separate mental health services operating under distinct management structures. In line with Vision recommendations, this has been restructured nationally into 17 extended catchment areas which are coterminus with the ISA structure.

Under the new National Director, there will be greater opportunity to reduce regional variation. The National Clinical Programmes are also aligned to this objective.

Services for Young PeopleHSE has placed a particular focus on services for young people, investing in community mental health teams and inpatient facilities and, as committed in NSP2013, additional inpatient CAMHS capacity will be available later in 2013.

Examples of Good PracticeIn his Report, the Inspector commends examples of good governance and progressive service reform citing the closure of the traditional psychiatric hospitals where there was active inclusion of the service users in achieving this objective and where staff at all levels of the service were included also in transition planning.

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The Inspector also recognised that, in a constrained resource environment, we are required to redouble our efforts to ensure all available resource is recast and utilised to maximum benefit in line with the recommendations of Vision. The flexibility provided by the Public Service Agreement and that provided more recently with the Haddington Road Agreement, provide the tools for supporting such change.

Question 27 (Deputy Denis Naughten )

To ask the Minister for Health & the HSE to outline the steps which are being taken to address staffing and related issues within the Psychiatric Services in County Roscommon

Response:

The mental health service is managed as a single service across the two counties with three acute units; Roscommon, Ballinasloe and University College Hospital Galway. If one acute unit has reached its maximum operational capacity because of the level of the patients' illnesses then incoming patients receive their treatment in one of the neighbouring units. This is normal practice in acute mental health units across Ireland.

Acute unit staff levels in Roscommon are reviewed on a daily basis to reflect the requirements of the patients, which can change based on their particular mental health needs and the numbers of patients in the care of the service.

There are 22 psychiatric nursing posts assigned to the Acute Unit in Roscommon County Hospital. Currently in the acute unit there are two staff on sick leave and a further three staff on maternity leave.

To overcome this temporary deficit in staff numbers, the Executive Clinical Director, Clinical Director, Area Director of Nursing and the Area Manager ensure that the staff resources across the Galway/Roscommon Mental Health Services are deployed in a flexible manner.

Galway/Roscommon Mental Health Services was successful in securing a significant number of new development posts in both 2012 and 2013. There are 44 new posts in total with 11 assigned to Roscommon (14% increase). These new posts are being used to enhance community mental health teams and to address suicide/self harm and emergency departments. A key development is the introduction of Psychiatry in Later Life mental health team – a first for Roscommon – this is being finalised and will be in place by the end of 2013.

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Given the current restrictions on employing staff and the economic climate this is a major development for Roscommon.

A mental health intensive care unit for the HSE West area is included in the Capital Development Plan. This will cater for patients who have higher dependency needs and challenging behaviour, but will involve a new build development. As an interim measure the HSE is currently working to put in place a higher dependency unit to support patients who have more intensive needs. Discussions are underway to progress this.

Currently there are 79 beds in the Galway Roscommon area which is above recommended level of 50 beds for this area. There are enough resources in Galway/Roscommon to meet the needs of the patients but the deployment of staff will have to change in order to deliver the services in line with Vision for Change.

A key priority for Vision for Change is to reduce hospital admissions, provide more services in a community setting and move towards a holistic service. This will reduce stigma and provide mental health services that prevent serious illness using new models of treatment; counseling; psychology and behavioral therapies.

Vision for Change is about moving away from the old model of mental health care – institutionally based – and towards a modern, holistic mental health service. We have the resources to implement Vision for Change to give better outcomes for patients and the key priority is to make that happen.

Question 28 (Deputy Ciara Conway)

To ask the Minister if he will provide a full update on palliative Care services for Waterford and the South East

Response:

Palliative Care – Development in the South East

The HSE South Regional Service Plan outlined the phased approach to the development of this service involving collaboration between HSE South, Waterford Regional Hospital and the Hospice movement.

The important role played by the Hospice movement, voluntary service providers and support groups as key partners with the HSE in supporting the effective delivery of services is fully recognised and appreciated and HSE South has

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fostered a partnership approach with the voluntary sector in palliative care medicine in the region. Significant work has been underway across the region over the past number of years to develop a number of key projects which, when implemented, will significantly improve the range and quality of services in the field of palliative medicine in the region. The HSE South, in collaboration with voluntary partners will progress the following significant regional initiative in Waterford:

Regional Specialist Inpatient & Day Service in Palliative Medicine at Waterford Regional Hospital (WRH)

The Regional Service Plan outlined how, the HSE South, in collaboration with Waterford Hospice Movement Ltd. and Waterford Regional Hospital (WRH), will progress to design stage, the planned development of the 20 bed Regional Specialist Inpatient Unit & Day Service in Palliative Medicine as part of an integrated development in WRH. This development is founded on the “Palliative Care Services: Five Year Development Framework 2009-2013” (HSE 2009). The Unit will act as a focal point for delivery of specialist palliative care inpatient, day services and community services to patients and their families in South East (population 497,000). The revenue cost for the palliative development, on completion, will be provided by the HSE South. Waterford Hospice Movement Ltd are significantly supporting the capital cost of the development and have collected €2.5m to date.

The Unit will be accommodated in the first two floors (both 900 sq mtrs) of an overall five storey integrated development in WRH. The ground floor will accommodate 20 single inpatient rooms and ancillary accommodation. The second floor will accommodate a Day Care Unit, consultation rooms, treatment rooms, therapy area, dining area and ancillary accommodation.

As outlined in the service plan the advertisement for the design team proceeded as planned and the design team will be provided shortly and thereafter, the next step will be to proceed to secure planning and all the pre-tender stage work which will take approximately 9 months.

Question 29 (Deputy Mattie McGrath)

Is the Minister aware that the level of overcrowding due to ward closures in South Tipperary General Hospital is profoundly undermining the effective provision of quality Healthcare and will he act to reverse these cuts particularly since South Tipperary General requires more Government funding due to the hundreds of extra patients from North Tipperary it is now treating arising from the reconfiguration of hospital services in the Mid-West Region?

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Response:

South Tipperary General Hospital (STGH) is a 197 bed (172 Inpatient and 25 Day) Level III Acute General Hospital providing Emergency Department, General Medicine, General Surgery, Obstetrics / Gynaecology, Paediatrics, and Day Case Oncology services to the catchment area of South Tipperary, West Waterford and part of North Tipperary. Whilst the catchment population for the South Tipperary area is 88,432, individual specialty catchment populations can increase to approximately 130,000. Outreach clinics are provided at several locations including Thurles, Tipperary Town and Cashel.

In relation to the resourcing of the hospital, as part of the National Service Plan 2013 a rebalancing exercise has been undertaken which seeks to ensure more sustainable budgets within the hospital sector which has struggled in recent years to break even. In this regard the budget at South Tipperary General Hospital was rebalanced by an additional allocation of €4.825million which can be broken down as €3.722m from rebalancing of hospital budgets and €1.103m from income adjustment. The rebalancing of budgets is just one part of a comprehensive programme of reform within the hospital sector as outlined in the government’s “Future Health” strategy. The focus within the hospital is now in the continued implementation of the National Clinical Programmes for scheduled and unscheduled care. Work is currently underway with the Special Delivery Unit in this regard.

South Tipperary General Hospital has experienced an increase in Emergency Department Trolley numbers since October 2011. In 2012 there was an 8.3% increase in Emergency Department presentations as a result of an increase in GP referrals and Ambulance presentations. This resulted in a 12.4% increase in Emergency Admissions to inpatient beds.

With the aim of addressing increased patient activity within the Emergency Department, the hospital in association with the Special Delivery Unit implemented a number of initiatives. The hospital continues to implement the Acute Medicine Programme and in this regard the Acute Medical Assessment Unit opened in January 2013 with a view of providing acute medical assessment for patients facilitated by a senior decision maker. The hospital opened a 10 bed short stay unit in November 2012 and an additional 5 temporary beds in January 2013 with the aim of providing additional capacity to meet demand and address the Emergency Department trolley challenge. As a result of this, all beds previously closed in South Tipperary General Hospital since 2011 have now reopened. An Unscheduled Care Manager is in place to manage patient flow throughout the hospital in an effort to ensure capacity is managed and decrease the number of patients on trolleys. In conjunction with this, hospital management

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and clinical staff hold a number of meetings on a daily basis to monitor and evaluate the ED Situation.

South Tipperary General Hospital delivers services to a diverse population however, 37% of the patients who were admitted to the hospital between the months of January to June 2013 were over the age of 70 years. This group of patients is of a higher level of acuity and requires a longer hospital stay. A combination of the number of Emergency Department presentations and the complexity of these presentations has further increased the challenge to the hospital to manage capacity.

Historically a small number of patients from the North Tipperary Area would have attended South Tipperary General Hospital. A comprehensive analysis of the overall number of presentations from the North Tipperary Area was undertaken in September 2012 comparing January to September 2012 against January to September 2011. Analysis of the overall total number of North Tipperary patient presentations to South Tipperary General Hospital has demonstrated that North Tipperary Patients permanently occupy an average of 21(13%) of the total inpatient compliment. Additional nursing resources are provided in the Emergency Department as required to ensure patient care and safety needs are met.

Admissions North Tipperary by Speciality – January – September 2012

Patient care is paramount in South Tipperary General Hospital and in this regard the Emergency Department situation within the hospital is treated as a priority and reviewed continuously by Hospital Management.

Hospital Management wish to acknowledge the hard work and dedication of all staff during this busy time, who try to ensure that all those waiting for treatment and admission are accommodated in a manner that is dignified and respectful in the circumstances.

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Question 30 (Deputy Mattie McGrath)Will the Minister acknowledge the ineffectiveness of his plans to reduce trolley waits under the Special Delivery Unit (SDU) initiative which was inaugurated last year, particularly in light of the fact that South Tipperary General currently has the third highest level of patient to trolley ratio in the country according to the INMO?

Response:

The SDU was established by the Minister of Health in 2011. Its purpose was to enable and ensure improved patient flow through out the Health delivery system. Particular focus being given to the necessary reduction in the number of patients waiting for admission within Emergency Departments

Over the period 2011-2013 significant ED ‘patient waiting’ volume reductions have been demonstrated nationally1

Period ED Patient Waiting Volume




2011 46320 (19% reduction)

2012 37433 (9% reduction)2013 33900 (27%

reduction)

Notes1 - data source IMNO

This performance improvement is directly attributed to:- constant SDU engagement with all hospitals- SDU daily on-line monitoring of patients waiting for admission, on a national

basis, three times daily, 7 days per week, 365 days of the year- a focus on driving and enabling Hospital internal process improvement and

necessary internal ‘escalation’ actions for managing peak activity periods- combined input and support from SDU / HSE - Clinical Programme (Medicine)

particularly in relation to improved management of presenting patients with medical conditions

In relation to South Tipperary General Hospital, it is clear that this hospital has experienced an increase in the number of ED patients waiting for admission particularly during May - July of this year1

Average number of patients waiting daily (ED) @ 08.00 April 2013 - 8.8Average number of patients waiting daily (ED) @ 08.00 May 2013 - 13.9Average number of patients waiting daily (ED) @ 08.00 June 2013 - 13.5

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Average number of patients waiting daily (ED) @ 08.00 July 2013 - 14.0Note1 - data source IMNO

Performance deterioration in terms of increased number of ED patients waiting for admission can be partially attributed to the unexpected resignation of 3 NCHDs in April. This resulted in less than optimal functionality of the Acute Medical Unit

To address this staff deficiency there has been a continued usage of agency staff and the direct recruitment of a full time Consultant Physician commencing 22.07.13. As well 4 NCHD (Medical Registrars) have now accepted contracts and are due to commence in July.

Performance in terms of ED patients waiting for admission and functionality of the Acute Medical Unit will be closely monitored for the remainder of this year by the HSE

Question 31 (Deputy Mattie McGrath)

Will the Minister explain why South Tipperary General Hospital is a nominated institution in which abortions of unborn children may be carried out and is he aware of the deep level of resistance by staff to such a practice being initiated at the Hospital under the proposed Protection of Life during Pregnancy Bill 2013?

Pending the introduction of a licensing system of health facilities, the bill provides that public obstetric units and a small number of large multi-disciplinary hospitals with intensive and critical care will be the appropriate locations for the provision of this medical treatment. South Tipperary General Hospital is one such obstetric unit and is therefore included in the schedule.

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