16 January 2014: Quarterly Meeting of the Joint Committee on Health and Children, the Minister for Health James Reilly TD and the HSE.

Question 9: Registered Nurse Prescribers
Question 10: Cardiac Rehabilitation Services
Question 11: Neuro-Rehabilitation Services 

Question 9: Registered Nurse Prescribers

To ask the Minister for Health the reason for the HSE policy that Registered Nurse Prescribers who work in private healthcare facilities including nursing homes are not issued with prescription pads; if he would agree that this discriminates against qualified registered nurse prescribers working in private facilities and may impact on patient care by preventing timely symptom relief for residents with medical cards living in private and voluntary nursing homes where access to a GP may not be immediately available; and if he has plans to ask the HSE to change this? 

Professional guidance is already in place with regard to scope of nursing and practice and specifically in relation to nurse/midwife medicinal product prescribing.  Nurse/midwife medicinal product prescribing has been in place in Ireland since 2007 underpinned by (a) legislation, and (b) the NMBI regulatory framework. There are currently 650 registered nurse prescribers.

The issue in question is the requirement for access for nurse prescribers in private nursing homes to primary care prescription pads for the purposes of GMS reimbursement for medical card holders. This is a matter primarily for the HSE to determine.
The Department supports, in principle, nurse prescribers in private nursing homes having access to primary care prescription pads, subject to robust governance and accountability structures being put in place. The provision of nurse prescribing services in nursing homes would greatly enhance continuity of care from the hospital sector through to the nursing home sector. Medicines legislation currently in place does not differentiate between prescribing by nurse prescribers in public or private setting. Nor does it deal with reimbursement under the Community Drugs Schemes of prescriptions by nurses.
The issue of reimbursement through the Primary Care Reimbursement Service (PCRS) is a matter that will be progressed through engagement with the HSE by the Primary Care Division in this Department.


In light of Irish Heart Foundation and Irish Association for Cardiac Rehabilitation survey showing serious staffing deficits in cardiac rehabilitation services in all hospitals providing this service nationally, is the Minister concerned that these services cannot therefore maximise their life-saving and quality of life-saving capability 

Rehabilitation is the phase following acute medical intervention, during which structured approaches to halt or slow progression of the underlying health condition are undertaken and where the patient is enabled to return to an optimal level of physical, psychological and social well-being. Rehabilitation goals focus on recovering lost function and reconditioning, reducing the risk of a recurrent event (secondary prevention) and optimising quality of life. To be effective, rehabilitation must start as soon as the patient is stabilised in the acute medical setting. Rehabilitative care should be integrated across acute, out-patient and community services, to include access to both intensive acute rehabilitation and long-term follow-up.

The development of cardiac rehabilitation services were accelerated under the National Cardiovascular Strategy and the Building Healthier Hearts (BHH) initiative from 2000 onwards. The BHH identified ten recommendations and three implementation measures for cardiac rehabilitation. These recommendations identified the need for a cardiac rehabilitation service in all hospitals that treat patients with heart disease, which would be multi-disciplinary, exercise based and involve family members. During the years 2000 to 2005, €72 million was invested for the development of cardiovascular services in line with the recommendations of Building Healthier Hearts.
The HSE is aware of the findings of the study by the Irish Heart Foundation and the Irish Association for Cardiac Rehabilitation. Cardiac rehabilitation is an important and significant part of the recovery process for patients who have experienced an ischemic event. As the report acknowledges, the number of patients attending cardiac rehabilitation services has significantly increased whilst demand for services has also continued to increase.

The report confirmed that following the expansion of cardiac rehabilitation services under the cardiovascular strategy, most services have many members of the clinical team in place. The report states:

· all services have a medical director in place
· all but two services have a designated rehab co-ordinator with 30 of the 34 services having a full time co-ordinator in place
· the majority of services have access to nursing and dietician services.
· requirement for further focus on integrating psychology services given the important and specialised role such professionals play in the rehabilitation process
· significant gaps in dedicated access to social work and occupational therapy services

It should be noted that where dedicated social work and occupational therapy services are not available to the cardiac rehab team, medical staff within hospitals have the ability to refer patients to the general social work and OT services of the hospital.
Although the report identifies staff cut backs as a significant service issue, the largest category of staff vacancies related to maternity and sick leave. In such cases, staffing returning from maternity or sick leave will resume providing services as part of the cardiac rehabilitation unit and therefore should not be considered a staff cutback. Similarly, the previously invested budget in cardiac rehabilitation services continues as part of the overall hospital budget. There have been no targeted reductions in cardiac rehabilitation budgets and hospitals will continue to manage this and all hospital services in line with their overall budget for 2014.

However, the report does highlight the need for further actions to ensure continuity of cardiac rehabilitation services where important clinical support services are not available for the reasons identified in the report (i.e. maternity leaves, retirements, transfer of staff, etc). Similarly, it is anticipated that demand for cardiac rehabilitation services will continue to grow requiring all units to be able to respond to increased levels of referrals in the future. The National Director of Acute Hospitals will further progress this area over 2014 utilising the findings from the report particularly focusing on required improvements in waiting lists, access to allied health professionals and levels of patient enrolment in programmes. The integration of pathways between cardiology services and referral to cardiac rehabilitation services is also another area which the HSE will focus on to ensure greater levels of access for patients requiring such service. As part of the reorganisation of services in the future, there will be opportunities to develop single site services into larger multi-site services which can share development opportunities and achieve greater economies of scale to the benefit of patients. As an example, the University of Limerick has its Clinical Operations Group currently working to develop a single clinically governed cardiac rehabilitation service that will be available and operate across the acute hospitals in its region.

In parallel, the HSE will also be expanding the range of services available to patients who experience ischemic events through initiatives implemented via the clinical programmes. For example, the National Clinical Programme for Heart Failure aims to reorganise the way heart failure (HF) patients are managed across the health service rolling out a co-ordinated, multi-disciplinary and patient focused disease management programme. The initial focus of this work has been on the creation of dedicated hospital centres where care and expertise in HF is concentrated. The programme also aims to develop appropriate support services for patients to be managed in the community and is currently working on a number of initiatives to advance this. To date structured heart failure services have been implemented in 11 sites under the HSE’s National Clinical Programme for Heart Failure.

Question 11: Neuro-Rehabilitation Services 

What progress has been made on the development of the promised implementation plan in relation to the National Policy and Strategy for the provision of Neuro-Rehabilitation Services in Ireland 2011 – 2015

The National Neuro-Rehabilitation Strategy made a number of recommendations for services for people with rehabilitation needs that covered a range of types of provision including: clinical, therapeutic, social , vocational and community supports.

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. 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 Division 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 Division 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.

Demonstration sites have been identified by Disability Services and mapping has commenced.

The Rehabilitation Medicine Clinical Programme and the HSE Disability Services Division will jointly agree an implementation plan for the Neuro-rehabilitation Strategy, the first draft of which has been completed and is undergoing a process of refinement before finalisation.

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