Seanad Order of Business: MRI Scanners for Children

Senator Jillian Van Turnhout: I wish to raise the issue of the MRI scanner for children in Our Lady’s Children’s Hospital, Crumlin and the associated waiting list for children. The scanner has broken down, and I believe this is not an irregular occurrence. It broke down at least one week ago but no contingency plan is in place to manage the care and assessment of children. My understanding is that there are only two MRI scanners for children in Ireland with the appropriate medical support, one in Crumlin and the other in the hospital in Temple Street. Children require a general anaesthetic. The result is that the waiting list in Crumlin currently stands at 28 months and I do not know the length of the list for Temple Street – perhaps the Minister can enlighten me. I understand the list is divided between the two hospitals.

I wish to share a case with the Minister of State. Obviously, I will not disclose the name of the person on the floor of the Seanad, but I am happy to provide it to the Minister of State. It is very illustrative of why this is such a critical issue.

One young boy, who is now six years of age, when aged three had symptoms including very poor balance, being tired and lethargic and the development of a tick in his head. His parents were able to afford to bring him to a neurologist on a private basis. The neurologist advised them that the child probably had flat feet and questioned whether something was happening in the home which caused him to develop the tick. Thankfully, the mother insisted on the scan. The neurologist was reluctant to put the child forward saying the child was not an urgent or high priority case. Given that there are only two MRI scanners, at that time the waiting list was eight months.

The child went for an MRI scan over two and a half years ago on a Friday morning and the parents were advised that they could receive the results in about four to six weeks. They were in the recovery room 30 minutes later and a team of medical staff surrounded the bed. The team said a brain tumour had been found and a biopsy needed to be done, the earliest opportunity for which was Monday. The first test was done on the biopsy on Monday and the parents were told there was an 80% likelihood that the child had cancer, but the results were inconclusive and a second, more intrusive, test needed to be done, and was done two weeks later. The further test found that it was a low-grade tumour which required regular monitoring but, thankfully, was not cancerous.

These parents initially brought their child for three-month checks, and then tests on a six-month basis to establish a baseline and ensure they could monitor the situation. At a six-month scan in April 2014, they were told that they were not allowed to leave the hospital as the child had developed hydrocephalus. He was transferred by ambulance to Temple Street, monitored overnight and had surgery the next morning. The parents advise me there were no obvious signs in the lead-up to that test in April 2014 and nothing made them feel that the test would be any different.

The child has scans every six months. Last Friday he was due to have his next six-month scan, but the parents were told on Tuesday last week that the machine was not working and it would take two weeks to get a part from Germany, which is mind-boggling – I would get on a plane and get the part. They were advised that the new appointment would most likely be in early 2016. Thankfully, because of the pressure the child’s mother applied and, I imagine, the debate we are having here today, she received a call yesterday to say the child would have an appointment early next week.

I am thinking of all the other parents out there. This is a low priority, non-urgent case involving regular monitoring. How many other children are low priority? How many other parents have been told that their children’s cases are not urgent and, therefore, they are on a waiting list? As I said, the waiting list is very long. Why are MRI scanners for children not in operation seven days a week? It would give parents assurance if an MRI scanner did not show anything of concern. A wait of 28 months to find out whether something is wrong is unacceptable.

The parent who contacted me is obviously concerned for her child, but in her generosity is extremely concerned not only for the children lucky enough to be in the system but those on the impossibly long waiting list. I have been told by a senior source in Our Lady’s Children’s Hospital, Crumlin, that children requiring a general anaesthetic, usually those aged under 12 years, face a waiting list of 28 months.

Over the past two days I have discussed this issue with a number of friends. I could not believe the number who shared frightening cases they knew directly or of friends’ children who are on the waiting list to ensure their children can get MRI scans. Over the past three and a half years waiting lists have increased from eight to 28 months. Even eight months is far too long, but the parents to whom I referred were told their child’s case was non-urgent and not a priority, it was likely the child has flat feet and something was happening at home. They were able to afford to go an alternative route, but I want to know the situation regarding the MRI scanner for children in Ireland and the length of the waiting list.

Deputy Joe McHugh: thank the Senator for raising this issue. I am taking this matter on behalf of my colleague, the Minister for Health, Deputy Leo Varadkar, who is elsewhere on Government business. I want to reassure the House about the MRI scanner in Our Lady’s Children’s Hospital, Crumlin. I understand some concerns may have been raised last week about whether the machine is in working order. I am happy to advise the House that the MRI scanner was fully operational last week, other than on Friday, 13 November, when scans were postponed to allow for repairs to be carried out on the machine. The repair on Friday affected five patientSLOTS and these scans have been rescheduled for this week. MRI scans recommenced fully on Saturday. Appropriate contingency plans were put in place by Crumlin hospital, with Temple Street hospital, for any emergency cases that might have arisen on the Friday while the machine was being repaired. On the broader issue of waiting times for MRI scans at Crumlin hospital, the capacity to provide these scans is, as the Senator pointed out, under pressure. Referral patterns reflect the tertiary paediatric nature of services provided in the hospital. The oncology specialty generates the largest portion of MRI activity. Crumlin hospital also provides the only paediatric cardiac MRI service in Ireland. The unit takes consultant referrals from local maternity hospitals and from hospitals nationally where paediatric MRI with general anaesthesia for younger patients is required. Demand for MRI services is steadily increasing from all specialties. In this context, particular attention has been paid to optimising existing capacity and managing demand through clinical triage. MRI capacity at Crumlin hospital has increased in recent years and is at almost 2,000 scans per annum. This compares with 1,600 scans in 2011. The MRI service now operates for 37 hours per week and staff are available to provide lunchtime cover as demand requires it. In addition, a service is provided from 8 a.m. to 3 p.m. on Saturdays, which is suitable for those patients who do not require anaesthesia or sedation. This has improved access and decreased the waiting list.

To maximise capacity there is a strong focus on active local management of appointments, with the result that did not attend, DNA, rates are extremely low. Triage is also a key element in managing demand and preventing inappropriate referrals. Under the triage process, between six and 14 referrals weekly are triaged as urgent and these are dealt with as soon as possible. Unfortunately, however, patients from specialties other than oncology and cardiology who require a general anaesthetic and who are categorised as routine experience long waiting times of between 15 and 27 months. I emphasise that the Government sees this as unacceptable and acknowledges the difficulties which delays cause for patients and their families.

Crumlin developed a business case for resources to increase capacity and submitted it for consideration in the context of the current service planning process, which is still ongoing. The HSE and the Department of Health continue to work together to address waiting times for diagnostic services, including MRI, and to ensure appropriate collection and reporting of MRI waiting times.

Senator Jillian van Turnhout: I thank the Minister of State. Obviously, somebody is telling somebody untruths because why would those at Crumlin hospital have telephoned the mother I mentioned on Tuesday and said the machine would be down for two weeks? For me, there are serious questions to answer. I am not questioning the veracity of what the Minister of State said but I am concerned that the truth is not being told. How do we actually know this is urgent? The Minister of State spoke about the routine waiting list of between 15 and 27 months. My reference to a 28-month waiting list is probably more accurate. I know the Minister of State is a parent and that he understands what it is like for parents to worry about a child. I welcome the fact that the Government sees this as unacceptable. I will continue to monitor it because I find it totally and utterly unacceptable that we are asking parents to wait this length of time to be reassured or to ensure their children get the correct and appropriate treatment. We know the importance of early intervention and prevention, particularly in the lives of children, and we need to increase the pressure in respect of this matter. I hope the business case will be put through and we will ensure children are seen in a timely manner. The case I have raised today was routine and the neurologist did not wish to refer it. How many other children are like this?

Deputy Joe McHugh: I appreciate the Senator raising this extremely important matter. I do not doubt that her contact with the parent concerned will have highlighted to her the obvious distress the family went through. Statistics are statistics and, unfortunately, demand for the MRI scans increased from 1,600 in 2011 to 2,000 per annum at present. The Minister is not using statistics as an excuse. However, he will use them to try to improve the service and I have no doubt he will ensure that, where possible, resources will be directed to where they are needed. I will certainly convey the Senator’s message to the Minister and I thank her for raising the issue.

Senator Jillian van Turnhout: I thank the Minister of State.

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

Questions submitted in advance by Senator Jillian van Turnhout and response received:

Question 9: Work undertaken by the HSE’s National Oversight group

Question 10: Allowing Pronouncement of death by advance Paramedics

Question 11: Poor performance in Children’s rights alliance report card 2014

 

Question 9: Work undertaken by the HSE’s National Oversight group

To ask the Minister to outline the work undertaken thus far by the HSE’s National Oversight Group that was set up to coordinate a response to requests for day service or rehabilitative training places for young adults with a disability, and to detail particularly the work undertaken in engaging with young people who require these services and their family members.

Revised Process to support School Leavers and those exiting Rehabilitative Training 2014

In line with the Social Care Division Operational Plan 2014, a revised process is being implemented this year to ensure a more streamlined approach to the assignment of places to School Leavers and those exiting RT places. A summary of key elements of the process is outlined below:

 

  • Providing for the emerging needs of the estimated 1,200 additional young people leaving school and rehabilitative training programmes using a newly developed streamlined approach (€7m and 35 WTE) and for emergency cases (€3m and 15 WTE).

Implement a standardised process to:

  • Identify, in conjunction with the Dept of Education and service providers the young people who will be leaving school or exiting a RT Programme who have a requirement for ongoing HSE-funded supports by 1st February, 2014.
  • In respect of those identified as having a requirement for ongoing support, identify and agree the supports required, with a specific focus on responses to those who have complex service needs.
  • Identify the service providers with capacity to respond to the individuals who require support by 1st April, 2014 and agree the allocation of additional resources in respect of individual placements as required.
  • Advise the school leaver and their families of the placement location and service they will be receiving in September, 2014.  Notification of placement will commence in May and all families will be advised no later than the 30th of June.
  • Implement a communications process with all stakeholders.
  • Building on the learning from 2014 review and refine the process for engagement and implementation in 2015.

 

An important aspect of the new process has been the establishment of a National Oversight Group, consisting of representatives of umbrella organisations, representing the Disability Service Providers, service user representation and senior staff from the health service. In addition, the health service has assigned a full-time Project Lead to work to co-ordinate the implementation of the Project in 2014.

Work has been ongoing on the 2014 process since October/November 2013. The Oversight group met and agreed the timelines. A template was agreed for collection of information regarding each individual seeking to access health funded services. A letter was circulated by the National Council for Special Education to all mainstream schools to ensure that individuals with disabilities and their families would be aware of the revised process. The Health Service Guidance officers engaged with the special schools directly. The National Disability Governance Group, which includes Lead Area managers and disability specialists meets monthly and receives updates on progress.

Following the meetings of the Oversight group the Regional Disability Specialists/Disability Managers engaged with local service providers to ensure a complete profile of each individual seeking to access service was submitted.

Each application is being reviewed to establish if the applicant is appropriate to specialist disability services, has the capacity to attend rehabilitative training programme or attend day services.

In relation to engagement with service users and their families the position is that in Dublin for example Individual meetings have occurred with the following:

a) School Leavers

b) Parents/Guardians

c) Teachers/Principals

d) Clinicians/Health Care Professionals (as appropriate)

 

Continuous communication with school leavers and parents/guardians on any issues or concerns arising regarding transition from school are ongoing with the Guidance service.

I am pleased to report that the deadlines set in the Operational Plan have been met in that in excess of 1400 applicants were received by February 1st 2014. The next milestone is 31st March and Disability Services are online to meet that target date where a review of service users’ needs and current service provision will be completed.

Tbe process commenced on October / November 2013

  • We achieved an agreed approach across the disability sector.
  • We will identify and implement a prioritisation process by the end of April 2014
  • We will consider appropriate placement options by end of May 2014
  • We will advise Individuals/Parents/Guardians of placement no later than 30th June 2014

A summary of the current position is that:

A total of 1407 number has been identified, 905 school leavers, 427 RT exits work is continuing on a further 75 who have been classified as other or no category.

Throughout the engagement a range of challenges continue to arise as the process is streamlined. The process is flexible enough to address many of these however a consistent theme that is emerging relates to some locations where the physical infrastructure is at maximum capacity and alternative accommodation will need to be identified. The health service is committed to appropriately supporting this group of young people to ensure that optimum outcomes are achieved

 

Question 10: Allowing Pronouncement of death by advance Paramedics

To ask the Minister for Health/HSE to give an update on progress regarding allowing pronouncement of death by advanced paramedics (as is allowed in other jurisdictions but currently not in Ireland) as recommended by the Pre-Hospital Emergency Care Council, and on allowing pronouncement of death by senior nurses. 

 The Pre-Hospital Emergency Care Council (PHECC) is responsible for clinical practice in pre-hospital care. PHECC approves clinical practice guidelines (CPGs) for all aspects of the clinical work of registered paramedic practitioners in Ireland.

There are two key PHECC CPGs in relation to the death of a patient – for recognition of death and for cessation of resuscitation. The procedures set out in these guidelines allow practitioners to cease treatment and resuscitation where a patient cannot be revived.

Currently, Irish paramedics, unlike paramedics in other jurisdictions, do not pronounce death. After a paramedic makes a clinical decision to cease treatment, a medical practitioner is required for pronouncement of death.  I am advised that PHECC is examining this issue through the Forum on End of Life in Ireland, with a view to engaging in broader consultation on this matter and developing appropriate and recognised clinical and legal procedures to resolve it.
The Nursing and Midwifery Board of Ireland (NMBI) is responsible for specifying standards of practice for registered nurses and midwives. NMBI has developed a Scope of Practice framework to enable decision making and development of practice for all aspects of a nurses’ clinical practice in Ireland. In addition NMBI provides guidance to nurses and midwives on their scope of practice and has published professional guidance to nurses regarding their scope of practice for pronouncement, verification or certification of death. The guidance outlined the processes required to develop an organisational policy to include the appropriate clinical governance supports and the professional responsibilities and authority for nurses to be involved with the pronouncement of death in a care setting. The HSE is consulting with the Directors of Nursing Reference Group on this matter.

 

Question 11: Poor performance in Children’s rights alliance report card 2014

To ask the Minister to give an update on the worrying E Grade his Department received for Mental Health in the Children’s Rights Alliance Report Card 2014, with emphasis on a number of key areas including the need to ensure all children under 18 receive age-appropriate and timely mental health services and treatment and can the Minister advise when the Child and Adolescent Community Mental Health teams will have the appropriate provision of in-patient beds and the 150 staffing posts filled to achieve this end. 

 

The Government has prioritised reform of all aspects of mental health services in line with A Vision for Change, including additional and improved quality care for children in both residential and community based settings. Total HSE Mental Health funding in 2014 is significant at around €766m. In this context, additional funding of €90 million, and around 1,100 new posts, has been provided over the last three Budgets. This has been primarily directed to strengthen Community Mental Health Teams for adults and children; specialist community mental health services for older people with a mental illness, improving services for those with an intellectual disability and mental illness, and enhancing Forensic Mental Health services.

Key to developing Child and Adolescent Mental Health Services (CAMHS), as per A Vision for Change, is the establishment of 99 multi-disciplinary CAMHS Teams providing acute secondary mental health care in the community, including hospital liaison and Day Hospital services. In 2008, there were 54 CAMHS Teams. There are now 66 Teams in place – 60 Community, 3 Adolescent, and 3 hospital liaison mental health teams.

The additional €90m provided for mental health over 2012–14 is being used, in part, to expand and enhance the skill mix of CAMHS Teams.  Around 230 new posts were allocated to CAMHS Teams over 2012-13, and recruitment of these is well advanced.  Of the 150 posts approved in 2012, 136 or 91% are complete with 8 further posts at an advanced stage in the recruitment process.  Of the 80 posts approved in 2013, 35 or 43% are complete, with a further 18.5 or 23% at an advanced stage of the recruitment process.  In summary, of the 230 new posts approved to CAMHS in 2012 and 2013, 197 or about 85% have been filled or are well advanced in the recruitment process.  Outstanding CAMHS posts will be filled as quickly as possible.

There are a number of posts for which there are difficulties in identifying suitable candidates due to various factors including availability of qualified candidates and geographic location. Alternative approaches being considered for posts not fillable in the normal way.

Just over 14,000 referrals were received by the Child & Adolescent Mental Health Teams in 2013.  This represents nearly 1,000, or 8% more, than projected in the HSE National Service Plan 2013, while the target of 70% of referrals being seen within 3 months was maintained.

A Vision for Change recommends the provision of 80 Child and Adolescent psychiatric in-patient beds nationally.  In 2008, there were 16 such beds and at present there are 51 beds operational country-wide, with more planned.   Capacity will be enhanced also, with the completion of the CAMHS Forensic Unit as part of capital developments now underway for the National Forensic Mental Health Service, and the National Children’s Hospital. In addition, improved community based services, coupled with increasing bed capacity, are all aimed at discontinuing the practice of placing children and adolescents in adult acute in-patient units, except in exceptional circumstances.  Admissions of children to adult units have decreased by almost 60% from 2008, when there were 247 reported, to a provisional figure of 106 in 2012.

The review of the Mental Health Act 2001, already well progressed, is a key step in providing a revised and more modern mental health legislation in this country. The Programme for Government contains a commitment to review the Act, informed by human rights standards and consultation with service users, carers and other stakeholders.

The review has been delayed due to a number of factors, including the wishes of members of the Expert Group to first see details of the Assisted Decision Making (Capacity) legislation, which was published in June 2013. Due to the high level of inter-connectivity between both sets of legislation, members of the Expert Group reviewing the Mental Health Act felt it would be necessary that the Capacity Bill should be finalised before they completed their own review.

Work is continuing on the completion of the report of the Expert Group, and members are carefully deliberating, re-examining and refining their recommendations on key central issues such as consent to treatment, capacity, criteria for detention, and treatment of children under the Act. It is expected that the final report will be completed in the near future, after which its recommendations will be considered at Ministerial level.

While noting the contents of the recent report by the Children’s Rights Alliance on Mental Health services, real and significant improvements have taken place on implementing A Vision for Change and modernising mental health services across the country over the last three years.  Nonetheless, historic deficiencies remain to be addressed.  The aim is to strive for equity in providing high quality services, while balancing residential and community-based provision.  This approach has already been proven in many areas at local level. The Government will retain its commitment to mental health, and focus on up-grading all aspects of mental health care, in line with evolving service demands and resources available overall for the Health sector, for 2014 and beyond.

to move to the following access targets:

–          6 month target inpatient / day care

–          9 month target for outpatient

–          again with hospitals effecting full compliance with performance targets in the first half of the year and subsequent maintenance for the remainder of the year

27 March 2014: Quarterly Meeting of the Joint Committee on Health and Children and the Minister for Children and Youth Affairs, Frances Fitzgerald TD

Questions submitted in advance by Senator Jillian van Turnhout and response received:

Question 9: Figures in relation to Special Care Placement.

Question 10: EU Commission Recommendation ‘Investing in Children: Breaking the cycle of disadvantage’.

Question 11: Amendment to Childcare Act 1991.

 

Question 9: Figures in relation to Special Care Placement

To ask the Minister for Children and Youth Affairs to provide the most up-to date figures on the following, in relation to Special Care Placements:

a)   What is the current waiting list for Special Care Placement?

As of 11th March 2014, there was one young person waiting for a special care placement. There have been ten admissions to Special Care since 1st January of this year.

 

b)   How many applications have been made to date since the beginning of 2013?

From 1st January 2013 to 5th March 2014 there were 116 special care applications – 22 of these applications were re-referrals.

 

c)    How many of these applications were successful?

Forty applications were successful, 27 were withdrawn or removed by the relevant Social Work Department, 46 were not approved and there were three in 2014 where further information had been sought and a decision has not yet been made. A Social Worker making an application for a Special Care place will also work to put in place other supportive mechanisms for the child while they await the outcome of the application. Where it is found that the alternative supports are meeting the needs of the child without the necessity of detaining the child for his/her own safety, the preference is to continue with the alternative programme. Where a child has been sentenced to detention in a Detention School, the child’s application for Special Care is withdrawn.

There is an appeals process available to Social Workers if they disagree with the decision where a child’s application to Special Care was unsuccessful. The Social Worker will also consider the Care Plan for the child and make other arrangements to find the most appropriate placement for that child. An unsuccessful application does not preclude the Social Work Department from applying at any other stage, especially in light of a child’s needs changing.

 

d)   How many State provided places are there in mainstream residential care and

e) How many are provided by Private Providers?

All Special Care placements in Ireland are operated by the Child and Family Agency and placements are under the direction of the High Court. There are no private providers of Special Care Services in Ireland, however some children with complex needs are placed out of State.

More generally, in December 2013 there were 142 Children’s Residential Centres in operation throughout the country; 47 of which were Agency-managed; 28 were run by the voluntary Sector; and 67 were operated by private providers.  These centres are typically found in domestic homes in housing estates, on the outskirts of towns and villages. The centres typically have between three and six children. These children are usually in their teens.  There is always some flux in placements available as services adapt to meet the needs of the resident children.

In December 2013, there were 356 children in care placed across the different types of residential care. Of these there were 143 children placed in the 67 privately run centres.

 

f)    What is the allocated budget for private provision?

The cost of the provision of mainstream residential placements in the privately-owned children’s residential centres for 2013 was approximately €50m. To date private placements have been commissioned on the basis of a child’s needs which will influence staffing ratio, the need for live-staff at night and additional supports to the child in the placement. There has been a consistent and predictable spend in respect of this type of residential provision, which reflects demand.

Significant work is under way within the Agency to secure the most appropriate and cost-effective care for children in the different settings in which they are accommodated. In early 2012 the HSE’s Children and Family Services undertook a tendering campaign to secure 80 places at a cost of €18.7 m per annum or €4,500 per place purchased for a two year period (extendible for a further two years if required). This arrangement will be for children whose needs can be met in a centre caring for 3 or 4 children. The process is now complete and contracts are currently being awarded in respect of 2014. It is estimated that the procurement arrangements utilised will reduce the spend in this area by €3.9m in 2014.

Any additional places that will be required will be purchased on an individual basis and in some cases may be more expensive where bespoke placements are commissioned for young people with particularly challenging needs.

The Agency has been working to increase value for money in this area by, as outlined above, seeking to promote cost effectiveness within the different options available and also moving to fostering where appropriate.

The Agency intends to undertake a centre activity audit of all aspects of residential care in 2014, and this will allow for a level of comparison of cost of placement across private and public group children’s centres and individual placement arrangements.

 

Question 10: EU Commission Recommendation ‘investing in children: breaking the cycle of disadvantage’.

To ask the Minister what action the Government is taking to implement the EU Commission Recommendation (20 February 2013) Investing in children: breaking the cycle of disadvantage, concerning child poverty and well-being and, having acknowledged that tackling poverty requires a whole-of-Government approach, will DCYA carry out a social impact assessment on any fiscal adjustments in Budget 2015 and onwards?

Ireland, led by the Department of Children & Youth Affairs (the first such Department in any EU member state), is committed to improving the lives and experiences of Ireland’s children and young people.

Many of the actions being implemented by this Government are in line with the EU Commission recommendation on ‘Investing in Children’ which was adopted by the Council of Ministers in 2013. These actions include:

·     Protecting and enhancing children’s rights on foot of the decision of the people in the Children’s Referendum 2012;

·     Improving child protection, welfare and family support services through the newly established Child & Family Agency;

·     Implementation of the recently-reviewed Youth Homelessness Strategy;

·     Continuing to be a world leader in both the areas of children’s participation (through the national Dáil na nÓg and local Comhairle na NÓg model); and childhood research (through the ‘Growing Up in Ireland’ longitudinal study and ‘State of the Nation’s Children’ reports).

Tackling Child Poverty

The EU recommendation on ‘Investing in Children’ includes a significant focus on tackling child poverty, referencing the ‘setting of national targets for reducing child poverty’ and access to quality services.

The draft National Policy Framework for Children & Young People, which is being prepared by my Department and which is due to be considered by Government shortly, currently includes a commitment to address child poverty.

With respect to services, my Department is responding through initiatives such as establishment of the Child & Family Agency (with an enhanced focus on prevention, early intervention and family support) and the roll-out of the €30m Area Based Childhood (ABC) Programme.

 

Early Years/Childcare

The EU recommendation on ‘Investing in Children’ recognises the importance of early childhood education and care. The EU Commission has set a target of member states having at least 95% of four year olds in pre-school. Ireland is in compliance with this target through provision of the free pre-school year.

The EU recommendation on ‘Investing in Children’ also recognises the importance of access to affordable childcare. In this context I announced a review of existing targeted childcare schemes to consider how best to structure future childcare support, to both support working families and to incentivise labour market activation, which could be expanded to more families as resources allow.

Delivering improvements in quality standards and staff qualifications is a critical precursor to any future expansion of universal childcare provision and/or Government supports. I have prioritised implementation of an eight-point Quality Agenda, and there has been significant and unprecedented progress in the implementation of this agenda over the past eight months. This will continue in 2014 with establishment of landmark new National Quality Support Service, which is being seen a significant development in the context of developing EU policy.

 

Social impact assessment

In February 2012, the Government decided to develop an integrated social impact assessment to strengthen implementation of the new national social target for poverty reduction and to facilitate greater policy coordination in the social sphere.

Work in the area of social impact assessment is being led by the Department of Social Protection. A social impact assessment of Budget 2014 was published in February 2014 by that Department.  My own Department liaises regularly with the Department of Social Protection to ensure a child-centred approach informs such assessments and consequently provides learning to use in the development of our policy and service responses for children.

 

Question 11: Amendment to Childcare Act 1991.

 

Can the Minister provide a timeline for the delivery of the legislation to amend the Child Care Act, 1991, to provide a statutory right to the preparation of an aftercare plan for eligible young people leaving care and will the Minister consider extending this statutory support to young people leaving detention, as they often present with very similar needs?

The amendment to the Child Care Act 1991 to strengthen the aftercare provisions for children in care was approved by Government on 25 February 2014 for publication, and has been submitted to this Committee for its consideration.

I understand that the Committee plans to consider the matter during the month of April. Following the Committee’s deliberations the text of the amendment may need to be refined in conjunction with the Office of the Parliamentary Counsel, after which a timeframe for the progression of the legislation will be discussed and agreed with the Houses of the Oireachtas. I am very appreciative of the work of the Joint Committee and the contribution of the members.

Regarding children leaving detention, on average approximately one third of such children normally would have care orders and so would, in the main, be required to have an aftercare plan prepared by the Child and Family Agency.

At present, the mechanism for supervision of a child post-release from a sentence of detention (other than those who were in the care of the Child and Family Agency) is by the Probation Service if the courts impose a “detention and supervision” (i.e. in the community) order at conviction stage. Extending the right to an aftercare plan to all children completing a sentence of detention would require significant and detailed examination by officials in the relevant units of my Department, and the relevant other Departments and agencies involved, before any recommendations in relation to the matter might be formulated.

25 July 2013: Quarterly Meeting of the Joint Committee on Health and Children and the Minister for Children and Youth Affairs, Frances Fitzgerald TD.

Question 3: Childhood Obesity

Question 4: National Consent Policy

Question 5: Counseling service for mothers

Question 3: Childhood Obesity

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?

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 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.

Question 4: National Consent Policy

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

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.

Question 5: Counseling service for mothers.

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?

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.

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.

23 May 2013: Quarterly Meeting of the Joint Committee on Health and Children, the Minister for Health, James Reilly TD, and the HSE.

Question 32: Provision of Neuro- Rehabilitation Services

Question 33: Neurologist waiting lists

Question 34: Children’s palliative care programme

Question 32: Provision of Neuro- Rehabilitation Services

Following the publication of the National Policy and Strategy for the Provision of Neuro-Rehabilitation Services in Ireland 2011-2015 (December 2011), an undertaking was given to publish an implementation plan “forthwith”. Why has this implementation plan not been published to date? When will it be published? And, will it meet its 3-year implementation schedule by December 2014?

The Department of Health and the Health Service Executive (HSE) have developed and published the “National Policy and Strategy for the provision of Neuro-Rehabilitation Services in Ireland 2011 – 2015”. In addition, the HSE is developing its Rehabilitation Medicine Programme within the Clinical Strategy and Programmes Directorate. The Report is the overarching policy on neuro-rehabilitation services and includes proposals for a framework for the future of neuro-rehabilitation services in Ireland, including key elements such as:
• guiding principles;
• implementation structure;
• methodology for implementation; and
• information and communication.

The Report recognises that given the current economic climate, the focus in the short to medium term has to be on re-configuration of services, structures and resources and the enhancement of the skills and competencies required to meet the changing context.

The key priority areas, as identified in the HSE’s National Operational Plan for 2013 are to:
• Map and develop Integrated Service Area level rehabilitation networks;
• Implement the model of care for rehabilitation services within the networks with a focus on community rehabilitation.

An implementation plan beyond the overall operational plan commitments would not be beneficial, as the work involved to progress networks and teams will require to be flexible and responsive to the areas identified and to their specific service profiles.

The Rehabilitation Medicine Programme has been working in collaboration with the National Disability Unit as part of an expert Working Group planning for the implementation of the Report. The Rehabilitation Medicine Programme has incorporated key elements of the Report into its own Model of Care and adopted the Strategy’s recommendation of “hub and spoke” model for specialist rehabilitation services and is keen to progress with a comprehensive model for the continuation of such service into the community. This co-operation will continue in 2013.

Question 33: Neurologist waiting lists.

What plans are in place to tackle waiting lists to see a neurologist in public hospital out-patients clinics, which are over 4 years for more than 1,000 patients? And, what will be done to cut the waiting time for neurosurgery, which is currently over 6 months for 37% of patients requiring this treatment?

Outpatient Services
An Outpatient Services Performance Improvement Protocol has been developed to improve the provision of outpatient services in all publically funded healthcare facilities providing outpatient services which will include neurology referrals. A minimum standard has been established of no patient waiting greater than 12 months by 30th November 2013. A primary target list has been developed for each hospital identifying all patients that will breach the target if not seen by 30th November 2013. Capacity analysis is currently being undertaken in all hospitals with regard to meeting this target. All hospitals are developing plans by specialty including neurology at present to address long waiting lists. Solutions being considered to tackle waiting lists to see a neurologist in public hospital out-patients clinics include data validation, patient level validation, additional clinic slots, additional clinics and capacity within the region.

Inpatient Services
In relation to inpatient neurosurgery services there are currently 452 patients awaiting inpatient/day case neurosurgery. Of this total 288 are waiting 0-6 months and 164 are waiting > 6 months.

The maximum wait time guarantee for all adults awaiting any type of inpatient or day case surgery is 8 months in 2013. The aim is for all hospitals to systematically reduce this maximum wait time each year by matching capacity with demand, eliminating inefficiencies in the patient pathway, ensuring the strict chronological management of patients of equal clinical priority and implementing the recommendations of the Surgery Clinical Programme

Question 34: Children’s palliative care programme

To ask the Minister for an update on the children’s palliative care programme currently funded by Irish Hospice Foundation (IHF) and HSE. In particular: an assurance that all 8 children’s outreach nurses (5 IHF funded/3HSE funded) are now in post and if not, why and when will they be in post?; to outline the plans the Department of Health and HSE have to identify sources of sustainable funding for the Children’s palliative medicine consultant post (IHF funded) and the 8 outreach nurses when the IHF funding ends in 2016; and to confirm that children with terminal illness are entitled to the medical card without means test in the same way as adults.

The HSE and the Irish Hospice Foundation work in very close collaboration in relation to children’s palliative care services and the National Development Committee for children’s palliative care is jointly chaired by both organisations.

This Committee;
• Provides national strategic guidance in relation to children’s palliative care needs
• Makes recommendations in relation to the resourcing of children’s palliative care services.
• Oversees the preparation of development plans for each HSE Region

In support of this work and to ensure streamlined services across the country, a network of Outreach Nurses, Consultant ‘champions’ and Directors of Nursing has been established.

Four Palliative Care Outreach Nurses are already in post and the process of recruiting the remaining 4 is at a very advanced stage, with candidates selected for the 4 posts.

The HSE continues to work with the Irish Hospice Foundation to develop a sustainable model of funding post 2016.

Other priorities for the Committee are
• Developing an appropriate monitoring and evaluation process for the Children’s Outreach programme
• Identifying the respite and home care needs of children with life limiting conditions including the development of a ‘Hospice-at-Home’ service model
• Improving clinical Governance, education and development
• Developing minimum information data sets

Children with terminal illness are entitled to a medical card without means test in the same way as adults. No means test applies to an application by a terminally ill patient and all terminally ill patients will be provided with a medical card number for a period of six months once their medical condition is verified by a GP or a consultant.

19 April 2013: Questions to the Department of Children and Youth Affairs, for answer before the meeting of the Committee on Health and Children.

Question 17: Child and Family Support Agency

Question 16 (Senator Jillian Van Turnhout)

Question 18 (Senator Jillian Van Turnhout)

Question 17: Child and Family Support Agency.

To ask the Minister to share with the Joint Committee on Health and Children the Implementation Plan for the new Child and Family Support Agency; including details of the transfer arrangements from the NEWB, Family Resource Centres and HSE; and the referral pathways for children and families to the new agency.

Vision for Child and Family Agency
The Programme for Government commits to “fundamentally reform the delivery of child protection services by removing child welfare and protection from the HSE and creating a dedicated Child Welfare and Protection Agency, reforming the model of service delivery and improving accountability to the Dáil.”

I established a Task Force to advise on the establishment of this new Agency. I requested the Task Force to base its work on “best practice in child welfare, family support and the delivery of public services, and according to principles that:

• The welfare of the child is paramount;
• Children and families should be supported in their local communities to the greatest extent possible;
• The welfare of children is founded upon strong and loving families and supported by the purposeful and shared responsibility of the state and society to always protect and promote their welfare;
• The Agency will operate to the highest standards of performance and value for money;
• Children will receive the best parenting when received into the care of the state.”

The final report of the Task Force was published in July last year and made recommendations on a number of key issues. The Task Force provided a specific chapter on the vision for the Agency, amongst which included the following:

“The Child and Family Support Agency, working in collaboration with the Department, provides leadership to relevant statutory and non-statutory agencies, ensuring that the conditions needed to achieve children’s wellbeing and development are fulfilled.

The Agency is responsible for the wellbeing of children and families who require targeted supports due to family and social circumstances. These range from support to families in the community to highly specialist interventions where children are at risk of being unsafe. Such children and families are not an isolated grouping nor are they a static grouping as children and families can move in and out of needing support as their life circumstances change.

In fulfilling its statutory role, the Agency ensures that:
• The needs of such children and families are identified at the earliest sign of their emerging need;
• A coordinated set of supports that addresses all the facets of a child’s wellbeing is put in place which incorporates and utilises well-developed interagency working mechanisms;
• The effectiveness of the supports is monitored;
• For the services provided directly or funded by the Agency, service delivery systems and practice are continuously reviewed to ensure they respond successfully to changing needs, and unmet need is clearly identified as a part of ongoing planning and reporting processes to the Department and the Minister;
• It provides mechanisms to engage with children, families and communities regarding the design and quality of service provision.”

I share the view of the Task Force that in order to achieve genuine improvements for children and families, the Agency must have a broader focus than child protection. Prevention, early intervention, family support and therapeutic & care interventions are all key to the provision of integrated multi-disciplinary services for children and families based on identified need.

It is my intention that the new Agency will address the persistent and difficult issues which have been found regarding the standardisation of services, communication, professional collaboration and coordination, and sharing of risk assessment, management and treatment for many children and families with the most complex needs. At the same time, the Agency will have a role in supporting families more universally – providing less complex, less intrusive, less expensive responses which have a preventive function.

The new Child and Family Agency and the wider transformation of children’s services represent one of the largest, and most ambitious, areas of public sector reform embarked upon by this Government. The reforms are much deeper than structural or organisational change as they embrace operational, cultural and inter agency improvement. As such, they will not be delivered overnight and the organisational arrangements are intended as an enabler of the improvement in outcomes which will be the real service goal in the years to come.

Progress on Planning and Implementation
On 13th July 2012, Government approved the drafting of Heads of a Bill to provide for the establishment of the Agency. The detailed policy decisions to inform the drafting of legislation were set out in these Heads of Bill and approved by Government in November last. Such policy includes:

• The functions and legal remit of the Agency;
• The constituent services that are to make up the new Agency;
• The governance arrangements between the Minister and the Agency and between the Board and the Executive;
• The funding relationship between the Minister and the Agency;
• The arrangements for the Agency to contract others to provide services on its behalf;
• The arrangements for dissolving the Family Support Agency and the National Educational Welfare Board; and
• Provisions for the transfer of staff, assets, liabilities and contracts.

The Government decided that the constituent elements of the Child and Family Agency on establishment day will be made up of:

● Child welfare and protection services currently operated by the HSE including family support and alternative care services.
● Other child and family related services for which the HSE currently has responsibility including pre-school inspections and domestic, sexual and gender-based violence services.
● Psychologists working in the community setting in relation to children and families
● The Family Support Agency.
● The National Educational Welfare Board.

The scope of these services is sufficiently broad to capture an enhanced range of both universal and targeted services operating to a unified management structure. These will constitute the immediate service responsibilities of the new Agency. Further consideration will be given to the subsequent transfer of additional services to the new Agency after the initial set-up phase and following further consideration of relevant recommendations of the Task Force in consultation with relevant departments.

The Agency will function as a separate statutory body with strong governance and a framework of public accountability underpinning its operations. The Agency will have a board appointed by the Minister based upon expertise and competency. Therefore, accountability and transparency will be a key feature of the governance and performance management frameworks to be introduced in the legislation.

The legislation must provide for the reassigning, under law, of the sensitive and complex legal responsibilities which arise in relation to the care and protection of children and the promotion of their welfare. Particular care is also being taken in respect of the disaggregation of the functions from the HSE to ensure that there are no unintended consequences (for either the Agency or the services remaining within the HSE) in the separation of functions, either in legal terms or in terms of the practical operation of day-do-day services for children and their families or other HSE clients.

Work on the drafting of the legislation has been progressing in conjunction with the Office of Parliamentary Counsel. The legislation is at an advanced stage and once it is finalised it will be brought to Government for the purposes of approving its introduction to the Oireachtas. The legislation is on the A list of the Government’s legislative programme and I intend to bring it before the House in this current term.

While the legislative process is under way, all necessary organisational preparations are continuing in parallel. These preparations are being led by the Programme Director/CEO Designate of the Child and Family Agency, Mr Gordon Jeyes. The preparations are being supported by an oversight group chaired by the Secretary General of the Department of Children and Youth Affairs. In addition to the CEO Designate, its membership includes officials of the departments of Children and Youth Affairs, Health and Public Expenditure and Reform; HSE Children and Families and a representative of the CEO of the HSE.

The oversight group is supported by a joint Department of Children and Youth Affairs and Child and Family Agency project team (led by the CEO Designate) which is driving day to day delivery of the overall project. Its responsibilities include the full range of activities required to bring the project to completion. Representatives of the Family Support Agency and the National Educational Welfare Board are also members of the team and are actively involved in leading the requisite change management programmes within those agencies. The project team undertakes integrated project planning, risk management and reporting. It reports to the Oversight Group and relevant matters are escalated to the Oversight Group if necessary.
Progress achieved to date in preparation for the Agency includes:
• the separation of children and family services within the HSE from other health and personal social services, with discrete management responsibilities and budgets;
• recruitment of a senior management team to lead the agency. All positions with the exception of the Chief Operations Officer and Head of Education Welfare are currently filled. These two positions are currently being re-advertised/advertised;
• the establishment of a dedicated sub-head for children and family services within the HSE Vote to bring transparency to the current budget of HSE children and family services;
• the undertaking of an external due diligence process, under the auspices of the two Departments, to inform the reassignment of budgets from the HSE to the Child and Family Agency;
• the establishment of an industrial relations process to communicate with staff representatives and resolve issues to facilitate the transition to the new Agency;
• the issuing in January 2013 of personal letters to almost 4,000 staff across the HSE, NEWB and FSA informing them of the plans to establish the new Agency and that it is intended that upon establishment their employment will transfer;
• commencement of external inspection by HIQA of the child welfare and protection services, in line with the goal of promoting enhanced transparency;
• the continued implementation of a comprehensive national change programme for the operational improvement of children and family services. This includes detailed design of referral pathways and assessment frameworks in order to ensure national consistency;
• continued implementation of the integration of education services within the NEWB and the development of the Family Resource Centre network in advance of the relocation of responsibilities to the new Agency;
• the appointment from January 2013 of Mr Gordon Jeyes as fulltime Programme Director for the establishment of the Child and Family Agency; and
• the recent approval of the Government that name of the new Agency will be the ‘Child & Family Agency’.

In line with the public service reform programme the replication and duplication of transactional or support functions such as payroll, financial transactions and property management will be avoided. These can be more effectively provided on a shared service basis in order to ensure that costs associated with disaggregation are entirely minimised. Accordingly, preparations are in place for the HSE to provide significant levels of such shared services to the new Agency. This will involve process and technical development within the HSE. HSE has recently received approval to contract for IT system enhancements necessary to facilitate this service which will be implemented this year.

In addition to these organisational preparations the decision has been taken to commence governance preparations on a shadow basis pending the enactment of legislation including its provisions for a Board. The Government has approved the appointment of Ms. Norah Gibbons as first Chairperson of the board of the new Child & Family Agency. Ms Gibbon’s expertise and experience in the area speaks for itself. It is intended that Ms. Gibbons will initially be appointed as Chairperson of the existing Family Support Agency which is one of the agencies being incorporated into the new Child & Family Agency. The appointment process will include appearance before the Oireachtas Health & Children Committee in line with procedures for the appointment of the chairpersons of state bodies. My Department will also be seeking expressions of interest for other board members by means of advertisement on the publicjobs and Department websites.
These appointments will reflect the intention, pending the legal establishment of the Child and Family Agency, to have the FSA Board prepare in advance for the governance task associated with the new Agency and provide oversight and direction to the preparations at an organisational level which are underway for the new Agency. The newly appointed board of the Family Support Agency will play this role on an administrative basis in addition to its existing statutory functions. Day to day statutory responsibility for child welfare and protection services and education welfare services will remain with the HSE and the NEWB respectively until these are transferred on the enactment of the necessary legislation. This approach reflects the overall strategy to undertake as much preparation as possible in advance of legislative enactment and the consequential transfer of onerous operational responsibilities.

It is important not to underestimate the scale of change involved and the absolute necessity for a carefully planned approach to be adopted while embarking upon such large-scale change within this crucial area of the public service. The approach to the project is informed by learning from the establishment of other major agencies, particularly where preparatory time was inadequate. Such preparations include allowance for sufficient consultation and consideration of the legislation by the Oireachtas and stakeholders in the period immediately ahead. A precise date for the establishment of the Agency will be set when consideration of the legislation by the Oireachtas has advanced.

Conclusion
In conclusion, it is considered that the intensive preparations underway and summarised here will provide for the effective establishment of the Child and Family Agency and will bring a dedicated focus to child protection, family support and other key children’s services for the first time in the history of the State, contributing in time to the transformation of what are essential services for families and communities.

Question 16 (Senator Jillian Van Turnhout)

To ask the Minister for Children and Youth Affairs to set out and provide details on the process for the selection of the sites; programmes; interventions; and supports to be provided under the new Area Based Approach to Child Poverty Initiative in 2013.

Written Response
The Area-Based Approach to Child Poverty Initiative was allocated €2.5m in Budget 2013. The amount allocated will rise to €4.75 in 2015. It is hoped that this Initiative will be co-funded by Atlantic Philanthropies and discussions are ongoing to this end. This Initiative will build on and continue the work of the Prevention and Early Intervention Programme (PEIP) which supported projects in Tallaght, Ballymun and Darndale/Belcamp/Moatview.

The new Initiative reflects the Programme for Government commitment to adopt an area-based approach to child poverty in co-operation with philanthropic partners, drawing upon best international practice and existing services, to break the cycle of child poverty where it is most deeply entrenched.

I can confirm that the focus will be, very firmly, on outcomes, rather than inputs and outputs, and these will be referenced in (a) the selection of areas where children are most disadvantaged, and (b) in measurement of the success of interventions.

It has been proposed that the Initiative will consist of the following components:

• Continuation of interventions, where appropriate, in the 3 existing PEIP sites, subject to those programmes being supported by positive evaluations and evidence regarding impact and cost effectiveness
• Selection of 6 sites (including as appropriate proven programmes in existing PEIP sites), where multi-faceted approaches to addressing Child Outcomes via evidence based programmes will be implemented. The impact of these interventions will be monitored in a cost-effective manner, to ensure they have the intended outcomes on child well-being
• In time, the mainstreaming of proven, cost-effective evidence-based programmes into service delivery in a wider context than the areas specifically participating in the Area-Based initiative.

The Initiative is being overseen by a Project Team, chaired by the Department of Children and Youth Affairs with participation of the Departments of An Taoiseach, An Tánaiste, Public Expenditure & Reform, Environment Community & Local Government, Education & Science, Health, Social Protection, HSE, and including Atlantic Philanthropies. The Project Team is supported by the Centre for Effective Services (CES) and Pobal, which has been asked to act as the fiscal agent for the Initiative.

A Working Group to Support the Project Team has been established. At present it consists of DCYA, CES, Pobal and Atlantic Philanthropy.

My Department published details on its website on 12th April last outlining the overall selection process. Details of a seminar arranged for 25th April where the Initiative will be explained to potential applicants have also been published. It is intended that Applications will close by the end of May, and Stage 1 of the selection process is expected to be completed at the end of June. It is inspected that the finalisation of proposals may be effected more quickly in the case of some successful applicants than with others, depending on their readiness. Shortly and in advance of the seminar my Department will publish detailed guidance for applicants and an application form. The Department of Children and Youth Affairs will be happy to supply the committee with copies of these documents as soon as they are published.

The criteria for selection of proposals to attract support under the programme are as follows:

• Evidence of need – The level of poor outcomes for children in the target area
• The quality of the proposal
• Additionality & Sustainability – The degree to which the proposal leverages other resources
• Understanding & ability of the applicants to capture outcomes

The Working Group and Project Team will conduct assessments of the proposals and recommend projects for selection.

Who should apply?
Applications are invited from area-based groups of not-for-profit organisations, with a proven track record of working with statutory and non-statutory service providers and local community groups with a capacity to form consortia. These consortia must be in a position to propose and deliver an area based initiative that delivers on the programme’s objectives of:
Breaking the cycle of child poverty within areas where it is most deeply entrenched and where children are most disadvantaged, through integrated and effective services and interventions that address:
1. Child development, and/or
2. Child wellbeing and parenting, and/or
3. Educational disadvantage,
From pre-natal to 18 years of age.

Proposals are invited across all elements but particular consideration will be given to proposals that focus on the quality and effectiveness of services and interventions from birth to 6 years of age.

What will the programme provide?
Successful applicants will receive funding to implement proven and cost-effective early intervention and/or prevention programmes and practices. The level of funding which will be available to individual projects for the duration of the programme will vary depending on the scale and impact of each initiative and the level of existing resources allocated to the area concerned. It will be a requirement of funding that the programmes and practices are implemented collaboratively by all relevant service providers in the area, both statutory and non-statutory, using existing resources. Applicants should have regard to the fact that, while the initiative is expected to provide additional levels of funding until 2016, the objective is to work towards withdrawal or reduction of additional funding from then on.

Research and evaluation
Research and evaluation were key elements of the PEIP and will continue to be important components of the new initiative to ensure that the outcomes from the interventions are evaluated and measured. Given that the new initiative will build on trialled and proven leaning from the PEIP, and other prevention and early intervention projects funded by the State and/or Atlantic Philanthropies, the research and evaluation component is expected to be less onerous and will be centrally directed.

Successful applicants will be subject to on-going research and evaluation requirements, overseen at central level by an Expert Advisory Committee. This process will be assisted by the Centre for Effective Services, acting on behalf of the Department.

Mentoring
With the exception of applicants who demonstrate an acceptable record in the delivery of prevention and early intervention programmes (e.g. the existing PEIP sites), successful applicants will be expected to avail of mentoring assistance over the course of the new initiative.

Systemic Change
It is anticipated that the initiative will expand over time, both in terms of the number and type of area based interventions and the degree of systemic change and mainstreaming of evidence based programmes and practices which is taking place. In tandem with this, it is anticipated that the range of area based projects which will be included in the initiative, will broaden.

Applications will also be required to demonstrate an approach which is based on additionality to existing levels of service provision and resources both statutory and non-statutory i.e. the proposal should demonstrate how existing services, practices and resources will be made more efficient and more effective as a result of the proposal. In effect, the initiative is expected to promote improved inter-agency collaboration at local level leading to systemic change which is capable of being replicated on a broader or national scale.

Question 18 (Senator Jillian Van Turnhout)

In light of the Fifth Report (July 2012) of the Government’s Special Rapporteur on Child Protection, Geoffrey Shannon, to ask the Minister to confirm the status of:
• The examination he called for to establish whether the system of Direct Provision itself is detrimental to the welfare and development of children and whether, if appropriate, an alternative form of support and accommodation could be adopted which is more suitable for families and particularly children.

• The establishment in the interim of an independent complaints mechanism and independent inspections of Direct Provision centres and the recommendation that consideration to these being undertaken through either HIQA (inspections) or the Ombudsman for Children (complaints).

Written Response

No answer provided.

17 October 2013: Questions to the Department of Children and Youth Affairs, for answer before the meeting of the Committee on Health and Children.

Question 17: Family participation in HSE reforms in disability services

Question 18: Emergency medical card procedures for terminally ill

Question 19: Paediatric hospitals integration

Question 17: Family participation in HSE reforms in disability services.

Can the Minister outline the Department of Health’s strategy and objectives in terms of family participation in the major strategic reforms currently being undertaken by the HSE in the area of disability services?

The HSE and the DOH acknowledge the importance of involving service users, parents & families and wider community in the planning organisation & delivery of services with people with a disability. In this context, the development of a partnership approach between all these stakeholders has been an important part of the model of service over many years. A range of both formal and informal processes are in place to give effect to this strategic objective.

At a national level, the National Consultative Forum (NCF) which was established by the HSE is the mechanism for bringing these key stakeholders together.
The forum includes representatives of the various umbrella bodies representing service providers e.g. Federation of Voluntary Bodies, The Disability Federation of Ireland (DFI), the Not for Profit Business Association, a number of bodies representing families or service users are involved e.g. Inclusion Ireland and National Parents and Siblings Alliance. The National Disability Authority is also represented as are the DOH & HSE.

Similar fora have been developed at regional and local level. In addition to the above, the development of many of the key strategic policy documents have included such representation e.g. the Report on Congregated Settings, New Directions the HSE’s policy document on the development of day services and the Policy on Progressing Disability Services for Children and Young People. As these strategic policies are being implemented, the HSE is ensuring that local implementation groups provide for the involvement of service users and/or parents & families as active participants.

The current process, for implementation of 0-18 Children’s Service model, as outlined below, is a good example of the processes being put in place to ensure full participation by service users, parents & family representatives.

Children’s Services Model:

• Membership of the National Coordinating Group includes Inclusion Ireland CEO and 2 parent representatives
• A subgroup on Communications was established to focus on improving communications with all stakeholders, including parents..
• The programme’s recent Local Implementation Group (LIG) Lead Workshop included a presentation by the Special Needs Parents Association representative on how to involve parents in the LIG from a parent perspective which was extremely very well received. Guidelines on Parent and Service User representation on Local Implementation Groups was developed with input from Special Needs Parents Association and Inclusion Ireland and shared with LIG Leads Subgroup on development Outcome Focused Performance Management Framework for Children and their Families” included a parent’s voice in the working group. Ongoing work being done at local level across the country to hold parent information/briefing sessions in order to inform parents of the proposed changes and to seek parental involvement on the local

Question 18: Emergency medical card procedures for terminally ill.

Can the HSE clarify the procedures in place in the event that an emergency medical card issued on the grounds of terminal illness (and therefore not subject to means test requirement) needs to be renewed after six months, to ensure that the renewal process will be on the same basis as the initial application – i.e. on the provision of evidence from the GP or hospital consultant of the terminal nature of the condition – and the applicant will not be asked to provide details of means?

The HSE can issue a medical card where a Doctor or a Consultant certifies that there is a terminal illness. Where a patient is terminally ill in palliative care, the nature of the terminal illness is not a deciding factor in the issue of a medical card in these circumstances and no means test applies. Given the nature and urgency of the issue, the HSE has appropriate escalation routes to ensure that the person gets the card as quickly as possible. The HSE monitors such cases and can renew the clients’ eligibility if necessary. In such circumstances there is no assessment of means.

Under the provisions of the Health Act 1970, the assessment for a medical card is determined primarily by reference to the means, including the income and expenditure, of the applicant and his or her partner and dependants.

While people with specific illnesses such as cancer are not automatically entitled to medical cards, the HSE can apply discretion and grant a medical card where a person’s income exceeds the income guidelines.

In these cases, social and medical issues are considered when determining whether or not undue financial hardship exists for the individual in accessing GP or other medical services. Discretion will be applied automatically during the processing of an application where additional information has been provided which can be considered by staff or a medical officer, where appropriate.

The HSE set up a clinical panel to assist in the processing of applications, where a person exceeds the income guidelines but there are difficult personal circumstances, such as an illness. The Medical Officer reviews and interprets medical information provided by the applicant on a confidential basis. He/she can liaise with general practitioners, hospital consultant and other health professionals as appropriate so as to determine the health needs of the applicant and his/her family and dependants.

It is important to stress that the medical card system is founded on the “undue hardship” test. The Health Act 1970 provides for medical cards on the basis of means. That is what the law states and we must operate within the legal parameters.

The HSE can also provide a medical card for patients in an emergency where they are seriously ill and in urgent need of medical care that they cannot afford.

Emergency medical cards are issued within 24 hours of receipt of the required patient details and letter of confirmation of condition from a doctor or consultant and are generally requested by a manager in a Local Health Office or a Social Worker.

Emergency cards are issued for six months on the basis that the patient is eligible for a medical card on the basis of means or undue financial hardship, and will follow up with a full application within a number of weeks of receiving the medical card.

The HSE ensures that the system responds to the variety of circumstances and complexities faced by individuals in these circumstances.

Question 19: Paediatric hospitals integration

With the Children’s Hospital Group Board appointed on 2 August 2013 to oversee the long overdue operational integration of the three existing paediatric hospitals in Dublin into a new children’s hospital, can the Minister provided us with an update on progress and the timeline for each phase?

The Children’s Hospital Group Board will oversee the operational integration of the three existing paediatric hospitals in advance of the move to the new hospital and is also the client for the new hospital. I appointed Dr Jim Browne as Chair of the Children’s Hospital Group Board last April. On 2 August I announced nine further appointments to the Children’s Hospital Group Board. The Chairs of the three paediatric hospitals are members of the Group Board. Other competency-based appointments have been made, with further competency-based appointments to be made at a later stage. The first meeting of the new Board took place on 2 October last.

On 13 September I announced that Ms. Eilísh Hardiman had been selected as CEO of the Children’s Hospital Group. This follows an open recruitment process led by the Public Appointments Service. The role of CEO of the Children’s Hospital Group is critically important in driving forward the integration of the three hospitals, and the project as a whole.

The Children’s Hospital Group Board will work closely with the National Paediatric Hospital Development Board on the capital project. The National Paediatric Hospital Development Board (NPHDB) is the body responsible for the design, building, planning and equipping of the new hospital building. Also on 2 August, I announced appointments to the NPHDB which will ensure that the necessary capital development skills are available to drive this priority project to completion, including the appointment of Mr Tom Costello as Chair. These appointments replace the transitional Board of officials from DOH and HSE who had been charged with progressing the project on an interim basis. The key post of Programme Director for National Paediatric Hospital Development Board was advertised on 4 October and will be recruited via open competition. The Programme Director will be the chief officer of the agency, will lead the project and will be responsible directly to the Board for the delivery of this priority project.

Work on developing a detailed project timeline is continuing and I expect to receive an update on this within the coming weeks. This will reflect the urgency and priority of the project and also its scale and complexity. The estimated programme will be kept under continuous review and validation by those to be charged with project delivery.

In the near term, the tender process for the procurement of a new design team is well underway, and the aim is to have the new design team in place by the end of 2013. Pre-application planning discussions have commenced and the aim is to secure planning permission by December 2014 with construction to commence in Spring 2015. A review of urgent care centre(s) configuration is almost complete; the number and location of these satellite centres in the Dublin area is a key decision, as the size, activity and infrastructure of these satellite centre(s) has implications for the main hospital brief. In parallel, St. James’s Hospital is working closely with HSE Estates and the National Paediatric Development Board in regard to the decant phase of the project.

The new children’s hospital is a priority for me and for this Government. Everyone involved in the drive to deliver the new children’s hospital capital project is working to do so by the earliest possible completion date. I am confident that the appointments made to the two Boards will ensure the new hospital is completed as swiftly as possible, with optimal design and value for money.

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.

Question 10: Cardiac Rehabilitation Services

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.

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.

QUESTION 10: CARDIAC REHABILITATION SERVICES

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.

Child and Family Agency Bill, 2013, Second Stage.

Wednesday 27 November 2013

http://www.kildarestreet.com/sendebates/?id=2013-11-27a.75#g85

The Minister is, as always, very welcome to the House, especially so given her introduction of the Bill before us. It provides us with immense potential to streamline and co-ordinate services for children. It is a huge and impressive undertaking involving three source agencies – the HSE, the Family Support Agency and the National Educational Welfare Board. I see the evidence and appreciate the seriously hard work that has been done by the Minister personally and her departmental officials. I thank Liz Canavan, assistant secretary at the Department, for a thorough briefing on the Bill yesterday afternoon and also the Minister for her clarification at the briefing.

I fully agree that what we are striving for now is to get the agency operational by 1 January 2014, the establishment date. In that vein, I wish to be very clear that I am approaching this Bill in as supportive and constructive a manner as possible. Any issues I raise are in the context of the fact that we are all striving to produce the best possible agency. I will do everything I can to ensure the Bill’s passage through this House.

I followed closely the Bill’s passage through the Dáil. I acknowledge and welcome the fact that the Minister has made significant changes to the Bill, in particular following suggestions from civil society organisations such as the Children’s Rights Alliance and Barnardos primarily. We have a unique opportunity to ditch ineffective systems and to finally make sure that children get the treatment they deserve, and that families get the supports they require also. I am concerned about the emphasis on management and the centralisation of services. I understand it in part but I fear the creation of a bureaucracy. What we want to do is ensure consistent standards throughout the country. An effective and accountable child and family agency will be a monumental step forward for a country that has so spectacularly failed some of the most vulnerable children in the past.

We must ensure consistency and standardised practice on the ground. This opportunity has been a long time coming. I thank the Minister for bringing it to fruition. We know that history is unforgiving. As the Minister outlined, there have been more than 30 reports. We must learn from our failings and demonstrate clearly that is the case. We are duty bound to get this right and everyone is striving for the best outcome for children. I will submit a number of amendments on Committee Stage and Report Stage in an effort to strengthen the Bill before us today. I will make every effort to ensure the Bill’s passage through the House. I look forward to a fruitful debate.

I commend the Minister on her role in securing Government approval of a proposal to strengthen legislation on aftercare, by introducing a statutory right to an aftercare plan. This will be done by way of an amendment to the Child Care Act 1991 and is an essential component to ensure stability in care and to enable young people to make the transition from care to independence in a safe, progressive, tailored and appropriate way. The Minister may be assured of our support when she brings this landmark legislation through the House.

At this juncture I want to focus on how we can ensure that we give the new agency the best start possible and restore public confidence in our child and family services. The Minister mentioned the referendum on children and when I travelled around the country, the biggest concern related to how people had been treated in the past by the agencies or how they perceived they would be treated. These perceptions are significant with regard to how people feel and we should not diminish those feelings. It is important we find ways to instil confidence in this new opportunity we are discussing today.

We heard in the news today about the potential overrun in the HSE. I will not get into a debate on that, but it gives rise to more concerns about the resources that will be transferred from the current HSE operations to the Child and Family Agency. Can we guarantee there will be enough of a budget transfer to do what is planned today? Can we guarantee there will be no loss of services? What improvements can we expect? I am concerned the agency may start with a deficit. That would be like a ball and chain being added on the starting line. I fear that the transfer of resources may mean the transfer of a deficit. This would be totally unacceptable. We have an opportunity with this new agency and we need to use it. During Committee Stage, I will look more closely at the details of the budget for the agency, particularly with regard to outsourcing. We know the agency has a budget of approximately €545 million, and I understand €100 million of that will go to outsourcing. I will seek further clarity on that on Committee Stage.

The issue I want to focus on today is the issue of special care. The issues in this regard are indicative of some of the issues I am raising about confidence and how we go forward. Under the special care order of the Child Care Amendment Act 2011, only children and young people aged from 11 to 17 with serious emotional and behavioural difficulties that put them “at a real and substantive risk to his or her health, safety, development or welfare” and who are unlikely to receive special care or protection “unless the court makes such an order” can access these facilities. An example of this may be a child who is self-harming, suicidal, abusing drugs and-or alcohol, where all other attempts by the Health Services Executive have not stabilised the current, serious situation. Rightly, one has to go to the High Court to obtain such an order. This is an appropriate safeguard due to the nature and seriousness of such intervention and the restriction of the individual’s liberty.

The recent report by the HIQA into Rath na nÓg raised serious concerns. The response from the HSE was to close the facility, which was relativity new. One could be forgiven for thinking as a result of that action that there is no demand for places. However, I understand there are currently 16 children on a waiting list for places and as many as 40 children who have not got onto the waiting list in need of a special care placement. Having read the definition, I cannot understand how there can be a waiting list for special care.

I am conscious that we are sending children to facilities abroad. For this to be done legally involves a time limit. Therefore, this involves returning to the High Court time and again to extend the period. The State is paying substantial costs both legally and for the provision of these places outside the State. Can we not develop a home grown solution that will be in the best interests of children? I am also concerned about the current arrangements around applications and placement for special care. The personnel in the HSE who decide whether to initiate a High Court application for special care are the same personnel who manage the number of special care places that are available. This is a serious concern because of the implicit conflict. Somebody said to me that the philosophy is: “If we do not have a place, we do not make an application in the first place.” Surely need and the best interests of the child should be the driving and deciding factor in whether a special care order is sought. Are we failing children today? Are we failing the 16 children on the waiting list? They have been assessed and identified as needing special care. At the least, I ask for the Minister’s assurance that this practice, as outlined, will not carry over into the new agency. There should not be a waiting list for special care.

The Minister was right to say we need to look at co-operation and bringing services together. I agree we must break down the barriers between agencies and services. We need an informed and integrated approach and for all of them to be under one roof. One of the regrets I have as we move forward with this is that children with disabilities will not be under the roof of the agency. Public health nurses will not be included either. All too often we hear that public health nurses are identifying upstream issues relating to a young child. At a recent meeting of the Oireachtas Joint Committee on Health and Children, the special rapporteur on child protection gave us what could be called a master class on children’s rights. One of the issues he raised was the issue of alcohol as a risk indicator and the need for social workers to consider this.

The issue now is how are all of these other services to communicate and liaise with the new agency. We have talked about integration and working together. Let us look for example at the Child and Adolescent Mental Health Services, CAMHS. We would assume, judging by its name, that this service would transfer to the new agency. CAMHS caters for young people up to 16 years, with an extension on occasion to 18 years. Social workers on the ground say they find it extremely difficult to access CAMHS, particularly once a child has been put into care. It is almost as if the perception is that once they are in State care, the State cannot outsource the facilities to CAMHS and will deal with them in the community. This is a further cost on the State. There is a concern that if CAMHS does not transfer to the new agency, this will further exacerbate the difficulty social workers are experiencing accessing these services for children. We have seen in the child death report the critical role that CAMHS plays. I do not understand why it is not being made part of the new agency. Is it because it does not want to be? This is a serious concern.

There is plenty more I could say, but I will keep it for Committee Stage. I am anxious to ensure the agency will be about all children and child welfare and that its remit is not limited. I do not question the Minister’s commitment, but the Bill is about outlining and putting down a foundation for the future. It is about a future when none of us will be here. We need to grasp the opportunity we have and maximise the potential of the Bill.

 

Link to Committee Stage: http://www.kildarestreet.com/sendebates/?id=2013-12-03a.189#g193

Links to Report Stage: http://www.kildarestreet.com/sendebates/?id=2013-12-05a.101#g110

The Lancet

In July 2021, Jillian co-authored an article in the world-renowned medical journal “The Lancet”