Commencement Matter: Neuro-Rehabilitation Services Provision, 2 December 2015

Senator Jillian van Turnhout: The Minister of State is aware that I have been tracking the issue of neuro-rehabilitation services for several years now. Such services are essential to support recovery and prevent disability for people with acquired brain injury, stroke, multiple sclerosis and a range of other neurological conditions. Thousands of Irish people still cannot get the rehabilitation they need when they need it. They face a lifetime of unnecessary disability, which can prevent them from returning to work and regaining their independence. It is estimated that there are 25,000 patients in need of rehabilitation in Ireland.

I have raised this issue because I am concerned about the deficits that exist in this area such as, for example, with regard to community teams. Since the three-year national strategy was published and came into place, little or progress has been made to deliver on any of its recommendations. For example, nine neuro-rehabilitation teams are needed in the community, but just three partially staffed teams are currently in place. No new teams have been established since the strategy was published in 2011. On the basis of the guidelines set by the British Society of Rehabilitation Medicine, our population means that 270 specialist inpatient beds are needed in this country. We currently have less than half of that number.

If we look at other rehabilitation services, we have a lack of longer-term rehabilitation supports, such as step-down units, transitional units and intensive home care packages, to allow people to go home after rehabilitation has come to an end. This means they end up in totally unsuitable facilities. For example, young people have to live in nursing homes, in acute hospital beds or in long-stay units with no ongoing rehabilitation. It is important to remember that people with neurological conditions need intensive therapy within a window of recovery. I know the Minister of State is aware of this. Those who are waiting to get specialist rehabilitation lose vital recovery time every day of their waiting periods. The National Policy and Strategy for the Provision of Neuro-Rehabilitation Services in Ireland 2011-2015 was published by the Department of Health and the HSE in December 2011. A joint HSE and Department of Health working group was established in 2013 tasked with the development of an implementation plan. Earlier this year, the HSE committed to releasing a draft implementation plan for consultation in December 2015. I now understand this will not be released until 2016, which is why I have tabled this matter. Separately, a model of care for specialist rehabilitation services is being developed by the national clinical programme for rehabilitation medicine. The draft of this model of care is being reviewed by the HSE following its submission in September 2015 and no date is available for its publication. Without the publication of the implementation plan for a neuro-rehabilitation strategy no money is being invested, no services are being put in place and thousands of people are not getting the rehabilitation they need. Yesterday, Mags Rogers of the Neurological Alliance of Ireland spoke about condemning people to live with an unnecessary disability. We are speaking about the vital window of recovery. As I have tracked this issue it has been a catalogue of delays, U-turns and no implementation plan. I have met many people in recent years whose quality of life would have been greatly improved if we could have intervened earlier. We have a strategy. Why do we not have a plan and why are we not implementing it?

Deputy Kathleen Lynch: We had difficulty at the outset, which I encountered very quickly, apart from having no money which was the biggest difficulty of all, as there was a difference of opinion as to how it should be delivered. It is very difficult to say to one specialist that what he or she is saying is wrong and say to another specialist that he or she is right. There was a clear difference of opinion as to how it would be delivered. This is why the implementation plan and the national clinical programme are so important.

The report, National Policy and Strategy for the Provision of Neuro-Rehabilitation Services in Ireland 2011–2015, made a number of recommendations for services for people with rehabilitation needs, including clinical, therapeutic, social, vocational and community supports. Following the development of the report, the Health Service Executive established the rehabilitation medicine clinical programme. The scope of the programme covers the whole of the patient’s journey from self-management and prevention through to primary, secondary and tertiary care. This provides a national strategic and co-ordinated approach to a wide range of clinical services. The programme includes the standardisation of access to and delivery of high-quality, safe and efficient hospital services nationally as well as improved linkages with primary care services. This is where the dispute arose with regard to whether it was better to do it within the community or whether it should be attached to an acute hospital.

The rehabilitation medicine clinical programme is nearing completion of a model of care for the provision of specialist rehabilitation services in Ireland, which will be the basis for the delivery of the service. 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. The disability services division will use the recommendations of the value for money and policy review of disability services to focus on disability funded rehabilitation services and enable reconfiguration of existing provisions through the establishment of demonstration sites. Close links will be maintained with the rehabilitation medicine clinical programme to ensure 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.

Having regard to the foregoing details, it is not accurate to say that no element has been delivered. A national steering group, chaired by the Health Service Executive social care division, has been assigned the task of developing an implementation framework for the national policy and strategy for neuro-rehabilitation services. The steering group includes representation from the national clinical programmes for rehabilitation medicine and neurology, the Department of Health, primary care, therapy professions and the Neurological Alliance of Ireland. Once the implementation framework has been agreed by the steering group, it will then go for consultation to the wider stakeholder interest groups. Following consultation, the framework will be revised and will guide and oversee the reconfiguration and development of neuro-rehabilitation structures and services at national and local level. The HSE is very aware of the needs of people with neurological conditions – how could it not be – and will continue to work towards improved services, making best use of available resources.

The disability sector is now connecting, and yesterday I met Enable Ireland which could play a very big part, and we all know the other non-governmental agencies with a particular interest in this area. The new hospital in Dún Laoghaire is on its way and it will provide not only outreach therapies but additional beds. It should have been done ten years ago, and the Senator and I know this, but with regard to thrombolysis, while prevention in accident and emergency department has played a significant role, much more needs to be done.

Senator Jillian van TurnhoutI agree with the Minister of State. As she knows I have been tracking this issue since I entered the Seanad. With regard to the people living with acquired brain injuries, strokes, multiple sclerosis and a range of other neurological conditions, if we got in during the window of recovery, we would not be speaking about disabilities but recovery. I said no element has been delivered, but for those looking for services during that period, they are not in place. It is not good enough and we must do more. I appreciate what the Minister of State said. We should see the implementation plan. We must give people hope, and the services should be in place in the way they are needed whether in the community or in settings. The pathway will very much depend on need. I will continue to track the issue for the remaining weeks I am here because it is an issue close to my heart, because of my father and because I have met too many people who would not be suffering every day if we had been able to intervene earlier.

Deputy Kathleen Lynch: I believe some of it has been put in place, based on a personal family experience. There is not one of us who will not have had such an experience as we go through life in whatever form. This will have involved going to an accident and emergency department at 12 o’clock on a Saturday and walking out, having been discharged, at 12 o’clock that night.

Senator Jillian van Turnhout: That is the window of recovery.

Deputy Kathleen LynchThe difficulty is that it is like suicide in that we will never know how many people we divert from the path of disability. It is difficult to know. However, we need to treat differently those whom we do not divert. The implementation plan and strategy must be published as quickly as possible.

Senator Jillian van Turnhout: On that we agree. The plan must be published.

Questions to Minister for Health: Early Supported Discharge programmes for stroke survivors

Questions to Minister for Health Leo Varadkar TD, Minister Lynch and HSE in advance of Health and Children Committee meeting 6 October 2015

Senator Jillian van Turnhout
To ask the Minister for Health if he will ensure that Early Supported Discharge programmes for stroke survivors are expanded by the HSE in 2016; what other actions he intends taking to develop community rehabilitation services for stroke survivors; whether he is concerned that the implementation plan for the National Neuro-Rehabilitation Policy and Strategy 2011-2015 has not yet been finalised with just four months left in its four-year lifespan; and if he will make a statement on these matters.

Response:
Currently there are 3 Early Supported Discharge (ESD) teams in Dublin North, Dublin South West and Galway respectively. These teams though small are functioning well.

The programme plans to increase the ESD teams over the coming years in larger urban areas first and then progress this expansion to less urban areas with a modified team to serve these areas, however resources are currently unavailable for this.

The National Policy & Strategy for Neuro-Rehabilitation 2011-2015 recognises the various possible challenges and the working group proposed an initial 3 year implementation plan.  Since the initial estimate of a 3 year implementation plan, the HSE has seen significant changes with the development of the Hospital Groups and the Community Healthcare Organisation configuration. This has changed the landscape within which services are to be configured to support implementation of this much needed strategy.

Currently, a steering group led by the HSE Social Care Division with representation from the National Clinical Programmes for Rehabilitation Medicine and Neurology, Department of Health, Primary Care, Therapy Professions & Neurological Alliance of Ireland has been assigned the task of developing an implementation framework for the National Strategy & Policy for Neuro-rehabilitation services. This group is working on finalising an implementation framework which will be released for consultation in Q4 2015.

The work of the steering group is overseen by an operational lead and a clinical lead with the group proposing a 2 phased approach to implementation which will begin at CHO level and expand to inpatient specialist rehabilitation services with connectivity across all service delivery sites.

The Model of Care of the National Clinical Programme for Rehabilitation Medicine (NCPRM) will be one of the primary reference points for the implementation of the Neuro-Rehabilitation strategy, given the importance in ensuring consistency and clarity in pathways to and across services.  The model of care of the NCPRM will provide a framework for the design and delivery of specialist rehabilitation services in the context of a strategy that addresses the broad continuum of services and supports required by those with neuro-rehabilitative needs.

The Model of Care for the NCPRM, which is currently being finalised post public consultation, details the role, function & benefits of these care teams, in line with the recommendations contained within the National Strategy & Policy for Neuro-rehabilitation Services in Ireland 2011-2015. This model of care proposes a 3 tiered model of specialist rehabilitation services namely complex specialist tertiary services, specialist in-patient rehabilitation units & community based specialist neuro-rehabilitation teams.

Both the National Clinical Programme for Rehabilitation Medicine and the National Policy & Strategy for Neuro-rehabilitation propose a needs-led service that meets the rehabilitative needs of people at acute, post-acute and community levels of people at all stages of the lifecycle who may benefit from medical, physical, cognitive, psychological and/or social Neuro-Rehabilitation service provision.

In this regard, it is not condition specific. While those who have suffered a stroke will be within the scope of this policy, services will not be exclusively for stroke survivors.

 

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.

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.

The Lancet

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