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.

 

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

The Lancet

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