Joint Committee on Health and Children

Questions to the Department of Health and the Health Service Executive, for answer at the meeting of the Committee on Thursday, 22 March, 2012.

National Issues

Question 1 (Deputy Jerry Buttimer)

To ask the Minister and the HSE the total amount paid out on foot of negligence claims in each of the last three years, the associated legal fees incurred and if the HSE avails of an insurance policy to assist in meeting both the claim and legal fees and also what steps are being taken to reduce these amounts.

Response:

1. Total amount paid on negligence claims by the HSE in the last 3 years via the State Claims Agency:

Transaction Year

*ELPLPD

CLINICAL

TOTAL

(€) (€) (€)2009 n/a 47,562,4

2947,562,429

2010 218,608 79,064,810

79,283,418

2011 2,122,225

79,081,343

81,203,568

*(ELPLPD) Employers Liability / Public Liability / Property Damage

2. Total amount paid on negligence claims by the HSE’s insurers in the last 3 years (including legal fees, which are not separately analysed). Note that since 2009 the HSE is substantially self insured. These claims payments relate substantially to payments made by former insurers of the HSE as cases settle:

Transaction Year

TOTAL(€)

2009 27,012,508

2010 28,695,090

2011 32,941,030

3. The associated legal fees incurred by the State Claims Agency which are included in the figures at 1. above;

Clinical Legal Fee Payments from 2009 to date

Transaction Year

2009 2010 2011

Total (€ million) 17.2 23.9 32.1

HSE ELPLPD Legal Fee Payments from 2010 to dateTransaction Year

2010 2011

Total €10,146 €339,380

*(ELPLPD) Employers Liability / Public Liability / Property Damage

4. If the HSE avails of an insurance policy to assist in meeting both the claim and legal fees?

Under the general rule of State indemnity enacted through statutory provisions above, the HSE carries its own insurance for the following areas of risk:

Personal injury to employees of the State; Personal injury to third parties (the public) – this includes injury resulting

from medical negligence; Third party property damage – this includes claims arising from road traffic

collisions (RTC’s);

The claims against the HSE that arise as a result of these categories of risk are managed by the State Claims Agency.  Typically a particular indemnity is enacted through an instrument of legislation. The provisions in relation to State indemnity for personal injury and third party property damage are set down under the National Treasury Management Agency (Amendment) Act, 2000.

The Clinical Indemnity Scheme (CIS) was established in 2002, in order to rationalise pre-existing medical indemnity arrangements by transferring to the State, via the Health Service Executive (HSE), hospitals and other health agencies, responsibility for managing clinical negligence claims and associated risks.

On 1 January 2010 the management of HSE personal injury and third party property damage claims was delegated to the State Claims Agency (SCA) under the National Treasury Management Agency (State Authority) Order 2009.  

The HSE continues to conventionally insure other risks (e.g. own property damage, professional indemnity, etc), which are not covered by State indemnity, with commercial insurers.

Where a State indemnity applies, i.e. the State bears its own insurance, a commitment is made to protect against losses, should any loss or damage arise where the State was negligent. 

5. What steps are being taken to reduce costs of claims?

State indemnity general cost savings:Where this State indemnity applies the HSE does not purchase insurance for personal injury (employer’s and public liability) and third party property damage and as such

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will not have to bear associated premium costs.   Indemnity works on a pay as you go basis so that all costs associated with personal injury and third party property damage claims are paid directly by the HSE through a reimbursement system operated by the SCA. Analysis has demonstrated that the States cost of dealing with claims directly is significantly lower than the premium cost of insuring the risk. This has yielded significant annual savings as the HSE no longer have to pay insurance premiums for delegated classes of claims.

In order to maximize the savings the State must manage the claims made against it at the best possible cost.  In conjunction with the HSE the SCA has a strong track record in reducing the cost of managing claims under its remit. For example during 2011 the SCA achieved significant savings on claims and related legal costs associated with the management of the Clinical Indemnity Scheme (CIS). An independent actuarial assessment projected that €106 million would be required to satisfy CIS claims and related costs in 2011. The outturn for the year was €81 million, representing a saving of €25 million.

Reduction of Legal Fees:The HSE, through the SCA, are actively involved in a number of initiatives to control and reduce defence legal costs:

An in-house legal team manage a proportion of the claims portfolio thereby appropriately limiting the use of external legal services.

All fees for external legal services provided to the SCA are subject to the 8% reduction as implemented by Government Decision S180/20/10/0964C of 3rd February, 2009 which came into effect from 1st March 2009 for services rendered after this date.

In view of the prevailing exchequer challenges the SCA invited tenders in respect of the provision of legal services for the SCA’s employers liability/public liability/property damage (EL/PL/PD) and CIS claims’ portfolios in 2010/2011.Prior to the tender the level of fees paid by the SCA to its defence solicitors was between 42% -52% of the agreed professional fee paid to the solicitors representing the plaintiff.  Following the recent tender, this level of fee was capped at 40% and, through a competitive bidding process, some panel firms have accepted fee levels of 35% and lower (note the combined impact of the 8% Government reduction following the government decision and the tendering has reduced panel solicitors legal fees by as much as 20% in some instances). In addition, the SCA has imposed caps on the levels of the fees paid to its panel solicitors in District, Circuit and High Courts and in respect of catastrophic Injury.

In addition, caps were imposed on the levels of the fees paid to its panel solicitors in District, Circuit and High Courts and in respect of catastrophic Injury.

In respect of plaintiff legal costs:

The legal costs paid to the solicitors/barristers representing plaintiffs in personal injury actions are higher than the legal costs of defendants’ legal representatives. The level of legal costs paid to plaintiffs’ legal representatives

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is carefully reviewed and the subject of robust negotiations by the SCA to achieve appropriate reductions in the legal costs. If the SCA cannot successfully agree the level of legal costs to be paid to plaintiffs’ legal representatives, the dispute is determined by the Taxing Master.   

The SCA has negotiated legal costs’ savings on plaintiffs’ solicitors’ fees of €5.6 million in 2011.

Risk Management:The SCA has a statutory duty to provide advice and assistance to all health enterprises under the various schemes. It collaborates with HSE risk management, clinical and administrative personnel to support patient safety and to help minimise the occurrence of clinical claims.

The SCA hosts a national electronic reporting system (STARSWeb) which facilitates the identification of clusters of adverse incidents and allows for root cause analysis of claims. The lessons learned from this analysis support the improvement of patient safety and contribute to the reduction of clinical claims in health enterprises.

When serious adverse events or trends are identified by the SCA, it responds by undertaking detailed analysis, providing advice and making recommendations, or by commissioning external reviews, as appropriate.

Annually, the SCA plans and implements employers liability/public liability/property damage (EL/PL/PD) and clinical risk management work programmes based on claims and incident data trend analysis, legal requirements and precedents and recent developments in litigation risk management, nationally or internationally. In addition to this, over 1,000 ad-hoc requests for advices and consultancy services are received from the HSE annually.

A comprehensive programme of training and seminars continues to be delivered by the clinical risk management unit. This programme is particularly targeted at hospital consultants, especially obstetricians, and other speciality groups. Examples would include:

Systems Analysis Training – 26 courses delivered to consultants and multidisciplinary staff;

Presentations provided to 17 forums ranging from medical emergency services, graduate medical programmes in various universities, clinical nurse management staff, mental health services, paediatric units, etc;

Bi-annual obstetric forum meetings, hosted by the Agency, of all maternity and maternity units in the State.

The SCA provide insurance advices on HSE contracts, licenses, schemes and tenders in circumstances where State indemnity applies or on insurances required where it does not apply. This ensures that the States liabilities are minimized in the most cost effective manner.

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Question 2 (Deputy Jerry Buttimer)

To ask the Minister and the HSE the progress being made on providing GP only cards to people on the long term illness scheme and the resource and cost implications of this initiative.

Response:

The Government is committed to major reforms of the manner in which health services are delivered. As part of the reform programme, Universal Primary Care is to be introduced on a phased basis during this term of office. In the first phase, GP care without fees will be provided to persons with defined long term illnesses in receipt of drugs and medicines under the Long Term Illness Scheme. Primary legislation is required to give effect to this commitment.

The Estimates for the HSE for 2012 include a sum of €15 million to fund this initiative. The Department is preparing a Memorandum for Government on this matter. Once the primary legislation has been approved by the Government the details of this initiative will be announced.

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Question 3 (Deputy Catherine Byrne)

To ask the Minister, in relation to the Nursing Home Support Scheme; if he can confirm if some patients in long term care in nursing homes under this scheme are being discharged back into the community? If so, why is this happening; who makes this decision; are families being consulted; will home care packages be provided to ensure these elderly people are adequately cared for at home; who will assess these patients for home care packages; what happens the funding approved for their nursing home care in the first instance?

Response

Under the Nursing Home Support Scheme, applicants are required to undergo a comprehensive and multi-disciplinary ‘care needs assessment’, (CSAR), in order to establish their need for long term residential care services – as outlined in Section 7 of the Nursing Home Support Scheme Act, 2009. All CSARs are considered by the LPF (Local Placement Forum), which are mainly chaired by a Consultant Geriatrician, before admission to long stay care in clinically approved.

There is no evidence to date of persons, who have been approved for State Support under the Nursing Home Support Scheme, being ‘discharged back into the community’. Patients who may have been sent home from nursing homes may be those who have been discharged from acute hospitals under 'intermediate care' arrangements (SDU funded), who subsequently were deemed well enough for discharge home (I.e. they did not meet the ‘care needs assessment’ criteria for NHSS) – so therefore were not ‘long stay’ patients.

However, if any resident wishes to return home, (long stay or intermediate care), and they wish to apply for community care they should contact the HSE and that option will be fully considered by the HSE in the context of the supports available including formal and informal care arrangements. Family representatives will be consulted in the best interests of the patient.

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Question 4 (Deputy Billy Kelleher)

To ask the Minister for Health to outline what steps have been taken to improve the Medical Card application process.

Response

The Medical Card centralisation programme went live on 1 July 2011 as planned. This project is a major reconfiguration of services and the requirement to utilise voluntary redeployment was pursued in the first instance. Essential redeployment was also utilised under the parameters of the Public Service Agreement.

Since centralisation of processing became effective in July 2012, the HSE has for the first time central governance over all of the associated processes e.g. standardisation of eligibility assessment and reviews. In addition we are achieving greater visibility of the financial exposure in the medical card scheme.

At the end of January 2012, the HSE decided to review the operations and processes within the central processing office with a view to ensuring that the most responsive service for the public is in place. Following a tendering process, PwC was engaged to provide external consultancy support to the HSE PCRS project team

The brief for the project was to undertake a review of current processes, develop proposals for the streamlining and improvement of these processes, and to develop proposals for improving customer service practice. The project consists of a number of work streams to focus specifically on a number of key areas including inter alia; the National Assessment Guidelines; the Medical Card Application Form, Customer Services and Local Health Office Support. This review commenced immediately and the report of the review is being completed and will be available shortly.

In addition, an action plan has been put in place with immediate effect, including a number of temporary processing changes, to clear the backlog by the end of April 2012.

The HSE has also taken a number of steps to streamline operations in the central office and to make the process for renewing a medical card simpler and easier for the public. A range of initiatives have already been implemented to address many of the issues which have arisen in the initial months of centralisation. A key change has been the introduction of self-assessment reviews for medical care renewals for most customers under 70 years of age, which has reduced complexity of the review process and eliminated related documentation requirements. Other initiatives implemented include extension of card expiry dates from two to three years in most cases, and the provision of system facilities to GPs to allow temporary extension of card eligibility for expired cards, and to add new babies to existing cards.

Under these new procedures for renewing a Medical Card, a card will remain valid, irrespective of the expiry date shown on the card, once the Medical Card holder is genuinely engaging with the HSE review process. Eligibility for services can be confirmed by any Doctor or Pharmacist or by the Medical Card holder online at www.medicalcard,ie or through the GP practice systems or in any Local Health Office or through the helpline at 1890-252-919.

In cases where a medical card is required in emergency circumstances, such as for terminal illness or for a serious medical issue, an Emergency Medical Card may be

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issued. Such an application can be initiated through the Local Health Office whose manager has access to a dedicated fax and e-mail contact line to the PCRS. Details of this procedure are available to all GPs and Social Workers. Such cards will be issued within 24 hours.

As before, 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.

In other emergency cases (e.g. where a person in need of urgent medical attention cannot afford to pay for it etc), the HSE issues all Emergency Medical Cards on the presumption that the patient is eligible for a medical card (i.e. that they satisfy the eligibility criteria in terms of a means test or on the basis of undue hardship), and that the applicant will follow up with a full application within a number of weeks of receiving the Emergency Medical Card. As a result, Emergency Medical Cards are issued to a named individual, with a limited eligibility period of six months.

The scale of the operation, and the continuing increase in demand, means that since July 2011 PCRS have received applications from 469,670 families and have issued or renewed nearly 1 million medical cards. The central processing office currently issues on average over 4,000 medical cards per day. The HSE plans to issue more than 100,000 new medical cards in 2012.

However, a backlog of open cases of 26,421 currently exists in respect of the period July to end December 2011. In a significant proportion of these cases the necessary information which had been sought does not appear to have been provided.

One of the main difficulties faced by the PCRS is incomplete applications. It is very important that all supporting documentation is included with the application form. Currently between 30% and 35% of all applications received by the central office are incomplete. While the application process is undoubtedly complex, more self assessment and longer eligibility periods will ease the burden on applicants. An initiative is also underway to make the application process easier for the public, the HSE is working with the National Adult Literacy Agency (NALA) to review the medical card application form, and other associated forms and letters.

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Question 5 (Deputy Billy Kelleher)

To ask the Minister for Health and the HSE if they are now establishing Hospital Trusts prior to legislation being enacted.

Response:

One of the priorities for the Special Delivery Unit in 2012 centres around the introduction of a major upgrade in the performance capabilities of the Irish health system. As stated in the Programme for Government, public hospitals will become independent, not-for-profit trusts: the SDU will develop and implement proposals to achieve this. The establishment of hospital trusts is an important stepping stone towards the introduction of universal health insurance which is the ultimate destination of the Governments reform programme. The rationale behind the establishment of hospital groups and trusts is to support increased operational autonomy and accountability for hospital services in a way that will drive the optimum service reforms. Performance improvement must be at the heart of the national reform programme: the creation of hospital groups and trusts is integral to a stronger and more systematic process of performance management for hospitals. Smaller hospitals will be managed as part of a group and their role will be protected in line with the Framework for Smaller Hospitals.

(i) Transitionary measure: hospital groupsAs a first step on that journey, hospitals will be aligned within groups on an administrative basis. Each Group will have a single consolidated management team, with responsibility for performance and outcomes, within a clearly defined budget and employment ceiling. The management team will have a critical role in reorganising hospital services within each Group, subject to an agreed policy framework and approval process. It is envisaged that the introduction of hospital groups will provide further opportunities for inter-side co-operation, on the basis of parity of esteem for the hospitals and teams within their hospital groups. Budgets for specialist and tertiary services will be set nationally. (i) (a) Limerick & Galway:In recognition of the significant financial and capacity issues identified in the Limerick and Galway hospital groups, acting CEOs were appointed to both in December 2011. Work is being progressed on related governance issues, including legal issues. These new arrangements are designed to deliver improved performance, organisational cohesion and effectiveness, and accountability for the efficient and safe delivery of acute hospital services within the hospital group on a unified basis. The new CEOs have full regard to the entire capacity of the hospital group, with a particular emphasis on developing the role of the smaller hospitals.

(ii) Hospital TrustsThe establishment of hospital trusts will require the development of the necessary corporate governance, management and clinical capacity to ensure that these hospitals are equipped to function efficiently and effectively, once established as independent service providers. This effective management of the core business will be defined, quantified and incorporated into a new accountability framework that can handle the move from the present arrangements towards the independent hospital Trusts envisaged in the programme for government. As a core part of the development of hospital trusts, the Department and the SDU will have due regard to international evidence based literature in this regard.The organisation of hospital services nationally, regionally and locally will be informed by the clinical programmes, which have been developed and implemented by the HSE,

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and by the work on the framework for the development of smaller hospitals. These inter-related programmes aim to improve service quality, effectiveness and patient access and to ensure that patient care is provided in the service setting most appropriate to individuals' needs.

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Question 6 (Deputy Billy Kelleher)

To ask the Minister for Health to provide details of the provisions that have been put in place to counteract the impact on services as a result of the plans to removal up to 800 beds from the Community Nursing Home service in view of the inordinate delay in processing applications for the Fair Deal scheme.

Response:

The HSE's Service Plan 2012 states that between a minimum of 555 Public Long Stay Beds and a maximum of 898 beds will close across the Public Long Stay Residential Care Units in 2012. The closures will be as a result of non compliance with HIQA Standards, lack of staffing and reductions in funding for Agency Staff and Over-time payments. Local management plans are still being finalised following confirmation of final retirement numbers of staff from the system. Further details of where and when these bed closures will take place will be finalised over the next number of weeks.

In relation to the proposed closure of any Public Long Stay Unit, a detailed Consultation Process will take place before any decision will be taken to close a Unit. All interested and affected parties will be given the opportunity to feed in to this process – either in a meeting format, by written submission or both before a decision is made to close a Unit.

The HSE Service Plan 2012 provides for the provision of State Support to an additional net 1,270 persons in long stay residential care services, under the Nursing Home Support Scheme, in 2012, when compared to the December 2011 activity levels. These places will be provided through a mix of public and private facilities. All applicants under the Nursing Home Support Scheme are free to choose either public or private nursing homes when deciding on their care provider – and applicants will pay the same contribution towards their long stay residential care services costs, whichever they choose.

However, it should be noted that, since the service plan was published, €13m has been transferred out of the Long-term Residential Care budget for the Home to Home initiative being developed by the Special Delivery Unit in the Department of Health. The initiative aims to reduce attendances at Emergency Departments, improve the management of acutely ill frail older adults in acute hospitals, reduce inappropriate admission to nursing homes and increase independence in the home. The implementation of the initiative in 2012 should impact on the number of people applying for the Nursing Homes Support Scheme and the target additional number of people to be supported should reduce accordingly.

The €13m re-allocation will mean that approx 620 beds to be provided under 2012 funding allocation will now be ‘transitional care beds’ rather than ‘long stay beds’ and will reduce the 1270 net additional long term care beds to approximately 650.

There are currently no ‘inordinate delays’ in processing applications for the NHSS. The HSE has a statutory obligation to administer the NHSS within the budget allocation provided – i.e. the NHSS is ‘resource capped’. All completed applications for State Support are generally brought to ‘determination’ within 4 weeks of receipt of completed application – and funding is approved within 2-3 weeks of ‘determination’.

Funding is approved from a National placement list, in strict chronological order – in accordance with the legislation. Delays may be experienced in applicants actually providing all documentary evidence required under the legislation, (i.e. Completing

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the application process-house/asset valuations, proof of income/assets etc required), but once completed application is received, there is no ‘inordinate delay in processing applications’.

The HSE strategic direction implements Government policy which has the following two core elements:

Community & home based care should be developed to maintain older people in their own communities for as long as possible and to support the important role of the family and informal carer

Where this is not possible high quality residential care should be available

The integrated model of care developed by the HSE provides for appropriate care in appropriate settings along a continuum from home and community based services through acute intervention to long term residential care with older people’s needs and preferences being central to decision-making. This approach will require the continued expansion of community services while also ensuring the provision of high quality long stay residential beds geographically located suited to older peoples need and supported through the NHSS.

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Question 7 (Deputy Denis Naughten)

To ask the Minister & HSE if they will outline their plans for the “reconfiguration” of services for people with a disability.

Response:

The Disability Strategy provides the overarching framework for legislative and policy development. (The Disability Act 2005, the Education for Persons with Special Educational Needs Act 2004, the Health Act (HIQA) 2007 and the Citizens’ Information Act 2007). This Strategy underpins a society where people with disabilities are supported to participate fully in economic and social life and have access to a range of value for money supports and services to enhance their quality of life and well-being. The vision is predicated on the principles of citizenship, control, informed choice, self determination, responsibility, inclusion, participation, equity, person-centredness, quality, effectiveness, efficiency, sufficiency, accountability, and transparency. Also underpinning this vision is Ireland’s commitment to the UN Convention on the Rights of Persons with Disabilities, 2009.

Currently Disability services in Ireland are facing a period of unprecedented change. In recent years, service provision has been transitioning from congregated to community provision and from segregation to inclusion. The pace of this change is rapidly accelerating. Disability provision requires radical transformation to achieve the vision for future service provision as articulated by the Disability Strategy.

This level of change is highlighted in the disability element of the HSE National Service Plan 2012 and contains a detailed list of the deliverable outputs regarding service provision and system re-configuration for 2012 and beyond. This change towards a community based model focusing on participation and inclusion is being progressed through the implementation of:

A Time to Move on from Congregated Settings New Directions Progressing Children’s Services The Neuro-Rehabilitation Strategy

The emerging Department of Health policy direction (Value for Money and Policy Review), coupled with recommendations from the above Reports has emphasised the need for a new model of service provision that, if agreed by Government, will further the independence of people with disabilities in a manner which is efficient and cost-effective. It envisages the existing level of funding being re-directed to support a person-centred approach where the funding will follow the individual, and it also envisages mainstream access to housing, employment, and education. This will ensure an appropriate balance of type and location of care brought about by a number of reconfigurations, such as the further development of integrated, geographic based, early intervention and school-age teams, a move away from congregated residential settings, the development of more choice in respite services, the development of more appropriate day services, and neuro-rehabilitation. This will require considerable cultural, structural and systemic change and will need to be driven and guided through strong and effective change management that can cut across both the public and NGO sector provision.

This radical change is not the sole responsibility of the HSE but, rather, a collaborative responsibility shared between the person, their families and carers, a multiplicity of

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agencies, Government, and society as a whole. There will be significant challenges for the many stakeholders. A major change programme over the next number of years has commenced. This will include a robust implementation plan which will be developed through the National Consultative Fora (NCF) and will include a monitoring and evaluation framework. The outcome of the Value for Money and Policy Review will provide the framework within which the constituent parts of the overall change programme will be developed and driven.

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Question 8 (Deputy Denis Naughten)

To ask the Minister & HSE if they will outline their plans for the “reconfiguration” of services for older people.

Response:

The HSE recognises the implications of the demographic changes facing Ireland, and in particular the projected 140% increase in the over 65 population (1.2m) by 2036, with 234% increase in the over 85 population (0.156m). Health and personal social services for older people need to be developed planned and reconfigured in a coordinated way to support this projected demand, with particular focus on following core elements:

Supporting the older person to live at home for as long as possible by providing appropriate community based services on an assessed needs basis

Providing, when required, accessible acute hospital care including inpatient services through a Consultant Geriatrician, where appropriate, and to support the older person in the acute hospital setting to return home or to an appropriate setting preserving and supporting their independence in as far as possible.

Providing transitional care facilities where required through rehabilitation, convalescence and respite to minimize the need and avoid unnecessary acute hospital care as well as providing such requirements when acute care is no longer required

When a person can no longer remain at home, providing person centered residential care in accordance with the Nursing Home Support Scheme 2009 (NHSS) and the requirements of the National Residential Care Standards, as inspected by HIQA since July 2009.

An integrated model of care for older people is being developed which will provide for appropriate care in appropriate settings along a continuum from home and community based services through acute intervention to long term residential care with older persons needs and preferences being central to the decision making that is required throughout the process. The Quality and Clinical Care Directorate has also developed a draft Acute Medicine Plan that acknowledges the role of public residential care units which will support older people with sub acute, rehabilitation and palliative care needs. A needs/gap analysis for rehab, intermediate, long stay and ‘community support’ beds (and home help/HCP provision) is being carried out presently at ISA level, which will identify current service provision against service requirements. This analysis will inform a consolidated plan for the provision of a continuum of residential care services

Community based services are being developed through the reconfiguration of current core services with access through Primary Care Teams to a range of home based services such as Home Helps (HH), Home Care Packages (HCP), day care, respite, meals on wheels and care supports provided as appropriate to residents in sheltered housing (in conjunction with Local Authorities). In recognition of the requirement for the provision of community based services, nationally €138m is available in 2012 for the provision of Home Care Packages which will provide packages to 10,870 persons at any time and it is expected that over 15,700 people will benefit from a HCP in 2012. Over €200m is available in 2012 for the provision of Home Help Services and 50,000 people will be in receipt of home help services at any time.At a social care network level (population 35,000 to 50,000), the older person will have access on referral to specialist type services including Consultant Geriatrician and

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Allied Health Professional inputs which can be provided in various community and hospital based settings which supports older people to remain living at home in their own community for as long as possible. The role of voluntary and community based groups who provide a range of services, activities, linkages to the community for older people and with older people’s involvement, cannot be underestimated and will continue to be encouraged in the context of supporting older people to remain living at home.

The HSE's Service Plan 2012 states that between a minimum of 555 Public Long Stay Beds and a maximum of 898 beds will close across the Public Long Stay Residential Care Units in 2012. The closures will be as a result of non compliance with HIQA Standards, lack of staffing and reductions in funding for Agency Staff and Over-time payments. Local management plans are still being finalised following confirmation of final retirement numbers of staff from the system. Further details of where and when these bed closures will take place will be finalised over the next number of weeks.

In relation to the proposed closure of any Public Long Stay Unit, a detailed Consultation Process will take place before any decision will be taken to close a Unit. All interested and affected parties will be given the opportunity to feed in to this process – either in a meeting format, by written submission or both before a decision is made to close a Unit.

While the Service Plan indicates that there will be beds closed during 2012 it should be noted that the HSE has also continued to open new fit for purpose long stay public units and beds over the past year with 279 additional beds and 268 replacement beds coming on stream in 2011. In 2012, a further approx 400 beds are due to come on stream. In addition a number of private nursing homes have indicated they will extend and or constructing new buildings in 2012.

The HSE Service Plan 2012 provides for an additional net 1,270 persons for long stay residential care services, under the Nursing Home Support Scheme, in 2012, when compared to the December 2011 activity levels. These places will be provided through a mix of public and private facilities. However, it should be noted that, since the plan was published, €13m has been transferred out of the Long-term Residential Care budget for the Home to Home initiative being developed by the Special Delivery Unit in the Department of Health. The initiative aims to reduce attendances at Emergency Departments, improve the management of acutely ill frail older adults in acute hospitals, reduce inappropriate admission to nursing homes and increase independence in the home. The implementation of the initiative in 2012 should impact on the number of people applying for the Nursing Homes Support Scheme, and the target additional number of people to be supported should reduce accordingly. The €13m re-allocation will mean that approx 620 beds to be provided under 2012 funding allocation will now be ‘transitional care beds’ rather than ‘long stay beds’ and will reduce the 1270 net additional long term care beds to approximately 650.

All applicants under the Nursing Home Support Scheme are free to choose either public or private nursing homes when deciding on their care provider – and applicants will pay the same contribution towards their long stay residential care services costs, whether they choose a public or private placement.

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Question 9 (Senator Colm Burke)

In view of the fact that so many Irish medical graduates are leaving Irish hospitals every year, would the Minister outline if research has been carried out on this issue, if such research was carried out, the reasons that have been identified as to why people are leaving in such large numbers and what remedial action is proposed in order to stem the outflow of very dedicated and committed medical personnel from the Irish health care system?

Response:

Response from Medical Education & Training Unit:

The issue of medical graduates who have been trained in Ireland deciding to leave the country is a matter of concern for the health service in terms of ensuring an appropriate level of medical staffing across hospital and community services. Previously, little concrete information was available to quantify the numbers of graduates leaving the country but anecdotal evidence indicated that the proportion was significant.

In view of this, the HSE’s Medical Education & Training Unit carried out a survey of intern doctors (the year immediately following graduation from medical school) and the information that follows provides a summary of the findings of the survey. Additionally, the Medical Education and Training Unit undertook a tracking study of recently completed interns. The HSE is actively addressing many of the issues which have arisen from these studies, and these developments will help to address the issue of graduate retention. Details of some of the areas of development are provided below.

The HSE is aware of three studies which have recently explored this issue:

1. The HSE MET unit has conducted an exit survey of interns who completed their posts, in mid-2011; a complementary study examined uptake of posts in Ireland by that cohort.

2. The RCPI has conducted a survey of trainees within its affiliated Faculties and Institutes, in mid-2011.

3. The IMO conducted a survey of NCHDs in September 2011.

Each study has indicated that significant numbers of NCHDs are considering options to take up posts outside the state. Key reasons identified include concerns about the availability of posts, Ireland’s economic situation, access to training and the perceived relative attractiveness of overseas health systems.

HSE-MET studies

In 2011, the HSE’s Medical Education & Training Unit recognised the importance of collecting data regarding the career intentions and movement of doctors who were completing internship in Ireland.

The MET Unit carried out:

1. an exit survey of interns who were completing internship in July 2011and

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2. a tracking study of interns completing in July 2011, based on the National NCHD Database, which allowed the HSE to confirm which of those interns remained in the Irish public health service after internship.

HSE-MET Intern Survey

The survey of interns was primarily focussed on training aspects, given the significant reforms to intern training which have been introduced over the past three years. The 2010/11 cohort of interns was the first to enter the health service through the new national application and matching system and to be trained during the evolution of the new National Intern Training Programme. Their views were therefore considered extremely important in terms of the further roll-out of the intern training reform process.

In addition to the training elements of internship, interns were also asked about their short-term and long-term career plans. It should be noted that the overall response rate to this anonymous survey was 44% overall and ranged from 26% in one Intern Training Network to 55% in another. Results must therefore be interpreted with great caution as it is unlikely that this is robust, representative data.

A significant proportion indicated their intention to leave Ireland for a time immediately after internship. 22% intended to work outside of Ireland in the long-term, including 8% non-Irish interns returning to their home countries. 52% indicated that their long-term intention was to work as a consultant in Ireland, 15% intended to work as a GP in Ireland, 6% favoured a career in research and a further 5% were unsure of their long-term plans.

Table 1: Long-term career plans of Intern Doctors (n=182)

The principal reasons provided by interns intending to leave Ireland for a time after internship included lifestyle choices, training opportunities abroad, dissatisfaction with medical training structures in Ireland and feedback from friends / colleagues in positions abroad. Based on comments provided by interns in the survey, it would

18

appear that for many, it was an opportunity for travel and a “gap-year” experience abroad after several years in college.

Table 2: Interns’ reasons for choosing to go abroad (n=182)

HSE-MET Tracking Study

In response to the results of the Intern Survey, the MET Unit ascertained the actual position of this cohort of interns, by conducting a tracking study of the 2010/11 doctors who took up posts in the Irish health service after internship. 513 interns were eligible for inclusion in this exercise.

This review was completed on grouped data using the newly implemented National NCHD Database. This database was funded by the HSE and implemented by the MET Unit and HSE ICT in conjunction with the Medical Council, the Postgraduate Medical Training Bodies and all clinical sites and mental health services nationally where NCHDs are employed.

Of the 513 interns, 43% were found to be in training positions in Ireland and 4% were in non-training positions in Ireland. 1% were still in internship (relating to maternity leave etc. during internship). A further 6% appeared to have accepted training positions but had not taken up employment. The remainder were no longer working in the Irish public health service.

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Table 3: Position of 2010-11 Intern Doctors, (as at September 2011), n=513

In training positions in Ireland 43%In non-training positions in Ireland 4%Still in intern training 1%Training & employment to be confirmed 6%No longer in employment in Irish public health service 46%

Key points arising from HSE-MET Studies

There is clear evidence that around half of the doctors who completed internship in Ireland in mid-2011, have left the country.

This is the first year that the Irish health system has had the data available to accurately estimate the number of interns who continued to work in the Irish health service after internship. Irish doctors leaving Ireland for a time is not a new phenomenon and, anecdotally at least, it appears that many return to Ireland after a period abroad. Often, the experience gained working in other health systems contributes both to the individual’s training and to the services that they provide to patients on their return. What will be important will be to continue to track this cohort of interns over coming years and subsequent groups of interns, in order to gain a clear picture about the movement of doctors, particularly those trained in Ireland.

Details of the Intern Survey and the tracking study will be published shortly as part of the HSE’s Second Implementation Report on the reform of the intern year.

Retention of Irish medical graduates

In relation to retention of Irish medical graduates, a key issue associated with NCHD retention has been access to training and career progression. Since 2007 the HSE has doubled the proportion of NCHD posts in structured training schemes, from 40% of NCHD posts to over 80%. The number of Consultant posts has increased by 30% (from 1,947 to 2,527) since the establishment of the HSE.

Each year the HSE invests more than €25m in medical education and training, much of which is transferred directly to the relevant training bodies under service level agreements for the provision of initial specialist and higher specialist training programmes and to the relevant Intern Training Networks for the provision of intern training. The HSE has also contracted with the postgraduate training bodies to deliver Professional Development Programmes to the 19% of NCHDs not in structured training.

In addition, the HSE funds or has funded in the past year:

Scholarships for doctors to train in centres of excellence abroad in novel or sub-specialist areas of medicine and patient care which are limited or unavailable in Ireland and to bring back the skills gained to the Irish health service. The HSE has awarded 24 scholarships and nine bursaries in this area since 2007. A number of those supported on this programme have since been appointed to consultants posts in Ireland.

Joint SpR / PhD training: Working with the Health Research Board, the HSE jointly funds a National Specialist / Senior Registrar Academic Fellowship programme which supports Specialist and Senior Registrars to enter an integrated training

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pathway leading to CCST and research leading to a PhD. Nine such awards have been made to date.

Introduction of 40 additional intern posts in new specialty areas like anaesthesia, general practice, emergency medicine and paediatrics;

Development and implementation of a three-year initial specialist training programme in emergency medicine, number of places available on programme is 78;

Expansion in the number of higher specialist training places in radiation oncology and anaesthesia;

Development and implementation of a structured four year basic specialist training programme in psychiatry.

While challenges remain, this represents a very significant investment in NCHDs and their future careers in Ireland. In December 2011 the Forum of Irish Postgraduate Medical Training Bodies and the HSE co-hosted a multi-stakeholder workshop on Retaining Medical Talent in Ireland. The aim of this workshop was to explore the reasons behind declining numbers of doctors working in the Irish health service, identify priority areas that need attention, and come to an agreement on how to proceed.

Participants included representatives from:

Doctors in Training (BST,HST) Postgraduate Training Bodies Department of Health Clinical Directors HSE Corporate (Directorate of

Clinical Strategy and Programmes, Quality and Patient Care, Human Resources, MET Unit, Integrated Services)

Hospital Managers/CEOs

Medical Council Programme Leads Medical Schools Medical Manpower Managers Regional Directors of Operations Unions (IMO/IHCA)

The workshop focused on developing, in a collaborative manner, strategies and actions to address the crisis facing the Irish Healthcare system in relation to retaining doctors, with an emphasis and focus on specific immediate/medium term actions to be taken.  The following themes were identified as having a major impact on the current situation:

- Access and Structure of Training Programmes- Career Path and Workforce Planning- Working Conditions- Trust and Respect

A number of recommendations were agreed on the day under each of these categories. Following the workshop a multi-stakeholder group was formed to review and refine the recommendations.  The role of the Steering Group is to oversee the implementation of the recommendations.   

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The Steering group is currently evaluating the recommendations considering what would have the greatest impact on improving retention of medical talent in Ireland.  Each Steering Group member has committed to represent their respective organisation and assign and/or oversee as appropriate the actions for that agency.  Steering Group members report back to the Steering Group on the progress of each action.

The attendees from the December workshop will be invited to reconvene for a briefing session in June 2012 that will include updates on each of the agreed recommendations. The June session will also discuss the action plan going forward.

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Question 10 (Senator Colm Burke)

Would the Minister give a detailed report as to the number of Hospital Consultant posts which are currently vacant, the number of Locums that are in place to fill those vacancies, the number of Consultant posts which were advertised but which were not filled and finally the number of posts that have become vacant as a direct result of the early retirement scheme which has a closing date at the end of February 2012?

Response:

Consultant posts are not subject to the same restrictions as other grades in terms of the government moratorium on recruitment and promotions in the public sector. Taking this into account, there have been significant increases in the number of consultant posts year on year since the establishment of the HSE. Between 2005 and December 2011, the number of posts of approved permanent posts increased by almost 30% (from 1,947 to 2,527). These increases continue as part of the implementation of the HSE’s Clinical Programmes.

In the period January 2010 to January 2012 the HSE approved 324 new and replacement posts. There were 178 approvals in 2010 and 146 in 2011.

Approved posts

2010 2011 Total

New 82 82 164Replacement 96 64 160Total 178 146 324

This meant that as of February 2012 there were 2,527 approved Consultant posts. Data from late 2011 indicates that there were 2,490 Consultants in employment, indicating that only 37 posts – mainly those approved in December 2011 and January 2012 were not filled. These posts are filled by non-permanent consultants pending the permanent appointee taking up post as service need arises.

Permanent approved Consultant posts at 31st Dec 2011

2,527

Consultants in employment (WTE) at 31st Dec 2011 2,490

Since January 2010 the HSE National Recruitment Service has processed 268 posts. The current position regarding these posts is as follows:

Position re Posts processed through HSE National Recruitment ServicePosts Advertised & Filled 122Posts Advertised & Vacant 87Posts on hold 17Posts not yet advertised 42Total 268

In relation to the effect of the grace period retirements on hospital services, approximately 48 of the 57 Consultants who have retired will be replaced. These posts are filled by non-permanent consultants pending the permanent appointee taking up post as service need arises.

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Consultant replacements (Acute hospital services)

Of the 57 Consultants who have indicated their intention to retire 48 will be replaced.

Specialty No. retiring No. being replaced

Anaesthetics 11 8Biochemistry 1 1Cardiology 1 1ED 2 1ENT 1 1General Medicine

3 3

General Surgery 7 6Histopathology 3 2Nephrology 2 2Neuropathology 1 1Obstetrics/ Gynaecology

5 3

Ophthalmology 3 3Orthopaedics 5 5Paediatrics 2 1Psychiatry 1 1Radiology 7 7Respiratory 1 1Urology 1 1Total 57 48

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Question 11 (Senator Colm Burke)

Would the Minister outline what proposals are in place for the recruitment of NCHD's for the period commencing July 2012?a) If the posts have been advertised?b) If interviews have been held?c) If there has been consultation with Hospital Consultants and Managerial staff in each Hospital within the HSE as to what their requirements for NCHD personnel is for 2012/2013?

Response:

It is important to note that the HSE is responsible for filling only a small proportion of all NCHD posts.

This is because the large majority – 81% of NCHD posts – are recruited for and filled by the postgraduate training bodies as part of their training schemes. These posts may be in HSE hospitals / agencies or in HSE-funded hospitals / agencies (such as St Vincent’s or the Mater).The remaining NCHD posts are service posts rather than training posts.

15% of NCHD posts are filled by the HSE as service posts;

4% of NCHD posts are filled by HSE funded agencies as service posts.

A key factor influencing NCHD recruitment in HSE and HSE-funded agencies is the extent to which the postgraduate training bodies fill posts. Data regarding fill-rates will not be available from the training bodies till mid-April at the earliest. If posts are not filled by the training body, they must filled as service posts by the HSE or the relevant HSE-funded agency. This has informed the HSE decision to run a continuous NCHD recruitment process. As of 15th March, the vast majority (more than 98%) of NCHD posts (both training posts and service posts) - are filled normally. Where staffing issues exist, there are sufficient agency staff to meet service needs. In this context, the challenge facing the HSE is that higher payments to agency staff are incentivising NCHDs to leave normal employment and work for agencies with the expectation that they will be hired back by the HSE. This is particularly relevant in Emergency Medicine and Psychiatry.

In February 2011 the HSE and the Public Appointments Service implemented a centralised recruitment process for the posts in HSE Hospitals and Agencies which are not part of structured training programmes. As noted above, these constitute approximately 15% of posts nationally.

In January 2012, this became a centralised application process only, as opposed to a full job offer process for the July 2012 intake.

The position regarding each of the issues raised by the Senator is set out below:

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a) If the posts have been advertised?

Campaign launched on 14th February

On 14th February the NRS launched a national centralised application process for Non Consultant Hospital Doctors.  The purpose of the launch is to generate sufficient numbers of qualified applicants for the July 2012 intake.

This high profile launch was intended to provide a continual stream of prospective candidates for locum positions and importantly gives access to ambulant applicants outside of the bi annual intakes.  In other words, permanent advertising, allowing for continual scheduled application for medical roles, working to meet the demand for particular nationally challenging specialties such as Emergency Medicine and Psychiatry.  

Centralised Application Process

The features of this process are:

Continual, ongoing ability to apply for HSE medical posts – e.g. a candidate can apply at any time

Internal, national and international launch Applications will be provided on an on going bases  - each hospital group can

interview based on service need Offers of employment / acceptances / contracting will be managed directly by the

services Applications will be made by Hospital Group and will not be site specific – full

information on each sites and services available with application The NRS will provide comprehensive reports on applicant numbers as required.

Marketing and Promotion

This campaign takes full advantage of new media – such as social networks as well as using visible but less effective traditional press advertising.

At national level it includes:

External / Internal Press Advertising - advertisements will appear in the relevant media such as Sunday / Irish Independent, Irish Medical Times HSE Website - continuous applications accepted

Talent Pool - the NRS will make contact with all 3,800 applicants to date to inform them of the new launches and encourage "tell a friend"

Public Appointments - job alert to all medical candidates registered with publicjobs.ie

Existing Staff - provision to all Clinical Directors / Medical Manpower Managers / Mental

Health Service Administrators launch poster for internal display -  and to share with any relevant professional networks / professional contact groups / overseas colleagues (see attached)

Information to prospective applicants regarding IMC registration

Internationally it involves:

Facebook -  launch advertisement targeted to doctors with Facebook profile LinKedIn - launch advertisement to doctors with LinkedIn profile

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Doctors.net.uk - launch advertisement to largest GMC registered forum in the UK Holland, Australia, New Zealand, Canada, America, South Africa - launch

advertisement on each countries Medical Journal Websites

Press Advertising is via the British Medical Journal.

b) If interviews have been held?c) If there has been consultation with Hospital Consultants and Managerial staff in each Hospital within the HSE as to what their requirements for NCHD personnel is for 2012/2013?

Interviews are being held at hospital group level at the current time and further interviews will be held in the coming weeks. These follow consultation with hospital consultants and other relevant staff in each hospital regarding their requirements and review of applications.

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Question 12 (Deputy Robert Dowds)

To ask the Minister for Health why eleven million euro less was spent on dental care provided to GMS (Medical Card) patients than was budgeted for last year; and whether he is concerned at the recent decision by the Irish Dental Association to withdraw its support from the public dental scheme?

Response:

The Dental Treatment Services Scheme (DTSS) was established in 1994 to provide a range of dental treatments to medical card holders. The Scheme is delivered by dental practitioners holding contracts with the HSE and expenditure has risen sharply in recent years. The Government decided in the context of Budget 2010 that it was necessary to reduce the level of expenditure in the DTSS.

Following the Government decision the Department of Health requested the HSE to cap expenditure at the 2008 expenditure level of €63 million. In April 2010 the HSE introduced measures to achieve this. Under the new measures the range of treatments available were prioritised. These measures were introduced to protect access to emergency dental care for medical card holders and to safeguard services for children and special needs groups. Services for high-risk patients and those requiring exceptional care continue to be available. The remaining care provision is subject to prior approval, which will be required from a clinician in the HSE, who will prioritise for:

High risk and exceptional patients, Those requiring emergency care, and Patients who are considered to have greater clinical urgency and/or

necessity in receiving care.

Following the introduction of these measures expenditure under the Scheme reduced from €79m in respect of 1,408,686 treatments in 2012 to €53m in respect of 1,030,032 treatments during 2011. The HSE has budgeted €63m under this scheme for 2012. The service is demand led and payments were made for all approved treatments during 2011.

In November 2100, standard administrative and clinical operating procedures were introduced to support equitable and priority funding. A National support system (National Clearing House) was developed and introduced to support these standard operation procedures and ensure no delays in implementation or approval.

As of February 2012, there is no backlog of requests for approval within the HSE. The HSE is currently reviewing the National Clearing House and as part of this review we plan to provide clear guidance to both dentists and the public in relation to DTSS entitlements for 2012. In addition, dentists have clear guidance of eligibility and entitlements from the Standard Operating Procedures. The HSE continue to monitor the ongoing effect of these changes and to offer guidance to individual contracted dentists on the implementation of the changes.

In 2009 there was a net increase of 233 in the number of dentists contracted to provide services under the DTSS bringing the total number of dentists contracted under the scheme to 1,582. The number of dentists contracted to provide services increased again in 2012 to 1,639 and as at the end of March 2012 there are 1,663 dentists providing services under the Scheme. Question 13 (Deputy Robert Dowds)

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To ask the Minister for Health whether forms for review or renewal of Medical and GP Visit cards are being sent out by the Medical Card section to patients in all cases; and to outline what is required from the patient to be considered to be "co-operating" with a review in order not to have the GMS card discontinued while a review is going on?

Response:

Every Medical Card shows an expiry date before which the eligibility of the holder is re-assessed by the HSE. A letter issues to the medical card holder three months before the renewal date (and again one month in advance of the renewal date). Once reviewed, and eligibility confirmed, the card is renewed. The vast majority of clients send their renewal forms in on time and have the appropriate decision made before their eligibility is due to expire.

In several cases, arising from delays in processing, the expiry date was reached before the card was fully assessed and a decision made. This resulted in some medical card holders who were entitled to a medical card losing eligibility.

In order to prevent such a scenario, new procedures have been implemented. Under these new procedures, a Medical Card will remain valid, irrespective of the expiry date shown on the card, once the Medical Card holder is genuinely engaging with the HSE review process. We consider engagement to include written communication from the client providing any additional information required.

Eligibility for services can be confirmed by any Doctor or Pharmacist or by the Medical Card holder online at www.medicalcard,ie or through the GP practice systems or in any Local Health Office or through the helpline at 1890-252-919. This means that a person can continue to claim free drugs and GP services while they await a decision on their medical card renewal application by simply using the medical card number.

The issue of people being able to continue to use their medical card where, for one reason or another, a decision has not been made by the review date, is not new. Since taking over medical card processing, the central office has extended eligibility for clients that are genuinely engaged with the office on their review, if the appropriate decision on their eligibility had not been made by the review date. For some time now medical cards have operated on the same basis as standard payment cards (e.g. VISA and MasterCard) where GP’s and Pharmacists etc. do not rely on the details on the physical cards, but rather on the confirmation from the back end system that the card will cover the service being received. PCRS confirm such eligibility requests from GP’s and Pharmacists for medical card services over 200,000 times daily. Since the majority of medical card services begin with a visit to a GP or Pharmacist then the information about eligibility is already readily available and is being regularly communicated in a standard way.

In line with the centralisation plan, the HSE has also taken a number of steps to streamline operations in the central office and to make the process for renewing a medical card simpler and easier for the public. As part of this the HSE has implemented self-assessment reviews for medical card holders who are 66 years or over. The self-assessment review model has also been extended to medical card holders under 66, who were granted their medical card on the basis of a means assessment. Question 14 (Deputy Robert Dowds)

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To ask the Minister for Health to outline his plans for groups of public hospitals in which each group is to have a board; and what he believes will be achieved by this in terms of services and costs?

Response:

See reply to question 5.

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Question 15 (Deputy Caoimhghín Ó Caoláin )

The crisis in mental healthcare arising from the loss of staff due to the early retirements at the end of February and the cuts imposed in the HSE National Service Plan.

Response:

The National Service Plan 2012 projects that at the start of January 2012 there would be 9,209 staff in the mental health services.

A total of 645 staff within mental health services have left at the end of February 2012. The figure for nurses of all grades is 450.

Of the 645 staff, 495 (76.7%) are 55 years or over (234 are over 60 and a further 261 are 55 years). Not all of these 645 staff are in frontline positions however – a total of 87 staff are general support staff.

The HSE is required to deliver its mental health services within a decreasing budget and headcount. Guiding the development of our services is A Vision for Change – a progressive, evidence-based and pragmatic policy document, which proposes a new model of service delivery designed around the service user, one that is recovery-orientated and community-based. A Vision for Change sets out a comprehensive change programme for the mental health services.

The cumulative impact of staff loss from the mental health services since 2009 and the attrition expected in early 2012 continues to challenge us to provide continuity of services to our patients and clients. The flexibilities available within the Public Service Agreement will allow mental health services at local level to adapt to this new reality.

We will continue to minimise the impact of the above on our obligations under mental health legislative and regulatory directives and to expedite our strategic reform programme with the closure of old psychiatric institutions and associated inpatient beds, wherever possible, with A Vision for Change remaining the strategic direction for the future delivery of mental health services in Ireland.

In 2012, prioritised under the Programme for Government, €35m has been reinvested to enhance both General Adult and Child and Adolescent Community Mental Health Teams, improve access to psychological therapies in primary care and implement suicide prevention strategies in line with Reach Out – National Strategy for Action on Suicide Prevention. From this €35m, €2m will be allocated to Genio projects.

414 staff will be recruited to the mental health service to deliver on these objectives, of these, 254 will be allocated to General Adult Community Mental Health Teams, 150 to Child and Adolescent Community Mental Health Teams and 10 to support the improvement in access to psychological therapies. These posts are broken down as follows:-

INDICATIVE ALLOCATION OF POSTS IN NSP2012Mental Health No of posts No. of Counselling Total

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Professional General Adult

posts CAMHS

in Primary Care

Clinical Psychology

81 19 100

Social Work 78 11 89Occupational Therapy

95 31 126

Speech & Language Therapist

28 28

Nurse 17 17Childcare Worker

38 38

Counsellor Co-Ordinator

10 10

Unallocated CAMHS posts

6 6

Total 254 144 10 414

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Mental Health all grades at 9th March 2012 Retirement Category

Care Group

NationalBoard Staff

Category Grade at Retirement CNERRetirement

Max Age 65+

Retirement Min Age 55 (Psychiatric)

Retirement Min Age

60-64

Retirement on Other Grounds Total

Mental Health HSE Dublin Mid Leinster

General Support Staff Chef I 1 1

Cleaner 1 1Clerk of Works 1 1Domestic 3 2 5Driver 1 1Gardener/groundsman 1 1General Operative 1 1Maintenance Craftsman/Technician 1 1

General Support Staff Total 2 5 5 12Health & Social Care Professionals Counsellor 1 1

Psychologist, Senior Clinical 1 1Social Care Leader 1 1

Health & Social Care Professionals Total 2 1 3Management/ Admin Clerical Officer 2 2

Grade IV 1 1 2Grade V 2 2Grade VII 1 1Supplies Officer Grade B 1 1

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Management/ Admin Total 2 5 1 8Medical/ Dental

Consultant Child and Adolescent Psychiatrist 1 1Consultant General Adult Psychiatrist 1 1 2Consultant Psychiatrist in the Psychiatry of Old Age 1 1Consultant Unclassified 1 1Medical Officer 1 1

Medical/ Dental Total 1 2 3 6Nursing Clinical Nurse Manager 1 1 1

Clinical Nurse Manager 1 (Mental Health) 2 2Clinical Nurse Manager 2 1 1Clinical Nurse Manager 2 (Mental Health) 2 1 4 7 14Clinical Nurse Specialist (Mental Health) 2 1 3Director of Nursing (Mental Health) 1 1Director of Nursing (Mental Health), Assistant 1 2 3Director of Nursing 1, Assistant 2 2Staff Nurse, Community Mental Health 1 1 1 1 4Staff Nurse, Mental Health 2 2 4 8Staff Nurse, Senior (Dual Qualified) 1 1Staff Nurse, Senior (Dual-Qualified Mental Health) 1 1 2Staff Nurse, Senior (Mental Health) 1 4 6 1 12

Nursing Total 4 2 20 20 8 54Other Patient & Client Care Attendant, Multi-Task 1 1 2

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Attendant/Aide 1 1 2 4Other Patient and Client Care Unclassified 1 1Workshop Supervisor/Instructor 1 1

Other Patient & Client Care Total 2 2 4 8

HSE Dublin Mid Leinster Total 9 6 24 38 14 91

HSE Dublin North EastGeneral Support Staff Boilerman 1 1

Chef I 1 1Domestic 3 1 1 5Maintenance Manager 1 1Porter 1 1

General Support Staff Total 4 4 1 9Health & Social Care Professionals Occupational Therapist, Senior 1 1

Social Worker 1 1Health & Social Care Professionals Total 1 1 2Management/ Admin Clerical Officer 1 1 2

Grade V 1 1Supplies Officer Grade B 1 1Telephonist 1 1

Management/ Admin Total 4 1 5Medical/ Dental

Consultant General Adult Psychiatrist 1 2 3

Medical/ 1 2 3

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Dental TotalNursing Clinical Midwife Specialist 1 1

Clinical Nurse Manager 1 (Mental Health) 1 1Clinical Nurse Manager 2 4 4Clinical Nurse Manager 2 (Mental Health) 11 4 2 17Clinical Nurse Specialist (Mental Health) 1 1Director of Nursing (Mental Health), Assistant 1 1 2Director of Nursing 1 1 1Director of Nursing 1, Assistant 2 2Nurse, Mental Health Community 1 1Staff Nurse - General 1 1 2Staff Nurse, Community Mental Health 1 1 2Staff Nurse, Dual Qualified (General) 1 1Staff Nurse, Mental Health 1 4 3 1 9Staff Nurse, Senior (Dual Qualified) 1 3 1 2 7Staff Nurse, Senior (Dual-Qualified Mental Health) 2 2Staff Nurse, Senior (Mental Health) 1 9 6 16

Nursing Total 3 1 42 16 7 69Other Patient & Client Care Attendant, Multi-Task 1 2 3

Attendant/Aide 1 5 1 7Chaplain 1 1

Other Patient & Client Care Total 1 1 6 3 11

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HSE Dublin North East Total 4 7 43 32 13 99

HSE SouthGeneral Support Staff Catering Officer, Grade III 1 1

Catering/Cleaner/Assistant 1 1Chef I 1 1 2Chef II 1 1Domestic 1 1 1 7 2 12

General Support Staff Total 1 1 1 9 5 17Health & Social Care Professionals Psychologist, Principal Clinical 1 1

Social Worker 1 1Social Worker, Principal 1 1

Health & Social Care Professionals Total 3 3Management/ Admin Clerical Officer 1 2 3

Functional Officer 1 1Grade IV 1 1Grade VII 1 1Supplies Officer Grade B 1 1Supplies Officer Grade D 1 1

Management/ Admin Total 3 1 1 3 8Medical/ Dental

Clinical Director (Psychiatric Services) 1 1Consultant General Adult Psychiatrist 1 1Consultant Psychiatrist in the Psychiatry of Old Age 1 1 2

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Medical/ Dental Total 3 1 4Nursing Clinical Nurse Manager 1 1 1 1 3

Clinical Nurse Manager 2 8 1 9Clinical Nurse Manager 2 (Mental Health) 3 21 3 1 28Clinical Nurse Manager 3 (Mental Health) 1 1Clinical Nurse Specialist (General) 1 1Director of Nursing (Mental Health), Assistant 1 4 2 7Director of Nursing 1, Assistant 1 1Staff Nurse - General 1 1 2Staff Nurse Senior, Mental Health (Nursing Bank) 1 1Staff Nurse, Community Mental Health 2 2Staff Nurse, Dual Qualified (General) 1 1 2Staff Nurse, Dual Qualified (Mental Health) 1 1Staff Nurse, Mental Health 3 10 9 3 25Staff Nurse, Senior (Dual Qualified) 3 2 1 6Staff Nurse, Senior (Dual-Qualified Mental Health) 5 5Staff Nurse, Senior (General) 1 2 3 6Staff Nurse, Senior (Mental Health) 1 2 29 5 2 39

Nursing Total 11 4 86 28 10 139Other Patient & Client Care Attendant, Multi-Task 1 3 3 7

Attendant/Aide 1 1 2Other Patient & Client Care Total 1 4 4 9

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HSE South Total 16 6 91 48 19 180

HSE WestGeneral Support Staff Catering/Cleaner/Assistant 2 2

Craftsman's Mate 1 1Domestic 3 1 4Domestic Supervisor 1 1Electrician 1 1Hostel Supervisor 1 3 4Maintenance Foreman 1 1Maintenance Foreman, Assistant 1 1Plumber 1 1Porter 1 1 2Stores Porter/Assistant/Attendant 1 1

General Support Staff Total 7 11 1 19Health & Social Care Professionals

Counsellor Therapist (Adult Counselling Services) 1 1Occupational Therapist Manager 1 1Psychologist, Senior Clinical 1 1 1 3Substance Abuse Consellor 1 1Therapist 1 1

Health & Social Care Professionals Total 2 1 4 7Management/ Admin Clerical Officer 2 1 3

Functional Officer 1 1Grade IV 1 1Grade V 1 1 2

39

Supplies Officer Grade A 1 1Supplies Officer Grade D 1 1

Management/ Admin Total 1 1 6 1 9Medical/ Dental

Consultant General Adult Psychiatrist 4 1 5Consultant Psychiatrist in the Psychiatry of Old Age 1 1House Officer, Senior 1 1

Medical/ Dental Total 6 1 7Nursing Clinical Nurse Manager 1 2 2

Clinical Nurse Manager 1 (Mental Health) 3 2 5Clinical Nurse Manager 2 2 2 4Clinical Nurse Manager 2 (Mental Health) 1 9 8 1 19Clinical Nurse Manager 3 3 3Clinical Nurse Manager 3 (Mental Health) 1 1Clinical Nurse Specialist (Mental Health) 6 2 8Director of Nursing (Mental Health) 1 1 2Director of Nursing (Mental Health), Assistant 1 1 2Staff Nurse - General 1 1Staff Nurse Senior, Mental Health (Nursing Bank) 1 1Staff Nurse, Community Mental Health 1 1 2 1 5Staff Nurse, Dual Qualified (Mental Health) 1 1Staff Nurse, Mental Health 2 22 29 6 59Staff Nurse, Senior (Dual Qualified) 2 1 3Staff Nurse, Senior (Dual- 2 2

40

Qualified Mental Health)Staff Nurse, Senior (Mental Health) 1 1 45 14 61

Nursing Total 2 4 101 62 10 179Other Patient & Client Care Attendant, Multi-Task 4 3 1 8

Attendant/Aide 1 2 4 1 8Other Patient & Client Care Total 1 6 7 2 16To Be Determined To Be Determined 1 1To Be Determined Total 1 1

HSE West Total 6 17 103 96 16 238VHSS/NHASS/LGSS/Other

General Support Staff Caretaker 1 1

Catering/Cleaner/Assistant 2 2 4Maintenance Foreman 1 1Maintenance Officer 1 1

General Support Staff Total 3 3 1 7Health & Social Care Professionals Instructor 1 1 4 1 7

Social Care Worker 1 3 4Health & Social Care Professionals Total 1 2 7 1 11Management/ Admin Functional Officer 1 1

Grade IV 1 1 2Grade V 1 1

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Grade VIII 1 1Management/ Admin Total 1 1 3 5Nursing Clinical Nurse Manager 1 1 1

Director of Nursing/ Midwifery Education Centre 1 1Staff Nurse - General 1 1Staff Nurse, Dual Qualified (Mental Health) 1 1Staff Nurse, Mental Health 1 1Staff Nurse, Senior (General) 1 2 3Staff Nurse, Senior (Intellectual Disability) 1 1

Nursing Total 2 6 1 9Other Patient & Client Care

Care Assistant (Intellectual Disability Services) 1 1 1 3Workshop Supervisor/Instructor 1 1

Other Patient & Client Care Total 1 2 1 4To Be Determined To Be Determined 1 1To Be Determined Total 1 1

VHSS/NHASS/LGSS/Other Total 3 7 20 7 37

Mental Health Total 38 43 261 234 69 645Total 38 43 261 234 69 645

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Question 16 (Deputy Caoimhghín Ó Caoláin )

The need for a special focus by the Department of Health and the HSE on the needs of children with rare diseases and conditions, many of them genetic, and their parents and carers, in terms of early diagnosis, clear pathways of care, networking for those with the same or similar conditions; these needs to be addressed and resourced in order to give real meaning to the forthcoming National Strategy on Rare Diseases.

Response:

Rare DiseasesRare diseases are life threatening or chronic debilitating conditions affecting no more than 5 in 10,000 people. Between 5,000 and 8,000 rare diseases have been described, affecting about 6-8% of the population in the course of their lives. Approximately 80% of rare diseases have a genetic origin. These conditions become evident in childhood and the life expectancy of patients with rare diseases is significantly reduced. Many of these conditions are complex, severe and debilitating.

Strategy for Rare Diseases Ireland has been supportive of the EU proposals on rare disease which concluded with a council recommendation in June 2009. The end point is that countries are recommended to develop plans or strategies preferably by the end of 2013. We are now well advanced in developing this work.

In January 2011, Europlan, the European Project for Rare Disease National Plan’s Development, organised a national conference bringing together patients, patient organisations and healthcare professionals to discuss what might feed into the development of a national strategy for rare diseases.

National Steering GroupIn April 2011, the Minister for Health established a National Steering Group to develop a policy framework for the prevention, detection and treatment of rare diseases based on the principles of high quality care, equity and to be patient centred. The policy will operate over a 5 year period, take account of the Council Recommendation on Rare Diseases (2009) and define priority actions subject to resource availability.

The National Steering Group is working on many areas relevant to the issue of rare diseases including:

The identification of appropriate centres of expertise for rare diseases is a key priority. The Europlan report which looked at services across Europe commented that in most countries, there are no designated centres of expertise and even where they exist that there is significant variation in their organisation and how they operate.

Access to appropriate medication and technology in the context of transparent processes to ensure equitable access to orphan drugs as well as the issue of orphan drug development.

Research is an integral part of overall care for rare diseases including access to clinical trials where appropriate. The group is also considering the most appropriate registries and data bases which can be used to plan and manage services in Ireland.

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The empowerment of patient organisations. The Europlan report contains a lot of practical guidance of what can be done to empower patients and their families in a meaningful way.

The National Steering Group is also considering how best to consult with patients and key stakeholders on the broad proposals and recommendations that will emerge.

It is expected that the group will submit a plan to the Minister during the latter half of this year.

HSE DirectorateA proposal submitted to the HSE’s National Director of Clinical Strategy & Programmes to establish a National Clinical Programme for Rare Diseases has been agreed by the HSE. However, the details of the programme remain to be worked through.

National Rare Disease DayRare Disease Day was held on 29 February this year and is an annual, awareness-raising event co-ordinated by EURORDIS* at the international level and National Alliances of Patient Organisations at the national level.The main objective of Rare Disease Day is to raise awareness amongst the general public and decision-makers about rare diseases and their impact on patients’ lives. 

*EURORDIS is a non-governmental patient-driven alliance of patient organisations representing more than 502 rare diseases patient organisations in over 46 countries

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Question 17 (Deputy Michael Colreavy )

The need to address the major deficiency in neurological and neuro-surgical services in this State.

Response:

A National Clinical Programme for Neurology has been established to improve the quality, access and cost effectiveness of neurological services. As part of this solution a range of initiatives are being implemented. This includes significant investment in services including the appointment of an additional 13 neurologists which will result in a 50% increase in the number of consultants, the funding of an additional 49 stroke clinicians (nursing and allied health professionals), the opening of additional 4 epilepsy monitoring beds for identification of suitable cases for neurosurgery and the appointment of additional 20 epilepsy nurses. This investment is being accompanied by innovative ways of delivering services. In addition the National Surgical Programme is implementing a range of initiatives to improve access to surgery including the productive theatre training module (to improve theatre safety and productivity) and bed capacity planning elective surgery by ring fencing of surgical beds. These surgical initiatives will encompass neurosurgery. The implementation of ring fenced beds for surgical activity is expected to commence in quarter 3 of this year. Taken to together these initiatives represent a major investment of time and resources to address recognised deficiencies in neurology services. However they provide a unique opportunity to improve clinical outcomes reduces waiting lists and improves cost effectiveness.

Neurosurgical services are delivered at Beaumont Hospital and Cork University Hospital. The following is an update on the developments at these hospitals.

Cork University Hospital:

Within Cork University Hospital a number of programmes have been identified for implementation to include Stroke, Epilepsy and Neurology. In order to progress these specific programmes the Executive Management Board established a project group to advance the development of a dedicated stroke unit. Following discussion with other specialties it was agreed to merge the clinical programmes for Neurology, Epilepsy and Stroke and develop a dedicated facility with 3 specific embedded components as follows:

Acute Stroke Unit – to meet the requirements of the National Stroke programme Regional Epilepsy Centre – to meet the requirements of the National Epilepsy

programme Rapid access diagnostic & therapeutic unit – to meet the requirements of the

National Neurology OPD programme

This coordinated approach will provide for the implementation of 3 Clinical Care programmes and potential maximisation of resources.

In addition the National Surgical programme is implementing a range of initiatives to improve access to surgery including the productive theatre training module which is presently being implemented within CUH. The programme has four main concepts:

Average Length of Stay Elective Surgery Model of Care

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Theatre journey(TPOT) Audit

A project group has been established within CUH to implement the above and the necessary dedicated facilities require to support the implementation of the programme have been identified.

Additional Staffing:The following are the staff grade and number allocated to the programmes

Programme AllocationNeurology Consultant Neurologist x 2 WTE (adult service)

Consultant Neurologist x 1WTE (paediatric service)Stroke Clinical Nurse Specialist x 1 WTE

Senior Speech and Language Therapist x 0.5 WTESenior Physiotherapist x 0.5 WTE

Epilepsy Staff Nurses x 5 WTEClinical Nurse Specialist x 4.5 WTENeurophysiological Technicians (Senior Grade) x 1 WTENeurophysiological Technicians (Basic Grade) x 1 WTEAdministrative Office x 1 WTE

The two consultants for the adult service have taken up duty and the consultant for the paediatric service takes up duty at the end of April.

Capital Allocation:To support the development for a dedicated ward for the Neurology/Epilepsy/Stroke service circa €155k was allocated to CUH by the programmes. The contractors for the required works have been on site since 5th March, 2012. Building works are expected to last 8 weeks followed by a commissioning period of 2-3 weeks for some equipment that needs to be purchased.

Beaumont Hospital:

Beaumont Hospital is the regional Centre for Epilepsy Services in Dublin North East and provides a shared National Service with Cork University Hospital for pre surgical assessments and treatments. The service is currently provided by 4 consultants and 1.5 Epilepsy Nurse Specialists. The Epilepsy programme has allocated additional staffing resources to the service as detailed below to develop nurse lead outreach clinics within the region and to expand the Complex Epilepsy Assessment and Treatment Unit.

The Stroke service is comprised of 10 acute in-patient beds, thrombolysis service and outpatient services. Additional staffing allocations are aimed at improving and enhancing the multidisciplinary service to stroke patients which is already in place.

In conjunction with the National Clinical Care Programmes for Neurology, Stroke and Epilepsy, approval has been granted for the following posts in 2012. Recruitment and Appointments are being managed by Beaumont Hospital.

Programme Description of Post Quantity

Appointment Status

Epilepsy Basic Grade Technician 1 Appointed

Epilepsy Chief Technician 1 1 Recruitment process

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underwayEpilepsy Senior Grade Technician 1 Recruitment process

underwayStroke Clinical Nurse Specialist (CNM2) 1 Appointed

Stroke Senior Speech and Language Therapist

1 Appointed

Epilepsy Consultant Neurophysiologist 1 Recruitment process underway

Neurology OPD

Consultant Neurologist 1 Appointment pending

Epilepsy Clinical Nurse Specialist 0.5 Appointment pending

Epilepsy Clinical Nurse Specialist 1 Appointment pending

Epilepsy Clinical Nurse Specialist 1 Appointment pending

Epilepsy Clinical Nurse Specialist 1 Appointed

Epilepsy Staff Nurse 1 Recruitment process underway

Epilepsy Staff Nurse 1 Recruitment process underway

Epilepsy Staff Nurse 1 Recruitment process underway

Epilepsy Staff Nurse 1 Recruitment process underway

Epilepsy Staff Nurse 1 Recruitment process underway

Epilepsy Basic Clinical Engineering Technician

1 Recruitment process underway

Epilepsy Admin 1 Internal process

Capital approval of €704,131 for the refurbishment and equipment of part of a neurology ward with an increase from 2 to 4 Epilepsy monitoring beds was approved in October 2011. This project is at detailed planning stage and progressing well.

47

Question1 8 (Deputy Michael Colreavy )

The need to learn from the lesson of the failure of the NHS Trust system which has undermined the NHS and not to repeat that failure in this State.

Response:

See reply to question 5.

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Question 19 (Senator Jillian Van Turnhout)

Does the Minister agree with the Government’s newly published National Policy and Strategy for the Provision of Neuro-Rehabilitation Services in Ireland 2011-2015 that there are “significant and substantial benefits” to be gained from neuro-rehabilitation services and that “in many instances, they make sound economic sense”? Given the accepted cost effectiveness, along with the enormous human benefits of such services, what is being done to tackle huge service deficits by meeting key recommendations of the policy, such as the development of:

Primary Care Teams providing low to moderate intensity therapy Geographic-based Community Neuro-Rehabilitation Teams, providing

specialised services to people with moderate to high-intensity therapy needs

Regional neuro-rehabilitation services providing high-intensity in-patient therapy and out-patient services

National neuro-rehabilitation services, catering for low-incidence, highly complex cases beyond the reach and competency of the regional services

Specific children’s neuro-rehabilitation services?

Response:

The National Policy and Strategy for the Provision of Neuro-Rehabilitation Services in Ireland 2011-2015 sets out a clear policy with a recommended service framework that, when implemented, will ensure that services are developed for those we serve in the most appropriate, most effective and most efficient way.

In this context, the Clinical Strategy and Programmes Directorate of the HSE, as part of its development of clinical care programmes, has established a Rehabilitation Medicine Programme, led by a team of national experts. The three main objectives of the Rehabilitation Medicine Programme are to improve the quality of care; improve access to services and improve cost effectiveness. The HSE has appointed Dr Áine Carroll, Consultant in Rehabilitation Medicine at the National Rehabilitation Hospital as clinical lead in respect of the Rehabilitation Medicine programme. Patricia McClarty, Specialist, National Disability Unit has been appointed as Executive lead for the implementation of the strategy.

The focus for service development in the first 3 years of this policy and strategy will be on:

network development; integration of services; development of protocols that will have mandatory compliance across the

delivery system; reconfiguration of existing resources; achieving greater cost-effectiveness through the development of greater

competencies by those tasked with delivering services; increased teamwork and using interdisciplinary approaches; more interagency collaborative working.

The National Policy is a welcome development and work is proceeding on the development of an implementation plan and a steering group is being formed to oversee the implementation

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The HSE National Service Plan for 2012 has committed to supporting the continued implementation of the reform programme including the HSE National Clinical Care Programmes.

The Service plan specifically supports the work of the Rehabilitation Medicine Programme in committing to the development of regional networks, local rehabilitation teams and the development of associated protocols, pathways and bundles. The service plan also commits to working with the Rehabilitation Medicine Programme to support the development of an implementation plan based on the recommendations of the National Policy and Strategy for the Provision of Neuro-Rehabilitation Services in Ireland, the establishment of Regional Rehabilitation Networks and also the commencement of the development of regional inpatient rehabilitation facilities.

There is a need for an intersectoral approach and commitment if the full continuum of need is to be addressed. The development of joint-working or interagency protocols are a key requirement and will be central to its implementation.

As part of the work of the Rehabilitation Medicine Programme and the National Policy and strategy, one of the key deliverables for 2012 will be the development of Regional Managed Clinical Rehabilitation Networks (MCRN). The aim will be to improve access to and the quality of, rehabilitation services, for adults with acquired disability. Managed clinical networks are defined as linked groups of health professionals and organisations from primary, secondary and tertiary care, working in a co-ordinated manner, unconstrained by existing professional and health board boundaries, to ensure equitable provision of high-quality, clinically effective services .

The concept of an MCN is a partnership of patients, clinicians and managers and, therefore, should be effective in delivering care in a local context. It is one simple way in which the Health Service can be encouraged to be more ‘joined up’ at local level.

These MCRNs will offer a new and potentially revitalising way of considering and delivering clinical services within the Health service and if widely adopted, there may be a quiet revolution in healthcare that will result in patients and clinicians acting as the main drivers for change and the principal arbiters on how finite resources are used in local healthcare systems. The principle of the MCRN is the delivery of services across the boundaries between professions and the different sectors of the Health Service, and that places the focus on patients and services rather than on organisations.

The MCRNs will have the following values and principles:

Care for patients living with acquired disability should be patient-centred and based on the principle of equity:

Patient Centred Equitable Information and Education. Access Standards and Quality Assurance Communication and co-ordination Effective use of resources

Children’s services

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The National Policy and Strategy for the Provision of Neuro-Rehabilitation Services concluded that the best interests of children with neurological presentations and associated rehabilitation needs are best served by including children with neuro-developmental delay within a children’s framework.

Complex specialist rehabilitation services are low number, high resource requiring conditions such as:

Disorders of consciousness Spinal cord injury Severe acquired brain injury Challenging behaviour post ABI Ventilator dependent cases

The key factors that determine complexity of rehabilitation needs are the patient’s requirements for:

basic care and safety skilled rehabilitation nursing care therapy input – a number of disciplines involved, intensity of treatment

and need for specialised equipment and facilities, medical care and intervention.

International recommendations are that the minimum size of a viable inpatient unit should be 20 beds for critical mass. The beds must be located together, in order to provide an appropriate environment for rehabilitation, and to make best use of the rehabilitation nursing complement which provide for patients with highly complex rehabilitation needs that are beyond the scope of their local and regional specialist services. These would normally provided in a tertiary rehabilitation centre covering a population of 1–3 million.

Given the small numbers of very complex cases in children, it would be difficult for staff to maintain competencies if these services are provided on a site remote from the tertiary adult centre.

If a service is to handle patients with complex needs, it must be able to demonstrate that it provides a level of rehabilitation inputs and facilities commensurate with addressing those needs.

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Question 20 (Senator Jillian Van Turnhout)

In line with the commitment in the Programme for Government to put the draft National Standards for Residential Services for People with Disabilities on a statutory footing, when will the Minister be in a position to give the necessary mandate to give legal power to HIQA to carry out independent inspections of disability services? Can the Minister confirm if there is an official audit of the number and location of centres that will be covered by the Standards? And, will the Minister explain why interim measures, such as instructing the HSE and Social Services Inspectorate to commence inspections of centres where children with disabilities live, has not been put in place until the inspection for children services is operational?

Response:

1. Commencement of independent inspections of residential services for people with disabilitiesAs the Senator will be aware, there is currently no statutory, independent inspection system in place in relation to residential services for people with disabilities (adults and children). The lack of regulation of this sector is clearly a matter of concern to the Government.

The legislative framework for regulating this sector is provided for by the Health Act 2007, which envisages a role for the Health Information and Quality Authority, HIQA, in this regard. The functions of HIQA, as set out in the Act, include, inter alia, the setting of standards on safety and quality in respect of these residential services and monitoring compliance with the standards. The Act envisages the registration and inspection scheme being supported by the standards and underpinned by appropriate regulations.

HIQA has prepared and published standards for the sector and the current Programme for Government includes a specific commitment to put these standards on a statutory footing and ensure that the services are inspected by HIQA. However, the relevant sections of the Health Act 2007 that allow for mandatory registration and inspection of designated centres for people with disabilities have yet to be commenced.

As announced by Minister Kathleen Lynch on 16th June last, discussions have begun between the Department of Health and HIQA to progress this issue.

Clearly a regulatory model that is tailored for the sector in question must be in place before the relevant provisions of the Act can be commenced insofar as they pertain to residential services for people with disabilities. Given the complex nature of service provision across this sector, ranging from congregated settings to dispersed housing in the community, careful consideration is being given to designing the most appropriate model and this work is ongoing.

As a first step, the resource implications for HIQA over the coming years of taking on the proposed regulatory role, as well as other regulatory functions set out in the Act, need to be clearly defined. Discussions on this particular issue are nearing conclusion.

Other steps in the process of preparing for mandatory inspections include:

Census of designated centres for people with disabilities that will be subject to statutory registration and inspection by HIQA;

drafting of appropriate regulations once the parameters of the regulatory regime are agreed;

52

recruitment and training, as required, of inspectors for the new regulatory model;

Liaison of HIQA with service providers to assist them prepare for regulation; preparation of a Memorandum for Government.

A target date of January 2013 has been provisionally set for the commencement of the new regulatory scheme which, while ambitious, is considered reasonable. It must be stressed, however, that the planning process is still in the early stages and clearly each of the steps outlined above will take time to progress.

At this point I would like to reassure the Senator that I and my Government colleagues are committed to addressing this issue and ensuring that vulnerable people with disabilities in residential services are safeguarded and protected, and that their quality of life is enhanced.

2. Number and location of designated centres for people with disabilities that will be subject to statutory registration and inspectionThe Health Service Executive (HSE) has collated data regarding the number and location of designated centres for people with disabilities that will be subject to statutory registration and inspection and has provided this information to HIQA. This will support HIQA in conducting its census if designated centres in the sector.

3. Inspections of residential services for children with disabilities As the Senator may be aware, children with disabilities in generic residential centres under the Child Care Act 1991 are covered by the standards and inspection regimes already applying to those centres.

However, there are a further approximately 150 centres offering residential or respite care to approximately 300 children with disabilities, the majority of which are run by non-statutory organisations funded by the HSE and are excluded from inspection under the Child Care Act 1991. The Social Services Inspectorate of HIQA currently has no statutory remit to inspect these centres and without such could not be instructed to do same. Although these centres are not currently inspected, it is worth remembering that the Health Act 2004 places on obligation on HSE and HSE funded agencies to have a robust complaints policy in place. In this regard, the HSE has worked with service providers across the disability sector to ensure that such a policy is in place, and that service users are able to register complaints and have them addressed appropriately. Processes are in place to ensure that the HSE is aware of any serious complaints and it is fully briefed on the nature of these complaints along with any action taken.

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Question 21 (Deputy Peter Fitzpatrick)

Can the Minister look at the possibility of relaxing the criteria for applicants of the Primary Medical Certificate and if he/she will make a statement on the matter.

Response:

A Primary Medical Certificate is provided under the Disabled Drivers and Disabled Passengers (Tax Concessions) Scheme. The Scheme is regulated by the Minister for Finance under the Finance Acts and the Disabled Drivers and Disabled Passengers (Tax Concessions) Regulations. The Scheme is operated by the Revenue Commissioners. The operation of the Disabled Drivers and Disabled Passengers Scheme does not fall within the remit of the Minister for Health. The medical criteria for the Primary Medical Certificate is a matter for the Minister for Finance.

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Local Issues

Question 22 (Deputy Jerry Buttimer)

To ask the Minister and the HSE to confirm the total amount paid in gratuities and lump sum payments to employees who availed of the early retirement scheme, if these payments have to be met from within the HSE budget for 2012 and, if so, the expected impact on service delivery, in relation Cork to confirm the number of retirements in the last 6 months, broken down by job category and location, and also to outline the changes in service delivery which have been implemented because of the reduced staff numbers.

Response:

IntroductionPublic sector pay rates were reduced on 1 January 2010.  Under the so-called ‘grace period’ employees can retire up to the end of February 2012 using their salary prior to the cuts.

All employees who have retired since 1 January 2010 have retired under these terms.  In the summer of 2011 when specific focus came on the ending of the grace period HSE Human Resources began a list of employees who would leave before the end of February 2012. 

The net saving to the HSE of a staff member leaving is about 36% of their salary. This can drop to 26% in the context of the need to replace staff on the front line at a 10% level as was provided for in the Service Plan 2012. The reason that the saving is a low percent of the gross pay of an individual is that the HSE will pay a pension of 50% of the salary and that the pension levy and superannuation charge to staff are income in the hands of the HSE. Separately the HSE has to provide a lump sum of one and a half times the finishing salary. This scenario is based upon a retiree with 40 years service as set out in the example below;

The HSE’s National Service Plan 2012 is based on 3,000 whole-time-equivalent staff retiring before the end of February 2012 and being paid lump sums in 2012. There are a number of factors which have to be taken into account in costing the impact of these retirees. These are set out below. This number has now risen to in excess of 4,300. The HSE will have to run a new estimate of the costs associated with this level of retirements once the data on retirees lump sums and pensions is available. It is likely that there will be a significant growth in costs associated with this higher number of retirees. If we apply the same assumptions as used in the service plan HSE

55

would require a further €60m for lump sums which may be offset to some extent by pay savings. We have yet to determine how many of the retirees are on payroll.

Calculation requirementsStaff with premium pay or allowances, are entitled to the ‘best 3 years out of the last 10’ to be reckoned for pension purposes.  This requires 10 years payroll records to be examined for each person.  In a recent sample of 413 retirees, 87% had premium pay or allowances.  If this percentage applies to the grace period it will mean pensions units will have 37,000 payroll records to examine.

In this context it will be some time before Manorhamilton is able to determine lump sums/pensions and full costings of the scheme are available.

Resources in 2012 The HSE has a normal lump sum budget of €136m. The projected cost of the people retiring in the 2012 service plan is €180m – an increase of €44m. This funding was additionally provided in the 2012 estimates process.

Additional costs to be funded by the HSE payroll savingsThe data included in the Service plan 2012 is set out in the Table below, these include the following;

1. The estimated cost of funding pensions for the retirees is €68m. This has to be funded by the HSE out of payroll savings.

2. The estimate of lost salary contributions for superannuation and the pension levy amount to €18.9m. This cost has to be funded by the HSE out of payroll savings.

3. The Service Plan contains a replacement factor of €16m for critical posts. The number of posts which can be supported by this funding depends on the salaries of those being appointed. This €16m has to be funded by the HSE out of payroll savings.

4. The 2012 estimate required the HSE to surrender a net €57m in payroll savings for staff retiring.

The impact of items 1-4 above is that the HSE has to target payroll savings of €159.9m (€68m + €18.9m + €16m + €57m) in services. These payroll savings will be achieved if the numbers of staff leave with the average salary used in the plan. If the profile of staff who retire causes different average salaries etc, the figures in this analysis will change.

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HSE SOUTH

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The numbers of retirement in the last 6 months are included at appendix 1.

As part of the preparation for the HSE South Regional Service Plan, HSE South worked on the development of contingency arrangements to address the replacement of retirements of staff in the period November 2011 to February 2012 from critical posts which would otherwise pose a risk to the safe delivery of services.

The impact on services both as a result of these retirements and reductions to 2012 budgets will be addressed as outlined in the HSE South Regional Service Plan and summarised below:

Acute Services:As outlined in the HSE South Regional Service Plan 2012, the strategy across acute hospitals is to mitigate the impact of both budget and staff reductions through rigorous implementation of the clinical programmes particularly in Acute Medicine, Emergency Department and Surgery within the hospitals, in an accelerated way. The capacity in the system will be tailored to available funding and staff resources to ensure a sustainable model of service delivery. Through this approach it is hoped to reduce on average the impact on services and activity by approximately 3%. This will involve:

Planned seasonal bed closures – comprehensive structured annual leave planning – redeployment

Top priority AMP, Surgery, ED-Supported by Stroke ACS, COPD, OPD programme

Increase move from inpatient to day care across all hospitals Increased rate of elective patients with procedures performed on day of

admission. Reduce average length of stay Maximise numbers treated Reduce numbers of beds required

Implementing National Clinical Programmes & SDU Initiatives 2012 Appointment of Consultant posts and key allied health professionals through

national clinical programmes to support the hospitals to meet their targets 50 posts including 20 consultant posts with overall investment of €6m.

Mitigation of volume reductions to 3% through implementation of National Clinical Programmes in all hospitals in HSE South

Capacity Planning of Acute Medicine Programme (AMP) & Surgical Programme informs decisions on reorganisation of capacity and sustainable models of care.

Further build on and expand on learning from AMP success in CUH across the region – appoint 13 consultants Acute Medicine Programme (AMP) & ED

Surgery Programme focus on Day of Surgery rates, Average Length of Stay (ALOS) and The Productive Operating Theatre programme (TPOT) maximising the useful resource and time in theatre

Emergency Department programme to support achievement of Speciality Delivery Unit targets on trolleys and waiting times.

Reduce admission rates and average length of stay through implementation of all programmes.

Specifically focus on implementation of programmes which complement each other, Stroke, Acute Coronary Syndrome, Congestive Obstructive Pulmonary Disease (COPD) & Outpatient Department (OPD) Programme.

Acute Hospitals Reduction/reorganisation of Bed capacity Inpatient 83 Paediatric 10

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Continued move from inpatient to daycase Inpatient to 5 day/day – 50 CUH – 35 Surgical bed closures and & 35 beds 7 to 5 day CUMH – Seasonal closure 8-10 beds 7to 5 day MUH – 1 Theatre & 12 Surgical and 6 Paediatric beds WRH – 2 Theatres & 25 Surgical beds, 1 ICU bed and 4 paediatric beds South Tipperary General Hospital – 5 inpatient to 5 day case beds St. Luke’s/Wexford – Implementing clinical programmes to achieve targets Seasonal Closures specifically – St. Luke’s (10 beds – June – Oct.), Kerry

General, Mallow, Bantry, SIVUH, Wexford

Community Services:Primary Care: Our vision for primary care is that the health of the population will be managed, as far as possible, within a primary care setting, with the population very rarely requiring admission to a hospital. Those with additional or complex needs will have plans of care developed with the local Primary Care Team (PCT) who will co-ordinate all care required with specialist services in the community and, for hospital attendance, through integrated care pathways.

Our overall approach is to deliver services at the lowest level of complexity which are available locally to maximise health outcomes whilst reducing the need for patients to travel outside their communities. The structured delivery of primary care will support the transfer of appropriate care from the acute hospital sector towards the primary care setting.

Mental Health: We will be maximising the reorganisation of rostering, reduction in overtime and agency, and increasing skill mix and other measures to limit the impact on frontline services. The re-organisation of services in line with A Vision for Change will support the development of community services while at the same time reduce the overall cost of services, maximising the benefit to service users.

Services for Older People: Having regard to the budget reduction and the numbers retiring it will be necessary to significantly reorganise our rostering arrangements, staffing levels and work practices as well as revising the Skill-mix of our staff and maximise the opportunities for redeployment to ensure that we minimise the impact on the reduction of public residential beds and the broader range of community services.

Prioritising Residential Beds Following the comprehensive assessment undertaken utilising criteria outlined in the HSE South Regional Service Plan, the position in relation to bed closures in HSE South has been revised downwards from a proposed minimum figure of 180 in the NSP to a planned reduction of 128 public residential care beds (of which 101 are currently vacant)

The successful implementation of our change programme and implementation of the model of care for older people will be a critical factor in enabling HSE South to minimise the impact on public long stay bed provision and full cooperation will be required from all stakeholders if this is to be achieved.

An important factor in the overall consideration of residential care bed closures was the fact that 101 of the 128 beds proposed for closure are currently vacant due to the staff retirements and reduction in agency costs as well as the demand for the Nursing Home Support Scheme, HIQA environmental standards, etc.

Community supports

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The priority in HSE South for 2012 will be to maintain Home Care Packages at target levels

Disability Services: To address funding issues and reduction in staff numbers a range of measures necessitated for Disability services in 2012 are summarised below.

Progress implementation change programme based on DOH policy set out in VFM & policy review

Develop a community based & inclusive model rather than institutional segregated Budget & staff reductions will be focused on

– Efficiency– Consolidation – Reorganisation – Rationalisation of back office activity

Some impact on services unavoidable but tailored to minimise impact to service users.

Disability services will be required to cater for demographic pressures, such as new services for school leavers and emergency residential placements, from within their existing budgets.

Child Care Services: Budgetary over runs in 2011 and cost management measures are required to reduce the cost base as set out below: Reduce costs related to private residential care provision by maximising capacity in

HSE services and reduce reliance on additional external provision.   Establish standardisation of approach and payments across the region for After

Care Services. Reduction in costs associated with agency staffing through management of

absenteeism and re-organisation of staff rosters. An independent review of staff rostering in HSE residential units is currently taking place in order to facilitate a more flexible approach in the services provided. It is envisaged that following the review more efficient rosters will be established providing greater capacity and cost savings. 

Reduction in funding to voluntary agencies in line with national direction Back office services efficiencies / reduction in travel expenses, procurement etc. Reduction in level of enhanced Foster Care payments and limits on discretionary

payments in excess of standard weekly foster care payment.  No reduction in service anticipated.

Social Inclusion & other services: To address the funding issues and reduction in staff numbers a range of measures necessitated for Social Inclusion and other services in 2012 are summarised below.

HSE South Social Inclusion services improve access to mainstream services, target services to marginalised groups, address inequalities in access to health services and enhance the participation and involvement of socially excluded groups and local communities in the planning, design, delivery, monitoring and evaluation of health services.   The Social Inclusion team including the Community Workers, Drug & Alcohol Addiction teams as well as Homeless services and the Travelling Community will work with all our care groups and services to ensure that we continue to support the most vulnerable within our community, while at the same time implementing the Regional Service Plan in line with the national framework

Table: Staff Retirements Cork

Region LHO Family Head WTE

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Hospital Group South West

Bantry General Hospital Consultants 1

1.00

Health Care Assistants, Nurses Aide, etc. 2

1.50

Household Services 1 0.50

Health & Social Care Professionals - Labs & Associated 1

1.00

NCHD's 1 1.00

Nurse Managers 3 3.00

Staff Nurses/ Midwives 6 4.17

Bantry General Hospital Total 15

12.17

Cork Area Office Management [VIII+] 1 1.00

Nurse Managers 1 1.00

Cork Area Office Total 2 2.00

Cork University Hospital Consultants 4

3.50

Dental Hygienist/Nurse 1 0.50

General Administrative [III to VII] 9

7.46

General Administrative Grades 2 0.92

Health Care Assistants, Nurses Aide, etc. 3

2.10

Household Services 5 4.64

Health & Social Care Professionals - Labs & Associated 6

5.60

Management [VIII+] 1 1.00

Nurse Managers 19 16.86

Other Health & Social Care Professionals 1

1.00

Portering 1 1.00

Social Workers 2 1.50

Speech and Language Therapists 1

0.50

Staff Nurses/ Midwives 30 20.76

Cork University Hospital Total 85

67.34

Mallow General Catering 1

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Hospital 1.00

Consultants 1 0.50

Health Care Assistants, Nurses Aide, etc. 2

2.00

Household Services 1 1.00

Nurse Managers 2 2.00

Staff Nurses/ Midwives 4 2.86

Mallow General Hospital Total 11

9.36

Mercy University Hospital Consultants 2

2.00

Health Care Assistants, Nurses Aide, etc. 1

1.00

Health and Social Care Professionals - Labs & Associated 1

1.00

Management [VIII+] 1 0.60

Pharmacists 1 1.00

Staff Nurses/ Midwives 2 2.00

Mercy University Hospital Total 8

7.60

Regional Acute Services Nurse Managers 1

0.53

Regional Acute Services Total 1

0.53

South Inifirmary Victoria University Hospital

General Administrative [III to VII] 1

0.80

Nurse Managers 6 4.46

Other Support 2 1.59

Staff Nurses/ Midwives 4 3.12

South Infirmary Victoria University Hospital Total 13

9.97

St Mary's Orthopaedic Hospital Household Services 4

3.57

Nurse Managers 1 1.00

Portering 2 2.00

Staff Nurses/ Midwives 4 2.39

St Mary's Orthopaedic Hospital Total 11

8.96

Hospital Group South East 146

117.93

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Total

PCCCBrothers of Charity Cork Catering 1

1.00

General Administrative [III to VII] 3

3.00

Health Care Assistants, Nurses Aide, etc. 3

3.00

Maintenance 1 1.00

Management [VIII+] 1 1.00

Nurse Managers 3 2.50

Other Care Grades 4 2.62

Psychologists 1 1.00

Social Care Grades 7 7.00

Social Workers 1 1.00

Staff Nurses/ Midwives 8 5.85

Brothers of Charity Cork Total 33

28.97

COPEHealth Care Assistants, Nurses Aide, etc. 3

2.50

Nurse Managers 1 1.00

Other Care Grades 4 3.51

Other Health & Social Care Professionals 1

1.00

Other Support 1 1.00

Social Care Grades 2 1.50

Staff Nurses/ Midwives 1 0.50

COPE Total 13 11.01

LHO North Cork Catering 1 0.50

Consultants 1 1.00

Dentists 2 1.52

General Administrative [III to VII] 3

2.77

General Administrative Grades 1 0.80

Health Care Assistants, Nurses Aide, etc. 8

7.50

Household Services 3 2.93

Nurse Managers 7 6.85

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Other Medical 2 2.00

Other Support 1 0.80

Social Workers 1 1.00

Staff Nurses/ Midwives 20 17.52

LHO North Cork Total 50 45.19

LHO North Lee Catering 1 1.00

Consultants 2 2.00

General Administrative [III to VII] 2

1.73

General Administrative Grades 1 1.00

Health Care Assistants, Nurses Aide, etc. 3

2.15

Household Services 2 1.10

Nurse Managers 6 6.00

Other Medical 3 2.47

Other Support 1 0.64

Public Health Nursing 1 1.00

Social Care Grades 4 2.47

Social Workers 4 4.00

Staff Nurses/ Midwives 20 16.66

LHO North Lee Total 50 42.22

LHO South Lee Dentists 1 1.00

General Administrative [III to VII] 2

2.00

Health Care Assistants, Nurses Aide, etc. 8

6.74

Household Services 1 1.00

Health and Social Care Professionals - Labs & Associated 1

0.60

Nurse Managers 11 10.06

Psychologists 1 1.00

Public Health Nursing 4 3.50

Speech and Language Therapists 2

1.60

64

Staff Nurses/ Midwives 32 24.58

LHO South Lee Total 63 52.08

LHO West Cork Counsellors 1 0.92

Dental Hygienist/Nurse 1 1.00

Dentists 1 0.80

General Administrative Grades 1 1.00

Health Care Assistants, Nurses Aide, etc. 3

2.92

Nurse Managers 12 11.11

Occupational Therapists 1 0.50

Other Care Grades 1 1.00

Other Medical 3 2.30

Psychologists 1 0.80

Public Health Nursing 1 0.21

Social Care Grades 1 1.00

Social Workers 1 1.00

Staff Nurses/ Midwives 24 20.94

LHO West Cork Total 52 45.50

St John of GodsGeneral Administrative [III to VII] 1

1.00

Health Care Assistants, Nurses Aide, etc. 3

2.59

Nurse Managers 2 1.92

Other Care Grades 2 1.59

Social Care Grades 1 1.00

Social Workers 1 1.00

Staff Nurses/ Midwives 3 2.09

St John of Gods Total 13 11.19

PCCC Total 274

236.16

Grand Total 420

354.09

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Question 23 (Deputy Catherine Byrne)

To ask the Minister to provide an update on the proposed closure of St Brigid’s Nursing Home, Crooksling, Co Dublin. What were the findings of the review/consultation process? Will there be implications for the new 50-bed community nursing unit (Hollybrook) in Inchicore?

Response:

The Health Service Executive is considering the closure of St. Brigid’s Hospital, Crooksling.  However, a decision to close the hospital will not be made without a comprehensive consultation process. For this reason, the previous decision to close St. Brigid’s Hospital was set aside.

The format of a National Consultation Protocol on the proposed closure of a public unit is now almost finalised. This Protocol will involve engaging with patients, relatives, staff, public representatives and any other party who wishes to make a submission.  Any such consultation process will be completed within a period of three months from commencement - at which point a final decision will be made regarding the future of any hospital. This National Protocol - when completed - will be applied in relation to any future plans for St. Brigid's Hospital, Crooksling.

The HSE is currently examining means of opening Holybrook House in Inchicore. Should the potential transfer of staff from St Brigid’s Hospital not transpire other means of opening the unit will have to be considered.

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Question 24 (Deputy Catherine Byrne)

To ask the Minister to provide an update on the former nursing home at Bru Caoimhin, Cork Street. What is the cost of refurbishing the building? Is the entirety of the building to be re-opened and used as a new ‘training centre’; who will run the centre; and who will access training at this centre?

Response:

Following the closure of the community nursing beds in Bru Caoimhin the vacant accommodation (units 2 and 3) are being altered and refurbished to accommodate primary care and community based services located in rented accommodation in the area. The following service has moved in to Unit 2 which has been refurbished and opened.  

Unit 2- Early intervention team for Children’s services Unit two is the main base for the Dublin south central area in carrying out early intervention children’s services assessment and treatment.

Clinical services for the early intervention team, the school age team and the assessment of needs team are delivered from this unit.

 Unit 3

Unit 3 is currently being upgraded and refurbished and is due to be completed in May 2012. When the building is ready, Eastern Vocational Enterprises (EVE) (60 staff and trainees) will be relocating to this unit from their existing accommodation in Emmet House.     EVE (Eastern Vocational Enterprises) is a programme within the HSE that provides community based recovery orientated programmes for adults who experience mental health difficulties, intellectual difficulties, and physical and sensory disabilities. EVE also provides comprehensive computer training and general education and this will be managed by EVE and will be accessed by people with mental health difficulties.

The overall cost of the refurbishment works (Units 2 and 3) is €2.7m.

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Question 25 (Deputy Eamonn Maloney)

What is the proposed future use by the Health Service Executive of Chamber House, Tallaght, Dublin 24.

Response:

While Chamber House has been designated principally as a Children's ServicesNetwork Centre for the Dublin South West area, it also provides accommodation for other services as outlined below.  These services which are currently provided from the centre will continue into the future.

1. Children’s Services Network Centre Dublin South West Area include;

Children's Disability Services Early Intervention Team School Age Team Primary Care Psychology Best Start Speech and Language Therapy - central assessment facility Children and Families Services - including fostering services, Family

Support, Child Protection etc

2. It also houses a range of primary care services for adults and children including:

Occupational Therapy Physiotherapy Public Health Nursing child health clinics

3. Barnardos also use the building for 4 mornings a week in provision of some of their children’s services and this will continue into the future.

Other services may be located in the future at the centre as and if determined by the primary care network needs of the area.

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Question 26 (Deputy Eamonn Maloney)

To ask for an update on the review in relation to St. Brigid's Nursing Home, Crooksling, Dublin 24.

Response:

The Health Service Executive is considering the closure of St. Brigid’s Hospital, Crooksling.  However, a decision to close the hospital will not be made without a comprehensive consultation process. For this reason, the previous decision to close St. Brigid’s Hospital was set aside.

The format of a National Consultation Protocol on the proposed closure of a public unit is now almost finalised. This Protocol will involve engaging with patients, relatives, staff, public representatives and any other party who wishes to make a submission.  Any such consultation process will be completed within a period of three months from commencement - at which point a final decision will be made regarding the future of any hospital. This National Protocol - when completed - will be applied in relation to any future plans for St. Brigid's Hospital, Crooksling.

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Question 27 (Deputy Eamonn Maloney)

To ask for an update on the proposed transfer of the Coombe Maternity Hospital, Dublin to Tallaght Hospital, Dublin 24.

Response:

In accordance with the recommendations of the KPMG report “Independent Review of Maternity and Gynaecology Services in the Greater Dublin Area” it is proposed that the Coombe Women’s and Infants University Hospital services should be relocated to AMNCH at Tallaght.

This new facility is to be capable of accommodating approx 10,000 births p.a. (up to 8,000 in the obstetric unit, and up to 2,000 in a proposed ‘midwifery led unit’).

A site specific outline business case & scoping proposal has been developed by the Coombe in relation to the proposed move. A project steering group has been set up to progress this development, co-chaired by Master of the Coombe and the CEO of Tallaght.  This group includes representatives from the Coombe and Tallaght hospitals, the HSE, and the National Development Finance Agency (NDFA). PPP funding mechanisms are being explored.  Early development of new maternity facilities would help deal with concerns over capacity and condition of existing accommodation in the Coombe. It is understood that the Coombe and Tallaght have made progress in relation to relocation from a service perspective. With the completion of the Brief   the next step would be to appoint Technical Advisors to progress the proposal. Subject to funding and other constraints.  

It is important to note that there is no capital funding included for this development proposal contained in the current HSE capital plan, nor has the PPP procurement approach achieved greater certainty.

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Question 28 (Deputy Denis Naughten)

To ask the Minister & HSE the impact of budget cuts on local acute services and their plans for the development of services at the Galway/Roscommon Hospital group.

Response:

The budget reductions for 2012 will provide a significant challenge for the acute hospital services in the Galway Roscommon area. The activity targets have been reduced by approx 3% overall, however emergency services will be protected and demand led services such as cancer / dialysis treatments etc will be maintained at or as near to 2011 levels as possible. The implementation of the national clinical programmes such as the acute medicine, surgery and ED programmes are key enablers, which will deliver the productivity improvements required to maintain activity such as reductions in average length of stay and earlier discharge of patients from hospital, increased same-day admission for surgery and more productive and efficient operating theatres. Improved income collection will also be required in order to maintain front line activity levels.

The service plan for 2012 also puts the focus on improving access to services and making it easier for patients to receive the care they need in the most appropriate setting. Key priorities include the achievement of the SDU targets for 2012 in relation to waiting times for hospital admission from ED and elective surgery waiting time targets. As part of the Government’s health reform programme, the Galway Roscommon Hospital Group structure was recently established bringing together Galway University Hospitals (GUH - University Hospital Galway and Merlin Park University Hospital), Portiuncula Hospital Ballinasloe and Roscommon County Hospital.  The Group is being managed by the newly appointed CEO, Bill Maher as a single unit sharing resources, budget and service activity in order to maximise effectiveness, reduce waiting lists and provide the appropriate care for patients in the right setting.

The Group has an overall budget of €287m for 2012, which is a reduction of €25m on last year, however with the deficit carried forward from the previous year, the full scale of the financial challenge this year is nearer to €36m.  The new structure will provide opportunities for the more efficient development of the services, with all hospitals playing a meaningful role in providing appropriate services to patients.  Key developments in the current year include;

Opening the Acute Medical Assessment Unit in University Hospital Galway in Q1 2012 and the transfer of acute medicine from Merlin Park to UHG.  Appointing three Acute Medicine Physicians.

Opening a Medical Assessment Unit in Portiuncula, as part of the Acute Medicine Programme.

Refurbishing the Neo Natal Intensive Care unit GUH. Developments at Roscommon:Endoscopy Suite – Capital project- Funding of €2m is assigned to this project. The design brief is being drafted and the project within the hospital footprint will be commenced in 2012 and operational in 2013.

Interim Endoscopy Decontamination Facility -The minor capital project to locate new Endoscopy decontamination equipment into an area in the theatre until such time as

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the Endoscopy Suite opened is now completed.  The new facility is fully commissioned and operational since early February 2012.  A new scope will also be purchased.

Rehabilitation Medicine Service (National Rehabilitation Hospital, Dublin) Roscommon County Hospital in association with the National Rehabilitation Hospital has submitted an application for the appointment of a Consultant in Rehabilitation Medicine. Roscommon County Hospital has been considered as a site suitable for the location of a HSE West Medical Rehabilitation Service under the remit of the National Rehabilitation Hospital in Dublin.

Services from GUH Elective day case surgical patients on GUH waiting lists are being treated in Roscommon County Hospital by RCH consultants in the first instance. The numbers treated at Roscommon County Hospital will increase over 2012.

Plastic Surgery from GUH The Day Case Elective Plastic Surgery service which commenced in September 2011 is now established and working well. In addition patients on GUH Plastic Surgery day case waiting lists are being seen and treated at Roscommon County Hospital. Discussions are ongoing for the further development of the service.

Recruitment of Consultant Physician with special interest in Respiratory Medicine This process is completed and the consultant Dr Imran Saleem commenced employment earlier this month (March).

Sleep StudiesWith the appointment of the Consultant Physician Roscommon County Hospital has commenced a sleep studies service to medically assess and treat patients with a range of conditions including sleep apnoea. In addition patients on GUH waiting lists for sleep studies will also be treated in Roscommon County Hospital.

Rheumatology Telemedicine Outpatient ClinicThe first Rheumatology Telemedicine Outpatient Clinic was held in Roscommon County Hospital on Friday, October 7th 2011. The clinic involved a computer link-up between patients in Roscommon County Hospital and Dr Robert Coughlan, Consultant Rheumatologist in Merlin Park University Hospital, Galway

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Question 29 (Senator David Cullinane)

To ask the Minister to provide a detailed report on the consequences of a €6.5milllion cut to funding on services at Waterford Regional Hospital on a department by department basis.

Response:

The HSE South Regional Service Plan, which sets out the plans for health service delivery for the region in 2012 was published on the 9 th February 2012.  In line with the HSE National Service plan, published on 16th January 2012, the HSE South Regional Service Plan has been prepared in the context of the challenges faced by the health services this year in terms of reduced staffing levels and a reduced budget combined with an increasing demand for services and outlines the actions being taken across the region to address these challenges.  It is important to acknowledge that a significant effort has been made to ensure that cost reduction measures are implemented in a way, which minimises the impact on frontline services at local and regional level. While the gross reduction in budget for the HSE South in 2012 amounts to €208m, this does not represent the service impact this year. Every effort has and is being made to reduce the impact of budget reductions and staff departures on frontline essential services.

The strategy across acute hospitals in the service plan is to mitigate the impact of budget and staff reductions through rigorous implementation of the clinical programmes particularly in Acute Medicine, Emergency Department and Surgery within the hospitals, in an accelerated way.

In relation to Waterford Regional Hospital there has been extensive engagement and consultation in preparing the regional service plan which has involved a comprehensive review of the hospital budget and overall financial performance. These reviews have involved the Hospital Management Team, Area Manager, RDO & Regional AND for Finance. In addition, the National Director ISD and the National Director Finance met with the RDO, Regional AND for Finance and the Hospital Management Team on the 29th of February to review the overall financial and service position.

The capacity in the system is being tailored to available funding and staff resources to ensure a sustainable model of service delivery.  Through this approach it is hoped to reduce on average the impact on services and activity by approximately 3%. WRH 2012 activity targets are outlined as follows:

ACTIVITY2012

TARGETDay Cases 19,564In-patients 22,237Outpatients 149,327ED Attendances 60,924Births 2,500

 In patient discharges will reduce by 3% and day case activity levels will be maintained at 2011 target. This is in line with National Strategy continuing the shift to day case activity and a reduction in in-patient activity.

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Overall additional investment of €6m is being provided  in the HSE South to support the change initiatives. WRH being the south east cancer centre and having a regional service component, has been prioritised in the allocation of the development funding receiving €2m respectively. The overall effect is that the capacity in Waterford Regional Hospital is being tailored to the available funding and staff resources to ensure a sustainable model of service delivery which is safe and responsive to the needs of the public. Activity levels for 2012 will be sustained  at the levels identifed based on the implementation of the National Clinical Programmes and targets as specified in the NSP. The Emergency Medicine, Acute Medicine Programme, Elective Surgery Programme and NCCP Key Performance Indicators (KPIs) and the associated national targets for unscheduled and scheduled care in line with DoH/SDU policy are the key performance measures underpinning same.

The detailed cost management & employment control measures for Waterford Regional Hospital are set out below

Impact of volume reduction to be mitigated through the implementation of National Clinical Programmes, Service Developments & Reorganisation outlined above, in particular Surgery, Acute Medicine & ED and other associated programmes

– Closure of 25 surgical beds– 1 Operating Theatre Closure– 1 ICU – efficiencies generated through opening 4 HDU beds– 4 Paediatric inpatient beds.–         Seasonal closures and comprehensive structured annual leave

 Clinical services internally will be aligned with the CCP and staffing reductions in line with impact of Resignations 2012. In addition to the reduced inpatient (25 beds) and Theatre capacity (2), 1 Intensive care Unit Bed (ICU) and 2 Paediatric Day beds will close. The impact of the ICU bed will be mitigated by the availability of the High Dependency Unit (HDU) which opened at end of 2011. The impact of the Paediatric Day Care bed reduction will be mitigated by efficiencies in line with the Elective Surgery and TPOT Clinical Programmes. Efficiencies in Regional Dept of Laboratory Medicine - These efficiencies will be achieved by introduction where possible of evidence based clinical protocols to standardise demand, optimise appropriateness of specialist testing and minimise duplicate testing to manage year on year increased demand across the acute and community services.

Efficiencies in the medical pay budget - This initiative requires the restructuring of the Regional Vitreo Retinal Ophthalmic Service and the associated consultant post. Temporary Consultant Post with Special Interest Vitreo Retinal will cease end February 2012 and an alternative service delivery model will be progressed

Further reduction in agency expenditure - Elimination of medical agency expenditure 2nd half of 2011 will apply for the full year 2012. Nursing agency, Laboratory Scientific staff and Catering Services costs will further reduce in 2012.

Efficiencies in the use of high drugs cost in the acute settings Increase car park charges Income generation and collection

 As referenced above additional investment of €2m is being provided in the HSE South to support the change initiatives in Waterford, these included

Acute Medicine Programme – Implementation of programme targets / focus on same day and early discharge i.e. within 0 to 2 days and reduced ALOS – 2 additional Acute Medicine Physician posts ( including 1 Consultant Endocrinologist) assigned to support the implementation of this programme

Emergency Medicine Programme – Implementation of the EMP to improve the safety and quality of care in EDs and to reduce waiting times for patients and to

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improve cost effectiveness in emergency care - 2 Emergency Medicine Consultants assigned to support the implementation of this programme

Stroke – Commence implementation of programme targets / reduce ALOS by 2 days over 3 years / Development of patient pathways & establishment of acute unit – 1 CNM2 and .5 Physiotherapist assigned to support the implementation of this programme

Elective Surgery Programme - Programme focussed on implementing national average length of stay and day case targets for most common elective and inpatient procedures, through implementation of TPOT in all theatres. Particular requirement to ensure that the organisation of surgical procedures is in line with the requirements of the SDU and that patients are seen in a chronological order to address the requirements of long waiters, while having regard to normal clinical protocols.

Diabetes – Continued roll out of this programme locally in conjunction with AMP programme, a consultant physician with a special interest in Endocrinology (as outlined above) and 1.75 Podiatrist assigned to support the implementation of this programme

Acute Coronary Syndrome – Focus of this programme on ensuring timely and appropriate care for cardiac patients - 1 Consultant Cardiologist assigned to support the implementation of this programme. The full year cost is being made available to the hospital, the post will be implemented on a half year basis from July to enable the detailed plan and programme of work to be agreed and the non-pay cost to be worked through

Heart Failure – 1 Nursing and .5 administrative post assigned to support the implementation of this programme.

Critical Care - .75 Nurse resource assigned to support the implementation of this programme. This resource will be made available initially to provide clinical care and when the audit of critical care services is ready to roll out, will be assigned to support the audit

Neurology – Focus of this programme on reducing OPD waiting lists - 1 Consultant Neurologist assigned to support the implementation of this programme

Dermatology – 1 Consultant Dermatologist assigned to support the implementation of this programme

Rheumatology & Orthopaedics – 2 Physiotherapists assigned to support the implementation of this programme

The Strategic Objective for WRH is to deliver services within the agreed budgetary and employment control parameters whilst simultaneously continuing to reduce the cost base. Despite the challenging budgetary and staffing environment the focus of Quality, Safety and risk remain paramount

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Question 30 (Senator David Cullinane)

To ask the Minister if he is advancing plans to build a new 50 bed community nursing unit on the grounds of St. Patrick's hospital in Waterford and if he has a timetable for delivery.

Response:

The background to the decisions on St. Patrick’s hospital was that St. Bridget’s Ward had been identified for several years as being unsuitable for continued use for residential care for older people. The relocation of patients to ground floor accommodation enabled the HSE to meet new HIQA standards which were being introduced at the time including fire and health and safety standards which had been highlighted by the Health and Safety Authority.

No patients were moved out of St. Patrick’s Hospital. As vacancies arose on the ground floor, in consultation with the patients themselves and their families, patients were relocated to wards downstairs and the 19 bed St. Bridget’s Ward no longer accepted admissions. In acknowledgement the reduction of 19 beds over time at St. Patrick’s, the HSE took action during 2009 to ensure that there was not a reduction in the number of beds to support older people in Waterford city. Arrangements were made for a total of 30 private nursing home beds to be available.

The HSE South at the time prioritised the development of a new 50-bed Community Nursing Unit (CNU) for Waterford which was included in the priority list of HSE capital projects.

To support the development the HSE South undertook an Historic Building Assessment Report of the existing convent building within the site at St. Patrick’s Hospital in Waterford and – in line with the requirement of the planning authorities – a Development Control Plan has been developed for the site in question. These two reports are required on any HSE site which has historic buildings and multiple services as a feature. The Historic Building Assessment Report was completed and submitted to the Waterford City Planning Office, where it has met with favourable reaction. The Development Control Plan at St. Patrick’s Hospital has been completed and submitted to the City Council.  Successful completion of this work means that should the community nursing unit receive a funding allocation under the future Capital Plan, it will be located on the grounds of St. Patrick’s Hospital.

Arising from the economic downturn a substantial reduction in the overall capital funding available for the health service capital programme arose in 2009/2010 and it was not possible to secure funding to proceed with construction.

Members will be aware from previous reports that, the Prospectus Report, which was prepared for the HSE in 2008, assessed the provision of nursing home places across the country and the need for additional places to meet demographic change. The report found that there were sufficient places in Waterford at that time and additional places would not be needed before 2013.

The up to date position is that the Department is engaged with the HSE in planning the provision of long-term care places, taking account of public and private nursing home provision. This will give further consideration to the Prospectus report recommendations and the requirements to upgrade facilities to meet the standards for nursing homes. It will also consider local demographic pressures and the extent of existing public and private

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provision, with a view to developing an overall strategy on how the HSE should continue to provide this service in view of current budgetary and other pressures. The future provision of long term residential services for the Waterford area in general will be considered in the context of this review.

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Question 31 (Senator David Cullinane)

To ask the Minister if he will outline at what stage plans to build an integrated oncology and palliative care unit in Waterford Regional Hospital are at and if he has a timetable for delivery.

Response:

The development of Palliative Care Services in Ireland has been undertaken in line with the Report of the National Advisory Committee on Palliative Care 2001.

In the South East the agreed priority proposal regarding Palliative Care is the development of a Specialist Palliative Care Inpatient Unit on the grounds of Waterford Regional Hospital. This will be a 20 bed unit and will serve as the regional hub for the delivery of specialist palliative care services throughout the South East. The four Community based (Carlow/Kilkenny, Waterford, Wexford, South Tipperary) and hospital based teams working in this service area will have direct links with this unit. It is planned that patients will be admitted for acute medical interventions in the unit in Waterford Regional Hospital – for instance symptom control, and will be discharged back to the community with access to the community based specialist palliative care teams.

Waterford Regional Hospital has recently (2011) completed a Development Control Plan to oversee and co-ordinate site development for the foreseeable future. The Specialist Palliative Care In-patient Unit is currently being planned as part of the next phase of major capital developments on the WRH hospital site, which is a multi-storey building and includes provision for Cancer Services, and space for the future provision of inpatient accommodation. A Business Case has been developed for a comprehensive integrated development across the Acute hospital and Palliative care unit. The Business Case is under discussion with the Estates Directorate nationally within the overall context of HSE Capital programme. At the same time the HSE will continue to engage locally with Hospice movement and has agreed a decision on matter will be finalised before the end of April.

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Question 32 (Deputy Peter Fitzpatrick)

To ask the Minister for health will there be any delays or risks to patients with the Louth Hospital laboratory services moving to Drogheda.

Response:

Under the Public Service Agreement 2010- 2012 agreement was reached by stakeholder groups to pursue a consolidated in-house model of service delivery with associated savings, changes in work practices, increased productivity, reduction in staff levels and improved governance structures. These changes provide a comprehensive responsive service with an increased range and repertoire of testing available. A risk evaluation was carried out as part of the consolidation process. Issues identified with the potential to impact on service delivery have been addressed with interim solutions with ongoing monitoring. As 85% of the workload of Louth County Hospital is GP driven, which only 15% generated from Clinical work, the GP specimens can be delivered/courier to Our Lady’s Hospital Drogheda instead, GP’s can access results through Healthlink IT system which is available in OLOL thus increasing turnaround times for results, improving service efficiency and ultimately improving the patient experience.

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Question 33 (Deputy Peter Fitzpatrick)

Has he any plans to open a dialysis Unit in the Drogheda area in the near future.

Response:

The National Renal Office (NRO) identified a need to expand haemodialysis capacity in the Dublin North East region to accommodate the growth in demand for dialysis. Renal Services in Dublin North East are currently provided in the Mater and Beaumont Hospitals, with a contracted satellite dialysis unit in North Dublin. The expansion funding for this development is included in the RDO base budget as allocated in previous NSP’s and from internal realignment in NSP 2011 and again in NSP 2012 for capacity expansion.

There is currently a tender process for the procurement of two satellite haemodialysis units in the Dublin North East Region and based on an assessment of patients home addresses the NRO has identified that one of these satellite haemodialysis units should ideally be located along the M1 Corridor within 10 miles of Drogheda Town Centre and have the capacity to treat approximately 80 outpatient HD patients. The Lead Clinical Governance will be provided from the Consultant Nephrologists group at the Mater and Beaumont hospitals, in partnership with the other Consultant Nephrologists practicing within the catchment area. The exact location is subject to an ongoing tender process and will be made known when the process is complete.

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Question 34 (Deputy Charlie McConalogue)

To ask the Minister for Health and the HSE CEO if the pacemaker and internal defibrillator service will be reinstated at Letterkenny General Hospital with immediate effect especially in light of the fact that patients still incur a cost to the HSE national budget but through a different hospital since they now travel to University Hospital Galway or St James Hospital in Dublin to have the treatments instead.

Response:

The cardiac pacing programme at Letterkenny General Hospital ceased in 2011 as part of cost containment measures introduced at the hospital. The programme was introduced in Letterkenny General Hospital in 2008 in an unplanned manner and without a dedicated funding resource identified. The programme ceased last year for financial reasons as its costs had escalated to in excess of €750k per annum. Patients in Donegal requiring this treatment are being seen in the cardiac services in Dublin and Galway. An evaluation of the impact of this decision is being carried out.

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Question 35 (Deputy Charlie McConalogue)

To ask the Minister for Health and the HSE CEO what their plans are for maintaining community hospital beds in Carndonagh Community Hospital, Buncrana Community Hospital and Ramelton Community Hospital in 2012 and if they will give a commitment that no beds will be closed during the year.

Response:

The Health Service Executive operates eleven Community Hospitals / Community Nursing Units in Donegal.  The current bed capacity of the named facilities are as follows: Carndonagh Community Hospital 42 bedsBuncrana Nursing Unit                       30 beds (plus 6 chalets – independent living)Ramelton Nursing Unit                       30 beds The HSE intends to maintain the above bed capacity.  

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Question 36 (Deputy Charlie McConalogue)

To ask the Minister for Health and the CEO of the HSE if an impact assessment was carried out on the effect budget cuts proposed in the HSE West Service Plan would have on services in Letterkenny General Hospital and if they will reconsider the proposed cuts in light of the hospital being rated as one of the most efficient in the country.

Response:

Letterkenny General Hospital (LGH) faces a significant financial challenge in 2012 stemming from a number of factors principally: - Year on year reductions in budget allocation. - The impact of geographical peripherality, particularly in relation to medical recruitment, resulting in increasing dependence on high cost agency cover- Over 90% of inpatient workload is non-elective or emergency in origin  As a consequence the hospital faces a financial challenge of €11.6m in 2012.  A range of cost containment measures have been identified and are being implemented at LGH. To date, these measures have reduced the projected deficit to €7.1m and work is continuing to further reduce this financial deficit towards a breakeven position for the hospital.   While the hospital will face a challenge to deliver on the level of services promised, there are a significant number of opportunities being pursued in order to improve both the quality of services in the hospital.  These include –

The opening of the new ED/Medical Assessment Unit/Medical Tower block in the summer.

A focus on improved waiting times. In conjunction with the SDU, waiting times for inpatient and day case will improve, with max waiting times down to 12 months and later in the year down to 9 months for routine appointments.

Working towards consistently meeting the 6 hourly target waiting times in ED. Participating in the roll-out of the National Clinical Care Programmes in areas

such as Stroke Care, Productive Operating Theatre, Acute Medicine Programme, Critical Care and Surgical Care.

Developing an Enhanced Recovery Unit leading to more efficient elective programmes meaning an increase of day of surgery admission rates and reduction in Average Length of Stay.  The effect will be that more patients can be treated using less beds.  

Building on CAWT (cross –border) initiatives in areas such as Urology; Vascular Surgery; ENT

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Question 37 (Deputy Caoimhghín Ó Caoláin )

The impact of the cuts in the HSE Dublin/North East Regional Service Plan 2012 on acute hospitals in the region.

Response:

In 2012 DNE acute hospital services are required to reduce costs by total of €76m (which comprises of incoming deficits from 2011 budget coupled with 2012 service impacting budget reduction and identified increased cost pressures). This represents approx 8% regional average cost reduction, ranging from 6% to over 12% across the ten acute hospitals. There has been an ongoing programme of cost reductions in DNE for the last number of years. In preparing the DNE Service Plan 2012 we were mindful of what further efficiencies can realistically be achieved and acknowledge that it is not possible to maintain 2011 levels of activity/access/capacity in acute hospitals in 2012. Simultaneously, there are planned service improvement initiatives in DNE acute hospitals this year - both capital and revenue investment. There will be €6m invested (full year costs basis) to implement the National Clinical Programmes to deliver improvements in clinical services including stroke care, acute medicine, emergency medicine, surgery and chronic disease management. The total DNE capital investment in 2012 for acute hospitals is in excess of €60m.

In summary, in 2012, our approach to reducing costs is underpinned by our commitment to achieving maximum delivery, within available resources, on all Key Performance Indicators across the Performance Scorecard of Quality, Access and Resources as per the National Service Plan 2012. While we will seek efficiencies in terms of the staffing costs of existing capacity, we will also need to reduce capacity in order to try and live within available resources. Initially, capacity reductions will focus on scheduled care, that is, elective inpatient and day case combined. There is not a simple linear relationship between capacity and activity (the number of patient consultations/procedures carried out at inpatient and outpatient settings). Therefore, we aim to achieve further efficiencies by treating proportionately more patients with less capacity (staff, beds, clinics, theatre schedules etc) to further limit reductions in activity volume and access times. We will use the opportunities presented by the National Clinical Programmes to assist this process. It is intended that further increases in our day case and day of admission rates will improve efficiency. It is important to note that the improvements we will implement under the National Clinical Care Programmes are important in their own right, and will help mitigate the impact of the necessary service reductions, but do not unfortunately provide an alternative to those reductions.

In 2012 we will

Provide 240,544 combined inpatient ad day case discharges, a reduction of 7,439 cases (3%) of projected outturn 2011

Provide for 15,406 births, an increase of 458 births (3%) of projected outturn 2011

Provide 475-495 dialysis treatments, an increase of 9-29 treatments (2.6%) of projected outturn 2011

Prioritise unscheduled care (ED trolley waits) particularly in the peak capacity pressure periods

Build on progress made in 2011 whereby DNE eliminated all adult elective waits over 12 months by seeking to comply with the new 9 month maximum wait time

Prioritise urgent elective/planned cases including relevant cancer cases.

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Emergency activity, although demand-led reduced in 2011, however it is not possible to be certain if this trend will continue this year.

Given the scale of the financial challenge, it is necessary to reduce overall activity levels which could result in bed closures in the region of 100 beds across the acute hospital system in the region. The decision regarding bed closures will be subject to the outcome of an ongoing assessment of medical and surgical bed capacity requirements (which can be provided within allocated budgets) and improved hospital egress options.

The role of the smaller hospitals in the region will be reviewed in the context of the Minister’s framework for smaller hospitals, available resources and ongoing reconfiguration plans. It is our intention to make our smaller hospitals busier during 2012 by increasing the amount of non-complex day and diagnostic workload going through these hospitals while significantly reducing their costs.

Cost containment strategies will include reducing agency staff costs and optimising permanent staff rosters.

We will engage early with the SDU around any further hospital reconfiguration within the region and we will continue to deliver reconfiguration on the basis of integrated plans which address the balance of capacity, demand resource and associated risks within the region.

The introductory section of the Service Plan (p 7), provides a useful over-view of the overall impact on DNE Acute Hospitals and further details regarding proposed levels of activity and service/infrastructure improvements within the acute hospital services are provided on (p 41-49).

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Question 38 (Deputy Michael Colreavy )

The impact of the cuts in the HSE West Regional Service Plan 2012 on acute hospital services in the region.

Response: The budget reductions for 2012 represent a major challenge for the west acute hospitals.

The overall budget allocation for the West in 2012 is €1.781 billion. The net reduction compared to 2011 is 5.2% or €104.8m.  The funding for acute hospitals within this is €750 million or 42% of the total HSE West budget. The scale of the cost reductions and the recent reductions in staff is such that the impact will increasingly be felt in frontline service areas.  The focus this year is therefore on reconfiguration, reform, greater productivity and challenging traditional cost structures and models of service delivery in order to reduce cost. We are also addressing staffing levels, skill mix and staff attendance patterns, including rosters within the context of the Public Service Agreement 2010-2014 in order to achieve the activity targets set out in the service plan. Acute Hospitals in the West area face additional challenges in view of the carry forward of last year’s deficits in the run rate.  Activity targets for inpatients and day cases are reduced by approx 3% overall, however emergency services will be protected.  Cancer and Dialysis treatments are demand-led in nature and activity in these areas will also be maintained in 2012. The objective is to maintain service levels to as near to 2011 levels as possible and deliver the highest quality services within the budget allocated. The implementation of the national clinical programmes such as the acute medicine, surgery and ED programmes are key productivity enablers, which will deliver productivity improvements such as reductions in average length of stay and earlier discharge from hospital, increased same day admission for surgery and more productive operating theatres. Improved income collection will also be required in order to maintain front line services.   

In 2012, we will focus on a number of key areas in order to improve access to services and make it easier for people to receive the care or service they need in the most appropriate setting. Key priorities in the service plan include the achievement of the waiting time targets for hospital admission and elective surgery.   Specific developments taking place in 2012 across the West area hospitals include; 

o Opening an Acute Medical Assessment Unit in University Hospital Galway in Q1 2012 and transferring acute medicine from Merlin Park to UHG.  Three additional Acute Medicine Physicians will be appointed.

o Opening a Medical Assessment Unit in Portiuncula as part of the Acute Medicine Programme.

o Refurbishing the Neo Natal Intensive Care unit GUH. o Upgrading endoscopy facilities in Roscommon County Hospital.    o Opening an Acute Medical Assessment Unit in the Mid Western Regional

Hospital Limerick and appointing three Acute Medicine Physicians. o Upgrading ward facility in Ennis Hospital. o Appointing additional consultants in Sligo i.e.  A Consultant Geriatrician,

Neurologist and Dermatologist. 

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o Upgrading radiology equipment in Sligo General Hospital. o Opening a new Emergency Department in Letterkenny General Hospital along

with the appointment of a new Emergency Medicine Consultant. o Enhancing Neurology, Rheumatology and Dermatology Services as part of the

Outpatient service improvement.   Decreased hospital activity will inevitably impact on elective care, and in this context the West hospitals will work closely with the Clinical Programmes to ensure greater productivity and also with the Special Delivery Unit to ensure optimum access to services within the funding available.

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Question 39 (Senator Jillian Van Turnhout)

Despite great strides achieved in developing new heart failure units under the HSE clinical care programme in some parts of the country, only one such unit has so far been opened in the HSE South region. Progress in Cork and Kerry appears to be particularly slow. Can the Minister explain why the South region is lagging behind others in relation to heart failure unit development and what is being done to address this?

Response:

The HSE South Regional Service Plan 2012 makes provision for the appointment of 2 Clinical Nurse Specialists and a 0.5 WTE administrative post in order to support the implementation plan for the Heart Failure Programme at Cork University Hospital.  The final details of the implementation plan for the Heart Failure Programme at CUH are currently being finalised with hospital management and the regional clinical lead for the programme.  Upon the completion of this process, the posts will be forwarded to the National Recruitment Services for advertising and interview.  In the interim CUH operates a pilot Heart Failure Clinic and a full clinic will be established as soon as the Clinical Nurse Specialists and administrative support posts are in place.

Kerry General Hospital has not been identified for the first phase of the programme however the KGH Consultant Cardiologists intend to develop a proposal in order to be in a position to address the requirements of the Heart Failure Programme in the future.  To that end, a proposal is being prepared and many elements of the Heart Failure Programme are being pursued informally in advance of formal participation this includes cardiac rehab and links with the Acute Coronary Syndrome Programme. To fully implement the programme some additional resources will be required and this will be reviewed in the context of the overall resources available in the hospital.

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Question 40 (Senator Imelda Henry)

Update on the Implementation Programme for Acute Coronary Care Syndrome in Sligo General Hospital

The Acute Coronary Syndrome Programme (National Clinical Programmes) has agreed protocols for the management of these conditions (ST and NonST  elevation myocardial infaction ). Initially the programme has focused on STelevation myocardial infarction (heart attack). Any patient presenting with this, who is outside a drive-time of 90 minutes from a Primary PCI centre, will be treated with Thrombolysis (clot dissolving drugs) and then transported to the nearest PPCI centre for angiography and possible intervention.    Sligo General Hospital is currently outside a 90min drive-time from the nearest PPCI centre (Galway or Dublin). Currently patients receive thrombolysis and are then referred for PCI (angioplasty) to hospitals in Dublin or Galway within the next week. In the initial phase of the proposal, patients in this area will have Thrombolysis either outside Hospital (and Sligo run an excellent ambulance service to deliver this) or in Hospital. Following this, the patient will be transferred to the PPCI centre in Galway or Dublin to receive further treatment with PCI (angioplasty). The patient will be returned to the referring Hospital (e.g. Sligo). This will represent a small number of cases (1 per week in Sligo). The patient will return to the referring Hospital after PCI.

The proposed changes will improve care because it will eliminate current waiting time between the development of the STEMI (heart attack) and the patient being transferred to a unit that can provide 24/7 angioplasty. This is important because some patients who receive thrombolysis therapy may need emergency PCI within the following 3 to 6 hours. This is the first step in the improvement of care. The next step will involve accessing the primary care PCI Centre within 90 minutes. This will require either an air - ambulance service or the provision of primary PCI services in the Northwest or a combination of both across a 24/7 basis.

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