Joint Committee on Health and Children

Responses to questions to the Department of Health and the Health Service Executive, for answer at the meeting of the Committee on Tuesday 20 th November, 2012

National Issues

Question 1 (Deputy Robert Dowds)

To ask the Minister for Health to outline the progress being made toward legislation on alcohol sales and marketing?

The report of the National Substance Misuse Strategy Steering Group - launched last February - is a roadmap for the future direction of policy to deal with the use and misuse of alcohol.

The report made a range of recommendations on the supply, availability and marketing of alcohol. It also recommended measures on minimum unit pricing to target at risk drinkers and includes measures on prevention strategies, treatment and rehabilitation as well as substance dependency research and information. Taken together, these policy measures will tackle the harms of alcohol misuse in our society.

My Department is in the final stages of preparing a concrete set of proposals on the basis of the National Substance Misuse Strategy Steering Group Report, and following consideration by the Cabinet Committee on Social Policy, the intention is to submit these to Government for consideration and approval as soon as possible.

Question 2 (Deputy Robert Dowds)

To ask the Minister for Health to outline the progress being made with regard to getting more funding from private insurers whose customers are patients in public hospitals, and to give an account of the obstacles which he has faced in this regard?

A significant proportion of private patients who are provided with treatment by a public hospital are not currently charged for the services because of the current rules on bed designation.  In contrast, the public hospitals’ consultants receive private fees even where the hospital cannot levy its maintenance charge.  This represents a loss of income to the public hospital system.  

It is intended to introduce new arrangements to allow public hospitals to raise charges in respect of all private patients. Work on this matter is proceeding, in preparation for 2013. In the meantime, the Department has agreed, in principle, a system of improved cash-flow and accelerated payment with private health insurers. This will provide a once-off cash flow benefit in 2012 in the order of €125m. The accelerated payment arrangements are at an advanced stage with the detail of the legal agreements between the HSE and Insurers expected to be finalised very shortly.

1

Furthermore, from 1st January 2012, the charges for patients who choose to be treated on a private basis in public hospitals increased by between 3% and 5% depending on the category of hospital. It is anticipated that the increased charges will yield additional revenue in the region of €18 million in 2012.

Where charges are raised, there are often lengthy delays in collecting these, with the result that the public system has an unacceptably high level of outstanding private income. As of the end of September 2012, €204 million was due to the HSE from private health insurance companies in respect of treatment provided to private patients. Of the €204 million, €100 million relates to claims under preparation in hospitals and €104m relates to claims submitted to insurers which are either being processed or have been pended.

There are a number of issues affecting the claims collation process in public hospitals including:

o a relatively complex process involving the completion and collation of significant personal and clinical information;

o a paper based claims management process which is unwieldy and time consuming in the majority of hospitals; and

o delays in completion and sign-off of claim forms.

In order to address these issues and accelerate income collection a number of initiatives are being progressed including:

The HSE has tasked hospitals with bringing down the value of claims awaiting Consultant action and hospitals will also target the highest-value claims.

The proposals agreed by health service employers and the two consultant representative bodies at the Labour Relations Commission included a commitment on the part of all consultants to expeditious processing and signing of claims for submission to private health insurers. Consultants will be required to fully complete and sign private insurance forms within 14 days of receipt of all the relevant documentation and to co-operate with the secondary Consultant scheme whereby a secondary Consultant involved in a case can sign the claim form if the primary consultant has not signed within a reasonable timeframe. They will also be required to support the implementation of electronic claim preparation. Health service management is now proceeding with implementation of this and other measures in the coming weeks, having regard to the relevant provisions in the Public Sector Agreement.

The HSE has also awarded the contract for the roll-out of an electronic claims management system in eleven HSE sites. The system is currently operational in 6 HSE sites and a further 3 sites are expected to be operational by mid-November. This system will address the deficiencies of the current paper based process, will streamline the claims collection process and will also ensure that standardised work practices are implemented across hospitals.

The Health Insurance Consultative Forum also enables dialogue with insurers on issues of cost and efficiency, including timely and efficient processing of claims.

2

Question 3 (Deputy Robert Dowds)

To ask the Minister for Health to outline the progress being made toward bringing the prices of prescription medication closer to the EU average, and to give an account of the obstacles which he has faced in this regard?

On the 15th October I announced that intensive negotiations involving the Irish Pharmaceutical Healthcare Association (IPHA), the HSE and the Department of Health have reached a successful conclusion with a major new deal on the cost of drugs in the State. The deal is an important step in reducing the cost base of the health system.

The new deal, with a value in excess of €400 million over the next three years, will mean

significant reductions for patients in the cost of drugs, a lowering of the drugs bill to the State, greater access to new cutting-edge drugs for certain conditions, and an easing of financial pressure on the health services into the future.

The deal is beneficial in two broad ways, about half the financial value is related to reductions in the cost of

patent and off-patent drugs the other half is related to the State securing the provision of new and

innovative drugs for the duration of the agreement in an exceptionally difficult economic climate.

These were complicated and protracted negotiations but the deal will be of enormous benefit to patients and the health services, particularly given the scale of the financial challenges facing the health services over the next few years.

Amongst the measures that have been agreed include;

the price of medicines marketed by IPHA companies which are off-patent prior to 1st of November 2012 will be reduced to 50% of their original price by 1st November 2013;

the price of up to 400 patent protected products which have been available on the HSE Community Drug Schemes prior to 2006 will be subject to a downward only price review to the average price of the basket of nine countries. The HSE has completed this review which has resulted in significant price reductions for many products.

The revised product prices resulting from this Agreement which will be applicable from 1 November 2012 are published on the HSE Central Pharmaceutical Unit webpage: http://www.hse.ie/eng/about/Who/cpu/pricereductionsfor1nov12.pdf

The new deal, combined with the IPHA agreement reached earlier this year, means that €16 million in drug savings will be made this year with much greater savings to be achieved in 2013/14/15. It is estimated that the deal will generate savings of up to €116m gross in 2013.

In addition, it is worth noting that previous agreements reached with IPHA on reductions in the price of medicines have accumulated savings in excess of €600 million for the taxpayer since 2006.

3

This landmark deal comes as legislation aimed at reducing the cost of generic drugs makes its way through the Oireachtas. The Health (Pricing and Supply of Medical Goods) Bill 2012, which will introduce a system of reference pricing and generic substitution, is a priority for the Government, and will deliver further savings in the costs of medicines for the health service and private patient.

The Department and the HSE have completed discussions with the Association of Pharmaceutical Manufacturers in Ireland (APMI), which represents the generic drugs industry, on a new Agreement to deliver further savings in the cost of generic drugs. Under this Agreement, from 1 November, the HSE will only reimburse generic products which have been priced at 50% or less of the initial price of an originator medicine. In the event that an originator medicine is priced at less than 50% of its initial price the HSE will require a generic price to be priced below the originator price.

The revised individual generic product reimbursement prices, which will come into effect from 1 November 2012, are published on the HSE Central Pharmaceutical Unit’s webpage: http://www.hse.ie/eng/about/Who/cpu/PriceReductions.html

Question 4 (Deputy Denis Naughten)

To ask the HSE if they will outline the results of the most recent ambulance response times survey both nationally and regionally; and specific local developments to improve these response times

Response –

The Health Information and Quality Authority (HIQA) have developed a suite of Performance Indicators within which 999 emergency calls have been classified in Clinical Status as follows:

1. Clinical Status 1 ECHO, life threatening emergency of cardiac origin, calls responded to by a First Responder* in 7 minutes 59 seconds

2. Clinical Status 1 DELTA, life threatening emergency of non cardiac origin, calls responded to by a First Responder* in 7 minutes 59 seconds

3. Clinical Status 1 ECHO calls should have a patient carrying vehicle at the scene of the incident within 18 minutes 59 seconds. 

4. Clinical Status 1 DELTA calls should have a patient carrying vehicle at the scene of the incident within 18 minutes 59 seconds

In relation to one and two above, HIQA have set the percentage target at 75%. In relation to three and four above, HIQA have set the percentage target at 80% with effect from the 1st January 2012. 

*A first responder is a person, trained as a minimum in basic life support and the use of a defibrillator, who attends a potentially life-threatening emergency. This response may be by the National Ambulance Service (NAS) or by a community /co-responder based First Responder Scheme which is integrated with the National Ambulance Service.

4

The latest available published data relates to August 2012 and year to date performance is as follows:

1. % Clinical Status 1 ECHO, life threatening emergency of cardiac origin, calls responded to by a First Responder* in 7 minutes 59 seconds – 51.14%

2. % Clinical Status 1 DELTA, life threatening emergency of non cardiac origin, calls responded to by a First Responder* in 7 minutes 59 seconds – 27.75%

3. % Clinical Status 1 ECHO calls should have a patient carrying vehicle at the scene of the incident within 18 minutes 59 seconds – 70.24%

4. %Clinical Status 1 DELTA calls should have a patient carrying vehicle at the scene of the incident within 18 minutes 59 seconds – 67.55%

Response times around the country vary significantly based on the nature of the area covered and the rural/urban mix, and as might be expected, response times are lower in remote areas of the country. However, the NAS is taking a number of steps to improve Response Time’s.

Performance Improvement Action Plan

The NAS has developed a Performance Improvement Action Plan focused on achieving an improvement in response time’s performance. This plan has 57 action points for improvement which are being worked through by local managers which focus on areas such as:

Faster mobilization times for crews Processes around call taking and dispatch Engagement with and development of Community First Responder

Schemes

Development of an Intermediate Care Service

One of the key issues for the Ambulance Service in Ireland in terms of effective response to Emergency Calls has been the continued use of Emergency vehicles for inter hospital transfers. In this context the NAS and Staff Representatives have, under the PSA, signed off on a Framework Agreement for the development of an Intermediate Care Service within the NAS. This service is specifically focused on the delivery of inter hospital transfers which frees up existing Emergency resources to focus on response to Emergency calls. Almost 50 Intermediate Care Operatives have appointed in 2012 across the country in areas such as Cork, Galway, Sligo, Letterkenny, South Dublin.

Control Centre Reconfiguration Project

The NAS is focused improving its call taking and dispatch functions in order to have a positive impact on response times. The NAS is in the process of rationalising the number of Ambulance Control Rooms across the country from the current 9 to one system across 2 sites, Tallaght and Ballyshannon. This project is also focused on delivering improved technology to the NAS which will assist in improving response times. Technology developments such as National Digital Radio, National Computer Aided Dispatch System, Mobile

5

Data, Route Planning and Electronic Patient Care Reporting will allow the NAS to deploy resources in a much more effective and efficient manner on a National basis rather than within small geographic areas.

The development of the National Control Centre will also allow the NAS to engage with and utilise First Responder schemes on a more effective basis. Current arrangements do not allow for effective capture of all data relating to a First Response on scene whereby technologies within the National Control Project will facilitate a more consistent approach.

Aeromedical Service

The Emergency Aeromedical Service, which was initiated as a pilot service in June of 2012 involves Irish Air Corps providing aeromedical support to the HSE National Ambulance Service (NAS).  Based in Custume Barracks, Athlone, the Irish Air Corps are providing a dedicated helicopter and personnel to fly and maintain the craft. The National Ambulance Service are responsible for patient care, which is provided by National Ambulance Service Advanced Paramedics. The Irish Coast Guard also provides additional support to the primary aircraft using their new SAR Helicopter based in Shannon, Co. Clare staffed by their own Paramedics and accompanied by an NAS Advanced Paramedic where necessary.

Engagement under the Public Service Agreement

The NAS is engaged with Staff Representative Bodies under the Public Service Agreement on a number of issues. One of the key areas of focus relates to more effective use of resources in order to improve performance against response time targets. Discussions in this regard have progressed significantly in a number of areas and it is hoped agreement can be reached on an overall Framework Agreement in early 2013.

Notwithstanding the above, it should be borne in mind that there are a number of factors outside of the control of the National Ambulance Service have the potential to negatively impact on Response Time Performance such as:

Hospital Turn Around times for release of Emergency Resources

Changes to the Acute Hospital System (e.g. Hospital Bypass Protocols)

Significant weather events (i.e. Prolonged cold snap effecting road accessibility)

Requirements, if any, to reduce staff staffing numbers to meet overall HSE requirements to remain within resource levels

Question 5 (Deputy Denis Naughten)

To ask the minister for health if he has completed his consideration of how best to address the long term health & social needs of people who were adversely affected by state funded vaccination programmes 

Consideration of this very complex issue continues within my Department. It cannot be addressed in isolation and must be considered in the wider context

6

of how best to address the long term health and social needs of people who may have experienced adverse outcomes from other health services.

Question 6 (Deputy Denis Naughten)

To ask the minister for health & HSE if they are satisfied with the laboratory capacity within the health sector to meet current demands and the plan, if any, to deliver on the medical laboratory modernisation programme

Response Approximately 84 million laboratory tests are undertaken annually across 42 public hospitals. The number of tests per lab ranges from 52,000 to almost 6 million. This comprises both urgent and non-urgent cases and a significant portion originates in primary care. Following a review of laboratory services in 2007, the HSE began modernising the service to reduce inefficiencies, turnaround times and costs. The recent introduction of an extended working day with revised on-call arrangements across the laboratory system represents one of the key tangible achievements to date under the laboratory modernisation process.

The proposed new national service will be based on a hub and spoke model. The HSE's cost benefit analysis recommended four public laboratories as hub labs, processing the high volume blood tests from primary care in addition to the hot lab workload from each hub’s acute site. The spoke labs will process the hot workload for their own acute sites. While some variation may be required in each region, because of geographical and logistical factors, alternative configurations will be evaluated against the recommended option in terms of costs and service quality. The hub and spoke option will provide a foundation for future service re-configuration in other laboratory disciplines, as part of the ongoing modernisation process. The HSE Interim Board has signed off on the establishment of a National Pathology Network to oversee the implementation of the new lab structure.

Progress in relation to laboratories is ongoing and we are satisfied at this time with the rate of progress

Question 7 (Deputy Caoimhghín Ó Caoláin )

To ask the Minister for Health if he will set out in full the listings of proposed locations for primary care centres under the headings of State capital funding, lease and public private partnership and the relevant criteria in each case.

It is important to state that the lists referred to in the media related to work that is ongoing; that they are work in progress. Delivery of primary care infrastructure is a dynamic process, constantly evolving to take account of changing circumstances, including the feasibility of implementation.

7

There are more than 200 potential locations under consideration for progression and the list of locations requires further work and objective analysis by the HSE and my Department particularly with regard to the feasibility of implementation. Accordingly it not proposed to publish lists at this time.

There are always more construction projects than can be funded from the Exchequer's capital health care allocation. The Health Service Executive is required to prioritise infrastructure projects within its overall capital envelope taking into account the existing capital commitments and costs of completion over the period. Therefore the consideration of projects for inclusion in the multi-annual capital programme is an evolving process.

Capital Plan 2012-2016The Capital Plan 2012-2016 – year 2012 has been approved recently and details are published on its websiteThis plan contains provision for HSE direct build PCCs at the following locations.

Cork City North West Finglas Corduff Grangegorman Monaghan town Ballinamore

In addition there is provision for the refurbishment of suitable premises at

Manorhamilton Sligo town

Criteria An assessment/evaluation of each proposed primary care centre location was undertaken with the infrastructural requirement evaluated under three headings: 1. An assessment of deprivation – The Deprivation Index for the

catchment population of the centre;2. The service priority identified by each Integrated Service Area / Local

Health Office;3. An Accommodation Assessment which assessed accommodation

available for the primary care team within the catchment area, the quality of the accommodation, and whether or not the accommodation was spread over more than one building.

Other factors factors: Agreements for lease in place - where there were good prospects of the

leased centre being delivered - these locations remained as lease strategy;

The size of the centre - the larger centres are more attractive to PPP bidders;

8

Extensions to existing facilities or refurbishment of existing buildings are not suitable projects for PPP.

The method and time scale for the delivery of PCCs is dependent on a number of factors including GP engagement, and site availability. The list will continue to be reviewed and revised as necessary.

It is envisaged that approximately 20 of the 35 potential locations published as part of the Government's Infrastructure Stimulus Package will be progressed by way of PPP.

The HSE is engaging with the NDFA as required to progress the Primary Care Centre Public Private Partnership Programme. The HSE is currently analysing the available sites in each location and engaging with the GPs in each location to determine their interest in participating in the primary care centre development.

Question 8 (Deputy Caoimhghín Ó Caoláin )

To ask the Minister for Health to advise his further considerations of the need to address the 55 to 74 age group from the outset of the roll-out of the planned bowel cancer screening programme, scheduled before this year's end; if he will advise the funding details and the progress towards full-funding from day one and if he will make a statement on the matter.

Background

Colorectal cancer is the second most commonly diagnosed cancer among both men and women in Ireland. Approximately 2,200 new cases are diagnosed each year, and it is cause of death in around 950 people each year.

There are two aspects to colorectal screening: it provides early detection of cancer and therefore facilitates earlier and more effective treatment, and it helps to prevent cancer by detecting pre-cancerous growths such as polyps. It is therefore imperative that the programme commences and continues on a sustainable basis.

Plans

Organised population-based call, re-call screening for colorectal cancer is a complex and layered process from initial invitation, through screening stage to possible diagnosis, surgery and treatment.

Plans for the development and implementation of the programme are at an advanced stage within the HSE and the National Cancer Screening Service (NCSS) and the programme will be introduced on a phased basis in quarter four 2012 (as stated in the HSE Service Plan 2012).

When fully implemented the programme will offer free screening to men and women aged 55-74 every two years. As 50 per cent of cancers within this age group are found in people aged 60-69 the programme will begin with this

9

age cohort (a population of approximately 500,000). It is anticipated that the first round will take up to three years to complete.

The screening programme is the first invitational screening programme in Ireland to be offered to men as well as women. To ensure quality and safety it is imperative that the programme is introduced in a carefully managed and monitored way to ensure that risks to patients are minimised and best clinical outcomes are maximised at all stages of the process.

A set of guidelines to support quality assurance in colorectal screening were recently issued. A Clinical Advisory Group has recently been established to support the ongoing development of the programme and to provide ongoing clinical advice to the HSE-NCSS.

The screening test, known as a Faecal Immunochemical Test is a home based test and approximately 94 to 95 per cent of people will receive a normal result and will be invited for routine screening again in two years time. A small number, in the region of five to six per cent, will receive a not normal result and will require an additional test. They will be referred for a colonoscopy (an investigation of the lining of the bowel) to a Screening Colonoscopy Unit within a hospital contracted by the NCSS for provision of this service.

Fifteen candidate colonoscopy units have been identified around the country to support the screening programme. Each candidate unit has responsibility to take a number of actions to become a Screening Colonoscopy Unit which include achieving or be well on the pathway to achieving NHS JAG accreditation, demonstrating capability of meeting the needs of the screening programme in accordance with its Quality Assurance Standards and maintaining service requirements for symptomatic patients within national targets.

Planning for colonoscopy capacity

The HSE, NCSS and the Special Delivery Unit in the Department of Health have been working together to develop the appropriate capacity in colonoscopy services nationwide to support the introduction, sustainability and growth of the screening programme, while maintaining and enhancing the capability of the symptomatic endoscopy service.

The focus on improving quality and access at all publicly-funded screening colonoscopy units is for the benefit of all men and women who require a colonoscopy or any other diagnostic endoscopic procedure and not just the small numbers who will be referred for colonoscopy as part of the screening programme. Over time the phasing of the programme will allow development of colonoscopy capacity to cater for the full 55-74 year old population.

This will be achieved by building sufficient capacity in endoscopy services nationwide to sustain the implementation of the national screening programme, while maintaining and enhancing the symptomatic service.

As the programme will begin with a gradual roll-out during 2013 additional funding (ie additional to NCSS base funding) for the programme is anticipated at €4.3m for that year. In 2014 and 2015 the invited numbers will increase and in addition surveillance colonoscopies will become a standard feature of

10

the programme. This increase in activity will be reflected in the costs anticipated at €6.6m and €7m respectively.

Question 9 (Deputy Catherine Byrne)

To ask the Minister for an update on the location of the new National Children's Hospital; if he is confident that the chosen site fulfils all the criteria of the McKinsey report (2006); if the chosen site is adequately accessible by both private vehicles and public transport; what are the future plans for Our Lady's Children's Hospital, Crumlin, and Temple Street Children's Hospital?

Response The Government’s decision to develop the new children’s hospital at the campus of St James’s Hospital in Dublin was announced on 6 November 2012. In identifying the new site, the Government has carefully considered the report of the Dolphin Group along with detailed supplementary information on cost, time and planning which was subsequently sought from those members of the Group with the relevant technical expertise.From 2006 to date there has been a consistency in agreeing with the overall principles and proposed assessment criteria set out in the 2006 McKinsey report. The importance of the principle of tri-location was emphasised in submissions to the various review groups (Joint Task Group 2006, RKW Framework Brief 2007, 2008 KPMG review of Dublin Maternity services and Independent Review 2011). In all cases, the reports and reviews concur that co-location with an adult teaching hospital and preferably tri-location with a maternity hospital is the optimal choice. The Dolphin Review Group recommended that the Minister remains on this path. Co-location, and ultimately tri-location with a maternity hospital, on the St James's campus will support the provision of excellence in clinical care that our children deserve.

Despite the fact that access issues were a dominant feature of previous discussions around the Mater site, An Bord Pleanala did not cite difficulty of access to, or lack of parking at, the site as reasons for refusal. The Dolphin Report notes that St James’s has “excellent public transport services” with four bus services, a LUAS stop on campus and two others adjacent. Data provided by the National Ambulance Service does not indicate any significant difference in national ambulance driving times overall to each of the location options. A higher percentage of children in Dublin (48%) live within a 10km radius of St James than live within 10km of any other potential site. It is recognised that most of the children who will attend this hospital will arrive by car. Dublin City Council has indicated to St James that the campus can accommodate about 2000 parking spaces in total.

The new children’s hospital will replace the three existing children’s hospitals in Dublin (CUH Temple Street, Our Lady’s Hospital Crumlin and the National Children’s Hospital, Tallaght), two of which are currently housed in buildings which are deemed not fit for purpose and in need of urgent replacement. There has been no decision made regarding future plans for CUH Temple Street and Our Lady’s Hospital Crumlin once the new children’s hospital is open.

11

Question 10 (Deputy Catherine Byrne)

To ask the Minister for Health what his Department is doing to combat obesity in this country, given that Ireland has the second highest rate of obesity in Europe; his views on calorie counts being displayed in restaurants and cafes; his views on a traffic light system on foods?

Response

● The prevalence of overweight and obesity has risen steadily in recent times, with 61% of Irish adults now overweight or obese. This trend is also being witnessed among Irish children.

● Obesity is a major public health challenge, particularly in regard to diabetes and cardio vascular disease, and the significant burden it places on health spending. The prevalence of overweight and obesity has increased at an alarming speed in recent decades, so much so that the WHO calls it a global epidemic. The problem has been exacerbated as a result of our changing social, economic and physical environment and by a dramatic reduction in physical activity, and changing dietary patterns. Because obesity is associated with premature death, excessive morbidity and serious psychosocial problems, the damage it causes to the welfare of citizens is extremely serious and for these reasons the Minister for Health has established a Special Action Group on Obesity to tackle this growing problem.

● In Ireland, The Growing Up in Ireland survey, 2011 found that 1 in 4 children as young as 3 years of age are overweight or obese and these figures are similar to those found in the Irish survey for the WHO Childhood Obesity Surveillance Initiative and The National Children’s Food Consumption Survey, 2005. One in five teenagers is overweight or obese according to The National Teens Survey. This is of great concern as there are a multitude of short and long-term effects in not only in childhood but also in later life.

Special Action Group on Obesity● The Minister set up a Special Action Group on Obesity, comprising representatives from Department of Health, the Department of Children and Youth Affairs, The Department of Education and Skills, the Health Service Executive, the Food Safety Authority of Ireland and Safefood to examine and progress a number of issues to address the problem of obesity. Alone no single initiative will reverse the trend, but a combination of measures should make a difference. For this reason the Group is concentrating on a range of measures including actions such as: calorie posting in restaurants, the introduction of a tax on sugar-sweetened drinks, nutritional labelling, marketing of food and drink to children, the supply of healthy food products in vending machines, the detection and treatment of obesity, healthy eating guidelines and the promotion of physical activity. The Group will liaise with other Departments and organisations in a cross-sectoral approach to help halt the rise in overweight and obesity.

The Special Action Group on Obesity is currently progressing, the following measures:

Calorie Posting on Restaurant Menus

12

● One of the measures being pursued at the moment is Calorie Posting on menu boards in fast food restaurants and coffee shops. SAGO identified calorie posting on restaurant and coffee shop menus as one of the issues which could have a positive impact in addressing the problem of our rising levels of overweight and obesity and as a means of educating the general public on the calorie content of food portions. The Minister has prioritised calorie posting on menus as one of the key initiatives that will have a positive impact in addressing the problem of our rising levels of overweight and obesity and as a means of educating the general public on the calorie content of food portions. It is a simple concept that will educate the general population on calorie content helping consumers make healthier choices, eat smaller portions and enjoy food without over-eating.

● It is in this context that the Department of Health commissioned the Food Safety Authority of Ireland (FSAI) to conduct a public consultation on the introduction of calorie posting on fast food outlet and restaurant menus. In October 2011, The Minister for Health wrote to Fast Food chains operating in Ireland to request that they introduce calorie posting in their restaurants and received a very positive response. The Minister launched a public consultation process in February 2012, involving the FSAI, which was designed to inform the next steps in the process. The final outcome of that consultation process was launched by the Minister on 4th July 2012.

● In an unprecedented 3,130 responses, top line statistics from the public consultation process indicate that - 96% of consumers want calorie menu labelling in all or some food outlets; 73% of food businesses have also indicated that they want calorie menu labelling in all (37%) or some (36%) food outlets although 25% do not want the calorie menu labelling in any food outlet compared to only 4% of consumers who hold that opinion. This indicates that there is support for this initiative among the general public and also, in fact, within the food industry itself.

● The Minister has indicated that he is very much in favour that the programme of putting calories on menus in Ireland be introduced on a voluntary basis at first, because it is clear from the consultation results that the food industry will need significant technical support in order to implement it. There are a number of issues which SAGO, in conjunction with the FSAI is now addressing, for example, technical support for providing calorie content information for small restaurant / coffee shop owners; priority based implementation; how the scheme might work in restaurants whose menus change frequently etc. Calorie posting has already commenced in a number of establishments and it is envisaged that in the coming months, when these considerations are finalised and the necessary implementation mechanism has been devised it will be further implemented.

● Nevertheless, if a voluntary approach fails to make the desired impact the consultation showed that 92% of consumers and 88% of health professionals supported a mandatory approach for large food service businesses although only 58% of food businesses would support that approach.

Consideration of a Sugar Sweetened Drinks Tax● The World Health Organisation has serious concerns over the high and increasing consumption of sugar-sweetened drinks by children in many countries. Given, the preponderance of Sugar Sweetened Drinks consumption among children and adolescents, several epidemiological studies have

13

examined the relationship between SSB and weight gain or obesity in this group.

● The Report of the Steering Group established to oversee the carrying out a Health Impact Assessment on the health and economic aspects of introducing a Sugar Sweetened Drinks tax is now completed and will be presented to the Minister for consideration in the coming weeks.

Revised Food Pyramid/Healthy Eating Guidelines● The Group have revised the Healthy Eating Guidelines, including the Food Pyramid and these were launched by the Minister for Health on 13th June 2012. They will help inform people about the food and drink choices required for a healthy lifestyle and set out in plain and simple language the food servings the Irish population need to consume to maintain health and wellbeing.

● Healthy Eating Guidelines for Pre-schools and Primary Schools have already been developed and are being implemented. The Department of Health has been working with the Department of Education and Science in developing Food and Nutrition Guidelines for Post- Primary schools and these will be available this year.

Healthy food and drink choices in vending machines in post primary schools: ● Research is underway in association with the Department of Children and Youth Affairs to establish the use and types of foods and drinks stocked in vending machines in post primary schools. The Food and Drink Industry Ireland and its’ members have met with the Minister and with the Special Action Group on Obesity to discuss the Minister’s action priorities. They have indicated to the Minister that this is an area they are interested in supporting. The Department of Health is awaiting concrete proposals.

Health Service Executive – ICGP Weight Management Treatment Algorithm● Treatment algorithms inform primary care staff of the steps to be taken with regard to managing obesity, from raising the issue and carrying out an initial assessment right through to counselling strategies, dietary advice, pharmacotherapy and referral. An ‘adult’ algorithm has been agreed with health care professionals and is now available. It is understood that the treatment algorithm for children is at final stages of agreement. These tools will make it easier for health care professionals to monitor and treat overweight and obesity at primary care level.

Opportunistic screening and monitoring of children ● The Special Action Group on Obesity has been discussing opportunistic screening and monitoring with the HSE with a view to earlier detection of overweight and obesity in children. This will improve the identification of overweight children at an earlier age and prevent these children from progressing into the obese category. Obese children will also be identified early and treated.

Redeveloped Physical Activity Web-site and Physical Activity Plan for Ireland

14

● There is ample evidence showing that in Ireland, we, like other developed countries, have become increasingly sedentary in our daily lives. We know that 3 out of every 4 Irish adults and 4 out of 5 Irish children do not meet the targets set in the National Physical Activity Guidelines developed by the Department of Health and the HSE in June 2009 and are consequently at risk of developing serious health problems due to inactivity.

The Guidelines, which include recommendations for all age groups and levels of ability were designed to help support people to be active every day in as many ways as they can. The basic message is that ‘physical activity is for everyone, and any level of activity is better than none’. For adults, the minimum level recommended is 30 minutes a day of moderate intensity activity, 5 days a week. Children need 60 minutes of moderate activity a day. Research has shown that children tend to be more active if their parents are physically active. To promote the Guidelines, a dedicated website - www.getirelandactive.ie was launched, where in addition to the Guidelines, information booklet and fact-sheets, links are provided to other sources of information and support. National Guidelines alone are insufficient to increase participation levels and so the HSE has also developed “A Physical Activity Plan for Ireland” to give clear direction for the promotion of physical activity in Ireland and address the risk of developing health problems associated with sustained inactivity. The National Physical Activity Plan which will contribute to addressing this major health issue, is currently being considered by SAGO and the Department of Health.

Traffic Lights SystemThe Department of Health supported both GDAs (Guideline Daily Amounts) and the Traffic Lights system of presentation during the discussions at EU level of the EU Regulation on the provision of food information to consumers.

The Regulation was finalised in late 2011. The Department of Health is currently attending an EU Working Group on the implementation of this Regulation and it is hoped that the Regulation will be transposed into Irish law during 2012/2013.

The Regulation will help to provide the consumer with the means to make informed choices regarding healthy eating. It includes such provisions as a mandatory nutrition declaration, allergen labelling and the extension of Country of Origin Labelling (COOL) to other meats (as well as beef).

The mandatory nutrition declaration shall include energy, fat, saturates, carbohydrate, sugars, protein and salt. In addition, the amounts of mono-unsaturates, polyunsaturates, polyols, starch and fibre may be presented on the label. Both mandatory and voluntary information must be presented in the same place (either front or back of package).

The Food Business Operator may repeat the information in relation to energy or energy with fat, saturates, sugars and salt values. Again, this information must be presented in the same place (either front or back of package).

The nutrition declaration must be presented using the GDA (Guideline Daily Amounts) system. In addition, it may be presented using the Traffic Lights system. The former uses words and numbers to denote the amount of each nutritional element present in the food, while the latter uses colours to denote same.

15

Question 11 (Deputy Ciara Conway)

To ask the Minister for Health to investigate why this committee heard from Dr Tony O Brien on 20th September that the amount outstanding because of the failure of consultants to sign off on insurance forms for private patients in public beds was in the region of 60 million euro, while the Public Accounts committee was told on 9th October that this figure was in the region of 74 million euro, can he account for this discrepancy and state what exactly is being done to resolve this situation and if he can confirm a timeline for recovering the monies owed and if he will investigate the reasons as to why this oversight has occurred in the first place and how will he ensure it does not continue.

Response –

The HSE and voluntary hospitals recoup a considerable amount from private health insurance companies in return for private and semi-private treatment services provided to patients with private health insurance cover. However, lengthy delays can often occur between the discharge of patients and the receipt of payment from the health insurance companies. This has led to an unacceptably high level of debtor days/months with a significant amount in fees outstanding.

As of the end of September 2012, €204 million was due to the HSE from private health insurance companies in respect of treatment provided to private patients. Of the €204 million, €100 million relates to claims under preparation in hospitals, and €104m relates to claims submitted to insurers which are either being processed or have been pended.

A delay in consultants signing off on health insurance forms is the main issue affecting the claims collation process in public hospitals. Of the €100m under preparation in hospitals, €73m relates to delays in Consultant sign off and circa €60m of this amount relates to aged claims (outstanding for over 30 days).

This is the reason for the apparent difference in the information provided at the PAC on 9 October and to you at the Health Committee in September.

The HSE has directed hospitals to bring down the value of claims awaiting consultant action. A number of initiatives to address this issue are underway including:

The HSE has set hospital targets for income collection. Hospitals have been instructed to bring down the value of claims awaiting Consultant action and hospitals will also target the highest-value claims.

This issue was also addressed by health service employers and the two consultant representative bodies at the Labour Relations Commission. An important feature of the proposals agreed between the parties was a commitment on the part of all consultants to expeditious processing and signing of claims for submission to private health insurers. Consultants will be required to fully complete and sign private insurance forms within 14 days of receipt of all the relevant documentation and to co-operate with the secondary Consultant scheme whereby a secondary Consultant involved in a case can sign

16

the claim form if the primary consultant has not signed within a reasonable timeframe. They will also be required to support the implementation of electronic claim preparation. Health service management is now proceeding with implementation of this and other measures having regard to the relevant provisions in the Public Sector Agreement.

The HSE has also awarded the contract for the roll-out of an electronic claims management system in eleven HSE sites to replace the current paper based system. The system is currently operational in 6 sites and a further 3 sites are expected to be operational by end of November.

The HSE has emphasised to all hospitals the importance of addressing the issue of income collection, in conjunction with the insurers, so that the maximum resources possible are available to the health system. The HSE expects that the range of measures outlined above will contribute to improving the collection of income that is outstanding to the public hospital system.

Question 12 (Deputy Jerry Buttimer)

To update the Committee on efforts being taken to collect outstanding revenue due from private health insurers to HSE.

Response –

The HSE and voluntary hospitals recoup a considerable amount from private health insurance companies in return for private and semi-private treatment services provided to patients with private health insurance cover.  However, lengthy delays can often occur between the discharge of patients and the receipt of payment from the health insurance companies.  This has led to an unacceptably high level of debtor days/months with a significant amount in fees outstanding.

Delays by consultants completing and signing off on health insurance forms is the main issue affecting the claims collation process in public hospitals. Hospital Managers have been instructed to address this issue as a matter of urgency. A detailed fortnightly review of the quantity and value of claims outstanding by hospital is taking place with Regional Directors of Operations (RDO), Clinical Directors and Hospital Managers engaging to address difficulties that arise in individual hospitals and at individual consultant level.

This issue was also addressed by health service employers and the two consultant representative bodies at the Labour Relations Commission.  An important feature of the proposals agreed between the parties was a commitment on the part of all consultants to expeditious processing and signing of claims for submission to private health insurers.  Consultants will be required to fully complete and sign private insurance forms within 14 days of receipt of all the relevant documentation and to co-operate with the secondary Consultant scheme whereby a secondary Consultant involved in a case can sign the claim form if the primary consultant has not signed within a reasonable timeframe.                                                 

17

In addition to addressing delays in consultant sign off, the HSE has also awarded a contract for the phased roll-out of an electronic claims management system.  This system will address the deficiencies of the current paper based process, will streamline the claims collection process and will also ensure that standardised work practices are implemented across hospitals.  The system is currently live in six hospital sites with a further three to come on board by end of November.

The Department and the three main private health insurers have reached an agreement in principle on an accelerated income collection process which will generate an additional once-off cashflow benefit in the region of €125m in 2012.

Question 13 (Deputy Jerry Buttimer)

What progress has been made on the delivery of the strategic framework document on reform of the health service.

Future Health: A Strategic Framework for Reform of the Health Service 2012-2015 was formally launched on Thursday November 15th.

Question 14 (Senator Jillian Van Turnhout)

To ask the Minister for Health why there is no national paediatric home nursing care budget in place for children with life limiting conditions in Ireland and does he foresee putting one in place during his term as Minister?

The financial allocation for Palliative Care in the HSE Service Plan 2012 is €78 million. Paediatric home care for those with life limiting conditions is a complex and individual situation, which can extend beyond Palliative Care, to include Acute Hospital or Disability services. It has been approached to date by the Executive on a multi-disciplinary and on an invididual case basis. There has therefore been no specific or national regional budget set aside for this service. 

There is regional variation depending on service and skill mix availability, with quite often relevant paediatric hospitals having to train/upskill homecare staff prior to discharge.  The variances have caused some challenges in terms of local provision. In 2011, HSE Dublin Mid Leinster piloted a project to allocate a specific budget for paediatric homecare packages for their region, with some success particularly for children with tracheostomies. The Regional Director has continued this budget allocation into 2012. The lessons from this pilot will be shared with other regional management to test feasibility on a national basis. The issue raised by the Senator will be considered in the context of evolving services and resources, and the planned health reforms. It should also be noted that the HSE has engaged in on-going discussions in recent times with relevant organisations that have an interest in this matter.

18

Question 15 (Senator Jillian Van Turnhout)

Palliative and end of life care is a strategically important component of the health service. Where will palliative care fit in the reformed health service and what are the Minister's plans in this regard? Only 3 of the proposed 8 Outreach Nurses for Children's Palliative Care are currently in post, despite that fact that funding has been available from the Irish Hospice Foundation to cover 5 posts since 2010. The HSE has agreed to fund 3 posts. What is the current situation and when will these posts be filled?

Response –

The HSE 2012 Service Plan provides a budget of €78 million for Palliative Care services.

The HSE remains committed to working in partnership with the Irish Hospice Foundation and the National Development Committee on Children’s Palliative Care to implement the recommendations contained within the national policy document Palliative Care for Children with Life-limiting Conditions in Ireland (2009).

The palliative care programme for children includes the employment of eight Outreach Nurses. To date four of these posts had been filled, with a nurse located in Temple Street Children’s University Hospital, Our Lady of Lourdes Hospital Drogheda, Waterford Regional Hospital and Limerick Regional Hospital. The nurse in Temple Street has recently left his post and the hospital is actively working to fill this vacancy.

The remaining four vacant posts are in Galway University Hospital, Cork University Hospital, Midland Regional Hospital Mullingar and Our Lady’s Hospital for Sick Children Crumlin. Significant efforts have been made previously to fill these posts, including a number of individually advertised recruitment campaigns. Unfortunately these campaigns were unsuccessful.

Notwithstanding the reduced financial envelop and WTE challenge, the three HSE Regions involved have prioritised the Children’s Outreach Nurse positions and the posts have also been exempted, at national level, from the current recruitment moratorium. All four posts have now been advertised and it is hoped that offers will be made to suitable candidates by the end of the year.

Question 16 (Senator Jillian Van Turnhout)

Can the Minister confirm whether the Department of Health is liaising with the Department of Justice and Equality to ensure that Advance Care Directives form part of the proposed Mental Capacity Bill and what stage is it at?

It is the intention of the Department of Health to include legislative provisions for advance healthcare directives in the forthcoming Assisted Decision-Making (Capacity) Bill. Officials in the Department are actively working in collaboration with colleagues in the Department of Justice and Equality to

19

that end. However, if it becomes apparent that including legislative proposals on advance healthcare directives will unduly delay the publication of the Assisted Decision-Making (Capacity) Bill then the Bill will be published without those provisions. Were this to be the case, then our intention would be to add the legislative proposals for advance healthcare directives to the Bill during its passage through the Houses of the Oireachtas.

Question 17 (Deputy Mattie McGrath)

To ask the Minister for Health how he proposes to deal with the intolerable situation of ongoing cuts to home help hours and home care packages and the serious difficulties that this is having for elderly and disabled people throughout the Country; if his Department and the HSE have carried out a cost-impact analysis on how these cuts will lead to increased costs in the long term due to an increased need for hospitalisation and long term care of patients who are unable to care for themselves due to such cuts and if he will make a statement on the matter.

Response –

The HSE has a statutory responsibility to live within the budget voted to it by the Oireachtas. In this context, the HSE developed a range of proposals for discussion which would reduce spending and yield cash reductions of €130M between September and the end of December 2012.

It is a priority for the HSE to minimise the impact on patients and clients of any spending reductions. Many of the proposals therefore focused on areas that do not have a direct patient impact such as furniture, education and training, office expenses, laptops and PCs, travel and subsistence etc.

Context to Home Help ServicesGiven the economic challenges faced by the health services, there will be a reduction of €8 million on home help services between October and the end of December. This reduction is from a total budget for Home Help services in 2012 of €195 million (i.e. a reduction of 4%).

The HSE Service Plan target for this year was to deliver 10.7million home help hours. After this reduction of approximately 400,000 hours takes effect, almost 10.3million home help hours will be provided this year to over 50,000 people.

Home help and home care services budgets have grown significantly in the last 10 years – up from a combined total of €156m in 2005* to almost €330million (€195m for HH plus €130m HCP) in 2012.

This is in keeping with the policy to support older people to remain in their own homes for as long as possible. (*This relates to HH service only - HCP funding was first provided on a national basis in 2006.).

Prioritising service provisionThe home help service aim to support those most in need and in the context of the limited resources and growing demand for the services. The HSE continues to ensure that essential personal care and essential household duties are prioritised.

20

The provision of home help services is under constant review to maximise the use of the considerable available resource. In any such review the key principles adhered to include:

No current recipient of home help service who has an assessed need for the service will have it fully withdrawn. The home help service will be available to new recipients who have a requirement based on assessed need and within the available resources. Alterations to services will be undertaken in the context of a review of the individual’s assessed need and will be documented on the recipient’s records.

The flexible nature of the service is fundamental to responding to the ever changing needs of service recipients.

Service ImpactThe average number of home help hours received by an individual is 5 hours a week. On average, this reduction would mean that this person would lose one hour and would receive 4 hours per week.

In seeking to achieve the savings required the HSE will continue to target the services at the most vulnerable (in need of very personal care) and will ‘recycle’ hours from clients who no longer require a service so that new clients who come on stream can also receive a service.

Question 18 (Deputy Mattie McGrath)

To ask the Minister for Health how he proposes to deal with the lack of funding support for the Jack and Jill Foundation; if he will acknowledge the work that they do and the savings that this organisation makes for the State; what plans he has to re-examine their funding situation to allow families to continue to provide care for their sick children in their homes and hence do not require acute care/ hospitalisation; his plans to ensure that adequate Home Care Packages are put in place for those children who go beyond the remit of the Jack and Jill Foundation and if he will make a statement on the matter.

Response –

The HSE engagement with the Jack and Jill Children’s Foundation relates to the provision of in-home services for children with life limiting conditions and their families. The Jack and Jill Foundation provide a range of services including:

Care and support to children, Emotional support and advice to families, Direct funding to purchase respite care, Helping families cope with bereavement, Assist families with accessing information about services and

developing support networks.

21

Their ethos is to respond to all referrals and while there is a traditional understanding to discharge children at the age of 4, Jack and Jill has continued to respond to needs up to the age of 6 in some cases.

HSE Disability Services, as part of its engagement with the Jack and Jill Foundation, undertook a review of children aged over 4 years receiving services from the Foundation. This process was to ensure that all children with life limiting conditions would receive services on an equitable basis and through a standardised approach. The review resulted in approximately 100 children being provided with alternative care; some care plans have reduced hours as the child is now attending education or availing of other respite options. In some cases, no further hours were required following discharge by Jack and Jill as the supports provided by the HSE or other providers involved in the case were sufficient to meet the child and family needs.

In a letter to the HSE, the CEO of Jack and Jill Children’s Foundationacknowledged that most of the children over four years of age "have been sorted out at this stage", and he thanked the HSE in this regard.

The HSE recognises the role the Jack and Jill Foundation has played over the years in the provision of nursing care and support to children with life limiting conditions, and appreciates the level of funding the Foundation has raised privately to fund its services. The HSE is committed to working with the Jack and Jill Foundation in a spirit of partnership and positive collaboration. The Jack and Jill Foundation’s allocation through the HSE Dublin Mid Leinster region for 2012 is approximately €526,000 for the provision of an agreed level of service under a service arrangement.

In addition to the Jack and Jill Foundation, the HSE and other contracted service providers provide services for children with life limiting conditions. Many children availing of services provided by Jack and Jill also avail of other specialist hospital based and community based health supports and disability services.

The HSE recognises that as well as providing specialist palliative care services, children and their families need to be supported by a broad range of disciplines working in partnership across the health services. These staff can avail of professional in-service training provided in partnership with the HSE, Irish Hospice Foundation and Our Lady’s Children’s Hospital Crumlin.

Paediatric home care is complex and needs to be addressed on a case by case basis. It can vary from region to region depending on the service and skill mix availability. Often the relevant paediatric hospitals will train/upskill homecare staff and families prior to the discharge of a child. Although to date there has been no specific or national regional budget set aside for Home Care packages for children, children are currently supported to remain at home through the provision of packages made available through HSE local health care services. Palliative Care for Children with Life – Limiting Conditions in Ireland

The current focus of the HSE on Children’s Palliative Care is the implementation of the recommendations contained in Palliative Care for Children with Life-Limiting conditions – A National Policy published in 2010. Ultimately, this policy aims to ensure that all children with life-limiting conditions will have the choice and opportunity to be cared for at home. In

22

line with the key findings of the Palliative Care Needs Assessment for Children, this policy prioritises community based care for children and their families.

The HSE is working in partnership with the Irish Hospice Foundation to ensure Phase 1 of the Policy, which involves the appointment of a Paediatric Palliative Care Consultant and 8 Outreach Nurses (2 per region) is fully actioned. To date Dr. Mary Devins, Paediatric Palliative Care Consultant has been appointed to Our Lady’s Hospital Crumlin along with Palliative Care Children’s Outreach Nurses in the Children’s University Hospital, Temple Street;, Our Lady of Lourdes Hospital, Drogheda; Waterford Regional Hospital; Limerick Regional Hospital. The HSE is in the process of advertising for four additional nurses to be placed in Galway, Cork, Crumlin and Mullingar. These nurses will ensure that children requiring specialist palliative care are supported to be cared for at home by their families. This will include facilitating a co-ordinated approach between statutory and non-statutory providers in order to make best use of the care available and to maximise efficiencies through avoiding the duplication of service provision.   

In 2011, HSE Dublin Mid Leinster area piloted a project of allocating a small, specific and ring fenced budget for paediatric homecare packages for their region with some success particularly in the area of those children with tracheotomies. The Regional Director has continued this budget allocation into 2012.

Although most families would prefer to be able to care for their children at home, respite care is at times necessary and it forms part of the continuum of care. A needs assessment report ‘Respite Services for Children with Life limiting Conditions and their Families’ (2010) was undertaken in Dublin Mid-Leinster and Dublin North East. It is hoped to have the needs assessment for HSE South and West completed before the end of 2012.

The HSE remains committed to working with all voluntary disability service providers, including the Jack and Jill Foundation, to ensure that all of the resources available for specialist disability services are used in the most efficient and effective manner possible. However, the Health Service as a whole has to operate within the parameters of funding available to it and given the current economic environment; this has become a major challenge for all stakeholders, including the HSE, voluntary service providers, services users and their families.

Question 19 ( Deputy Seamus Healy)

Proposals for hospital network structures, details, present proposals, consultations and implementation

Response A key stepping stone towards the introduction of Universal Health Insurance in 2015 will be to develop independent not-for-profit hospital trusts in which all hospitals will function as part of integrated groups. 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 service reforms and provide the maximum possible benefit to patients.

23

The establishment of such Trusts is a complex matter and will require primary legislation. Prior to this, by the end of 2012, the Government will decide on initial hospital groups to be established on an administrative basis pending the legislation. Before those trusts are legally established, the functioning of the Groups will be reviewed and if changes prove necessary, these will be made with Government approval when the hospital trusts are being formed.

In June of this year, the Minister for Health appointed Professor John Higgins to chair a Strategic Board on the Establishment of Hospital Groups. The Strategic Board has representatives with both national and international expertise in health service delivery, governance and linkages with academic institutions. A Project Team was established to make recommendations to the Strategic Board on the composition of hospital groups, governance arrangements, current management frameworks and linkages to academic institutions. In order to do so, they carried out a comprehensive consultation process with all acute hospitals and other health service agencies. Over 70 meetings have taken place as part of this process. In addition a significant number of submissions have been, and continue to be received by the Project team. In addition, the project team has taken account of the principles laid down in "The Framework for Development - Securing the Future of Smaller Hospitals", which was approved by the Cabinet Committee on Health on 14th

February 2012. The Framework defines the role of the smaller hospitals. It outlines the need for smaller hospitals and larger hospitals to operate together and therefore is intrinsically linked to the on-going work regarding the development of hospitals groups. The Minister for Health is determined to ensure that as many services as possible can be provided safely and appropriately in smaller, local hospitals. Whereas the project team have identified that a second phase of activity is necessary to progress the implementation of its recommendations, it is outside of the remit of the Strategic Board to determine specific implementation measures, as these must take account of the actual composition of each hospital group, as decided by government

The project team is currently finalising its Draft Report for submission to the Strategic Board. The Strategic Board is scheduled to meet in mid-November to consider that report. When the Board have signed off on this Report it will be submitted to Minister Reilly, who will then bring it to cabinet for decision: it is anticipated that this will take place at the end of November.

Question 20 (Deputy Seamus Healy)

The proposals to address the huge numbers and long delays effecting out patient clinics.

Response –

There is no doubt that waiting times for outpatient services are unacceptably long and are the focus of considerable attention for the HSE. This is particularly so in some specialties including ENT orthopaedics, otolaryngology, ophthalmology, rheumatology and dermatology.

24

A priority action for the HSE has been the development and implementation of standardized reporting for outpatient access through the HSE Outpatient Data Quality Programme. Significant business process and IT changes were required in each hospital in order to deliver on this programme. When these were in place in the majority of hospitals, reporting of Outpatient Waiting Lists re-commenced in January 2012. Subsequently, waiting times have been published by us on our website www.hse.ie each month as part of the HSE Performance Reports.

Improving access to OP services is a priority for the Special Delivery Unit (SDU). The principle that data should drive decisions is paramount to the work of the SDU. In the context of OP Waiting Time Data the SDU together with the NTPF will replicate the approach taken with the collection of existing inpatient and daycase waiting time data. In other words it will begin with the systematic collection of waiting time data, at an individual patient level in a standardised format from all hospitals providing an OP service. This will be the first time that individual patient level data will be available at a national level from all hospitals.

The collation and analysis of OP waiting time data in a standardised format will reveal the distribution of long waiters across all hospitals. This will allow in the first instance for the SDU and NTPF to target their resources towards those patients who are waiting longest and ensure that they are seen and assessed.

Over the course of 2013-2015 the HSE together with the SDU and the HSE Clinical Programmes intend to radically reform the structure, organisation and delivery of OP services to ensure that the right patient is seen and assessed by the right health professional at the right time. Key elements of this programme of reform will include on going validation of waiting lists, the systematic and standardised management of referrals from primary care, a reduction in unacceptably high ‘do not attend’ rates and appropriate discharging from OP services when clinically appropriate to do so.

A maximum waiting time target of 12 months for a first time OP appointment by 30 November 2013, 26 weeks by 30 November 2014 and 13 weeks by Nov 2015 are the goals for the HSE and the SDU

Local Issues

Question 21 (Deputy Caoimhghín Ó Caoláin )

To ask the Minister for Health to clarify what are the agreed staffing levels for nursing (nursing floor) in the acute in-patient mental health services in Dublin Mid Leinster (see list below), what the current number of nursing posts by grade is in each of these units, the number of posts in each grade currently filled by:

1. Permanent staff

2. Agency staff

3. Temporary staff

and will the Minister give assurances that the current staffing of each of the acute in-patient mental health services in Dublin Mid Leinster provides a safe

25

and appropriate level of care.

1. Acute Psychiatric Unit AMNCH (Tallaght) Hospital, Dublin 24

2. Central Mental Hospital, Dundrum, Dublin 14

3. Department of Psychiatry, Midland Regional Hospital, Portlaoise, Co. Laois

4. Elm Mount Unit, St Vincent's University Hospital, Dublin 4

5. Jonathan Swift Clinic, St James's Hospital, Dublin 8

6. Lakeview Unit, Naas General Hospital, Naas, Co. Kildare

7. Newcastle Hospital, Greystones, Co. Wicklow

8. St Bridget’s Ward & St Marie Goretti’s Ward, Cluain Lir Care Centre,

9. St Mary’s Campus, Longford Road, Mullingar, Co Westmeath

10.St Fintan's Hospital, Portloaise, Co. Laois

11.St Loman's Hospital – Admission Unit & St Edna’s Ward, Delvin Road, Mullingar, Co. Westmeath

Source: http://www.mhcirl.ie/File/AC_List_180912.pdf

Response –

The HSE is committed to ensuring the best quality care is provided to everyone who uses its services, including the mental health services in Dublin Mid Leinster.

There are approximately 510 staff attached to the 11 named units. Services in each unit are managed by the Executive Clinical Director and Director of Nursing who on a continual basis, conduct professional needs assessments for each of the service users.

Additional staff are deployed where clinically indicated and warranted and nursing floors as such do not apply. As with the rest of the public service, each unit does have a staff ceiling against which it is monitored.

The HSE also has a Risk Management Framework and all managers and clinicians within these units follow the agreed protocols for managing all aspects of risk.

Furthermore, each unit is inspected by the Inspector of Mental Health Services against over 30 quality standards which include staffing. Reports of the Inspector's unannounced visits are published online.

Acute in-patient facilities are just one component of the overall mental health service. Many staff have been redeployed into acute community and rehabilitative services to ensure that patients are treated in the most appropriate setting and that the focus of the acute unit is on acute care needs.

26

The Dublin Mid Leinster region has by developing real alternatives within the community e.g. Home Care, Day Hospitals, Assertive Outreach and supported residential care, managed to rationalise its acute bed base to meet the recommended levels set out in Vision for Change.

The table below lists the levels of nursing staff in each unit.

Acute In-patient mental Health Service

Permanent staff

Agency staff

Temporary staff

Elm Mount Unit, St. Vincents University Hospital, Dublin 4

40 0 3

Newcastle Hospital, Greystones, Co. Wicklow

26 0 0

Jonathan Swift Clinic, St. James's Hospital, Dublin 8

30.5 2.5 3

Acute Psychiatric Unit,AMNCH, Tallaght Hospital, Dublin 24

48 9 5

Lakeview Unit, Naas General Hospital, Naas, Co. Kildare

18 0 13

St. Mary's Campus, Longford Road, Mullingar, Co. Westmeath

31 0 0

St. Lomans Hospital - Admissions Unit & St. Enda's Ward, Devlin Road, Mullingar, Co. Westmeath (includes St. Brigid’s and St. Maria Goretti’s wards.)

48 0 0

Department of Psychiatry, Midland Regional Hospital, Portlaoise, Co. Laois

25.5 5 9

St. Fintans Hospital, Portlaoise, Co. Laois

16 0 4

Central Mental Hospital, Dundrum, Dublin 14

182 0 2

Total 465 7.5 39

The breakdown of staff by grade is in the attached appendix.

Question 22 (Senator Imelda Henry)

I would like to ask the Minister for an update on the promised appointment of a radiographer to carry out mammography services at Sligo General Hospital

Response –

Great effort has been made by GUH to put a follow up mammography service in place in Sligo which would cater for approximately 6 women per week.

There are currently 2.8 wte mammographers in Galway University Hospital Radiology Department. The identified need is 5. HSE West continues to work through the recruitment channels and through a number of agencies to try to

27

recruit suitably trained mammographers. However to date these efforts have been unsuccessful.

Our plan in July was that we would send radiographers from Galway to be trained as mammographers.  2 of our radiographers have commenced training in Dublin. The training programme runs over 16 months. It is our intention to send more radiographers this time next year and so on in order to ensure availability of this skill set into the future. Both of these radiographers have been replaced within the Galway department.

Galway University Hospital and Sligo General Hospital continue to explore any possible short term solutions to this issue and continue to examine all possibilities.

It is important to reassure women who avail of symptomatic breast services in the West that while there are staffing difficulties which are preventing us getting the Sligo follow up service up and running, we continue to provide an excellent service in Galway to women from all across the West. This service is provided on the basis of clinical need and without regard to county boundaries.

Regarding the service to Sligo patients, all patients are placed on the common waiting list at the Symptomatic Breast Unit in GUH where they are seen on the basis of clinical priority. No differentiation is made with respect to county boundaries. The current waiting time for routine mammography at the unit is 3-4 months, which reflects our current deficit in the number of mammographers.

Question 23 (Deputy Catherine Byrne)

To ask the Minister for Health if he will confirm when the new 52 bed long stay facility in Inchicore, now known as 'Hollybrook' will open and what plans are in place to recruit staff for this service? Also, will these be 52 new beds or replacement beds from other long stay units?

Response –

Earlier this year the HSE proposed to relocate current services, including staff and patients, away from St. Brigid’s Hospital, Crooksling as this was not HIQA compliant. This would then enable the closure of St. Brigid’s Hospital.

However, having regard to the wishes of patients at St Brigid’s Hospital and the need to maximise the level of service provision in the region. The services at Crooksling will be maintained and alternative avenues of opening the Inchicore Unit are being explored.

In light of the public sector moratorium and the significant additional reductions in staff numbers required over the next two years it is essential that all possible approaches are considered as to how this unit may be opened. One option is through use of a public private partnership agreement. The HSE has successfully used this model to open a 100 bed unit for older persons at Ballincollig, Co Cork and this unit delivers real cost benefits and value to the system which would not be possible through direct employment.

Staff involved in the commissioning of the Inchicore Unit are currently examining all aspects of the Ballincollig agreement with a view to drafting a

28

proposal to open the new unit using a similar agreement. Such an agreement will require approval in relation to the use of funds from the Older Persons subhead of the Vote for that purpose. In addition, staff representative bodies will have to be consulted and allowed an opportunity to put forward other viable means of opening the unit.

The beds at this Unit will be new beds and used to address the need to care for the most highly dependent patients who currently have difficulty in accessing appropriate long term care options.

Question 24 (Deputy Ciara Conway)

To ask the Minister if he will provide a full update on what the delay is , and what exactly is being done to reduce the length of waiting lists at Waterford Regional Hospital -given that the most recent figures from the HSE show that Waterford Regional had 20,945 patients waiting longer than a year to be seen as outpatients.

Response –

There is a centralised Waiting list Management System for the South East Regional Specialities based at WRH. All referrals for ENT, Services, Orthopaedic, Dermatology and other Services from the 5 counties are received at WRH. Patients are seen in Out-Patient Clinics at WRH and at external clinics in the other hospitals and community clinics across the South East by WRH based Consultants.

Activity in relation to patients seen at each external clinic is not included in the local activity reports at the moment (i.e. not WRH Reports). Validation of the Out-patient waiting lists is ongoing since June. The hospitals Patient Administration Systems have been upgraded to ensure Reporting in line with National DoH/SDU Policy for Out Patient Waiting List Management. New posts have funded specifically to assist with initiatives to improve Waiting Times  Orthopaedic Waiting List –Musculoskeletal Physiotherapy Programme

Two MSK Physiotherapy Posts appointed – 3rd post to follow. The overall aim being to reduce the OPD waiting list for Orthopaedics and Rheumatology Services there are 1,700 patients on the Orthopaedic Waiting List that have been contacted. There are 720 Patients who have confirmed that they will attend.

In relation to the Rheumatology Waiting List of those selected as suitable, 115 have confirmed they will accept appointments. The MSK Physiotherapy pathway of care will facilitate access for 40 Patients from the Orthopaedic waiting List each week and 10 patients each week from the Rheumatology Waiting List. The hospital continues to receive approximately 400 new referrals each month to the Orthopaedic Service and 120 to the Rheumatology Service. Patients will continue to be selected from these Waiting Lists for this pathway.  

Arthroplasty Nurse Led Initiative

29

For the care of Patients after Joint Surgery (predominantly Hip and Knee surgery). Patients return for their outpatient appointment and are seen in the nurse led clinic which is run by a senior member of the nursing staff in accordance with agreed clinical Protocols.

This Post was developed through internal redeployment and reassignment of duties. The plan is that up to 500 patients will be seen for post operative care in this Nurse led Clinic and this will increase the number of new patient slots are the Consultant Clinics for patients on the Waiting Lists.

Cappagh Orthopaedic Hospital

2000 of the longest waiters are being validated, seen and treated at Cappagh Orthopaedic Hospital

Regional Dermatology

2nd Consultant commencing 1st March 2013 - 3rd Consultant Post advertised.  Regional Neurology

2nd Consultant Post advertised. In addition to the above a 3rd Consultant Vascular Surgeon will commence in November 2012.

The hospital is meeting all its financial and Activity targets as set out in the HSE South Service Plan 2012

Question 25 (Deputy Ciara Conway)

To ask the Minister what progress is being made on the reducing the high numbers of missed outpatient appointments at Waterford Regional Hospital, if he can outline what measures can be put in place to communicate more effectively with those due to attend , thus reducing waiting times and costs and if he will make a statement on the matter

Response –

There is a centralised Waiting list Management System for the South East Regional Specialities based at WRH. All referrals for ENT, Services, Orthopaedic, Dermatology and other Services from the 5 counties are received at WRH. Patients are seen in Out-Patient Clinics at WRH and at external clinics in the other hospitals and community clinics across the South East by WRH based Consultants.

The hospitals Patient Administration Systems have been upgraded to ensure Reporting in line with National DoH/SDU Policy for Out Patient Waiting List Management. New posts have funded specifically to assist with initiatives to improve Waiting Times

Orthopaedic Waiting List – Musculoskeletal Physiotherapy Programme

30

Two MSK Physiotherapy Posts have been appointed with a 3rd post to follow. The overall aim is to reduce the OPD waiting list for Orthopaedics and Rheumatology Services. There are 1,700 patients on the Orthopaedic Waiting List that have been contacted and 720 Patients have confirmed that they will attend.

In relation to the Rheumatology Waiting List of those selected as suitable, 115 have confirmed they will accept appointments.

Arthroplasty Nurse Led Initiative

For the care of Patients after Joint Surgery (predominantly Hip and Knee surgery). Patients return for their outpatient appointment and are seen in the nurse led clinic which is run by a senior member of the nursing staff in accordance with agreed clinical Protocols.

This Post was developed through internal redeployment and reassignment of duties. The plan is that up to 500 patients will be seen for post operative care in this Nurse led Clinic and this will increase the number of new patient slots are the Consultant Clinics for patients on the Waiting Lists. 

Cappagh Orthopaedic Hospital

2000 of the longest waiters are being validated, seen and treated at Cappagh Orthopaedic Hospital

Regional Dermatology

2nd Consultant commencing 1st March 2013 - 3rd Consultant Post advertised.

Regional Neurology

2nd Consultant Post advertised. In addition to the above a 3rd Consultant Vascular Surgeon will commence in November 2012.

The hospital is meeting all its financial and Activity targets as set out in the HSE South Service Plan 2012

Other Measures

In addition to these measures, new governance arrangements of the Waterford Regional Hospital centralised Waiting List Referral Office has been put into place with a revised management structure in line with SDU guidance. Processes have also been reviewed with the aim of enhancing communication between the hospital and patients in line with SDU Guidance on Validation. Validation by telephone is increasingly used which reduces opportunities for missed appointments.

The SDU has confirmed that a series of Technical Guidance documents will cover, amongst others: (a) governance and accountability structures; (b) the management of referrals, (c) the management of waiting lists, booking and scheduling; (d) the management and delivery of out patient clinics; (e) the

31

management of DNAs; (f) clinical outcome management and (g) discharging patients from outpatient services.

The Waterford Regional Hospital Outpatient Steering Group established in accordance with the SDU Criteria will oversee the implementation of the DNA Policy when issued.

Question 26 (Deputy Eamonn Maloney)

A)What is the time frame for the introduction of legislation regarding the Hospital Charter for Tallaght Hospital B) When is the new Statutory Board for Tallaght Hospital being announced.

A) Work is ongoing at present in relation to hospital groups, with the preparation of a report for consideration by the Strategic Board on the Establishment of Hospital Groups, chaired by Professor John Higgins. Following approval by the Board, this report will be presented to the Minister, who will bring it to the Cabinet before the end of the year. The report will contain recommendations on governance and management frameworks for hospital groups, aligned to the recommendations of the HIQA Tallaght report. Hospital groups will be formed initially on an administrative basis. It is not anticipated that the independent hospital trusts will be established before 2015. Creation of new hospital governance arrangements for Tallaght will be in the context of the establishment of these trusts.

B) When is the new Statutory Board for Tallaght Hospital being announced.

An interim board is currently in place in Tallaght Hospital, pending ongoing developments in relation to hospital groups/trusts.

The interim board was appointed and met on 21 December 2011. It comprises nine non-executive members, who were appointed based on competencies identified for good governance. Taken together, the executive and non-executive directors make up a smaller board than before. The current structures provide the framework for the board to receive appropriate management information and to take the lead rapidly on remedial action should the need arise.

Question 27 (Deputy Eamonn Maloney)

When will consultant appointments be made to fill vacancies in the Orthopaedic Department of Tallaght Hospital

Response –

In total there are 5 vacancies in the Orthopaedic Department at Tallaght Hospital which occurred for the following reasons:

3 due staff resignations 1 due to retirement 1 to facilitate a consultant transfer to another hospital.

32

The permanent appointment of Consultants is a lengthy process as it normally takes take 3 to 6 months for a Consultant to take up duty once an offer of appointment has been made.  With the approval of the HSE and following a recruitment and selection process a panel was formed in July 2012 from which Consultant Orthopaedic vacancies in Tallaght Hospital could be filled. Two appointments have been made from this panel and a third appointment is in process.  A new panel will be formed to fill the remaining vacancies in a permanent capacity.  Locums are in place to fill vacancies until permanent appointments have been made and to ensure continuity of service provision. The HSE will continue to support Tallaght to have these posts filled in a permanent capacity as expeditiously as possible.

Question 28 (Deputy Eamonn Maloney)

I acknowledge the real progress made in the model of care and management of Tallaght Hospital and I commend the staff and management for the reduced length of stay for patients, the saving of 6% in their budget achieved under circumstances of a 5% increase in additional patients and recognising the results of the Acute Medical Assessment Unit in treating 800 patients who would previously have been admitted to the hospital, can progress be made in improving the support structures for consultants, by providing additional junior doctors at weekends

Response –

Additional Consultant Staff have been allocated to Tallaght under the auspices of the Clinical Care Programmes. The Clinical Care Programmes focus on a Consultant delivered service and senior clinical decision making. Hospitals like Tallaght may be required to internally realign their existing NCHD staff to meet service needs to support this new model of care. The Hospital will continue to reconfigure its staffing resources to support this.

In relation to the provision of additional junior doctors at weekends, current policy is to move to a consultant provided service on a 24 hour basis where appropriate having regard to service requirements.

The 2012 NCHD contract provides for the rostering of junior doctors on a 5/7 basis. However, recourse to this provision to increase weekend NCHD availability would have to have regard to the requirements of the European Working Time Directive in relation to the average working week and rest periods."

In 2012, the management at Tallaght Hospital worked closely with the HSE and the SDU to build on the substantial progress made to date and to maximise the use of the Hospital’s existing resources to ensure the provision of patient care in the most efficient and effective manner through the implementation of the Clinical Care Programmes. 

A new 24 bed Acute Medical Assessment Unit was opened during 2012 and became fully operational in July resulting in improved access for patients to Senior Clinical Decision Makers and Diagnostics. Patients are treated more quickly and discharged or admitted in a more timely manner. Waiting times in the ED have improved considerably. In January 2012 only 35.3% of all new ED patients were treated and discharged within 6 hours and by August this had increased to 59.7%. In August, 80.9% of all new ED patients waited less than 9 hours.

33

Question 29 (Deputy Mattie McGrath)

To ask the Minister for Health if he is satisfied with the implementation of Community Mental Health Services in South Tipperary; who is ultimately responsible for the care of a patient who has been moved from secure care in St. Michael's Psychiatric Unit to an open un-secure unit in Clonmel and where such patients have went missing from the unit on a number of occasions; and if he will make a statement on the matter.

Response –

Community Mental Health DevelopmentsThere has been a major change programme in Mental Health Services across the extended catchment area of Carlow/Kilkenny and South Tipperary in line with A Vision for Change. It is intended that the majority of service users will be treated in the community by enhancing Community Mental Health Services. This will contribute to an overall reduction in the number of people who require care in an acute inpatient setting. The development of Community Mental Health Services in South Tipperary is underpinned by a comprehensive €20m Capital Infrastructure Programme. These key developments in Community Mental Health Services include:

Community Mental Health Teams – In October 2011 the Community Mental Health Teams across the area were amalgamated and enhanced with the redeployment of additional nursing staff from the closure of old long stay institutions and the reduction in inpatient capacity in St Michael’s. This has resulted in the following changes:

Location Pre October 2011 Number of Community Mental Health Teams

Post October 2011 Updated number of Community Mental Health Teams following amalgamation of Teams

Numbers of additional Allied Health Professional Staff redeployed to Community Health Teams following closure of old long stay institutions

Carlow 2 1 1Kilkenny 3 1 2South Tipperary

3 2 3

Total 8 4 6

34

The existing South Tipperary Community Mental Health Team (CMHT), Home Based Treatment Team and Acute Day Services (Day Hospital) relocated to the newly purpose built permanent location South Tipperary Mental Health Centre which became operational on 24 th

September 2012. This facilitates the co-location and further enhancement of these services. Six additional Allied Health Professionals have been appointed from May 2012

The Acute Day Services (Day Hospitals) operate in each area providing daytime care, support and an individualized care plan for each mental health service user. Two additional Acute Day Services (Day Hospitals) were established in both Clonmel and Cashel. The existing Acute Day Services (Day Hospital) in Carlow and Kilkenny have been extended from a 5 day to a 7 day service. Service Users can attend as little as 1 day a week or as much as 7 days a week depending on their individual need. Each of the acute day services are co-located within the Community Mental Health Team and the Home Based Treatment Team and have access to a range of mental health professionals.

Number of attendees at Acute Day Services 2012:

Location Number of attendances Acute Day Services Jan - Sept 2012

Kilkenny Acute Day Services

43

Carlow Acute Day Services

55

South Tipperary Acute Day Services

57

Home Based Treatment Teams – Three additional Home Based Treatment Teams are in operation since October 2011 following the recruitment of 10 additional nursing staff and the reorganization 11 nursing staff across the catchment area. The aim of the Home Based Treatment Team is to support service users in the acute phase of their illness and to provide an accessible service to patients in the community through home visits or specific targeted therapeutic. Interventions as appropriate. .Each Home Based Treatment Team is lead by a Consultant Psychiatrist and is supported by Allied Health Professionals. Activity for the Home Based Treatment Team is monitored on an ongoing basis and is outlined from commencement to date in the table below.

Location Number of Service Users

Carlow Home Based Treatment Team

150

Kilkenny Home Based Treatment Team

340

South Tipperary Home Based Treatment Team

244

35

Crisis/Respite House – Glenville House (a temporary location while the permanent facility is provided) opened following the cessation of admissions to St. Michael’s Unit Clonmel on the 5th of June 2012. Since its opening the Crisis Respite House has received 44 admissions. This facility provides an alternative to Acute Inpatient Care for service users who based on these requirements do not require admission to the Acute Inpatient Unit.

Haywood Lodge Community Nursing Unit – is a residential 40 bed community nursing unit which is operational from April 2012 and involved the relocation of patients and staff from St Mary’s and St Paul’s Ward from St Lukes Psychiatric Hospital Clonmel. The unit is built to a very high specification based on a national design. Each resident has their own bedroom and access to outdoor garden areas and occupational activity. There has been very positive feedback from relatives of service users and from the Mental Health Commission following a recent unannounced visit,

Garryshane House (High Support Services): Garryshane House is a twelve bed High Support Hostel which opened on the 26th of July 2012. The opening of this unit involved the redeployment of staff and residents from St. Teresa’s Unit, St Luke’s Hospital Clonmel. Each resident has an individualized care plan that involves active rehabilitation and recovery care elements. This unit has been fully occupied since its opening.

St Michael’s Unit, South Tipperary General HospitalSt Michael Unit, South Tipperary General Hospital was an acute inpatient unit providing care and treatment for persons with acute mental illness. St Michael Unit was not a long stay secure unit. Following the significant developments in community based mental health services in South Tipperary, St Michael’s Unit closed on 13th July 2012 which facilitated the transition and transfer of acute inpatient mental health services to the Acute Inpatient Unit, Department of Psychiatry, St. Luke’s General Hospital, Kilkenny. As a result of the closure of St Michael’s Unit 21 staff were redeployed to work in Glenville House, the new Community Nursing Unit and the Community Mental Health Teams. Admissions from South Tipperary to Kilkenny are actively managed with co-operation across the mental health services in Carlow/Kilkenny and South Tipperary

Acute Inpatient Unit St. Luke’s Hospital, KilkennyThe Acute Inpatient Unit (Department of Psychiatry) in Kilkenny has 44 beds which comprise of:

1. An acute ward with 19 beds2. A sub acute ward with 25 beds.

This unit provides for the acute inpatient mental health care needs for the catchment area of Carlow/Kilkenny and South Tipperary. There have been 92 admissions to this unit from the South Tipperary Area since the closure of St Michael’s Unit in early June 2012 with an average bed occupancy of 82.5%. The average length of stay ranges from 7 to 10 days (excluding two long stay transfers from St Michael’s Unit, Clonmel). The great majority of admissions have occurred in a safe and unproblematic manner. As with any change process there are occasionally difficulties and these are logged and discussed with the relevant stakeholders and this governance and learning process will continue.

36

Bed occupancy levels and admissions are very actively managed by use of community facilities across the entire catchment area and close communication with colleagues in South Tipperary. This is facilitated by the use of Acute Day Services and Home Base Treatment Teams who either provide alternatives to admission or significantly decrease the length of stay.

Service Users Discharged from Acute Inpatient CareWhere Service Users are discharged from acute inpatient care, the mental health services offer follow-up services in conjunction with primary care services dependent on service users assessed needs and care plans. Each service user is allocated a Consultant responsible for their ongoing mental health care. In addition all individuals, depending on their ongoing assessed care needs will have access to a range of community based mental health services including: Community Mental Health Teams, Acute Day Services (Day Hospitals), Home Based Treatment Teams, Crisis/Respite House, and High Support Hostel Services.

Managing Service Users Absent Without Leave The circumstances by which a patient/service may go missing from hospital or supported accommodation without first discussing their absence with staff may be varied depending on their assessed individual needs. A voluntary patient may choose to leave the unit at any time he or she wishes and there is no requirement upon him or her to discuss this with staff.

On occasions where service users may choose to go Absent without Leave (AWOL) the South Tipperary Mental Health Services Absent without Leave Policy activated. This policy identifies the action to be taken in all instances of a patient being missing from the hospital/supported care unit. The Assistant Director of Nursing, Duty Doctor, Consultant on-call, Gardai and next-of-kin are informed as appropriate. There is ongoing monitoring of the individual situation and close communication with relevant personnel and family members.

Approved Centres should not be considered as “Secure Units”; Secure Units have a particular meaning in Mental Health Centre’s in Ireland and are associated with Forensic Psychiatry Settings. However, most Approved Centres have a Locked Ward; in addition to this every attempt is made to ensure that service users care needs are addressed safely and appropriately. It should be noted that episodes of absence without leave occur within all HSE Approved Centres. The rates of absconding from the Approved Centre in the Department of Psychiatry, Kilkenny are similar to those in other HSE Approved Centres. St Michael’s Psychiatric Unit was an Approved Centre and was not a Secure Unit.

Success of the Mental Health Change Programme The comprehensive change programme is in the process of delivering a modern, quality and responsive model of mental health care for the people of Carlow/Kilkenny and South Tipperary. This will ensure that mental health service users have easy access to appropriate care in the most appropriate setting The change programme has seen a continued move away from the old model of institutional care to a wide range of modern community based mental health services.

The key areas that are being developed include: Development of patient centred services.

37

An increased focus on the requirement for cultural change. Development of Community Mental Health Services including:

- Amalgamation and enchantment of Community Mental Health Teams

- Development of 3 additional Home Based Treatment Teams- Establishment of 2 additional Acute Day Services (Day Hospital)

in Clonmel and Cashel. Extension of a 5 day service to a 7 day service in Carlow/Kilkenny.

- Establishment of additional Crisis/ Respite House, Glenville House

Further development of Governance structures and leadership across the extended catchment area.

Significant capital development programme at final stages of completion - €20 million

In addition, in line with the ethos of a Vision for Change, there is a move towards a service that facilitates recovery. The recovery ethos ensures that individuals take responsibility for their own recovery with the necessary levels of support from the Mental Health Services. These services are providing alternatives to acute inpatient admission and thus reducing the average length of stay.

This has facilitated a decrease in the number of acute mental health inpatient beds from 93 beds to 44, which equates of a 52.4% reduction. Of the 44 acute mental health inpatient beds in current use 18 - 20% (7 -8) beds are unoccupied at any one time. The reduction in the number of acute mental health inpatient beds can be attributed to the development of Community Based Services and the change in the culture. As outlined above all community based services are working effectively and this is evident from the ongoing increase in uptake of the additional community based services. Further to this there has been extensive involvement of service users and their carer’s in every aspect of the service development and delivery. In Carlow, Kilkenny and South Tipperary service users are involved in service planning and development through their membership of consumer panels and the Mental Health Services Management Team.

Summary

Voluntary patients are supported through a range of high support facilities occasionally they may for their own reason decide to absence themselves from a residential facility usually this will be managed by consultation with their treatment team. On occasion where this consultation does not take place and the service user is considered to be at risk and in conjunction with the Treatment Team the Absence Without Leave Policy may be activated. At all times this will be sensitive to the patient’s rights as an individual balanced against their mental health needs at a given time with at all times the focus being on ensuring the safety of the service user. Where the Absent without Leave policy has been activated and following the return of the service user the situation is immediately reviewed by the multidisciplinary team in association with the service user and an agreement is reached with the service user in relation to their immediate care plan. At all times the safety and the individual rights of the service user are central to the decision making process. It is recognized at all times that a voluntary service user can exercise their own independent judgment as to whether or not they wish to remain absent or leave the facility indefinitely. Where the treatment team

38

consider that the individual service user is not capable of acting in their own self interest consideration may be given to invoking the voluntary admission process should the service user’s mental health presentation at that time warrant it.

The comprehensive Community Mental Health Services that has been developed for Carlow/Kilkenny & South Tipperary in line with Vision for Change has proven to be a very positive change for patients. This is referenced by satisfaction surveys in relation to the specific treatment options for South Tipperary i.e. satisfaction with the service from the Home Based Treatment Team and Day Hospital in South Tipperary.

The extensive change programme undertaken within the mental health services of the Carlow/Kilkenny and South Tipperary catchment area has been a positive experience for both service users and staff alike. The ability of the service to respond in a timely manner to service users in crisis (in their own homes if necessary) considerably advances the capacity of the service to provide early intervention to service users who may have a significant mental health presentation. This will inevitable reduce the impact of the crisis in terms of its severity and duration and result in a better quality of care to service users. The service continues with the support of service user representatives to evaluate the continued effectiveness of our broad range of services with the emphasis being on continued quality improvement.

Question 30(Deputy Seamus Healy)

The position regarding the promised re-opening of 22 closed beds at The Community Hospital of the Assumption , Thurles, Co, Tipperary.

Response –

The position of the Hospital of the Assumption (HOA) must be viewed in the context of the provision of older persons public residential facilities in North Tipperary. There are three services in North Tipperary. These are the Dean Maxwell Community Nursing Unit Roscrea, the St. Conlon's Community Nursing Unit Nenagh and the Hospital of the Assumption Thurles. Over the course of the moratorium and various other recruitment pauses/retirements in the public sector since 2009 the bed numbers in these facilities have varied. Further cost containment measures in September 2011 lead to a reduction in bed numbers in these facilities, because the unfunded level of dependence on agency staff had grown to an unsustainable level. The resulting changes in bed numbers which have been previously published can be viewed as follows;                                        Nov 2009        Apr 2011         Sept 2011 Roscrea                            35                  33                 27 The pre service plan position for 2012 would have seen this unit reduce further to 20 beds and it did go as low as 22. Nenagh                            33                   24                24 

39

The pre service plan position for 2012 would have indicated concern for this facility and it reach as low as 18. Thurles                            72                   67                45 The pre service plan position for 2012 would have indicated ongoing concerns at any further erosion in this facility. Following a service plan consideration and the management of some 'grace period' retirement replacements, the established service plan for HSE West and the Mid West non acute services as a sub set of that demonstrated the following; Roscrea - 20 bedsNenagh - 27 bedsThurles - 45 beds. In April/May this year the HSE developed a new service configuration plan for the North Tipperary older persons public beds and this included discussions with all relevant stakeholders including the Action Groups and Friends Support Groups in both Roscrea and Thurles, together with a number of public representatives. The HSE set out its targets and undertakings in summary as follows; 

1. To bring the three services into one service spread over three sites with a single Director of Nursing and structure as opposed to three entities.

2. To negotiate a staff to bed allocation and associated changes with the relevant Unions including the INMO, SIPTU and IMPACT giving a revised bed configuration. This included the recruitment of 6.5 nursing posts to deal with the 'grace period' retirements and some limited agency conversion. This was to yield an increase in bed provision by 5 to 50 in Thurles, by 5 to a permanent 25 in Roscrea with a commitment to pursue to 27 and to 27 in Nenagh (the latter requiring some capital investment for compliance issues).

3. To place an emphasis on any bed growth within the domain of respite where the greatest reductions had taken place. (Using the standard population measurements for long stay care requirements North Tipperary does not have a deficit at this time in provision in long stay care when public and private capacity is combined). The rehab beds in Thurles were to move from nurse lead to Consultant lead which they have not been for many years.

 The change process was undertaken by local management and the following is the outcome against the undertakings given; 

1. The position of single director was consulted with the relevant Union and is in dispute however the HSE has advertised the post and an interview date will be given in the coming weeks.  In the interim the three Acting Directors are working closely together on the plan.

2. A new staff to bed allocation has been devised having regard to differences in long stay care and rehab and respite.  This has been

40

implemented and within these changes the bed numbers have grown as follows and as undertaken;

 Roscrea - 25 beds now permanent and registered for 27 in anticipation of increasing in the future subject to resource changes or other efficiencies. Nenagh - 20 beds scheduled for 27 on completion of the building works and the recruitment of the 6.5 nursing posts.  (The 6.5 nursing posts have to date had 5 accepted offers, 3 commenced, 2 more scheduled and the exceptional additional measure of a local recruitment drive in the Mid West papers to attract staff to the Area.  North Tipperary has proved difficult to recruit to.)   Thurles - 50 beds with the main emphasis on the increase to date being in respite provision.

3. A new Consultant Physician and Geriatrician at the MWRH Limerick has taken the lead role in the rehabilitation beds at Thurles (Dr. Catherine Peters) and this has commenced with weekly direct Consultant input.  In order to enhance this further an NCHD at Registrar level was specifically recruited to work under the direction of Dr. Peters and he has commenced with a 50% commitment to Thurles and a 50% commitment to the MWRH Limerick, the latter being necessary because of the relationship between the hospitals in mutual patients/users and for overall response to the older persons population.  Both doctors have commenced provision in the Hospital of the Assumption in Thurles.

 Special Additional Support The HSE in the Mid West has received a once off allocation from the Special Delivery Unit in the last quarter of 2012 and this is being directly targeted at North Tipperary in the context of both SDU and local priorities.  €275,000 is available and has been deployed locally which in summary will be targeted as follows; 

The provision of additional respite for those on the lists at Thurles and Roscrea (Note Nenagh is on the Thurles list and therefore included) as a hospital avoidance measure.

The provision of respite for new referrals to the list who have not yet received a service as a hospital avoidance measure.

The provision of some post acute discharge convalescence from the Mid Western Regional Hospital Group for people from North Tipperary where such provision will facilitate timely discharge.

The provision of some post acute or hospital avoidance in home short term supports by way of Home Care package.

 These supports because of the nature of the funding and associated issues will be utilised between now and year end by buying short term capacity in the private sector where available and where those to whom it is offered wish to avail of it. Its relevance to Thurles and North Tipperary is clear in its intention in that it is being co-ordinated through the Hospital of the Assumption with clear liaison with all other services. Named personnel in both the older people’s services in North Tipperary and the Acute Hospitals

41

are now actively planning to implement these measures in the coming days and given the particular time of the year this is a welcome development. 2013The HSE like all public service organisations faces substantial challenges for 2013 and the main emphasis of activity is to sustain and consolidate our current provision and to pursue efficiencies where possible and appropriate.  The HSE has assessed the costs and requirements for opening additional public beds in the Hospital of the Assumption and will keep this under review in the context of a difficult resource climate.

Question 31 (Deputy Jerry Buttimer)

That the HSE provided an account of the measures or initiatives being implemented at CUH in Cork to reduce the number of people on trolleys and to ensure the experience of patients in the ED are at an acceptable level.

Response –

The implementation of a range of measures in Cork University Hospital has seen an 80% reduction in the number of patients on trolleys to an average number of 6 in the 4 month period since July 2012 compared with 2011

The graph hereunder demonstrates the enormous progress made in respect of trolleys in the Emergency Department this year.

This improvement is due to a major change process at hospital level. This has been enabled and supported by the focus brought by the SDU and the National Clinical Care Programmes. In addition there is an area wide commitment to support patient flows through the hospital with close collaboration between CUH, Primary Care and Community services.

This represents major success for the hospital and represents the outcome of the implementation of the Acute Medicine Programme in the hospital over the past 2 years. The hospital is at the vanguard among large hospitals nationally in implementing this programme. The reduction is particularly

42

noteworthy since it has been achieved at a time when the numbers presenting to ED in CUH and the numbers treated in the hospital have increased significantly following the transfer of cardiology from SIVUH to CUH and the subsequent closure of acute medicine and surgery in SIVUH. There has been an increase in ED attendances of 13.6% for the year to date 2012 to end of September over the same period last year, while unscheduled admissions to CUH have increased by 13.3% as evidenced by the table below

Cork University Hospital 2011 2012 % increase 2012/2011

ED Attendances January -Sept

42542 48317 13.6%

Unscheduled Admissions Jan -Sept

17145 19418 13.3%

As part of the implementation of the National Clinical Care Programmes, Cork University Hospital (CUH) is a designated site for the Acute Medicine, Emergency Medicine and Surgical Care Programmes. The Executive Board of the hospital is committed to maximising the impact of these programmes on the patients experience in the Emergency Department and on shortening the patient’s length of stay in the hospital. In this context the length of stay for medical patients has already been shortened by 2 days to 6.4 days and is now amongst the shortest length of stay for medical patients in the country.

The Executive Board has prioritised the reduction in patients on trolleys. The improvement in trolley numbers demonstrated in the graph above provides evidence of the impact which a range of initiatives have had on trolley figures in 2012.

Initiatives in Place

Acute medical Short stay Unit Opened Jan 2011Acute Medical Assessment Unit Opened January 2012Additional 24 bed short stay unit Opened April 2012Cardiac Day Unit / Assessment Unit Opened January / June 2012Paediatric Assessment Unit In Place

1) Acute Medicine Programme (Short Stay and Assessment Units)

The Acute Medicine Programme aims to improve the experience of medical patients presenting as emergencies in acute hospitals. The programme outlines a holistic approach across hospital and community. The Programme outlines an optimal patient pathway through the hospital, linked to Primary Care and other community services. A whole hospital approach is critical to achieving successful outcomes. The Key elements of the programme are to ensure that patients are seen by a senior doctor within an hour of presenting to hospital and that the decision making of this doctor is supported by fast access to diagnostics, blood tests, x-rays, CT scans, etc. By providing senior decision makers and fast access to diagnostics, a portion of patients presenting at hospital, who would otherwise be admitted, can be discharged home. For patients who do require admission, their length of stay in hospital is reduced due to the earlier decisions on the condition of the patient and earlier commencement of appropriate treatment.

43

As part of the Acute Medicine Programme a Medical Short Stay Unit opened in January 2011 providing 23 short stay beds managed by 4 Acute Medical Physicians. The philosophy of this ward is to rapidly move patients through the hospital and to have a significant number discharged within 48 hours. This has been extremely successful in reducing waiting times in the Emergency Department.

In January 2012 a 13 bed assessment area was opened located adjacent to the Acute Medical Unit and the Emergency Department. Medical patients presenting at the hospital, as an emergency, are transferred rapidly from the Emergency Department or alternatively General Practitioners can contact medical and nursing staff in the Medical Assessment Unit and arrange to have patients admitted for assessment. Typically between 25-30 patients per day are managed through this unit thereby decreasing pressure on the Emergency Department. Rapid access to diagnostics and senior doctors mean that there is a maximum of a 6 hour turnaround time in this unit.

Specific funding was received in April 2012 to open an expansion of the Acute Medical Unit. This 20 bed ward is managed by the specialist physicians in the hospital. The care pathways that have been developed in relation to access to this ward are based on a length of stay of 48 hours or less by which time the patients transfer either to specialist beds or are discharged. The opening of these additional beds has made a significant contribution to reducing the numbers of patients on trolleys.

2) Cardiac Assessment

In the summer of this year a 4 bed Cardiac Assessment Unit for patients presenting in ED who would otherwise require admission. Patients who require cardiac assessment are taken to the unit each morning in order that the diagnostic care they require can be provided speedily and efficiently. The unit operates from 7.30am to 5.00pm Monday to Friday and the experience is that 60% of the patients taken to the Cardiac Assessment Unit are discharged within a few hours of presentation. The remaining patients are admitted to the Cardiac Renal Centre.

The importance of this unit is that it provides an alternative to patients being admitted to beds and significantly improves patient experiences.

3) Management Information Processes

The management of beds is now a 24/7 function that requires the involvement of all senior leaders in the hospital to ensure that patients who require admission do not spend excessive time waiting in the Emergency Department.

In this regard it is worth noting that meetings take place each day to review the situation and for any corrective action that may be necessary to reduce pressure on the Emergency Department and these are summarised hereunder:

• 07.45 – Patient flow handover (night / day staff, bed management, DON, AMU physician, CEO)

44

• Bed management feedback to DON / CEO / CD on ED status and bed status on wards as day progresses

• 12.30 – Formal ED / Bed Management situation status• 16.00 – Bed Management update to DON/CEO/CD• 20.00 – Patient flow handover day/night staff and bed management• 3 times daily reporting to SDU and weekend reporting structure in

place with senior management

The success which has been achieved in CUH in improving the patient experience in ED is a reflection on the work of doctors, nurses, allied health professionals, management and other staff in the hospital and the community. These people have embraced new ways of working to ensure that patients presenting to the ED receive the appropriate treatment as quickly as possible.

4) Community initiatives

In addition to the above measures, over the past year HSE South has enhanced the following measures in order to reduce hospital admission and facilitate earlier discharges and thus maximise the number of beds available for patients waiting in ED.

Fast access to home care packages for patients who require additional support to be discharged home.

Enhancement of existing Community Intervention Team across a wider geographic area with the capacity to provide a greater number of patients who could receive IV antibiotic treatment at home.

Access to intermediate nursing home type beds to facilitate early discharge for patients who are awaiting financial approval under the nursing home support scheme or who require a period of convalescence prior to discharge.

A patient transport initiative was also put in place to expedite routine patient transfers from the hospital and, in this way, to ensure that beds occupied by patients being discharged were made available earlier.

Conclusion

The above measures have resulted in a very substantial improvement in the flow of patients through the Emergency Department and the Acute Medical Unit. Seasonal variations in the number of patients presenting and in the type of illnesses that predominate make sustaining the low numbers on trolleys particularly challenging from time to time. However, the hospital leadership is continuing to work with in close collaboration Community Services, the Ambulance Service and others to ensure that this improved performance is sustained.

Question 32 (Deputy Peter Fitzpatrick)

What treatment is available to people in Ireland with Obesity

Being overweight, having a Body Mass Index (BMI 25 – 29.9) or obese (BMI > 30) contributes significantly to the impairment of health, reduction in the quality of life and increased health care costs. Obesity in adults is treated by losing weight, which can be achieved through a healthy, calorie-controlled

45

diet and increased physical activity. Bariatric surgery is needed for the 2% of the Irish population who have severe obesity (BMI > 40kg m2). For children treatment focuses on weight maintenance in the growing child.

Based on extrapolated figures from the U.K. and an estimated 2% of the Irish population with BMI > 40 “ The estimated number of procedures that could be carried out in Ireland if the NICE 2007 U.K assumptions hold, is estimated to be 420 procedures per year.” (M.Laffoy, HSE paper Issues relating to the surgical management of morbid obesity in Ireland, 2008)

To provide a tertiary care service for those with severe obesity requires 4 Hospital Weight Management Treatment Centres of Excellence for adults, 1 per HSE Area and 1 National Paediatric Hospital Weight Management Treatment Service.

The National Taskforce on Obesity recommended bariatric surgery as a third line treatment for morbidly obese patients. This was based on, among others: - Surgery is the most effective treatment for morbid obesity The mortality for untreated morbid obesity (> 100% above ideal weight,

BMI ≥ 40) is estimated at 4-6% per annum. The mortality in a surgically treated cohort is 0.6%.

For the large majority of patient’s good weight maintenance has been observed for 3 to 8 years post-op.

Currently 2 of the 4 adult Hospital Weight Management Treatment Services are in operation. Connolly-Beaumont was due to commence a start up service early in 2012, but to-date has only provided medical management to obese patients who require other services at the hospital. In the longer term they will require resources to provide the full multidisciplinary team to achieve a capacity of 100 surgical procedures per annum (see above). Despite the interest among medical and surgical colleagues in Cork there has been, to date, a lack of engagement by hospital management with a projected commencement date difficult to predict.There is no national paediatric service for obese children and adolescents. The only service for children is confined to those children in the Dublin area who attend Temple Street, Tallaght and Crumlin Children’s Hospitals with other co-morbidities and who first present for treatment as hospital inpatients. Ongoing weekly hospital based intervention programmes are only accessible to those in the adjacent area.

Available hospital services (Treatment) and local community interventions (Management)

There is one Paediatric Hospital Weight Management Service in AMNCH Tallaght led by a Consultant Endocrinologist & Paediatrician. No new referrals have been accepted since March 2011 due to lack of Dietetic support as a result of the recruitment /non-replacement of staff embargo. At that time there were 150 children attending the hospital waiting to see a Dietitian. Two 6 month programmes of weekly outpatient obesity clinics are run each year led by a multidisciplinary team which does include Dietetic support. Each patient is allocated 10 appointments in 6 months. This clinic

46

has managed to continue through the dedication and interest of team members, some of whom dedicate their time voluntarily. However this clinic is not sustainable and is only accessible to children in the locality who can attend weekly. The embargo has also resulted in a situation where there is no Community Nutrition & Dietetic Service in the Tallaght area since 2009.

Obese children attending Our Lady of Lourdes Hospital, Crumlin with other complaints are referred to the Endocrine Clinic. Parents with overweight or obese children with no other co-morbidities cannot access the service and are recommended to their local Community Nutrition & Dietetic Service. Due to the high level of general demand for Dietetic services these children will, through necessity, be placed well down the waiting list to be seen.

Temple Street Hospital runs a 6-week (2hrs a week) obesity programme called Weigh2Go. A multidisciplinary team led by a Consultant Endocrinologist, leads this programme. There is a full time Senior Physiotherapist (who is doing a PhD on the programme), a half time (0.5 Whole Time Equivalent (WTE)) Dietitian and 0.3/ 0.5 WTE Psychologist. Twelve children, who must be referred by a Paediatrician, attend each programme, which is adjusted and delivered to the various age groups e.g. 7-10, 10-12 year olds. Here again referral only applies to children living in the locality.

The need for Community based weight management programmesThe main problem now is dealing with patients who are not morbidly obese but are pre-obese or obese class 1 and 11. Regional multidisciplinary teams need to be established to treat these providing community based support. This is also needed for the treatment of those who have been through the 4 Hospital Treatment Centres for morbidly obese but still require ongoing management of their Class I or Class II obesity. Specialist weight management Dietitians, Physiotherapists/ Physical Activity Specialists, Psychologists with clerical support are required to provide these services on a regional basis and to train others to deliver evidence based programmes in their locality. Currently there are 82 Community Dietitians employed by the HSE and 70% of their work is clinical. Obese patients can only be referred to a Dietitian if they have at least 1 co-morbidity. The focus to achieve greater progress in reducing obesity needs to change individual patient sessions to group sessions, thereby increasing throughput and maximising the group dynamic in providing ongoing support. Here the management of obese patients with different diseases (e.g. cardiovascular disease and type 2 diabetes) could be treated together in groups.

Childhood School Health Checks: We are currently working on the development of a system that will give the HSE the weight and height (and thus the BMI) of every 5-6 year old in Ireland. So far the scientific group has agreed on the growth charts and the algorithm for detection and appropriate referrals. The Faculty of Paediatrics and the ICGP have already given their support for this. The HSE-ICGP Weight Management Treatment Algorithm for Children will be signed off by the Quality in Practice Committee of the ICGP in early November. It is hoped to incorporate height and weight measurements into the School Health check of 5-6 year olds on a phased basis in 2013.

Treatment of the overweight or obese child

47

The Pediatric Treatment Algorithm differentiates between Obesity and

Overweight. All overweight children can be dealt with by the Primary Care

Team and most GPs could deal with most Obese children.

Currently there are no dedicated childhood obesity Consultants, Dietitians or

Psychologists within the HSE. However, the HSE employs 18 Community

Child Health Officers, two Development Pediatricians and 37 General

Pediatricians all at Consultant level. Furthermore, the HSE employs 7

Community Dietetic Managers, 90 Senior Community Dietitians and 20 entry

level Dietitians. All of these, as part of their overall responsibilities, dedicate

some of their time and expertise to children who are overweight and obese.

Local Community Programmes

The Bounce – Built to Move Pilot ProgrammeHealth Promotion HSE West and Titans Basketball Club, Galway City came

together in 2011 to offer a 12 - week (2 sessions of Physical Activity (P.A.) per

week) programme to self referred overweight & obese 9 – 12 year olds. The

ethos was healthy weight maintenance in the growing child. The HSE

provided nutrition input

(Supermarket tours, interpretation of nutritional labeling, healthy snacks cooking demo for the parents) via the Community Nutrition & Dietetic Service. A HSE Child Care Manager, who happens to be the Head Coach of Titans Basketball Club, provided motivational support. A local GP undertook voluntary one to one sessions with all the children’s parents half way through the programme. A trained Dietitian carried out anthropometric measurements (height, weight, waist circumference measurements & Body Mass Index (BMI) calculation) at the beginning and end of the programme. Titans Basketball club provided the facilities, coaching and Physical Education/Physical Literacy training. A blueprint was drawn up which can be offered to other clubs in the area who may be interested in partnering the HSE in providing similar programmes in the future. While weight loss was not significant the increase in physical activity levels was significant, particularly in girls.

ACE Families (Activity, Confidence & Eating)ACE is an interdisciplinary (Dietitians, Psychologists, Health Promotion and others) family based approach for the treatment of childhood obesity. It is a

Consensus among professionals dealing with childhood obesity as part of their remit all agree that interventions such as these should take place in the community close to where the client lives.

48

one-year programme, which targets 5-12 year olds. It focuses on behaviour change, with an initial intensive weekly phase (for 9 weeks) of education and physical activity for both children and their families and monthly follow up thereafter that also focuses on local environmental determinants (predominately schools ACE). It has been in operation successfully in the midlands since 2006. In 2011, due to limited resources only 1 programme for 15 families ran in Co. Longford. As availability of Psychology has been an ongoing problem, Dietitians have been trained by the Psychology Dept. to deliver the behavioural change & motivational elements of the programme. The parents receive their Physical Activity training from health professionals with the children receiving their Physical Activity from peer led school liaison/homework club parents who have been trained & Garda vetted. Schools ACE a peer led schools programme is also running in schools in Co. Longford. This is designed to support the children on the Families ACE programme and to prevent overweight & obesity among the other school children. It assists the school through policies & various initiatives to provide an environment that promotes physical activity and healthy nutrition. Both these programmes could, subject to the provision of resources, be replicated nationally as part of a primary care team/network.

Way To Go Limerick Kids

This project aims to support overweight and under active kids between 10 and 12 years to develop a healthy approach to weight management over an 8 week period. A Dietitian must classify participants as overweight or obese to qualify for entry to the programme. The project takes a partnership approach. Partners include HSE West (Limerick Health Promotion, Dietetic Services and Parent Support Services), Limerick City Sports Partnership and Get Back challenge (www.getbackchallenge.com). All 3 partners work closely in areas classified as lower socio economic with priority public relations and recruitment given to these areas. The emphasis on this 8-week program is to prevent further weight gain in the overweight child while making sure their growth and development continues as normal. This program focuses on a balanced approach to eating and increasing physical activity each day. It is delivered to both parent (3 support sessions) and child by registered Dietitians and professional Fitness Instructors. Anecdotal evidence from one to one clinic sessions with this particular age group have yielded poor outcomes in terms of maintaining healthy weight and acquiring positive messages on nutrition and physical activity. The programme which is already established across the US is new to Ireland, piloted here in 2011. Fifty per cent of participating children lost weight and 25% maintained their weight by the end of the programme.

Following evaluations of these programmes it is hoped to reach consensus on a standardised multidisciplinary community based programme for the different age groups that can be, subject to resources (outlined in the HSE corporate plan 2012-14), rolled out nationally through primary care teams and networks.

Question 33 (Deputy Peter Fitzpatrick)

Would the Minister consider a treatment Clinic in the Louth Hospital Dundalk for Obesity

49

Obesity clinics are very specialised services, and require both specialist personnel within the context of an outpatients services, as well as significant links for the provision of other services such as gastric surgery. The development of obesity clinics as a specialise service must be considered and reviewed at a National Level due to the implications on resources.

The LMHG are currently not in a position to provide these services.

Question 34 (Deputy Peter Fitzpatrick)

Would the Minister Consider reducing the 100euro Charge for the Louth County Hospital Dundalk

The current statutory out-patient charge, i.e. the A&E charge, is provided for by the Health (Out-Patient Charges) Regulations 1994 (as amended). The A&E charge is currently €100 for the first visit of any episode of care at a designated accident and emergency or casualty department, subject to a number of exemptions. These include medical card holders and persons who have a letter of referral from a registered medical practitioner. The charge applies nationally for each episode of emergency care and there are no plans to reduce the A&E charge in a particular hospital.

50