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 20th
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
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agreements between the HSE and Insurers expected to be finalised very
shortly.
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.
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
The Health Insurance Consultative Forum also enables dialogue with
insurers on issues of cost and efficiency, including timely and efficient
processing of claims.
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 offpatent 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
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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.
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
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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.
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
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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
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)
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
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
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
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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.
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 2012-2016
The Capital Plan 2012-2016 – year 2012 has been approved recently and
details are published on its website
This 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;
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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;

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 fullfunding 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.
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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
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.
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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 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
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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.
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.
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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
●
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
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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
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
14
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
●
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 System
The 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.
15
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 monounsaturates, 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.
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
16
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
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.
17
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.
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 20122015 was formally launched on Thursday November 15th.
18
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.
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
19
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 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
20
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 Services
Given 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 provision
The 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.
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.
21
Service Impact
The 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
developing support networks.
about
services
and
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.
22
In a letter to the HSE, the CEO of Jack and Jill Children’s Foundation
acknowledged 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
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
23
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 MidLeinster 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.
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.
24
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 ongoing 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.
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.
25
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
and appropriate level of care.
1. Acute Psychiatric Unit AMNCH (Tallaght) Hospital, Dublin 24
2. Central Mental Hospital, Dundrum, Dublin 14
26
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.
The Dublin Mid Leinster region has by developing real alternatives within the
community e.g. Home Care, Day Hospitals, Assertive Outreach and
27
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 Permanent Agency
Service
staff
staff
Elm Mount Unit, St. Vincents University 40
0
Hospital, Dublin 4
Temporary
staff
3
Newcastle
Wicklow
0
0
2.5
3
48
9
5
Lakeview Unit, Naas General Hospital, 18
Naas, Co. Kildare
0
13
St. Mary's Campus, Longford
Mullingar, Co. Westmeath
0
0
St. Lomans Hospital - Admissions Unit & 48
St. Enda's Ward, Devlin Road, Mullingar,
Co. Westmeath (includes St. Brigid’s and
St. Maria Goretti’s wards.)
Department of Psychiatry, Midland 25.5
Regional Hospital, Portlaoise, Co. Laois
0
0
5
9
St. Fintans
Laois
0
4
0
2
7.5
39
Hospital,
Greystones,
Jonathan Swift Clinic,
Hospital, Dublin 8
St.
Co. 26
James's 30.5
Acute Psychiatric Unit,AMNCH, Tallaght
Hospital, Dublin 24
Hospital,
Central Mental
Dublin 14
Road, 31
Portlaoise,
Hospital,
Co. 16
Dundrum, 182
Total
465
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
28
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.
29
Staff involved in the commissioning of the Inchicore Unit are currently
examining all aspects of the Ballincollig agreement with a view to drafting a
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.
30
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
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
31
Orthopaedic Waiting List – Musculoskeletal Physiotherapy
Programme
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
32
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
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
33
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.
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
34
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.
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 Developments
There 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:
35
Location
Pre October
2011
Number of
Community
Mental
Health Teams
Post October 2011
Updated number
of Community
Mental Health
Teams following
amalgamation of
Teams
Carlow
Kilkenny
South
Tipperary
Total
2
3
3
1
1
2
Numbers of
additional Allied
Health Professional
Staff redeployed to
Community Health
Teams following
closure of old long
stay institutions
1
2
3
8
4
6
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 24th
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
Kilkenny Acute Day
Services
Carlow Acute Day
Services
South Tipperary
Acute Day Services

Number of attendances
Acute Day Services
Jan - Sept 2012
43
55
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
36
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
Carlow Home Based
Treatment Team
Kilkenny Home Based
Treatment Team
South Tipperary Home
Based Treatment Team
Number of
Service Users
150
340
244

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 Hospital
St 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
37
Acute Inpatient Unit St. Luke’s Hospital, Kilkenny
The Acute Inpatient Unit (Department of Psychiatry) in Kilkenny has 44 beds
which comprise of:
1. An acute ward with 19 beds
2. 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.
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 Care
Where 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
38
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.
 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.
39
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
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.
40
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;
Roscrea
Nov 2009
Apr 2011
Sept 2011
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
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 beds
Nenagh - 27 beds
Thurles - 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
41
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
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.
42
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
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.
2013
The 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.
43
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 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
ED Attendances January - 42542
Sept
Unscheduled Admissions Jan 17145
-Sept
2012
% increase
2012/2011
48317
13.6%
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.
44
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
Acute Medical Assessment Unit
Additional 24 bed short stay unit
Cardiac Day Unit / Assessment Unit
Paediatric Assessment Unit
Opened Jan 2011
Opened January 2012
Opened April 2012
Opened January / June 2012
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.
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.
45
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)
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.
46
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 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
47
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 /nonreplacement 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
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 programmes
The 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
48
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
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.
Consensus among professionals dealing with childhood obesity as part of their
remit all agree that interventions such as these should take place in the
Local
Community
community
close toProgrammes
where the client lives.
The Bounce – Built to Move Pilot Programme
Health 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
49
(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 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
50
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 201214), 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
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.
51