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Opening Statement

Joint Committee on Health and Children


Wednesday 07 October 2009

by

Professor Brendan Drumm


Chief Executive Officer
Health Service Executive

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Chairperson and Members, thank you for the invitation to attend today’s meeting
and make an opening statement.

A number of questions on specific issues have been put to us prior to the


meeting and I understand that written replies have been issued. Before taking
your questions I would like to update you on some issues.

So far this year we are meeting, and in many instances exceeding, our Service
Plan targets.

Between inpatient and day cases we are ahead of target by 24,500 (3%)
patients. We have seen 30,000 (6%) more new patients in our Outpatient clinics
so far this year compared with the same period last year. Overall we have seen
80,000 (3.8%) more patients in Outpatient clinics than we had planned to see.

Year on year the number people waiting over 6 months for inpatient care is down
by 15.5% and 38% for day case care.

Last week there was some media comment on cancellations during the first six
months of this year. I would like to put these figures in perspective.

The figures show that there were almost 9,000 inpatient and day case
cancellations. This sounds high in isolation but amounts to around 1.4% of total
inpatient and day case activity during the period. While I appreciate that
cancellations can be distressing for patients, the health service must adapt swiftly
and put emergencies first. Against this backdrop it is a tribute to staff across the
country that cancellations rates are relatively low.

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Regarding Primary Care Teams, at the end of August, 127 teams were holding
clinical team meetings. This is 60% of our target for 2009 which is to have 210
teams holding clinical team meetings by the end of the year.

In relation to staffing we are operating slightly below the allocated ceiling and
absenteeism rates are coming down. At the start of this year absenteeism was at
5.96%. At the end of July it came down to 4.96%. Our absenteeism target is
3.5%.

As indicated to the Committee last March, there are a number of issues emerging
that are putting pressure on our budget. For example more people are now
eligible for medical cards. At the end of August 14,288 more medical cards than
planned had been issued. This upward trend is likely to continue.

Euro Health Consumer Index (ECHI)


Last week the fifth annual Euro Health Consumer Index (ECHI) Report was
published. The Index compares healthcare systems across Europe. The report
shows that since the HSE's transformation programme started in 2006, we have
moved up 15 places to 13th out of 33.

The report points out that the Irish health service has been steadily climbing up
the ranks and noted that, and I quote, "the creation of the Health Service
Executive was obviously a much-needed reform".

In addition to improving services, more transparent performance data has


contributed to our improved ranking. It demonstrates that our transformation
programme is delivering results thanks to the commitment and support of staff
right across the country.

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Corporate Plan Performance
On a related subject, we have recently completed an analysis of our performance
in relation to the HSE’s three year Corporate Plan’s objectives. The plan sets out
what we are seeking to achieve by 2011.

The analysis shows that in 23 of the 35 representative areas measured we are


performing at 70% or greater against our 2011 target. With over two years to go
in the life cycle of this Corporate Plan, these are positive results.

We are performing well in the level and speed of reduction in MRSA levels,
childhood vaccination which is reaching 95% and the establishment of child and
adolescent mental health teams.

Areas that need focused attention include breast-feeding and caesarean section
rates, disability assessment rates against regulations and emergency department
experiences in selected hospitals.

This is the first time we have carried out such a detailed analysis and, in line with
our total focus on performance measurement; it will be repeated every six
months.

H1N1
The H1N1 pandemic continues to pose a challenge to the population and the
health service.

The rate of influenza-like illnesses has risen from approximately 45 per 100,000
to 76 per 100,000 following the opening of schools. This increase was anticipated
and we expect this figure to plateau over the next few weeks.

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It is important to note that the vast majority of cases are relatively mild and in
most situations people can look after themselves at home and return to normal
activity within 7 days.

Plans are advanced for a mass vaccination programme to begin in early 2010.
Prior to this programme beginning, the Expert Group has advised that those at
higher risk should be vaccinated first, followed by health care workers and
children. This will begin later this month.

GPs have played a very important role in dealing with the pandemic to date and,
as they have the best record of who in the community is considered at higher
risk, they have been invited to participate in vaccinating the higher risk group.

Integrated services
This week we introduced two important initiatives that will, over time, deliver
many tangible benefits to patients and clients and indeed health care staff.

Firstly, we have devolved a significant amount of decision making from national


level to our four regions Dublin North East, Dublin Mid Leinster, West and South.

The immediate impact of this new arrangement is that operational responsibility


is being transferred from the National Hospitals Office and Primary, Community
and Continuing Care Directorate (PCCC) at national level to the four local
management teams, headed by Regional Directors of Operations.

This means Regional Directors will be fully responsible for all service delivery
and reconfiguration in their areas. This will simplify our management processes
and enable strong local responsibility coupled with national consistency.

The second initiative involves bringing together the National Hospitals Office and
the PCCC directorate into one single unit - the Integrated Services Directorate.

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This unit will hold the regional teams to account by monitoring and measuring
their performance against agreed targets in accordance with our Service Plan.

These are not changes for the sake of change. They will make it easier for staff
to form effective teams unencumbered by whether somebody works in a hospital
or in the community. They will enable us to forge stronger connections between
our services such as acute hospital, long stay care, GP, mental health, child
care, emergency, rehabilitation, social work services and so on.

Most importantly they will make it easier for patients and clients to get access to
all the health and social care they need without delay or inconvenience.

Paediatric Services
In relation to acute paediatric services, I would like to advise the Committee that
we are establishing a team to be headed by John O’Brien (CEO of St James’
Hospital on secondment to the HSE) to manage the relationships between the
HSE and the acute paediatrics community.

The team’s focus will centre, in particular, on the three paediatric hospitals in
Dublin in the context of ensuring that the total resource deployed is used to
maximum effect and assuring their preparedness for the move to the new
Children’s Hospital in 2014.

The team will also manage the HSE’s relationships with the National Paediatric
Hospital Development Board and ultimately, acute paediatric services in
hospitals outside Dublin and in primary and community care. The team will begin
its work over the coming months.

In a related development Our Lady’s Children’s Hospital is to begin engaging


fully with the development of the new paediatric hospital and will have
representation on the hospital’s development board.

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This is a very positive step forward for paediatric care in Ireland. I am conscious
that there has been a degree of uncertainty among staff at the hospital. They
have had genuine apprehensions about the model of care to be provided in the
new paediatric hospital. While there will never be a perfect plan for such a
development, the full participation by Our Lady’s Children’s Hospital will ensure
that the best possible decisions are made as we go forward. It will add greatly to
the overall project which I believe will deliver a paediatric service to the country
that will be admired across the world.

Now that we have arrived at this important point, where all three hospitals are
sharing a common purpose, I believe it is an opportune time for these hospitals,
Temple Street, Our Lady’s Children’s Hospital and the National Children’s
Hospital in Tallaght to actively move towards coming together under a single
governance structure. The benefits of such an arrangement would I believe not
only deliver many better service to children and their families and indeed staff,
but also pave the way for a smooth and more effective transition to the new
paediatric hospital.

I would encourage the Boards of the hospitals to move in this direction and I am
happy to pledge the HSE’s support to such a development.

That concludes my opening remarks.

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Project for the Future Development of Acute Hospital Services
South East Hospital Group
The HSE future strategies for health service delivery are now proceeding to implementation
through the Transformation Programme. The aim is to substantially align Irish health
services with recognised international best practice.

The HSE is now seeking the implementation of these strategies across the South East.

A steering group was established in April 2009 to lead the project to plan and implement the
acute hospital transformation programme in the South East. The title of the project is
““Future Development of Acute Hospital Services””.

Membership of the Steering Group


x Chair: Mr R Dooley, Hospital Network Manager.

Members
x Dr. G. Courtney, Clinical Director, St. Luke’’s Kilkenny
x Dr. C. Quigley, Clinical Director, Wexford General Hospital
x Dr. A. Majeed, Clinical Director, South Tipperary General Hospital
x Dr. R. Landers, Clinical Director, Waterford Regional Hospital
x Dr. O. O’’Reilly, Director Public Health.
x Mr. M. Doyle, ED Consultant Waterford Regional Hospital

x Ms. B. Kavanagh, Project Manager.

The Steering Group is now considering broadening the membership to include a General
Practitioner, Nurse Manager and an Allied Health Professional.

Steering Group Terms of Reference:


x To agree the future organisation of Acute Hospital Services in South East Hospital
Group with reference
x To HSE Corporate Strategy, National Service Plan and best practice taking
cognisance of Teamwork Reviews.
x To agree a priority work programme to gain and maintain confidence in the process
on a regional basis.
x To make decisions on the basis of proper analysis with reference to agreed criteria.
x To establish Regional Specialty Advisory Groups to provide specific advice and
information as required by the Steering Group
x To develop an approach to consultation and communication
x To develop a strategic plan and develop an accompanying implementation plan
x To oversee implementation of agreed plan

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Regional Specialty Advisory Groups
In the process of defining and planning the future Organisation of services the Steering
Group has established three Regional Specialty Advisory Groups to provide specific advice
and information on individual services.

This advice / information will advise the strategic plan to be completed by the end of 2009.
The following Specialty Advisory Groups chaired by Hospital General Managers have been
established:
1. General Medicine
2. General Surgery
3. Women and Children’’s Health

It is also planned to establish 2 Reference Groups in September in the following areas to


provide specific advice and information on services and integration:

1. Primary, Community and Continuing Care (PCCC)


2. Pre-Hospital Care (Ambulance)

On completion of the planning phase a ““Project Operational and Quality Assurance Group””
will be established to plan and implement the operational aspects of the project. This group
will be supported by operational subgroups dealing with issues such as resource deployment,
employee relations, ICT, logistical planning etc.

The project structure is illustrated in diagram No 1 below.


Diagram No 1: Project Structure

Project Structure

Steering Group
Acute Service Development

Project Operational Specialty Advisory Groups x 3


And 1. Medicine, 2.Surgery, 3.Women & Children’s
Quality Assurance Group Reference Groups x 2
1. Pre-Hosp Care 2. PCCC

Operational Subgroups
Resource Deployment, Communications,
Employee Relations, ICT, Transport,
Capital Projects, Logistical Planning.

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All hospitals in the South Eastern Hospital Group - consisting of Wexford General Hospital,
Waterford Regional Hospital, South Tipperary General Hospital, and St Luke’’s Hospital
Kilkenny - will be included in the plan for the revised model of care.

In this regard, no decisions regarding the roles of services of any hospitals will be taken until
this plan is completed through a process of broad based consultation within the services. It
is likely to be the end of 2009 before this review is completed. The review will be published
in the first quarter of 2010.

Progress to Date:

Progress to date is mapped on the Gantt chart in Diagram No 2 below.

Diagram No 2: Progress to Date

Company HSE - SEA

Current Date 01/09/2009

Title Project Progress to August 2009

Project Start 01/04/2009 08:00:00

Project Finish 31/12/2009 08:00:00

The Steering Group has met monthly since April 2009. The Specialty Advisory Groups in
General Surgery, General Medicine and Women and Children’’s Health have been established
and meetings are ongoing. The Steering Group has posed a series of questions to each
Specialty Advisory Group to obtain advice on the best model for the future provision of
acute hospital services in the South East.
Page 3 of 4
Examples of the questions posed include:
The Specialty Advisory Groups are working to deadlines for the completion of reports in
time for meetings with the Steering Group scheduled from18th September to 16th October
2009. These meetings will inform the Steering Group decisions. A full ““summit”” meeting of
all the project groups will be held on 30th October to discuss interdependent issues.
The Steering Group will then meet at 3 separate decision making forums to finalise decisions
and to commence writing of the final report. These meetings are scheduled from 13th
November to 27th November. Writing of the final report will commence in early December
2009.

Communication
Communication has been an integral part of the project to date. A communication strategy is
in operation, this has been discussed with Corporate Communications. Briefings have been
held with Hospital Department Heads, Oireachtas Members, Forum Members and Medical
Boards. A number of additional meetings are scheduled in September and October with
General Practitioners, PCCC Management, Patient Representative Groups, Oireachtas
Members and Staff Representative Bodies. These meetings take the format of presentation
and interactive discussion.

_________________________
Ms. Ann Doherty,
National Director,
National Hospitals Office.

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Briefing for CEO
Re: H1N1, Pandemic 2009

x The GSK vaccine is now licensed and it is expected that Baxter vaccine will
receive a licence this week.

x The schedule of delivery of both vaccines is slower than expected because of


poorer yields. We understand this situation is now improving.

x As a consequence of the availability of the vaccine, it is not possible to vaccinate


everyone at the same time so a staggered approach is required. The basis for these
steps originates from the advice of the Pandemic Influenza Expert Group on the
prioritisation of certain groups.

x We will commence with those in clinically at risk groups under the age of 65yrs.

x Our preferred means of delivering this vaccine to such people is through General
Practice.

x We wrote on 1/10/09, inviting GPs to participate at the fixed fee of €10 per dose.

x We require a minimum 75% participation rate among General Practitioners.

x On the basis of the delivery of 111,000 doses of GSK vaccine during the week
beginning 5th October, we will distribute vaccine to participating GP sites so that
vaccination can begin during the week commencing 19th October.

x In the event that GPs do not participate, we will commence vaccination during
that same week in HSE mass vaccination clinics.

x Once we become clear about uptake rates during that 4 week period we will be in
a position to begin to commence vaccination for healthcare workers in
occupational settings. We will distribute vaccines for healthcare workers for about
4 weeks and review the need for further distribution based on response rates,
requirements for 2 doses etc as we go along.

x In the event that vaccination of young (under 65) clinically at risk groups through
General Practice does go ahead the HSE will be ready to commence mass
vaccination clinics late in November. The order in which groups will be
vaccinated will be determined by NPHET with expert advice.

x Once the initial two priority groups are vaccinated the vaccine will be offered to
those under 18 (primarily in schools), those over 65 and then the rest of the
population. The order in which these groups will be vaccinated will be determined
by NPHET with expert advice. This phase should start in December 2009.
Item 5 (i) 7.10.09 (JCHC) Louth/Meath Hospital Group
Service Reconfiguration in Louth Meath
Senior HSE management have briefed staff on the 3rd and 4th of September at Louth
County Hospital, Our Lady’’s Hospital Navan and Our Lady of Lourdes Hospital along
with union and staff representative bodies on the intended changes required in order to
safely centralise all acute medicine within Louth Hospitals including:
{ opening of the new and expanded Emergency Department at OLOL,
{ the establishment of a Medical Assessment Unit at OLOL ,
{ Reducing average length of stay and improving discharge planning,
{ Provision of home care packages,
{ Reconfiguration of acute beds to rehabilitation and step down beds in LCH
{ Opening of two new inpatient wards over the new ED
{ Development of an observation ward and short stay ward
{ Increasing ICU and CCU capacity ,
{ Conversion of the ED in Louth County Hospital to a 12 hour service,
{ On the transfer of acute medicine to OLOL (mid 2010), the 12hour ED will
convert to a Minor Injuries Unit.
{ Centalising relevant day medical and surgical procedures,
{ Increasing access to diagnostics for GP’’s,
{ Enhancing ambulances services.
{ Transfer of ambulance borne trauma from Navan to OLOL when the new
ED opens

x A proposed date for the transfer of acute medical care from the Louth County
Hospital has not yet been determined and will be subject to a number of services
being in place, but will occur in a phased basis,
x Phase 1: now to end 2009:- will see the opening of the new ED, establishment of
the Medical Assessment Unit at OLOL, development of short stay and observation
wards at OLOL, enhancement of medical services and transfer of ambulance borne
trauma from Navan to OLOL.
x Phase 2: end 2009 until mid 2010:- will see new inpatient accommodation, the
increased ICU and CCU capacity and the development of an enhanced ambulance
service. Continued development of non-acute services.
x The HSE now expects that these developments will be put in place over the next
few months which will determine the final transfer date. This will remain under
review and the transfer will be announced once these key elements are in place and
working satisfactorily.
x Louth County Hospital will continue to play a valuable role in the provision of
health services to the people of the North East. This includes day surgery services,
day medical services, outpatient services and minor injury services.

x The existing Medical Wards at Louth County Hospital will in the future provide
rehabilitation and step down services. There will be a 11 bed dedicated Stroke Unit,
in addition to general rehabilitation and beds for step down care.

Update of the new ED


The target date for all construction, equipping and commissioning work to be complete
on the new purpose built Emergency Department is November 09. Thereafter
redeployment and reconfiguration within existing (March 2009 moratorium) staffing
levels will enable us to provide the additional staff necessary to open the facility which is
significantly larger that the current ED, has more treatment capacity (25 bays compared
to current 19) and for the first time facilitates best practice in terms of separating
children’’s’’ emergency department services from adult services. All of these
improvements have a clear staffing impact. This department will also have its own
dedicated x-ray facility.

Update on the Medical Assessment Unit (MAU)


The development of the Medical Assessment Unit (MAU) at OLOL is an advanced stage
as we build on our positive experience of developing MAU’’s in Navan which opened in
December 2008 and Cavan in March 2009. It is planned that the 8 bay MAU will open
in the area vacated when the current ED moves to the new ED. The MAU will be
staffed by Consultant Physicians, a Clinical Nurse Manager, Staff Nurses, and Support
Staff. It will open 12 hours per day 7 days per week.
The MAU is expected to reduce the demand for admissions by providing full assessment
and initiation of treatment without the need to admit all patients who are currently being
admitted. There is evidence that 25% of emergency admissions can be treated in a MAU.
A number of Irish and UK experts consider this to be a conservative estimate.

Capacity at Our Lady of Lourdes Hospital


The reconfiguration of services will further enhance the delivery of a one hospital on
multiple sites model, with the care pathways for the patient being delivered on one or
more sites depending on clinical needs. Some specialties have already established Joint /
single Departments e.g. Emergency Medicine, Radiology, Surgery and joint Departments
are being developed in General Medicine and Anaesthesia. This will enhance the
development of such clinical pathways with patient care being delivered in the most
appropriate setting.
A number of additional measures and service improvements are being implemented in
the Louth Hospitals area which will assist OLOL in dealing with patients from LCH
when acute inpatient care is transferred.
1. There will be 35 non acute beds in LCH, including a dedicated Stroke Unit which
will provide specialist rehabilitation and better outcomes for individuals who
suffer a stroke, general rehabilitation beds and step-down convalescent beds. It
is estimated that the rehabilitation beds will have an average length of stay of 6
weeks and the step down beds 3 weeks. These beds will be used to facilitate early
discharge of patients from OLOL and to provide rehabilitation and
convalescence in a more appropriate setting. The transfer of patients to OLOL
for rehabilitation is expected to free up a number of beds in OLOL for patients
currently waiting for these types of intervention.
2. Extra packages of care are to be provided specifically to facilitate early discharge
from hospital and to avoid admissions.
3. In 2007 the average length of stay (ALOS) for medical patients in OLOL was 9.4
days and in Louth County was 7.2 days. There is a need to reduce the ALOS in
line with hospitals such as Letterkenny, Mullingar, Wexford, and Navan (5.2 -6.3
days). An integrated and sustained approach to discharge planning can reduce the
ALOS.
4. A significant proportion of emergency admissions have a length of stay of only
one day. A new observation ward, and a short stay ward can reduce the need for
some of these patients to be admitted to beds on the wards
5. In the building to accommodate the new ED, two of the floors will house new
and additional inpatient beds and the other floor will provide coronary care beds
and services.
6. While our overall plan is to increase the number of physicians in the Louth
Hospitals from eight to twelve, the initial appointment of two additional
consultants allows us to strengthen medical and other services at Our Lady of
Lourdes and Louth County Hospitals (LCH) and to develop quality services e.g.
respiratory and chest pain services. These will facilitate the development of
develop clinical pathways to enhance early assessment, avoid unnecessary
admissions and expedite inpatient management and therefore reduce average
length of stay (ALOS) of inpatients.
The approach being taken to reconfiguration is that planned changes can only be
implemented when the necessary dependencies identified to ensure changes can be safely
made are in place. This requirement is a key principle and is in the best interest of the
safety of our patients. This ensures that services will be safe in terms of sufficient
throughput and complexity enabling clinical staff to maintain their skills, and facilitates
recruiting and retaining high calibre staff and will provide patients with an improved
range services and skills.

A Louth Meath Transformation Steering Group has been established under the Chair of
Mr. Des O’’Flynn Group General Manager, Ms Eileen Whelan( Director of Nursing and
Midwifery is Project Director and Ms Catriona Crowley Asst Director of Nursing is
Project Manager, and it is expected that the steps above can be completed by Mid 2010.
Members of the Steering Group include Consultants working in Critical Care,
Emergency Medicine, and General Medicine and Geriatrics, Directors of Nursing and
representatives from PCCC and the Ambulance service. The Steering group will now
establishing a number of project groups to oversee the implementation of the various
service developments.

Resourcing the Transformation


Since its inception in 2007 there has had to be a significant re-adjustment of expectations
around resources available to support the North East Transformation Process.

Despite the challenges of keeping clinicians, managers and staff on board we have
managed to maintain momentum as we have moved in phases from:

x An expectation of significant additional recurring investment to support what


represents a major and very complex change project
x Through an expectation of modest incremental investment
x Then needing to make the changes within current overall resources
x And now transforming the quality and safety of services with less resource

This readjustment of expectations is necessary and must be managed albeit it is


exceptionally challenging for all concerned.

Our Plan is to build on the momentum achieved in transferring services from Monaghan
in July and to utilise the remaining resources freed up from that change to provide a
““risk”” dividend across the region in terms of further progressing the resolution of long
standing risk issues well flagged in many reports over the years including:
x Tackling remaining issues from Lourdes Inquiry Report.
x Bringing midwifery staffing levels up to recognised standards.
x Strengthening staffing levels in Neonatal Intensive Care.
x Ensuring a minimum of one paediatric trained nurse on each shift in Cavan and
Drogheda Emergency Departments.

We will also use this initial freed up resource to kick start the transformation of services
in Louth / Meath.

It is also the case that innovation and demographic funding has been secured to support
the transformation in the North East. Specifically within demographic funding there is
capacity for a number of posts that are essential to ensure the transfer of services from
Louth County Hospital to Drogheda Hospital takes place by mid-2010 which dovetails
with the date that training in medicine for NCHD’’s will no longer be accredited by the
RCPI.

Conclusion
This is a major and very complex change process that we have no option but to complete
if we are to address the many issues that have existed particularly within hospital care
within the North East for many years.

It will have significant benefits in terms of the safety and quality of the services that we
provide for patients.

The major project risk we are currently facing is how best to deal with the complexities
of the staff process in the context of the very necessary moratorium on public service
staffing numbers. For these front line services, and despite the fact that we are
significantly below (170WTE) the March 2009 staffing level within Dublin North East
Hospitals overall, it is proving very difficulty to put in place the necessary staff to make
the changes viable.

It is likely that unless this is resolved quickly major milestones within the Louth / Meath
project as well as the overall ““risk dividend”” for the region will slip significantly.
Item 5 (iv) 7.10.09 (JCHC) – Proposed New Paediatric Hospital

The new Children’s Hospital of Ireland

1. Background
The National Paediatric Hospital Development Board (NPHDB) was established in
May 2007 to plan, design, build, furnish and equip the new national children’s
hospital. This will involve the transfer of services from the three existing Dublin
children’s hospitals currently based at Crumlin, Temple Street and Tallaght. The new
children’s hospital will play a central role in an integrated network of paedaitric
services across Ireland. This development will fundamentally change and improve the
provision of paediatric healthcare in Ireland because merging the three existing
hospitals into a single hospital structure will ensure a critical mass of specialised skills
to provide highly complex treatment and care to sick children. The new children’s
hospital will be co-located on Eccles Street with the Mater Misericordiae University
Hospital, which will provide additional benefits for sub-specialisation and the
development of campus-wide support services. The project is progressing in
accordance with the project plan and is due for completion in 2014.

2. Membership of the Board


There are twelve members appointed to the Board, including representatives from the
Children's University Hospital, Temple Street, the National Children's Hospital,
Tallaght and two nominations from the Health Service Executive which is working
closely with the Development Board to progress the project. The full Board
membership is at Appendix A.

Our Lady’s Children’s Hospital, Crumlin has not yet taken up the Minister’s
invitation to appoint a member to the Board, but is participating on the Board’s sub-
group on the National Model of Care for Paediatric Healthcare Services in Ireland.
There remains an open invitation to Crumlin to nominate a representative to the
NPHDB.

3. Management Team
In discharging its functions, the Board has appointed a Chief Executive, Eilísh
Hardiman (formerly Deputy CEO, St James’s Hospital), Medical Director, Dr Emma
Curtis from NCH, Tallaght and Jim Farragher, Finance Officer. This executive will,
together with any other support staff appointed by the Board, represent the
management team. The Board will discharge its functions through this management
team and through the external consultants and contractors appointed under public
tendering arrangements.

4. A National Model of Care for Paedaitric Healthcare Services in Ireland


The Development Board established a sub-group, with broad stakeholder
representation, including representative of the three children’s hospitals in Dublin
to develop a National Model of Care for Paediatric Healthcare Services in Ireland.
This report was endorsed by the Development Board at its meeting in Aug 2009
and will be presented to the HSE executive for their endorsement in Sept 2009.
The model of care is based on the delivery of contemporary healthcare and best
practice standards for paediatrics services and provides a clear vision and

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direction for how and where services are provided to meet the future healthcare
needs of children and young people in Ireland.

5. Developments

1. Headquarters for the NPHDB have been established in 2/3 Parnell Square
East, which is also the office of the HSE Estates Directorate.
2. The designated site for the new children’s hospital at the Mater Campus has
been transferred to the HSE.
3. Active collaboration with the Mater Adult Hospital has commenced with
progress being made to optimise the potential for appropriate sharing of
services across the hospitals on the Mater Campus. Progress is also being
made on the required decanting of the ceded site.
4. The Business Case for the new children’s hospital has been signed off by the
Development Board and a process is in place to engage with the NDFA on the
project.
5. The Design Brief is being prepared and will be presented to the Integrated
Design Team on their appointment in October 2009.
6. Dr Emma Curtis has been liaising with the clinicians from both inside and
outside of Dublin and the professional bodies to inform the brief. A significant
number of clinicians across the three children’s hospitals have already
contributed to the development of the design brief.
7. Discussions have commenced with management at AMNCH to cede a suitable
site for the Ambulatory & Urgent Care Centre at Tallaght.
8. ICT strategy developed for the Children’s Hospital of Ireland and ICT
Programme in progress to meet the hospital’s remit for its role in an integrated
network of paediatric services in Ireland
9. Engagement with the RPA to develop an Eccles Street entrance to the Metro
North – Mater Stop is continuing. This entrance will directly support access to
the new children’s hospital and appropriately meet expected demands on
public transport to service this facility.
10. Arrangements are begin progressed to hold 2 consultation days with children
and young people in December 2009, to seek their opinions and views on
designing the new children’s hospital.

6. Business Services Team


The Board appointed a Business Service Team in July 2008 made up of Project
Management Group, Health Partnership, BDO Simpson Xavier and Beauchamps to
support its executive in executing the project to build the new children’s hospital.

The Business Service Team is charged with providing the following services and
supports:

ƒ Support the Chief Executive, Management Team and secretariat,


ƒ Support the NPHDB,
ƒ Establish business processes and operational business model,
ƒ Provide all administrative and business support,

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ƒ Lead the procurement of all services, supplies and works necessary to
deliver an operational class-leading national tertiary children’s hospital,
ƒ Provide all project support services from a client perspective,
ƒ Advise on all clinical planning matters
ƒ Medical Planning, including forecasting health-care trends, methodologies
and medical technology development,
ƒ Nurse planning,
ƒ Flexibility and future expansion provisions,
ƒ Prepare the Preliminary Project Brief and the Definitive Project Brief,
ƒ Mandatory consultation with the National Development Finance Authority
as to the most appropriate means of funding the procurement of the new
children’s hospital,
ƒ Provide workforce planning,
ƒ Establish facilities management structure and contracts,
ƒ Manage the operational commissioning process,
ƒ Procure and manage training for all staff (front-line, support, technical
etc.) in the operation of the completed facility,
ƒ Develop and oversee the execution (by others) of validation procedures,
ƒ Provide data for audit and attend any meeting required by auditors and, if
necessary attend and participate in, audit hearings such as the Public
Accounts Committee

7. Project Management
The Board is the process of finalising the contract for the appointed Project
Management Service Team.

The Project Management Service Team will be responsible for


ƒ Structuring the project management function (client objectives, resources, project
set-up),
ƒ Project Management planning (Project, Resource, personnel, financial, quality,
risk management, value management, acceptance criteria, communications,
procurement),
ƒ Optional services such as establishing code of ethics etc
ƒ Carrying out Gateway Reviews,
ƒ Endeavoring to ensure that the project objectives of function, design and
specification quality, cost and timely delivery are achieved,
ƒ Being the Client’s Design Champion with responsibility for assessing design
proposals,
ƒ Developing Project Procedures (handbook) for the Integrated Project Team,
ƒ Recruiting (in accordance with public procurement law, national guidelines and
regulations) the
Design Consultancy service will
o Prepare scheme designs, exemplar designs and tender documents,
o Seek tenders
o Examine, comment on tenders received and recommend a preferred
tenderer
o Oversee construction and technical commissioning
o Manage final construction issues (defects, certification, final account)
ƒ Managing (allocation and control) of the capital budgets prepared.

ȱ 3
ƒ Contractual and non-contractual claims: claims avoidance, anticipation and
management
ƒ Ensuring compliance with all statutory matters and in particular the Client’s statutory
Health and Safety requirements,
ƒ Dispute resolution within Integrated Project Team
ƒ Managing Client instructions/Changes,
ƒ Validating payments
ƒ Validating insurance cover,
ƒ Assisting the Design Consultancy service in the technical aspects of the procurement
of building contractors
ƒ Advising the Client on the need to engage specialists (e.g. Planning Consultants,
Landscape architects, Traffic consultants, Consultants to prepare Environmental
Impact Statements)
ƒ Recruiting (in accordance with public procurement law, national guidelines and
regulations) specialists,
ƒ Ensuring with the Design Consultancy service that the project objectives (design,
function, quality, cost etc.) are achieved
ƒ Value management,
ƒ Risk Management,
ƒ Managing change, variations etc.,
ƒ Establishing, monitoring and updating the project execution plan,
ƒ Monitoring and managing project execution slippage,
ƒ Managing technical aspects of equipment procurement, (the specification and
quantities for equipment shall be prepared by the Client/ Client Business Service
Provider).
ƒ Establishing and managing User Groups including administrative and secretarial
support
ƒ Managing technical commissioning,
ƒ Managing direct contracts including technical aspects of procurement,
ƒ Managing all construction and equipping related contracts,
ƒ Monthly project reports (Quality, time, cost) to the Client,
ƒ Examining and approving the construction final account
ƒ Executing Project closure and preparing and distributing the Project Closure
report
ƒ Executing the Post Project Review
ƒ Prepare and submit final Post Project Review report,

8. Integrated Design Team

A pre-qualification selection process for an Integrated Design Team was completed


by Q1 2009, with 6 candidates qualifying to compete to tender for the design the new
children’s hospital. Invitations to tenders were issued to these 6 candidates, with an
assessment process currently underway to appoint a successful candidate as the
Integrated Design Team for the project. The successful candidate will be announced
by mid-October 2009 and will commence work immediately. This team will take the
Functional Design Brief completed by the NPHDB project team and develop a
Detailed Design Brief for the new hospital.

ȱ 4
The Integrated Design Team will provide the following services:
ƒ The completed design of demolition, enabling including temporary works, piling
and diversion works in order to clear and prepare the sites for the Children’s
Hospital of Ireland, Eccles St, Dublin and the Ambulatory and Urgent Care
Centre, Tallaght. This will include tendering of the works, preparation of
production information and construction support during completion of the works.
The construction contracts for demolition, enabling including temporary works,
piling and diversion works will be procured as ‘Traditional Build’ contracts.
These construction contracts will be then novated to the Design and Build
contractor
ƒ The design to Exemplar Design level, tender action and reporting and construction
supervision of the Children’s Hospital of Ireland and Ambulatory and Urgent Care
Centre, Tallaght. It shall also include detailed design of specialist areas within the
hospital as outlined. The construction contracts shall be Design and Build
contracts.
ƒ Act as Employer Representative, in accordance with the terms of the Government
Standard Conditions of Engagement, for the Construction stages of the Project.
The duties and responsibilities will include, but are not limited to, the following:-
inspection, monitoring, testing and assessment of the contractor’s work proposals
and executed works, issuing instructions, directions and change notices as
appropriate, requesting information from the contractor, scheduling progress
meetings, assessment and certification of contractors’ progress payments, snagging
and commissioning of the works and generally ensuring that the works are being
executed in a safe and timely manner in order to meet the Project objectives.
ƒ Commissioning support and post project review of the Project.
ƒ Provision of architectural, healthcare, civil and structural, mechanical and
electrical, cost control and quantity surveying, environmental and other necessary
specialist services appropriate to the successful delivery of a large complex
Hospital Project.
Services of a Planning Consultant, PSDP and Fire Consultant shall be procured
separately. The Fire Consultant shall be novated to the Integrated Design Team.

9. Site Master Plan

The Site Master Plan for the new children’s hospital on the Mater Campus has been
completed. This was an extensive exercise undertaken to ensure adherence to medical
planning and urban planning principles for the new children’s hospital on the Mater
Campus. A preferred option is recommended for consideration by the Integrated
Design Team on their appointment in Oct 2009. The Site Master Plan reinforced the
potential of the ceded site to accommodate the capacity requirements of new
children’s hospital. The Site Master Plan also involved ‘future-proofing’ the facility to
allow for advances in medical technology and flexibility for change to meet future
medical advances and healthcare requirements.

ȱ 5
10. The current timetable for the development of the project is:
x Q3, 2009 - Completion of the Project Brief (including the Business Case):
x Q3, 2009 - Sign-off Design Brief and Project Execution Plan
x Q4, 2009 - Appointment of the Integrated Design Team
x Q3, 2010 - Preliminary foundation works with site development to begin
(subject to Planning Permission):
x 2012 / 3 Completion of the A/UCC at Tallaght (Estimated, not finalised
as subject to Planning Permission):
x Q4, 2013 - Construction of hospital completed:
x Q4, 2014 - Fit-out and commissioning of hospital:
x Q4 2014 - New children’s hospital operational:

x €11.5m has been expended on the project to date.

Appendix A: National Paediatric Hospital Board Membership

Philip Lynch – Chairman

Norah Casey - Chief Executive Officer of Harmonia Ltd


Harry Crosbie – Businessman
Kathryn D’Arcy – Director of ICT Ireland, IBEC
Linda Dillon – appointed to represent the interests of the parents of sick children
Dr Alan Finan - Facility of Paediatrics (RCSI)
Michael Flaherty – Partner in KPMG
Brian Gilroy - HSE
Dr Owen Hensey - Children's University Hospital, Temple Street
John O’Brien - HSE
Dr Edna Roache - National Children's Hospital, Tallaght
Vera Wegner – appointed to represent the public interest
Vacant – Our Lady’s Children’s Hospital, Crumlin

ȱ 6
Item 5 (ix) 7.10.09 (JCHC) CEO Briefing Document Sept 09
Capital Expenditure 2009

1 Expenditure to Date

The Expenditure on Capital Projects by the HSE up to the end of September 2009
(excluding Dormant Accounts) was €342,744,346.70

This can be broken down by Care Group as follows;

Care Group Capital Payments (€m)


ICT 3.895
Nursing Education 0.768
Medical Training 0.378
Acute Hospital 170.440
Primary Care 7.510
Mental Health 17.170
Children & Families 2.437
Disabilities 25.678
Older People 101.746
Palliative Care 0.720
Social Inclusion 1.003
Community Health 6.320
Project Management 2.889
Clar/Rapid 1.890
Pobal (Dormant
Accounts) 3.151
Total 345.995

This figure of €345.995m includes Dormant Accounts.

2 Expenditure, Actual v Projected

The HSE’s original expenditure in the first half of this year amounts to €342.744m
(excluding Dormant Accounts) which is approximately €36m over the projected
expenditure of €306.788m.

The ICT expenditure is approximately €13.5m under profile and the construction
capital expenditure is approximately €49.5m over profile at this time.

3 Construction Expenditure
As detailed above construction expenditure is currently approximately €49.5m over
profile. This over expenditure will reduce by year end. Expenditure in September was
the lowest of any month and this level of expenditure will remain constant over the
remaining months of the year. The expenditure profile for these last 3 months is
higher than the anticipated spend in this period. There will also be a slight
reconciliation of the Capital Vote expenditure which will result in a minor downward
amendment to the total expenditure in October. The projected capital expenditure
overrun at year end is projected to be in the region of €30m to €35m.
This overrun is due to a number of factors which include
x The number of reductions in the HSE’s capital allocation experienced since
the start of the year
x The fact that it was anticipated that the expenditure on Mental Health projects
would be funded from the proceeds of historical sale of lands (€17.17m has
been spent on Mental Health projects to date in 2009).
x Some major projects are cashing ahead of projection due to the increased
resources contractors applied to these projects (e.g. CNU’s, OLOL Ward
Block, etc).

4 Acute Hospital Projects

Complete by year end


CUH Cardiac Renal
Beaumont AMU/HDU
OLOL Emergency Department
Connolly Hospital Surgical Block
Cavan General HDU & MAU
Mullingar Phase 2 Stage 1
St James’s Hospital PET Scanner
Ennis Hospital CT
MWR Limerick Trauma Theatre
Mater A&E Extension and 2nd CT
Advanced Works Mater Adult
UCHG Recompression Chamber
Crumlin Children’s Hospital Stem Cell Lab

Commenced in 2009
Letterkenny Emergency Dept and Ward Block
Mater Adult
NIMIS Project (contract awarded)
St Vincent’s Hospital Phase 2 Enabling Works
MWR Limerick Critical Care Block (contract awarded)
NPRO Phase 1 Works at Beaumont and St James’s Hospitals

5 PCCC Projects

Complete by year end


St Vincent’s Raheny CNU (100 beds)
St Mary’s Phoenix Park (50 beds)
Clonskeagh CNU (100 Beds)
St Mary’s Cork CNU (50 beds)
St John’s Enniscorthy (72 beds)
Fermoy CNU (30 beds)
Harold’s Cross (50 beds)
Tralee CNU (50 beds)
Dingle CNU (50 beds)
Pearse St PCC
Irishtown PCC
Letterkenny PCC
Bloomfield Hospital (68 beds)
Cope Foundation Cork
Milford Hospice Ambulatory Care
Outreach and Day Facility Balgaddy
St Joseph’s Unit, Portrane
St Vincent’s Fairview C&A Unit
St Dympna’s Unit (ID) Carlow
And many others

Commenced in 2009
Bessboro C&A Unit
St Ann’s C&A Unit Galway
Ballinasloe CNU (50 beds)
Loughrea CNU (100 beds)
St Vincent’s Fairview CNU (100 beds)
Navan CNU (50 beds)
Inchicore CNU (50 beds)
Ballincollig CNU (100 beds)
Fearnlee Rd CNU Cork (100 beds)
Marymount Cork CNU & Palliative Care Unit
St Brigid’s Crooksling Palliative Care Unit
CRC Facility Waterford
St Raphael’s Unit Cork
Item 5 (v) 7.10.09 (JCHC) Crumlin (Scoliosis Patients) CEO’’s FileUpdate on
the Waiting List for Spinal Deformity Surgery in Our Lady’’s Children’’s
Hospital

This endeavour is to address the 70 children that are classified as the more urgent on the
waiting list in Our Lady’’s Children’’s Hospital and that have had all of their preoperative
assessments completed and are waiting for a surgery date.
The solutions agreed are for these specific patients and will be in addition to and not
instead of the current throughput of paediatric orthopaedic work in the hospitals. The
solutions have been made possible through the joint cooperation of Our Lady’’s
Children’’s Hospital, The Children’’s University Hospital Temple Street, Cappagh
Orthopaedic Hospital, the Adelaide & Meath Hospitals incorporating the National
Children’’s Hospital and most particularly Mr P Kiely, Mr J Noel, Mr P Connolly and
Prof D Mc Cormack orthopaedic surgeons.

Waiting List

The waiting list comprises 70 patients as provided by OLCHC on 13 August 2009.


Further to mapping of the patients on the waiting list by the clinical staff there have been
two groups of patients identified:
¾ Patients over the age of 15 years have uncomplicated scoliosis and require
single stage surgery (Group 1)
¾ Patients require more complex surgery and may require more than one
procedure and the support of other paediatric services including the
availability of paediatric intensive care. These children need to have their
surgery in either Our Lady’’s Children’’s Hospital or the Children’’s
University Hospital. (Group 2)
Surgeons
Mr Pat Kiely OLCHC and AMNCH
Mr Jacque Noel OLCHC and AMNCH
Prof Damien Mc Cormack CUH/TS, Mater Hospital and Cappagh Hospital
Mr Paul Connolly CUH/TS, Mater Hospital and Cappagh Hospital

As each of the consultants’’ work in 2 of the 4 hospitals then the team on the north of the
city are undertaking the cases in CUH/TS and Cappagh and those on the south of the
city are undertaking the cases in AMNCH and OLCHC.

Update on Waiting List

x By the end of September almost a third of the children have had their surgery.
x Surgery dates for a further number of patients and is being communicated to
patients and families and will be carried out in the coming months.
x A number of patients have been assessed by the consultant orthopaedic surgeons
and have had their surgery deferred for clinical reasons.
x A small group of patients have deferred their surgery for academic reasons and
will have their surgery mid 2010 and this has been clinically approved as the
deferral will not impact their condition.
Pre Operative Assessment Clinics

x All patients referred to Cappagh will attend the Pre-Operative Anaesthetic Clinic
(PAC) prior to surgery.

x All patients being referred to CUH/TS will attend a pre-operative out patient
appointment prior to surgery.

x Following receipt of referral letters from OLCHC, Pre operative Anaesthetic


Clinic/ OPD dates will be scheduled and patients will be advised of same by
Cappagh/ CUH/TS

x Patients been referred to AMNCH are already aware of referral. At their last
OPD appointment this was discussed with them by their appropriate consultant
and agreed with them. AMNCH will notify the patients directly for admission
when a date has been determined. Pre assessment clinics will not be required for
these patients.

Post operative Care OPD Follow up

Following surgery at Cappagh Hospital and CUH/TS, patients of both Prof Damien Mc
Cormack and Mr Paul Connolly will be reviewed and followed up in the respective
hospital.

Long term follow of patient

Those patients who are over 15 years of age and have agreed to transfer their ongoing
care to another Consultant in the adult services, they will thereafter continue ongoing
care in the adult service.
Item 5 (vii) JCHC –– 7.10.09 –– Houses in Castlepollard.

St Peter’’s Centre, Castlepollard

Phase-2 of transfer programme

Update on progress for Joint Committee for Health & Children

The St Peter’’s Centre at Castlepollard has been in the process of actioning phase-2 of its programme to
continue the transfer of residents to smaller domestic-type, community based dwellings. Phase-1 was actioned
in 2003 with fifteen residents now living in the community, enabling the closure of the ‘‘Hilltop’’ unit on the St
Peter’’s campus. Staff on the unit relocated with residents at the time and this first phase has been a complete
success.

Phase-2 consists of the proposed closure of a full unit at the St. Peter’’s Campus Manor House), relocating 17
residents to the three community-based dwellings which were recently furbished for this purpose. Residents
were selected some time ago by a selection committee, as to who were the most appropriate residents to be
prioritised for transfer to community houses. A review of all residents needs have recently been reassessed
and the outcome is known to all concerned.

The accommodation has been specifically tailored to meet the needs and challenges of these residents. It is
also anticipated that staff will pursue activities of a day service nature on and off site at the three houses and
will make use of various facilities in the local town and surrounding areas.

The details of the individual residences and the service to be provided are as follows:

House Location Tullynally, Ballinamee, Rathowen, Johnstown


Castlepollard Gaulstown

Number of 6 5 6
Residents
Dependency Level High Support High Support High Support

Staffing Staffing 24/7 Staffing 24/7 Staffing 24/7


Staff Nurses - 4 wte Staff Nurses - 4 wte Staff Nurses –– 4 wte
Care Assistants –– 5 wte Care Assistants –– 5 wte Care Assistants –– 5 wte

While the aim of all concerned has been to commence services at these houses, considerable difficulties have
arisen regarding the required staffing levels, the manner of the transfer, the facilities in the houses themselves
and the prevailing circumstances which affect the provision of services. This has resulted in a series of issues
which must be overcome before the proper and appropriate opening of these residences can take place for all

1
concerned. The issues involved have been the subject of discussion by the committee and have also been
extensively focussed on and actively engaged in at local level.

Minister of State, John Moloney TD, has been given an indication that the phased opening of the residences
will commence on October 1st and this remains the intention of the HSE. Within the local Health Office for
Longford/Westmeath, extensive discussion with the Staff associations involved have been taking place with a
view to exploring every option to ensure this happens. These discussions are taking place against the
background that no increases in wte staffing numbers are permitted.

These discussions have reached an advanced stage and have been informed by a report carried out by HSE
staff members who have expertise in services for Persons with Intellectual Disability. This report was
commissioned in early July to investigate efficiencies and mechanisms within the St. Peter’’s Intellectual
Disability Service that could be deployed to permit the opening of the residences.

The transfer of some services currently provided at St. Peters to other providers, with a view to freeing up
staff to facilitate the opening of the residences while remaining within existing HR resources is also being
actively pursued.

Following a tendering process, a local voluntary organisation has indicated that it will be in a position to take
over the provision of respite care services, currently provided by HSE staff in Longford Westmeath PCCC,
from November 1st this year. This Process is already underway with families. There is an agreed transition with
families and agencies to ensure a smooth transition fro these children. The transfer of this respite service to a
3rd party will allow HSE staff to be redeployed to the St Peter’’s service thus partially facilitating opening the 3
community houses.

Similarly, the transfer of up to 10 of St. Peter’’s residents to private nursing home accommodation and/other
is actively being explored at the moment. Assessments on possible suitable residents are complete.
Discussions are ongoing with family members of suitable residents .as well as a search using the appropriate
procedures for private nursing home accommodation that is best suited to these residents ’’ needs. The
decision for clients to be moved to private nursing home must be based fully on the consent of the family
members involved.

Expressions of interest to work in the three new community residences have been invited from staff at St.
Peter’’s and these have actually exceeded the required number of staff. To ensure the selection process
iequitable as possible and in accordance with proper HR procedures, a series of informal interviews have
taken place between 17-23rd September. Having gone through the selection process –– a total of 29 staff have
been identified as suitable to work in community houses. These selected staff will be going through an
induction programme to work in the houses and to familiarise themselves which the clients and clients with
the community houses from 1 October 2009.

The process has also enabled the constructive re-evaluation of services which are to remain at the St. Peter’’s
site, with a view to ensuring that the 43 clients who will remain are accommodated in the best possible setting
given the physical limitations as a result of the age of the building.

Given the progress made in the arrangements to free the necessary staff for the community residences and the
positivity expressed by the staff. The HSE is hopeful at the time of preparing this briefing that the transfer of
clients will be take place presently.

2
Index 5 (viii) 7.10.09 (JCHC) - Hospital Co-location Initiative (CEO’’s File)

Action 79 of the Health Strategy Quality and Fairness states: ““A significant proportion of
additional capacity in the acute hospital system will be supplied in future by private providers.
Government policy will aim to incentivise and attract private providers to develop private facilities, thereby
freeing up capacity in public hospitals to treat public patients. The public sector will also procure a
greater degree of services from the private sector””

The Programme for Government includes a commitment to provide an additional 1,500


public acute hospital beds. About 1,000 of these public acute beds are to be provided
through the co-location initiative and the balance through the HSE's capital plan. The
co-location initiative aims to benefit public patients by making available additional acute
public beds through the transfer of private activity from public hospitals to co-located
private hospitals.

Co-location is considered the quickest and least expensive means of providing significant
additional public bed capacity for public patients. No capital outlay is required as the
beds in the public hospitals are already in place, having been funded by the Exchequer.

Significant progress has been made on the Co-location Initiative. The Board of the HSE
has approved preferred bidder status for the development of co-located hospitals at the
following six sites:
Beaumont Hospital,
Cork University Hospital,
Limerick Regional Hospital,
St. James's Hospital,
Waterford Regional Hospital and
Sligo General Hospital.

Project Agreements for the Beaumont, Limerick and St. James’’ sites have been signed.
The necessary preparatory work for Project Agreements in respect of Waterford
Regional Hospital and Sligo General Hospital is proceeding. Planning permission has
been sought and granted for the Beaumont, Cork and Limerick projects. A decision on
the planning permission for the St. James’’ site is due in the coming weeks.

The HSE has indicated that it anticipates that the overall construction and
commissioning period will be approximately 26 to 30 months in each case.

Connolly Hospital and Tallaght Hospital, which are also participating in the co-location
initiative, are at an earlier stage of the procurement process.

The HSE and Beacon Medical Group are at present in discussion, as provided for under
the Project Agreement, in relation to certain issues with a view to ensuring that (subject
to the planning process) the co-located hospitals being developed by Beacon at
Beaumont, Cork and Limerick can be built and brought into operation as soon as
possible.
Item 5 (x) 7.10.09 –– JCHC - HSE Plans for funding released from sale of Mental
Health Service lands )CEO’’s File

The HSE’’s organisational framework for mental health service development is based on
the Government policy published under the title ‘‘A Vision for Change’’. The selection of
the mental health projects which are being progressed in 2009 and planned in 2010 was
based on service need, readiness to proceed and requirement to vacate premises to free
up lands to fund the remainder of the programme.

While Vision for Change and the report from the Modernisation of MH Infrastructure
Working Group clearly state the service priorities, this has to be tempered by the state of
readiness to progress projects and the necessity to sell land to fund the programme.
Therefore, projects in Clonmel, Ballinasloe, Grangegorman, Waterford, etc have to be
prioritised to allow funding to be generated, while absolute service priorities such as the
C&A Residential Units and the Acute MH Units can progress in tandem.

In 2009 the projects being progressed are those which have been proposed by the Mental
Health Services, have been through the Project Approval Process and are (in the main)
under construction.

Many of the projects which are planned to be progressed in 2010 are at or are close to
Tender Stage and will be ready to proceed once funding has been approved. A Design
Build Framework tender is now in place which will allow any Residential Unit or Acute
Ward accommodation development be progressed rapidly. Contractors will be appointed
to the Acute Unit at Letterkenny and the Residential Unit in Clonmel once funding has
been secured and the Residential units at Limerick and Waterford can follow within 6 to
8 weeks.

All of the HSE’’s main current Mental Health service priorities are included in this
development programme. These priorities are
x Central Mental Hospital
x Child & Adolescent Residential Units
x Acute MH Units in Letterkenny and Beaumont
x Mental Health Primary Care Facilities (initially to be provided as part of the
Primary Care Centre Strategy)
x MH Residential Units & Hostel Accommodation

Proposed Sale of Lands

The Lands being proposed for sale in 2010 are available for sale at this time and are
relatively unencumbered (or contain lands which are unencumbered and can be released
for sale). All these lands will be (or have been) sold by public tender. The only exceptions
are where the HSE has agreed sales to the Local Authority. In this case both parties will
obtain independent valuations and negotiate from there. These transactions require
approval by the Board of the HSE and it has to be demonstrated that market value has
been achieved and the sale provided Value for Money for the HSE. While it may be
argued that a better price could be achieved by inviting bids on the open market for these
lands, in today’’s market the opposite is just as likely to be the case.
The sites under consideration for sale at this time are:

Tuas Nua, Kildare Sale agreed (open tender) for approx 3 acres for €€1.5m.
Another 7 to 8 acres are available for sale
St Loman’’s Mullingar Sale agreed with Local Authority, 6 acres for €€3.5m
St Luke’’s Clonmel Sale agreed with Local Authority for 200 acres approx.
Payments to be phased. May have to be re-tendered.
Our Lady’’s Hospital Cork Sale agreed with Local Authority. 17 acres for €€10m.
Payments to be phased. Comprises a vacant site and
buildings.
St Conal’’s Letterkenny 40 acres around building available now for sale
St Finian’’s Portlaoise 10 acres available now for sale
St Canice’’s Kilkenny 20 acres available now for sale
St Brigid’’s Ballinasloe 110 acres available now for sale (including some
buildings) Other land to follow.
Enniscorthy Over 200 acres can be sold. First tranche available for sale
now.
Kelvin Grove Carlow 8 acres available for sale now.
Item 6(i) JCHC – 7.10.09 (C&AG) Dublin Ambulance Srevices

The following document sets out the actions to date and the proposed action in
relation to the C&AG Report recently published. In particular it refers to Chapter 40-
titled Dublin Ambulance Service. It also includes the updated position in relation to
Pre-hospital provision within Carrick-on-Suir.

C&AG Annual Report 2008 – Chapter 40 (Dublin Ambulance Service)

Work in relation to the Audit concerns and conclusions within the above report have
already begun.

Both the HSE National Ambulance Service and Dublin City Council Fire Brigade
have established an inter service project management team to implement a seamless
service, in order to respond to the needs of the patients within the catchment area of
Dublin, Wicklow and Kildare.

This has taken the form of rationalising the control rooms in the Eastern Region of
Dublin Mid-Leinster from four to three which will eventually become two over the
next three months.

In order to deliver this integrated approach the project team are developing policies
and procedures, reviewing existing information technology systems, to ensure that the
catchment area of Dublin City and County have a single point of contact, and an
immediate response.

Over the next three months new technology in the form of an advanced medical
priority dispatch system will be introduced and this will assist in developing the
appropriate resource to the emergency. A Memorandum of Understanding is being
developed to ensure that ongoing governance arrangements operationally, clinically
and financially are clearly set out and agreed. This Memorandum of Understanding
will be continually reviewed in line with service changes in consultation by both
parties.

On a National basis, option appraisals and a cost benefit analysis has already been
completed and the output from both pieces of work have indicated the need to have
two national ambulance control centres, with one to be based in the HSE West and a
second in Dublin Mid-Leinster, serving the total population.

The outcome from these evaluation processes have been shared with the Department
of Health & Children and the Health Information Quality Authority and are at the
centre of ongoing discussions with both organisations.

Draft project scoping documents have been developed, however more detailed
planning is required in order to achieve the desired future state of service provision.
Carrick-on-Suir

The spatial analysis report for the South Eastern region has indicated that Carrick-on-
Suir be resourced via a dynamic standby model. The dynamic standby model is a
model based on the level of activity and response time performance. This means that
ambulance resources will be dispatched to the Carrick on Suir area for standby
periods based on the activity in the Carrick-on-Suir area. The dynamic standby points
maybe the local primary care centre, shopping centre facilities, schools or an
alternative appropriate site. For example predictive analysis of the historical
information may illustrate a trend that at a particular time of day, day of the week,
week of the month that there is a high indication of road traffic collisions. The
dynamic response in this case will be to have the ambulance resource on scene in
anticipation of a collision. This is an international approach by ambulance services to
improve the response to patients and improve the clinical intervention and subsequent
clinical outcomes. The other factor is that the presence of an ambulance in this area on
a regular basis will become known to the local community and therefore act as a
mechanism for drivers to take more care. This approach will undoubtedly enhance
the service provision to the population. This coupled with the consideration of a
report on the reconfiguration of acute services will further develop the appropriate
pre-hospital model of care within the overall South Eastern region.
Item 6 (ii) 7.10.09 (JCH) –– Consultants Contract (CEO’’s File)
Implementation of Consultant Contract 2008 –– Briefing Note
28th September 2009

Table of Contents

1. Key points...................................................................................................................................2

2. Longer, more flexible working hours .....................................................................................2

3. Greater equity for public patients............................................................................................2

4. Regulation of public : private mix ...........................................................................................3

5. Delivering and measuring public:private mix ........................................................................4

6. Ensuring patient safety..............................................................................................................5

7. Teamworking..............................................................................................................................5

8. Better services for patients .......................................................................................................5

9. Clinical Directors appointed to manage Consultants ...........................................................6

10. 49 Clinical Directors in place .................................................................................................6

11. High uptake of Consultant Contract 2008...........................................................................7

12. Large increases in Consultant workforce .............................................................................7

13. Verifying contract delivery .....................................................................................................8

14. Payment to Consultants..........................................................................................................9

15. Implementing Public Accounts Committee recommendations..................................... 10

1
1. Key points

Consultant Contract 2008 introduces a range of reforms which will benefit patients, help
develop a consultant-provided service and ensure that maximum value for money is
obtained from the investment in existing and additional Consultant posts.

Key changes include:

x a longer working week,


x a longer working day,
x weekend working when required,
x greater equity for public patients through a public-only contract type, limits on
private vs. public practice and a common waiting list in diagnostic services,
x measures to ensure high quality services and patient safety,
x the introduction of Clinical Directors to manage Consultants and ensure clinicians
have a senior role in planning and managing services, and
x a significant increase in Consultant posts over the past 12 months.

In early 2009 the HSE engaged in a detailed verification process regarding


implementation of Consultant Contract 2008. This was designed to ensure that the
changes described above were being implemented for patients and that value for money
is achieved.

2. Longer, more flexible working hours

Consultant Contract 2008 provides for a 37 hour working week delivered over the period
8am –– 8pm Monday to Friday. In addition, Consultants rostered on-call may be
scheduled to work on-site for up to 5 hours on Saturday, Sunday or public holidays.

This contrasts with the Consultant Contract 1997, which provided for a 33 hour week,
delivered over the period 9am –– 5pm Monday to Friday with no provision for scheduled
on-site work at weekends.

3. Greater equity for public patients

Together with a series of measures introduced by the HSE in recent months, Consultant
Contract 2008 introduces a series of measures designed to improve equity for public
patients, including a limit on private practice –– for new Consultants –– of 20% of clinical
activity. Existing Consultants may engage in up to 30% private practice.

Consultant Contract 2008 provides for two main contract types:

i. Type A: Works exclusively for the public hospital and will be remunerated solely
by way of salary.
ii. Type B: Works exclusively for the public hospital by may engage in limited
private practice on campus (80% public, 20% private).

The measure include requirements that all patients –– public or private –– requiring
diagnostic or treatment procedures following an outpatient consultation must be placed
on a Common Waiting List if there is a waiting period for access to the procedure.

2
A Common Waiting List is one which includes all patients –– irrespective of public or
private status –– awaiting a particular procedure.

Patients must be called from Common Waiting Lists regardless of public or private
status:

i) in order of clinical priority, followed by


ii) length of waiting time.

Any outpatient diagnostic or treatment services / sessions / clinics organised to meet


demand must be open to both public and private patients called in order of clinical
priority and length of waiting time.

Separate outpatient diagnostic or treatment services / sessions / clinics for private


patients are not permitted within contracted hours or otherwise.

Section 21 of Consultant Contract 2008 sets out the circumstances under which the
Consultants employed under Consultant Contract 2008 may charge private fees in
relation to private patients undergoing diagnostic investigations, tests and procedures on
an outpatient basis. These are as follows:

x the volume of such private practice not exceeding the set ratio of public to
private practice (a maximum of 30% for existing Consultants in employment
when offer of Consultant Contract 2008 was made in July 2008, 20% for new
appointees).

x all billing being processed by the Consultant in a manner that is satisfactory to


the hospital and in the event that insufficient information is available for
verification purposes recourse may be had to the measures provided for at
Section 20 (d) and (e) of the Contract. Section 20 (d) notes that the Employer has
full authority to take all necessary steps to ensure that for each element of a
Consultant’’s practice, s(he) shall not exceed the agreed ratio.

x A common waiting list operated by the public hospital applying to both public
and private patients undergoing diagnostic investigations, tests and procedures
(including radiology and laboratory procedures) on an out-patient basis in public
hospitals (including referrals from General Practitioners). Status on the common
waiting list will be determined by clinical need only. The list will be subject to
clinical validation by the relevant Clinical Director.

All outpatient diagnostics are included as regards the Common Waiting List. For
example, outpatient diagnostic tests and procedures in cardiology, neurophysiology and
gastroenterology.

4. Regulation of public: private mix

Section 20 of the Consultant Contract 2008 deals with the regulation of private practice
and the mechanisms for ensuring compliance with the 80:20 / 70:30 ratio of public to
private practice. It provides that the volume of private practice may not exceed the
specified ratio in any of the Consultant’’s clinical activities including inpatient, day-patient
and outpatient.

3
The volume of practice refers to patient throughput adjusted for complexity through the
casemix system. It does not include non-clinical activities, nor does it apply to time.

Section 20 of the Contract states that the Employer has full authority to take all necessary
steps to ensure that for each element of a Consultant’’s practice, s(he) shall not exceed the
agreed ratio.

Other relevant sections include Section 4 b), which states that

““both the Consultant and the Employer shall co-operate in giving effect to such
arrangements as are put into place to verify the delivery of the Consultant’’s
contractual commitments””

and Section 12 l), which requires the Consultant

““to participate in and facilitate production of all data/information required to


validate delivery of duties and functions and inform planning and management of
service delivery.””

5. Delivering and measuring public:private mix

A key requirement for the implementation of Consultant Contract 2008 is the


monitoring of private practice activity by Consultants individually. Since September 2008
the HSE has developed new measurement systems in order to fulfil this requirement in
the manner set out in the Contract negotiations, i.e. clinical activity adjusted for case mix;

x The ESRI has been central to the development of the measurement system, which
has now been rolled out to the 49 acute hospitals through the HIPE (Hospital In-
Patient Enquiry) system. The measurement system captures inpatient and day case
activity (as weighted for case mix) per consultant and reports on the level of private
practice on a monthly basis.
x Where residual activity which is not yet captured by the HIPE system (e.g. details
of on-site private OPD activity and certain diagnostic activity) is being collected
manually by hospitals as an interim measure pending the development of
automated data collection systems.
x Each Consultant in the employment of the public health service –– irrespective of
whether they hold Consultant Contract 2008 or not - should be issued with a
public private mix measurement report every month since January 2009. This
documents their activity in relation to inpatient, daycase, outpatient and diagnostic
activity over the previous three months. The report is also issued to the relevant
Clinical Director and Hospital Manager / CEO for consideration and to facilitate
action to ensure with Consultant Contract 2008.
x An overall status report is also prepared for internal HSE monitoring and
management purposes and monitoring. From the January 2009 reporting period
this report is considered as informing decisions by Clinical Directors and managers
on individual Consultant compliance on a contractual basis. It will be provided
monthly to the HSE Board, the Department of Health and Children and will be
available under FOI.
x There is an inevitable time lag (minimum of 4 months) in providing reports due to
the time required for coding activity from the patient charts.

4
A small number of hospitals are still dealing with data collection difficulties, particularly
with the reporting of on-site private OPD activity and diagnostics.

In this context, the HSE has instructed that - should Consultants engage in private
outpatient practice on campus such practice should, like all other public or private
activities undertaken on the public hospital campus, be subject to measurement as part of
the 80:20 / 70:30 ratio of public to private practice under Consultant Contract 2008.
Measurement includes co-located hospitals on campus, private rooms on campus and
private clinics on campus –– with three exceptions. The exceptions are the private
outpatient practice of existing Consultants in private clinics (as of 26th July 2008) on the
campus of St James’’, Beaumont and Cork University Hospital.

The HSE has issued a substantial volume of guidance on the measurement of public :
private practice, including three volumes of guidance on the implementation of
Consultant Contract 2008, separate guidance on the measurement of inpatient and
daycase activity, diagnostic and outpatient activity most recently, in September 2009,
comprehensive guidance on the treatment of public and private patients.

6. Ensuring patient safety

Consultant Contract 2008 requires that the Consultant –– while clinically independent –– is
subject to statutory and regulatory requirements and corporate policies and procedures.
Consultants will be expected to work in teams, participate in competence assurance
arrangements and provide education and training to other clinicians.

The Contract also requires that new appointees to Consultant posts must now be eligible
for membership or have membership of the relevant division of the Register of Medical
Specialists maintained by the Medical Council. This means that patients can be assured
that Consultants meet the highest standards –– both when appointed and throughout their
careers.

7. Teamworking

Under Consultant Contract 2008, Consultants must work as part of a team of


Consultants - this means that the Consultant provides diagnosis, treatment and care to
patients under the care of other Consultants on his/her Consultant team and vice versa.
This may include discharge and further treatment arrangements thereby facilitating a
more timely discharge of patients and speedier access of patients into hospital.

8. Better services for patients

Consultant Contract 2008 offers a significant opportunity for hospitals to achieve greater
flexibility in relation to the delivery of services to patients and move to a Consultant-
provided service.

Consultants are on-site for longer periods –– meaning that there is a greater senior clinical
decision-making presence on-site. Key service enhancements can include:

x Improved decision making in Emergency Departments utilising 8am to 8pm by 7


day cover as appropriate and the additional 4 hours for Consultants to reduce
inappropriate admission waits;

5
x Rostered daily ward rounds that deliver improved Discharge Planning to address
bed occupancy rates;
x Reduced overtime costs for NCHDs arising from a Consultant-provided service
–– €€100 million in savings currently being negotiated with NCHDs.
x Theatre Schedules that reflect a shift to day work and address elective waiting
times and deliver improved equity across specialties. This should ensure
inappropriate queue-jumping related to patient designation is addressed;
x Re-designation of inpatient beds to day beds to improve day case throughput;
x Re-designation of 7 day to 5 day beds that promotes reduced length of stay,
allows for improved budgetary performance and eases pressure on WTE
rostering and staff;
x Improved day of surgery admission rates;
x OPD schedules that reflect increase in new patient consultations while decreasing
return patient reflecting new ratios and reductions in DNA's to 5% target
through improved scheduling.
x Improved access rates for GP's to diagnostic services by ring-fencing additional
Consultant hours to direct access initiatives for GP diagnostic radiology, scoping
etc;
x Improved clinical governance through the Clinical Directorate model that
facilitates the relevant Quality and Risk frameworks, Serious Untoward Incident
policies and maintenance of Risk Registers;
x Improvements in compliance with Hospital Accreditation, Medical Records
Audit, and Hygiene standards

9. Clinical Directors appointed to manage Consultants

Consultant Contract 2008 introduces a new senior management position across the
health service –– that of Clinical Director. Consultant Contract 2008 describes Clinical
Directors as key members of the local corporate management team. Clinical Directors
are expected to plan how clinical services are to be delivered, how resources are
employed, contribute to strategic planning and achieving service and organisational
priorities and deploy and manage Consultants.

The Contract requires that each Consultant will report to a Clinical Director who ensures
service standards and governance requirements are met; monitors and manages
public:private mix; develops and manages rosters (with an emphasis in the short to
medium term on move to an 8am –– 8pm day and obtaining value from the additional 4
hours per Consultant per week) and deals with grievances and disputes, manages the
initial stages of the disciplinary process, and helps organise medical education and
training.

The HSE is working with the Forum of Postgraduate Medical Training Bodies and a
number of sub-groups to develop the role of and support the work of Clinical Directors

10. 49 Clinical Directors in place

In December 2008, taking account of significant engagement with Clinicians,


management and other health service staff over a period of months, the HSE
commenced an appointment process for Clinical Directors under Consultant Contract
2008.

6
To date, 35 Clinical Directors have been appointed across the hospital system from
amongst those Consultants who accept Consultant Contract 2008. A further 14 have
been appointed in the Mental Health Services. Further Clinical Director appointments
will made over the next two years as services evolve. Up to 77 appointments may be
made in total. Appendix I refers.

11. High uptake of Consultant Contract 2008

The Consultant workforce is composed of a mix of permanent, temporary and locum


appointees. The whole time equivalent (wte) workforce eligible for offer of Consultant
Contract 2008 comprised 1,888 permanent employees and 312 locum or temporary
employees –– 2,200.

Of the 1,888 permanent Consultants, negotiations continue between the Universities, the
Department of Education and Science and the Higher Education Authority on the offer
of the contract to 150 Academic Consultants.

An element of the HSE vote for 2009 was transferred to the Department of Education
and Science and subsequently to the HEA and the Universities to fund the offer of
Consultant Contract 2008 to Academic Consultants. The HSE has no further
involvement in the matter.

In June, some of the Universities employing Academic Consultants began the offer of
Consultant Contract 2008 to those Consultants in their employment. At 7 July 2009,
around 50% of Academic Consultants had accepted the terms of the new contracts.

By July 2009, 1,688 consultants out of the 1,888 permanent consultants had accepted the
offer of Consultant Contract 2008. This represents an acceptance rate of approximately
90%. The breakdown by Contract Type is as follows:

x Type A: 629
x Type B: 703
x Type B*: 356

12. Large increases in Consultant workforce

In March 2008 the IMO and IHCA agreed to advertisement of Consultant posts under
Consultant Contract 2008. Following this agreement, the HSE approved 128 Consultant
posts which were advertised by the Public Appointments Service throughout April.

In the period up to 31st December 2008, a further 155 posts were approved –– for a total
of 283 posts in 2008. 156 of these were new posts and 127 replacement.

During 2009 and noting the constraints imposed by the Government Recruitment
Moratorium which requires the abolition of two NCHD posts for every Consultant post
approved, the HSE approved 127 Consultant posts –– 65 additional and 68 replacement.
Of the posts approved in 2009, 18 were Type A, 109 Type B, none Type C.

This means that during the period March 2008 to September 2009 the HSE approved
221 new Consultant posts and 195 replacement. This represents an increase of 10.4% in

7
the number of Consultant posts in an 18-month period. There are now 2,342 Consultant
posts in the Irish public health service.

Tables setting out the current distribution of Consultant posts and the distribution of
additional posts between March 2008 and September 2009 are set out below:

Additional Consultant posts approved under Consultant Contract 2008


March 2008 –– September 2009
HSE Area
Specialty Dublin Dublin Total
Mid- North South West
Leinster East
Anaesthesia 6 5 4 1 16
Intensive Care 2 2 4
Emergency
4 2 1 3 10
Medicine
Medicine 15 11 10 15 51
Obstetrics &
3 3 1 7
Gynaecology
Paediatrics 2 7 5 5 19
Pathology 6 2 5 8 21
Psychiatry 12 8 10 6 36
Radiology 12 8 7 8 35
Surgery 4 6 4 8 22
Total 66 54 46 55 221

Permanent Consultant posts in the Irish public health system


September 2009
HSE Area
Specialty Dublin Dublin Total
Mid- North South West
Leinster East
Total 748 570 497 527 2342

13. Verifying contract delivery

Each signed Consultant Contract was reviewed and documented by HSE Internal Audit
as part of an internal audit process. This was a key means of ensuring that the significant
contribution made by Consultants to the delivery of health services was recognised and
recorded, that there was absolute transparency on the delivery of public hospital services
and that value was achieved for the resources allocated to contract implementation.

The review examined all contracts issued and accepted by consultants employed in the
HSE and HSE funded agencies. Each contract was reviewed to identify any alterations to
the standard terms and conditions contained in the pro forma contract agreed with the
medical representative bodies in July 2008. The review found:

8
x The vast majority of contracts signed by consultants and authorised by the employer
were in accordance with the standard terms and conditions;

x A relatively small percentage of contracts had been signed as approved by the


employer prior to being issued to the employee (none of these contained any
anomalies);

x A small percentage of contracts were not physically signed as authorised by the


employer, but these were included in the employer’’s records as issued contracts;

x A very small number of contracts did contain manual amendments relating to the
treatment of private out-patients, however, these were not found to materially affect
the standard terms and conditions.

The HSE Human Resources Directorate also engaged in a verification process for the
1,385 permanent Consultants who have accepted the offer of Consultant Contract 2008
to confirm that the arrangements below were in place.
a) Appropriate standardised Contract documentation

b) Increased working hours, particularly:


i. the service gain resulting from the increase from 33 to 37 scheduled
weekly working hours.
ii. The extent of service delivery over an extended working day as required
(8am to 8pm in contrast to 9am to 5pm).
iii. The introduction of scheduled overtime on Saturdays, Sundays or bank
holidays in place of C Factor payments, the service gain arising and cost
basis for same.

c) New measurement arrangements for Public Private Mix, particularly:


i. measurement arrangements regarding each of the Consultant’’s clinical
activities, including Inpatient, daycase, outpatient and diagnostics ––
Section 20 and 21 of Consultant Contract 2008 refer.
ii. The extent to which there is compliance with the specified ratio of
public:private practice
iii. The extent to which a single waiting list for outpatient diagnostics has
been introduced in line with Section 21.

d) The appointment of Clinical Directors

The verification process concluded in March 2008.

14. Payment to Consultants

Following the HSE’’s verification process and to ensure the gains to patient services from
the new contract were secured, the Minister for Health & Children set out in a statement
on the supplementary budget of the 7th April 2009 that the Consultant Contract was to
be implemented on the basis of part payment of the new Consultant Contract salary
rates.

Approximately half of the differential between the 1997 and 2008 salary rates was to paid
in 2009 as and from 1st January 2009. The original payment schedule had identified the

9
new rates for Consultants accepting the new contracts to apply from the 1st June 2008.
The other half scheduled for the 1st June 2009 was not sanctioned and has not been
sanctioned to date.

The HSE has no authority to make payments other than those approved by the Minister
for Health & Children.

15. Implementing Public Accounts Committee recommendations

The 3rd Interim Report of the Public Accounts Committee on the 2006 Report of the
Comptroller and Auditor General regarding health service expenditure recommended
that:

x the new contract should provide absolute transparency on the time commitment to
public hospital duty of Consultant staff: These commitments should be monitored
and enforced in order to ensure that value is received for the salaries paid to
Consultants
x the HSE should introduce a stringent monitoring regime of public and private
caseloads in hospitals and publish data on the level of private practice in public
hospitals;
x the terms of the 1997 contract should be strictly enforced in respect of those
consultants who do not transfer to the new contract so that these consultants are
seen to deliver services in accordance with their commitments
x six-monthly progress reports should be provided to the Minister for Health and
Children.

The HSE’’s implementation of key provisions of the 2008 Contract has significantly
addressed the recommendations of the Oireachtas Public Accounts Committee regarding
Consultant Contracts.

In addition, the HSE has moved to ensure that the provisions of Consultant Contract
1997 regarding the Consultant’’s private practice being aligned with the number of
designated private beds is enforced.

The HSE will be taking further measures to implement these recommendations in


coming months.

10
Appendix I –– Clinical Directors appointed under Consultant Contract 2008

Clinical Directors in the acute hospital setting


Hospital
Network and
Hospital Groups Clinical Director
Network
Manager
Louth Meath Hospital
1 Interviews in Mid-October 2009
Group
Dr Alan Finan, Consultant
North East 2 Regional remit
Paediatrician
Cavan Monaghan Hospital Dr James Hayes, Consultant
3
Group Physician & Gastroenterologist
Beaumont (Incl. the National
4 Prof Shane O'Neill
Rehabilitation Hospital)
Mater Misericordiae Hospital
5 (Incl. Cappagh National Prof J Conor O'Keane
Dublin North Orthopaedic Hospital)
Dr Sam Coulter Smith, Consultant
6 Rotunda Hospital
Obstetrician & Gynaecologist
Dr Patricia McCormack, Consultant
7 Connolly Hospital
Geriatrician
8 St. James' Hospital Dr Barry White
St. Vincent's University
Hospital (Incl. St. Michaels),
Dublin South 9 Dr Risteard O Laoide
St. Colmcille's & The Royal
Victoria Eye & Ear Hospital
National Maternity, Holles Dr Peter Boylan, Consultant
10
Street Obstetrician & Gynaecologist
Dr John Barragry, Consultant
11 ADMiNCH Tallaght
Physician
12 Naas General Hospital Dr Catherine Collum
Dr Gerard Crotty, Consultant
13 Tullamore General Hospital
Haematologist
Dublin Dr Ron Charles, Consultant
Midlands 14 Mullingar General Hospital
Anaesthetist
Dr John Connaughton, Consultant
15 Portlaoise General Hospital
Physician
Dr Chris Fitzpatrick (Master of
Coombe) filling position on
16 Coombe Women's Hospital
temporary basis pending interview
process
Dr Rob Landers, Consultant
South East 17 Waterford Regional Hospital
Histpathologist
Dr Colm Quigley, Consultant
18 Wexford General Hospital
Physician

11
Dr Garry Courtney, Consultant
19 St. Luke's Hospital, Kilkenny
Physician

South Tipperary General


20 Dr Aamir Majeed
Hospital

CUH (Incl. Mallow &


21 Professor Richard Greene
Bantry)
Kerry General Hospital, Dr Richard Liston, Consultant
22
Tralee Physician
Southern
South Infirmary/Victoria Mr Denis Richardson, Consultant
23
Hospital General Surgeon
24 Mercy University Hospital

Mid-western Regional Dr Anthony Dempsey, Consultant


Mid-west 25
Hospital Obstetrician & Gynaecologist

26 Galway University Hospitals Mr Jack McCann


Portiuncula Hospital (Incl. Dr Gerry Clarke, Consultant
27
Roscommon) Physician
West/North- Mayo General Hospital, Dr Michael O'Neill, Consultant
28
west Castlebar Paediatrician
29 Sligo General Hospital Dr Paul Mullaney
Dr Paul O'Connor, Consultant
30 Letterkenny Hospital
Anaesthetist
National Renal
31 Dr Liam Plant
Programme
Other
Clinical 32 Southern Reconfiguration Prof John Higgins
Directors
MidWestern
33 Mr Paul Burke
Reconfiguration
National Cancer Control
34 Mr Arnie Hill
Programme
National Cancer Control
35 Prof Donal Hollywood
Programme
National Cancer Control
36 Prof Maccon Keane
Programme
Total Appointed Acute
35 and 1 outstanding
Sector

12
Clinical Directors in Mental Health

Area Remit Clinical Director


Limerick Mental Health Services
Located at Churchtown Day Dr Jack O'Riordan Con Psychiatrist
1 Hospital (Adult)
Sligo Mental Health Services Dr Owen Mulligan Consultant
2 Located at Ballytivnan Sligo Psychiatrist (Adult)
West Galway Mental Health Services
Located at St Brigids Hospital
3 Ballinasloe Dr Kieran Power Clinical Director
North Lee/North Cork Adult
Mental Health Services Located Dr Maeve Rooney Consultant
4 at North Lee Psychiatrist (Adult)
South Lee/WestCork/Kerry
Adult Mental Health Located at Dr Eamon Moloney Clinical
5 South Lee Director
South Dr Noel Shepard Consultant
6 Waterford/Wexford Psychiatrist
Dr Francis Kelly Consultant
7 Carlow/Kilkenny Psychiatrist
North Dublin Mental Health Dr. Mary Cosgrave Consultant
8 Located at St Ita Psychiatrist (Old Age)
Dr Anne Jackson, Consultant
Dublin North 9 Louth/Meath/Cavan/Monaghan Psychiatrist
East North West Dublin/Dublin Dr Margo Wrigley Consultant
10 North Central Psychiatrist (Old Age)
Wicklow Adult Mental Health
Service located at Newcastle Dr Justin Brophy A/Clinical
11 Hospital Director
Dublin West, South West Adult
Mental health Service located in
12 St Lomans Palmerstown Dr Ian Daly Clinical Director
Dublin Mid- Laois Offaly Mental Health Dr Maurice Gervin A/Clinical
Leinster 13 Service Director
National Forensic Mental Health
Service Located at Central Dr Harry Kennedy Clinical
14 Mental Hospital Dundrum Director
Total Appointed in Mental
14
Health Services

Overall Total 49 (one post to be filled)

13
Item 6 (v) 7.10.09 (JCHC) C&AG – Private Income (CEO’s File only)

Management of Private Patient Income

Government policy has been to ensure that there is equitable access for public
patients, that the proportion of private activity in public hospitals is appropriately
controlled and as far as possible additional resources provided to the hospital system
benefit public patients in the first instance.

Action number 88 of the 2001 Health Strategy provided for the following:

“All of the extra Acute Hospital capacity within the public sector, both in- patient
beds and day beds, will be designated for use by public patients. The only exceptions
will be Intensive Care Units, Coronary Care Units and other specialised beds which
will continue to be non-designated. The provision of additional beds announced in
this Strategy will be a significant step forward in ensuring that the needs of public
patients are adequately met”.

On average 20% of beds in the public hospital system are designated as private or
semi-private. Currently approximately 52% of the population hold private health
insurance.

The current bed designation system could not therefore ensure that all private patients
are charged a maintenance charge by the hospital in which they are treated. The
Health Service Executive is only entitled to charge private patients who occupy
designated private beds.

The Comptroller and Auditor General’s report noted that 45% of all private in-patient
throughput was not the subject of a maintenance charge because the patient was
accommodated in a public bed. The main reason for this is that public patients were
accommodated in private beds for infection control and clinical reasons relating to
patient safety together with the fact that private patient activity is limited in public
hospitals as a matter of Government policy.

The Comptroller also noted that 5% of private patient activity was not charged for
because the patient was accommodated in a non-designated bed.(e.g. Intensive Care,
Coronary Care and other specialised beds). It is a matter of Government policy that
there is no charge levied for non-designated beds and the policy rationale for non-
designated beds is that accommodation for persons who are acutely ill or where a
national specialty is concerned should not be differentiated into public an private.
This was done to ensure that it is solely clinical factors which determine which
patients are accommodated in those facilities.

The Comptroller and Auditor General further noted that the full economic cost of
maintenance in public hospitals is not being levied at present. However there has been
significant increases in recent years in the proportion of that cost recovered and in
2009 this charge was increased by 20% in a move to close the gap.
The Department of Health and Children has recently set up an independently chaired
group to establish the most appropriate way of charging the full economic cost of
providing services to private patients in public hospitals.

Timeliness of Debt Recovery.

The Health Service Executive fully accepts that the delay in recovering private
insurance accommodation claims is excessive and has set in motion a number of
initiatives to resolve this issue. The timeliness of debt recovery is a cash flow issue for
the H.S.E. and 97% of all private insurance claims are ultimately paid by the insurer.

No patient services have suffered as a result of this delay in cash payments.

Hospital Managers have been instructed to reduce their debtor days down to 60 days
initially and budget sanctions will be imposed on Managers who fail to reach this
target in 2010.

A high level group chaired by a Hospital Network Manager and with representatives
from H.S.E finance and Voluntary Hospitals has been established to negotiate with
the Private Insurance Providers on business processes and the reduction of debtor
days and with the following terms of reference.

- Streamlining transaction processing and data exchange


- Setting parameters for private and semi-private charges by public hospitals
both voluntary and statutory
- Billing and payment methods
- Implications of new Consultants contract.
- Level of debt
- Administration of Private Insurance claims process.

Negotiations are ongoing with the Private Insurance providers to implement electronic
exchange of data which will significantly speed up the claims and payment process.

The H.S.E has secured agreement with the major insurance providers for signoff of
claims by a secondary Consultant Clinician where the primary Consultant has failed
for whatever reason to signoff in a timely manner.

Approval has been obtained from the Department of Health and Children and the
Department of Finance to commence the centralisation of the entire H.S.E billing
system which will lead to streamlining of this process and focus the attention on
collection of all outstanding debts.

H.S.E. Finance Department


15th September 2009.
JOINT OIREACHTAS COMMITTEE

ON

HEALTH & CHILDREN

7th October, 2009

National Priority Issues for the Quarterly Meeting

with the Minister for Health and Children

and the

CEO of the Health Services Executive


1. To ask the Minister for Health and Children and the HSE Chief
Executive if they will immediately scrap plans to centralise the
processing of medical card applications.

The Health Services Executive has embarked on major programme to transform


health service delivery. In the recent past various reports have clearly pointed to a
lack of clarity in relation to roles, responsibilities and accountability in the delivery of
the Primary Care schemes but in particular highlighted the following:

x The need for standardisation, streamlining and rationalising organisation


arrangements in relation to the determination of eligibility,
x The need to integrate all local scheme systems with an national scheme index,
x Duplication of effort and the existence of silos of expertise across the country,
x Data integrity issues leading to incorrect payments to GP’’s,

The Public Accounts Committee has also considered these matters in some detail.

In this context a decision has been taken by the HSE that these issues could be best
addressed if the Primary Care Schemes were operated centrally. In order to be
managed more effectively and consistently from a national perspective it has been
decided to centralise the core operation of these schemes in one location, namely the
HSE Offices at the Primary Care Reimbursement Services (PCRS) in Finglas, Dublin,
with Local Health Offices continuing to provide local assistance and advice to the
public as normal.

The proposed changes are intended to address the concerns set out above and
enhance service delivery to the client. There will be no impact on patient care or the
quality of service provided and there will be no affect on the assessment of people
whose income exceeds the guidelines but have a case to be considered on medical or
hardship grounds. The HSE is aiming for significant improvements in turnaround
time for all completed Medical Card/GP Visit Card applications. A fast track process
is already in place in the new central office in Finglas, which is currently dealing with
all of the applications and life cycle events of the Over 70’’s clients, to cater for
special emergency cases, with emergency applications dealt with immediately, and a
card issuing within 24 hours. It is anticipated that most such emergency requests will
come through Local Health Offices following contact by clients or the local health
services.

There are no plans to close any of the local health offices that currently process
medical card and GP visit card applications. However, the process will involve a
reassignment of existing human resources within the HSE. Local Health Offices will
continue to provide service to clients of these schemes by providing information and
assistance to clients about their entitlements, and they will also provide assistance
with the completion of application forms etc. An on-line tracking service linked to
the central processing centre at PCRS will be available in Local Health Offices to
provide clients with information on their current eligibility status or the progress of a
client’’s application.

Page 1 of 20
The reorganisation will facilitate the application of a consistent approach to assessing
eligibility across the country and will:

x Ensure consistency of service provision and application of eligibility criteria


across the country,
x Drive customer orientated service delivery,
x Provide clearer lines of governance and accountability, and
x Provide value for money by maximising the use of national ““back”” office
processes.

Persons acting on behalf of applicants, for example local representatives making


representations on behalf of an individual client will also be able to make
representations directly to the central HSE office in Finglas.

It is envisaged that other HSE services, e.g. Public Health Nursing Departments,
Paramedic services and Doctor on Call services, Hospitals etc. will also be in a
position to determine the eligibility of a client for services by accessing the national
on-line system at PCRS. A small group is currently engaged in scoping the
requirements of these services.

This re organisation will reduce the numbers of staff required to work in the schemes
process in Local Health Offices without reducing the level or quality of service
provided to the public, and will provide staff with an opportunity to move to
developing services such as Primary Care Teams.

The HSE would view this change as the type of innovation signalled in the
Transforming Public Services Programme announced by the Taoiseach last
November. It demonstrates how the HSE can deliver improved services within the
more limited resources available in a way that meets the needs of citizens in a modern
society.

2. To ask the Minister for Health and Children and the HSE Chief
Executive the process by which they are assessing the proposals
regarding healthcare provision within the Report of the Special
Group on Public Service Numbers and Expenditure Programmes
(the McCarthy Report), and if the preliminary conclusions have
been reached or decisions made in relation to these proposals.

The Department of Health & Children will provide response to this question.

3. To ask the Minister for Health and Children and the HSE Chief
Executive for an update on the FairDeal (Nursing Homes Support
Scheme Act 2009) scheme, including details on: when it will
commence, proposed changes to the scheme and if negotiations
have been completed with nursing home people etc.

The Department of Health & Children will provide response to this question.

Page 2 of 20
4. To ask the Minister for Health and Children and the HSE Chief
Executive for an update on the HSE budget and proposed
redundancy programme.

Performanceȱyearȱtoȱdate
The HSE is substantively delivering upon its Service Plan in terms of service levels,
employment and finances. As indicated above there are a number of newly emerging
pressures that are driving cost upward.

We anticipate that the VFM target of €€115m will be achieved by year end on the
basis that the saving trend from 2008 is repeated. The VFM delivery of 2008 of
€€280m will be maintained. It is clear that some measures relating to non basic pay
reduction and service reconfiguration are not delivering or are delayed in
implementation due to industrial action. We are assessing the effect of other
measures that have been taken locally to compensate for these challenges.

The gross vote is €€162m ahead of profile at the end of September 2009. The HSE is
continuing to take action to address this and working with the Department of Health
and Finance on some key emerging issues.

Risks
The key risks to be considered between now and year end in terms the vote include
the following;

x The risk of substantial additional expenditure on community schemes;


x Non –– resolution of the capital issues;
x Any potential adverse impact of the court cases relating to advance payments to
pharmacists or the challenge to be heard in October to the recent reductions
relating to pharmacy;
x Ensuring full funding for any incremental cost of the pandemic including vaccines
and the mass vaccination process. 2009 costs are estimated in the region of €€70m;
x Shortfall in Appropriations -in-Aid

Page 3 of 20
Appendix 1
Budget adjustments based upon letter from Minister

€m
Total without measures in place at Special Board
Meeting - 23 February 2009 469
Implementation of the reduction in the wholesale margin
following the Minister's approval (50)
Health Repayment Scheme - costs which will not arise
until 2010 (12)
Funding provided in REV for health levy (160)
Assurance provided in Minister's letter regarding
supplementary funding for medical cards (100)
147
National Treatment Purchase Fund transfer (10)
Transfer from other health agencies (3)
Further reductions to be specified (9)
Savings on consultant contract determined by the
Department of Health & Children (75)
Acceleration of VHI outstanding monies (50)
Balance remaining -

Page 4 of 20
Appendix 2

Pensions

The following table shows how pension lump sums have grown since 2008. Given the
range of staff within the organisation who can validly choose to retire before the end of the
year, it is very difficult to predict the ultimate cost of lump sums in 2009 (this includes all
staff who have reached age 60, psychiatric nurses etc).

Accelerated retirements are a problem which has been affecting the public service generally
since the introduction of the emergency budget, the pension levy and speculation regarding
taxing of lump sums. It is not unique to the HSE.

Using data to the end of June 2009, the estimated potential full year deficit is in the order
of €€80m. However there was further growth in lump sum payments in July 2009 and it is
more prudent to increase our estimate to €€95m at this point.

In addition to lump sum increases, pension payments have also grown and anticipated
increased income collection from the consultants pay award and demographic staff costs
have not materialised. These 3 factors contribute to the forecast overrun of €€95m.

Page 5 of 20
The HSE does not have a proposed redundancy programme apart from the question
of the Incentivised Scheme for Early Retirement (ISER). The Minister for Finance
announced the introduction of new incentivised schemes for public servants as part of
the budget on 7th April 2009. These schemes include the Incentivised Scheme for
Early Retirement, Special Incentive Career Break Scheme and the Shorter Working
Year Scheme. The ISER and other schemes were advertised in the Health Sector on
receipt of the requisite Departmental Circulars on the 18th May 2009.

The purpose of the incentivised schemes is to facilitate a permanent, structural


reduction in the numbers of staff employed along with an associated restructuring of
organisation and operations, in as timely a manner as possible and in line with the 2009
Employment Control Framework for the Public Health Sector. While the reduction in
numbers achieved under the schemes is intended to contribute significant and ongoing
savings to the Exchequer, this must be done in a way that does not undermine essential
service provision.

Unfortunately, the HSE suspended the availability of the schemes following the issue
of a ““directive”” issued by the joint group of health unions. This ““agreed-directive””
directly contravened the expressed condition contained in the original circular that staff
co-operation and flexibility in respect of redeployment and mobility was a requirement
for making these schemes available. Consequently this action had the effect of
restricting the operation of the scheme and the ability of the Organisation to ensure
continuity of its affairs.

The HSE has been actively pursuing the matter in an effort to find a resolution. To
date this has not been successful. A total of 230 applications for access to the ISER
(121 in HSE, 109 in Voluntary Hospitals, Disability and other agencies) have been
received to date.

5. To ask the Minister for Health and Children and the HSE Chief
Executive when will residential services for children with a disability
be inspected and registered.

The Department of Health & Children will provide response to this issue

6. In view of the call from the Human Rights Commission and Patient
Support Groups will the government reconsider its decision not to
establish an external review into the practice of symphysiotomy in
Ireland.

The Department of Health & Children will provide response to this question.

Page 6 of 20
7. What protocols are currently in place to deal with people who
present themselves at psychiatric units with suicidal tendencies and
if there are procedures in place to contact the family of psychiatric
patients when they are being discharged from hospital.

Psychiatric Units accept referrals from Community Mental Health Teams and
General Practitioners. In some instances, clients self refer and in these circumstances
staff perform an assessment on the patient. If there are concerns in relation to the
patient’’s health, the Consultant on call will undertake a psychiatric assessment and
depending on the outcome, invite the patient to stay if clinically indicated or offer an
early appointment at an appropriate community facility. These facilities may include
an outpatient clinic, day hospital or follow up home care.

With their expressed permission, family members and carers of the patient can be
invited to become involved in the care programme. This is the HSE preferred model
and indeed is the model recommended in ““A Vision for Change”” to work with, but
this is dependent on the agreement of the individual concerned. We are bounded by
patient confidentially which we must respect.

8. The vast majority of expectant women experience an uneventful


pregnancy requiring no or minimal intervention antenatally, during
labour and in the postnatal period. Pregnancy is a normal life event
and despite the fact that delivery normally takes place in a hospital
based maternity unit here in Ireland, the fact is that pregnant
women are not ill. Will the Minister/HSE acknowledge that to
provide care in a holistic and women centred way, we must move
away from the idea that a ““centre of excellence”” is necessary for all
pregnant women and, in fact, if implemented would ultimately only
increase the amount of interventions made through increased
inductions/instrumental deliveries/caesarean sections etc as a
result of facilitating the increased numbers passing through such a
unit.

The HSE is committed to extending and enhancing primary and community service
models as a preferred approach to providing care to mothers and babies with
uncomplicated pregnancies and treatment needs. We recognise the centrality of
clinical involvement and leadership in the design provision and improvement of
care. The role of the midwife is recognised as being fundamental to delivering
women and baby-centred maternity services.

The provision of maternity care is constantly evolving to respond to the changing


needs of women in Ireland and their families. The Primary Care Strategy (2001)
highlighted the need to develop national community midwifery schemes to align
with the development of primary care schemes nationally. Midwives provide care in
maternity hospitals/units, recently developed midwifery-led units and increasingly
through the provision of midwifery-led services in the community. Midwives work in

Page 7 of 20
partnership with obstetricians and other members of the healthcare team in the
provision of care, particularly to women with complicated pregnancies.

The HSE has made a commitment in its Transformation Programme to develop its
strategic approach to Maternity Services nationally and this started in 2007 with the
Independent Review of Maternity & Gynaecology Services in the Greater Dublin
Area. The HSE/KPMG report on the Review of Maternity & Gynaecology services
in the Greater Dublin Area was published in February 2009 and is available on
www.hse.ie. The report is an integral blue print for maternity and gynaecology
services. The review provided an opportunity for organisations and individuals to
debate and exchange ideas for positive change maximising improvement for
mothers and babies in terms of the model of care and choice/safety agenda.

The report concluded that Dublin’s current model of stand alone maternity hospitals
is not the norm internationally. It is well recognised that for optimal clinical
outcomes maternity services should be located with adult acute services. This
allows the mother to access a full range of medical and support services should the
need arise for (for example) cardiac and vascular surgery, diabetes services,
intensive care facilities, haematology services, psychiatric services among others.
The development of co-located Midwifery led Units (MLUs) alongside obstetric
units is a key recommendation for the Greater Dublin Area. Pilot co-located MLUs
were established in 2004 in the North East area in Cavan General Hospital and Our
Lady of Lourdes Hospital in Drogheda and are still ongoing. These units are
currently being evaluated by the School of Nursing and Midwifery Trinity College
Dublin and early indications are that they are popular with women. Formal
evaluation of these MLUs is imminent.

We are aware of the desire of all parties to progress the implementation of the
HSE/KPMG report recommendations and we are arranging to put in place
appropriate national, regional and local level supports for the work streams
identified across service redesign, workforce needs, clinical governance, teaching
and training and physical infrastructure requirements.

9. In line with European best practice and as endorsed by NICE


(National Institute of Clinical Excellence, UK) does the Minister
envisage the introduction of out-of-hours support services for those
at risk of self-harm or suicide, as well as those involved with child
protection, elder abuse and mental health problems?

Deliberate Self-Harm, Suicide and Mental health:

With regard to out-of-hours services for those who are at risk of self-harm or suicide,
or those who have mental health problems, the HSE provides 24-hour Mental Health
Services. Out-of-hours services can refer clients to acute Psychiatric Units where
patients are assessed and either admitted or offered follow up out patient inputs.

Clients who are acutely ill and present as a risk to others or indeed themselves can be
admitted on an involuntary basis to an acute Psychiatric unit under the provision of the
Mental Health Act 2001, where appropriate psychiatric interventions can be provided.

Page 8 of 20
For clients where a full psychiatric assessment and interventions are required, these are
arranged through the Consultant Psychiatrists and their on-call team.

Crisis Nurse service:


The HSE also provides a Crisis Nurse service in emergency outpatients departments
whose role is to access clients self referring or presenting at emergency departments.
The Crisis Nurse service is an innovative response to the issue of persons presenting
having deliberately self-harmed (DSH) or attempted suicide and has as its main aim the
improvement of the response to these patients with a corresponding improvement in
their care. The service was piloted in what is now the HSE South area from 2001 and
rolled out following a successful evaluation in 2005.

The specific role of the crisis nurse is to take a full psychosocial history and define
problem areas with the client, aiming to identify psychiatric illness, suicide risk or co-
existing problems. This enables the most appropriate intervention(s) to be offered and
the crisis nurse also liaises with the client’’s family or significant others to engage the
most appropriate person with the nurse and the client beyond the initial intervention.
Crisis Nurses take the responsibility to devise care pathways for the client which
encourage management and solving of problems being experienced, thus opening the
possibility of options other than DSH or suicide to the client. Home care follow up for
up to six weeks after the incident is also provided, as is liaison with the client’’s GP and
other voluntary or statutory services of all types in the community which can provide
assistance tailored to the client.

Child Protection:

Regarding out-of-hours child protection, the HSE has established the Emergency Place
of Safety service earlier this year. This service enables Gardaí to access an appropriate
place of safety for children found to be at risk out of hours (outside normal working
hours, 5pm-9am Monday to Friday and weekends and bank holidays) under Section 12
of the Child Care Act 1991.

Under the Act, an Garda Síochána has sole legal responsibility where there is an
immediate and serious risk to the health or welfare of a child, and it would not be
sufficient for the protection of the child from such immediate and serious risk to await
the making of an application for an emergency care order by the HSE under section
13, to remove the child to safety.

The Emergency Place of Safety service provides a standardised response across the
country for children who can be appropriately placed in a family setting. This service
applies outside the Dublin, Kildare and Wicklow areas. Such services are available
currently for these areas.

The HSE retains custody, within the meaning of section 12 of the Child Care Act,
1991, through its agent Five Rivers Ireland, of a child placed with Five Rivers Ireland
by the Garda Síochána under section 12(3) of the Child Care Act, 1991. Day to Day
care will be provided by Five Rivers Ireland as agent for the HSE.

The service conforms with relevant Child Care Regulations and with the National
Standards for Foster Care.

Page 9 of 20
A joint HSE/Garda Protocol provides a code of conduct and set of standardised
procedures for staff of the HSE and members of the Garda Síochána in the placement
of children with Five Rivers Ireland in the operation of this service.

This protocol outlines an agreed procedure between the Health Service Executive and
the Garda Síochána and clarifies the roles and requirements of the agencies in relation
to the placement of children out of hours by the Garda Síochána under Section 12 of
the Child Care Act, 1991.

The on-going operation of the service is under review by a joint HSE/Garda


Committee. Since the service began on 5th June, there have been 63 referrals relating to
72 children perceived to be at risk.

Of the referrals, 26 (41%) were appropriate and placements were provided for children
with Five Rivers Carers; in two cases (3%) the referral was appropriate but there was
no placement available. Of the referrals 10 (16%) were inappropriate as children
already had a care placement, in four cases (6%), referrals were appropriate and
placements were offered but refused. In the remaining 21 referrals (33%) advice about
an appropriate place of safety service e.g. acute hospital or psychiatric evaluation or
another course of action was provided.

Elder abuse
Regarding out-of-hours services for Elder Abuse, the HSE has made significant
progress in the provision of a dedicated elder abuse service over the last two years. The
HSE has taken a number of initiatives to prevent and combat elder abuse including:

x The appointment of Senior Case Workers in Elder Abuse. There are currently 28
Senior Case Workers in Elder Abuse providing a service in almost all of the Local
Health Offices. In addition, there are three Dedicated Officers in Elder Abuse who
provide training, advice and expertise in the area of elder abuse.

x A comprehensive national and local media campaign. In 2008, the HSE launched a
comprehensive national and local media campaign in order to raise awareness of
elder abuse. The campaign included local and national radio advertisements,
national and regional newspaper advertisements, the distribution of almost 500,000
information leaflets and a number of radio and television interviews by HSE staff
in relation to elder abuse.

x The establishment of a National Centre for the Protection for Older People in
UCD. The National Centre was established in 2008 and will provide original
research on elder abuse in Ireland as well as acting as an advice and resource centre
for the HSE and other groups.

x Significant training of staff, both within the HSE, and private and voluntary
organisations, has been undertaken in order to help staff recognise and respond
appropriately to elder abuse.

x A comprehensive HSE database has been established which records the number
of abuse referrals, the types of abuse, age profile of abuse victims and other details.

Page 10 of 20
In 2008, a total of 1,840 elder abuse referrals were made to the HSE. Up to the end of
August, 2009, the figures show a consistent referral pattern, with 1,225 referrals. The
HSE elder abuse service focuses on training people in how to recognise and respond to
abuse, preventing abuse from happening and stopping abuse when it occurs. The HSE
senior Case Workers, in dealing with cases of elder abuse, work with, and respect, the
wishes of the older person as much as possible.

The service does not have dedicated out-of-hours provision. However, if a situation
arises in which there is an immediate and potentially serious risk to an individual, there
are emergency services in place. These include GP services, community nursing teams,
accident and emergency departments and An Garda Siochana. All of these agencies,
depending on the situation, would have close working relationships with the Senior
Case Workers on Elder Abuse and training is provided to these groups on an ongoing
basis.

10. Does the Minister have an update on the timeline for the
introduction of HPV vaccine for 12 year old girls?

The Department of Health & Children will provide a response to this question.

11. What is the Department doing about the monitoring of the new
common contract?

1. Key points
Consultant Contract 2008 introduces a range of reforms which will benefit patients,
help develop a consultant-provided service and ensure that maximum value for money
is obtained from the investment in existing and additional Consultant posts.

Key changes include:

x a longer working week,


x a longer working day,
x weekend working when required,
x greater equity for public patients through a public-only contract type, limits on
private vs. public practice and a common waiting list in diagnostic services,
x measures to ensure high quality services and patient safety,
x the introduction of Clinical Directors to manage Consultants and ensure clinicians
have a senior role in planning and managing services, and
x a significant increase in Consultant posts over the past 12 months.

In early 2009 the HSE engaged in a detailed verification process regarding


implementation of Consultant Contract 2008. This was designed to ensure that the
changes described above were being implemented for patients and that value for
money is achieved.

2. Longer, more flexible working hours


Consultant Contract 2008 provides for a 37 hour working week delivered over the
period 8am –– 8pm Monday to Friday. In addition, Consultants rostered on-call may be
scheduled to work on-site for up to 5 hours on Saturday, Sunday or public holidays.

Page 11 of 20
This contrasts with the Consultant Contract 1997, which provided for a 33 hour week,
delivered over the period 9am –– 5pm Monday to Friday with no provision for
scheduled on-site work at weekends.

3. Greater equity for public patients


Together with a series of measures introduced by the HSE in recent months,
Consultant Contract 2008 introduces a series of measures designed to improve equity
for public patients, including a limit on private practice –– for new Consultants –– of
20% of clinical activity. Existing Consultants may engage in up to 30% private practice.

Consultant Contract 2008 provides for two main contract types:

(i) Type A: Works exclusively for the public hospital and will be
remunerated solely by way of salary.
(ii) Type B: Works exclusively for the public hospital by may engage in
limited private practice on campus (80% public, 20% private).

The measure include requirements that all patients –– public or private –– requiring
diagnostic or treatment procedures following an outpatient consultation must be placed
on a Common Waiting List if there is a waiting period for access to the procedure.

A Common Waiting List is one which includes all patients –– irrespective of public or
private status –– awaiting a particular procedure.

Patients must be called from Common Waiting Lists regardless of public or private
status:

(i) in order of clinical priority, followed by


(ii) length of waiting time.

Any outpatient diagnostic or treatment services / sessions / clinics organised to meet


demand must be open to both public and private patients called in order of clinical
priority and length of waiting time.

Separate outpatient diagnostic or treatment services / sessions / clinics for private


patients are not permitted within contracted hours or otherwise.

Section 21 of Consultant Contract 2008 sets out the circumstances under which the
Consultants employed under Consultant Contract 2008 may charge private fees in
relation to private patients undergoing diagnostic investigations, tests and procedures
on an outpatient basis. These are as follows:

x the volume of such private practice not exceeding the set ratio of public to
private practice (a maximum of 30% for existing Consultants in
employment when offer of Consultant Contract 2008 was made in July
2008, 20% for new appointees).

x all billing being processed by the Consultant in a manner that is satisfactory


to the hospital and in the event that insufficient information is available for
verification purposes recourse may be had to the measures provided for at
Section 20 (d) and (e) of the Contract. Section 20 (d) notes that the

Page 12 of 20
Employer has full authority to take all necessary steps to ensure that for
each element of a Consultant’’s practice, s(he) shall not exceed the agreed
ratio.

x A common waiting list operated by the public hospital applying to both


public and private patients undergoing diagnostic investigations, tests and
procedures (including radiology and laboratory procedures) on an out-
patient basis in public hospitals (including referrals from General
Practitioners). Status on the common waiting list will be determined by
clinical need only. The list will be subject to clinical validation by the
relevant Clinical Director.

All outpatient diagnostics are included as regards the Common Waiting List. For
example, outpatient diagnostic tests and procedures in cardiology, neurophysiology
and gastroenterology.

4. Regulation of public: private mix


Section 20 of the Consultant Contract 2008 deals with the regulation of private
practice and the mechanisms for ensuring compliance with the 80:20 / 70:30 ratio
of public to private practice. It provides that the volume of private practice may
not exceed the specified ratio in any of the Consultant’’s clinical activities including
inpatient, day-patient and outpatient.
The volume of practice refers to patient throughput adjusted for complexity
through the casemix system. It does not include non-clinical activities, nor does it
apply to time.

Section 20 of the Contract states that the Employer has full authority to take all
necessary steps to ensure that for each element of a Consultant’’s practice, s(he)
shall not exceed the agreed ratio.

Other relevant sections include Section 4 b), which states that

““both the Consultant and the Employer shall co-operate in giving effect to such
arrangements as are put into place to verify the delivery of the Consultant’’s
contractual commitments””

and Section 12 l), which requires the Consultant

““to participate in and facilitate production of all data/information required to


validate delivery of duties and functions and inform planning and management of
service delivery.””

5. Delivering and measuring public:private mix


A key requirement for the implementation of Consultant Contract 2008 is the
monitoring of private practice activity by Consultants individually. Since September
2008 the HSE has developed new measurement systems in order to fulfil this
requirement in the manner set out in the Contract negotiations, i.e. clinical activity
adjusted for case mix;

Page 13 of 20
x The ESRI has been central to the development of the measurement system,
which has now been rolled out to the 49 acute hospitals through the HIPE
(Hospital In-Patient Enquiry) system. The measurement system captures
inpatient and day case activity (as weighted for case mix) per consultant and
reports on the level of private practice on a monthly basis.
x Where residual activity which is not yet captured by the HIPE system (e.g.
details of on-site private OPD activity and certain diagnostic activity) is being
collected manually by hospitals as an interim measure pending the
development of automated data collection systems.
x Each Consultant in the employment of the public health service ––
irrespective of whether they hold Consultant Contract 2008 or not - should
be issued with a public private mix measurement report every month since
January 2009. This documents their activity in relation to inpatient, daycase,
outpatient and diagnostic activity over the previous three months. The report
is also issued to the relevant Clinical Director and Hospital Manager / CEO
for consideration and to facilitate action to ensure with Consultant Contract
2008.
x An overall status report is also prepared for internal HSE monitoring and
management purposes and monitoring. From the January 2009 reporting
period this report is considered as informing decisions by Clinical Directors
and managers on individual Consultant compliance on a contractual basis. It
will be provided monthly to the HSE Board, the Department of Health and
Children and will be available under FOI.
x There is an inevitable time lag (minimum of 4 months) in providing reports
due to the time required for coding activity from the patient charts.

A small number of hospitals are still dealing with data collection difficulties,
particularly with the reporting of on-site private OPD activity and diagnostics.

In this context, the HSE has instructed that - should Consultants engage in private
outpatient practice on campus such practice should, like all other public or private
activities undertaken on the public hospital campus, be subject to measurement as
part of the 80:20 / 70:30 ratio of public to private practice under Consultant
Contract 2008. Measurement includes co-located hospitals on campus, private
rooms on campus and private clinics on campus –– with three exceptions. The
exceptions are the private outpatient practice of existing Consultants in private
clinics (as of 26th July 2008) on the campus of St James’’, Beaumont and Cork
University Hospital.

The HSE has issued a substantial volume of guidance on the measurement of


public : private practice, including three volumes of guidance on the
implementation of Consultant Contract 2008, separate guidance on the
measurement of inpatient and daycase activity, diagnostic and outpatient activity
most recently, in September 2009, comprehensive guidance on the treatment of
public and private patients.

6. Ensuring patient safety


Consultant Contract 2008 requires that the Consultant –– while clinically
independent –– is subject to statutory and regulatory requirements and corporate
policies and procedures. Consultants will be expected to work in teams,

Page 14 of 20
participate in competence assurance arrangements and provide education and
training to other clinicians.

The Contract also requires that new appointees to Consultant posts must now be
eligible for membership or have membership of the relevant division of the
Register of Medical Specialists maintained by the Medical Council. This means
that patients can be assured that Consultants meet the highest standards –– both
when appointed and throughout their careers.

7. Teamworking
Under Consultant Contract 2008, Consultants must work as part of a team of
Consultants - this means that the Consultant provides diagnosis, treatment and
care to patients under the care of other Consultants on his/her Consultant team
and vice versa. This may include discharge and further treatment arrangements
thereby facilitating a more timely discharge of patients and speedier access of
patients into hospital.

8. Better services for patients


Consultant Contract 2008 offers a significant opportunity for hospitals to achieve
greater flexibility in relation to the delivery of services to patients and move to a
Consultant-provided service.

Consultants are on-site for longer periods –– meaning that there is a greater senior
clinical decision-making presence on-site. Key service enhancements can include:

x Improved decision making in Emergency Departments utilising 8am to


8pm by 7 day cover as appropriate and the additional 4 hours for
Consultants to reduce inappropriate admission waits;
x Rostered daily ward rounds that deliver improved Discharge Planning to
address bed occupancy rates;
x Reduced overtime costs for NCHDs arising from a Consultant-provided
service –– €€100 million in savings currently being negotiated with NCHDs.
x Theatre Schedules that reflect a shift to day work and address elective
waiting times and deliver improved equity across specialties. This should
ensure inappropriate queue-jumping related to patient designation is
addressed;
x Re-designation of inpatient beds to day beds to improve day case
throughput;
x Re-designation of 7 day to 5 day beds that promotes reduced length of
stay, allows for improved budgetary performance and eases pressure on
WTE rostering and staff;
x Improved day of surgery admission rates;
x OPD schedules that reflect increase in new patient consultations while
decreasing return patient reflecting new ratios and reductions in DNA's
to 5% target through improved scheduling.
x Improved access rates for GP's to diagnostic services by ring-fencing
additional Consultant hours to direct access initiatives for GP diagnostic
radiology, scoping etc;
x Improved clinical governance through the Clinical Directorate model that
facilitates the relevant Quality and Risk frameworks, Serious Untoward
Incident policies and maintenance of Risk Registers;

Page 15 of 20
x Improvements in compliance with Hospital Accreditation, Medical
Records Audit, and Hygiene standards

9. Clinical Directors appointed to manage Consultants


Consultant Contract 2008 introduces a new senior management position across
the health service –– that of Clinical Director. Consultant Contract 2008 describes
Clinical Directors as key members of the local corporate management team.
Clinical Directors are expected to plan how clinical services are to be delivered,
how resources are employed, contribute to strategic planning and achieving
service and organisational priorities and deploy and manage Consultants.

The Contract requires that each Consultant will report to a Clinical Director who
ensures service standards and governance requirements are met; monitors and
manages public:private mix; develops and manages rosters (with an emphasis in
the short to medium term on move to an 8am –– 8pm day and obtaining value
from the additional 4 hours per Consultant per week) and deals with grievances
and disputes, manages the initial stages of the disciplinary process, and helps
organise medical education and training.

The HSE is working with the Forum of Postgraduate Medical Training Bodies
and a number of sub-groups to develop the role of and support the work of
Clinical Directors

10. 49 Clinical Directors in place


In December 2008, taking account of significant engagement with Clinicians,
management and other health service staff over a period of months, the HSE
commenced an appointment process for Clinical Directors under Consultant
Contract 2008.

To date, 35 Clinical Directors have been appointed across the hospital system
from amongst those Consultants who accept Consultant Contract 2008. A
further 14 have been appointed in the Mental Health Services. Further Clinical
Director appointments will made over the next two years as services evolve. Up
to 77 appointments may be made in total. Appendix I refers.

11. High uptake of Consultant Contract 2008


The Consultant workforce is composed of a mix of permanent, temporary and
locum appointees. The whole time equivalent (wte) workforce eligible for offer
of Consultant Contract 2008 comprised 1,888 permanent employees and 312
locum or temporary employees –– 2,200.

Of the 1,888 permanent Consultants, negotiations continue between the


Universities, the Department of Education and Science and the Higher
Education Authority on the offer of the contract to 150 Academic Consultants.

An element of the HSE vote for 2009 was transferred to the Department of
Education and Science and subsequently to the HEA and the Universities to
fund the offer of Consultant Contract 2008 to Academic Consultants. The HSE
has no further involvement in the matter.

Page 16 of 20
In June, some of the Universities employing Academic Consultants began the
offer of Consultant Contract 2008 to those Consultants in their employment. At
7 July 2009, around 50% of Academic Consultants had accepted the terms of the
new contracts.

By July 2009, 1,688 consultants out of the 1,888 permanent consultants had
accepted the offer of Consultant Contract 2008. This represents an acceptance
rate of approximately 90%. The breakdown by Contract Type is as follows:

x Type A: 629
x Type B: 703
x Type B*: 356

12. Large increases in Consultant workforce

In March 2008 the IMO and IHCA agreed to advertisement of Consultant posts
under Consultant Contract 2008. Following this agreement, the HSE approved
128 Consultant posts which were advertised by the Public Appointments Service
throughout April.

In the period up to 31st December 2008, a further 155 posts were approved –– for
a total of 283 posts in 2008. 156 of these were new posts and 127 replacement.

During 2009 and noting the constraints imposed by the Government


Recruitment Moratorium which requires the abolition of two NCHD posts for
every Consultant post approved, the HSE approved 127 Consultant posts –– 65
additional and 68 replacement. Of the posts approved in 2009, 18 were Type A,
109 Type B, none Type C.

This means that during the period March 2008 to September 2009 the HSE
approved 221 new Consultant posts and 195 replacement. This represents an
increase of 10.4% in the number of Consultant posts in an 18-month period.
There are now 2,342 Consultant posts in the Irish public health service.

Tables setting out the current distribution of Consultant posts and the
distribution of additional posts between March 2008 and September 2009 are set
out below:

Additional Consultant posts approved under Consultant Contract 2008


March 2008 –– September 2009
HSE Area
Specialty Dublin Dublin Total
Mid- North South West
Leinster East
Anaesthesia 6 5 4 1 16
Intensive Care 2 2 4
Emergency
4 2 1 3 10
Medicine
Medicine 15 11 10 15 51

Page 17 of 20
Obstetrics &
3 3 1 7
Gynaecology
Paediatrics 2 7 5 5 19
Pathology 6 2 5 8 21
Psychiatry 12 8 10 6 36
Radiology 12 8 7 8 35
Surgery 4 6 4 8 22
Total 66 54 46 55 221

Permanent Consultant posts in the Irish public health system


September 2009
HSE Area
Specialty Dublin Dublin Total
Mid- North South West
Leinster East
Total 748 570 497 527 2342

13. Verifying contract delivery


Each signed Consultant Contract was reviewed and documented by HSE Internal
Audit as part of an internal audit process. This was a key means of ensuring that
the significant contribution made by Consultants to the delivery of health services
was recognised and recorded, that there was absolute transparency on the
delivery of public hospital services and that value was achieved for the resources
allocated to contract implementation.

The review examined all contracts issued and accepted by consultants employed
in the HSE and HSE funded agencies. Each contract was reviewed to identify
any alterations to the standard terms and conditions contained in the pro forma
contract agreed with the medical representative bodies in July 2008. The review
found:

x The vast majority of contracts signed by consultants and authorised by the


employer were in accordance with the standard terms and conditions;

x A relatively small percentage of contracts had been signed as approved by the


employer prior to being issued to the employee (none of these contained any
anomalies);

x A small percentage of contracts were not physically signed as authorised by


the employer, but these were included in the employer’’s records as issued
contracts;

x A very small number of contracts did contain manual amendments relating to


the treatment of private out-patients, however, these were not found to
materially affect the standard terms and conditions.

The HSE Human Resources Directorate also engaged in a verification process


for the 1,385 permanent Consultants who have accepted the offer of Consultant
Contract 2008 to confirm that the arrangements below were in place.

Page 18 of 20
a) Appropriate standardised Contract documentation

b) Increased working hours, particularly:


1) the service gain resulting from the increase from 33 to 37
scheduled weekly working hours.
2) The extent of service delivery over an extended working day as
required (8am to 8pm in contrast to 9am to 5pm).
3) The introduction of scheduled overtime on Saturdays, Sundays or
bank holidays in place of C Factor payments, the service gain
arising and cost basis for same.

c) New measurement arrangements for Public Private Mix, particularly:


1) measurement arrangements regarding each of the Consultant’’s
clinical activities, including Inpatient, daycase, outpatient and
diagnostics –– Section 20 and 21 of Consultant Contract 2008
refer.
2) The extent to which there is compliance with the specified ratio
of public:private practice
3) The extent to which a single waiting list for outpatient diagnostics
has been introduced in line with Section 21.

d) The appointment of Clinical Directors

The verification process concluded in March 2008.

14. Payment to Consultants


Following the HSE’’s verification process and to ensure the gains to patient
services from the new contract were secured, the Minister for Health & Children
set out in a statement on the supplementary budget of the 7th April 2009 that the
Consultant Contract was to be implemented on the basis of part payment of the
new Consultant Contract salary rates.

Approximately half of the differential between the 1997 and 2008 salary rates was
to paid in 2009 as and from 1st January 2009. The original payment schedule had
identified the new rates for Consultants accepting the new contracts to apply
from the 1st June 2008. The other half scheduled for the 1st June 2009 was not
sanctioned and has not been sanctioned to date.

The HSE has no authority to make payments other than those approved by the
Minister for Health & Children.

Page 19 of 20
An Comhchoiste um Shláinte agus Joint Committee on Health and
Leanaí Children
Dáil Éireann Dáil Éireann
Teach Laighean Leinster House
Baile Átha Cliath 2 Dublin 2
Phone: (01) 618 3021
Fax (01) 618 4124
E-mail: sinead.mccann@oireachtas.ie
10th September 2009

Professor Brendan Drumm,


CEO,
Health Service Executive (HSE),
3rd Floor, Block D
Parkgate Business Centre
Parkgate Street
Dublin 2

Dear Professor Drumm,

I am directed by Mr. Seán Ó Fearghaíl, T.D., Chairman of the Joint Committee on


Health and Children, to invite you to come before the Joint Committee to give an
update on health & HSE issues. The meeting will take place at 10.00 a.m. on
Wednesday 7th October 2009 in Committee Room 3, Leinster House, 2000.

You should note that Ms. Mary Harney, Minister for Health and Children has also
been invited to attend the meeting.

I will be in contact shortly with your Parliamentary Affairs Officials in regard to the
format of the meeting.

I would like to draw your attention to the fact that members of the Committee have
absolute privilege but this same privilege does not apply to witnesses appearing
before the Committee.

I would be grateful if you would confirm in writing whether you can attend the
meeting as soon as possible.

If you require further information do not hesitate to contact me at Tel: 6183021.

Yours sincerely,

__________________
Sineád McCann
Clerk to the Committee
Question 3 (national Question) CEO Only

Update on ““A Fair Deal –– The Nursing Home Support Scheme””

Joint Oireachtas Committee on Health & Children meeting

7th Oct 2009

To ask the Minister for Health and Children and the HSE Chief Executive for an
update on the Fair Deal (Nursing Homes Support Scheme Act 2009) scheme,
including details on: when it will commence, proposed changes to the scheme and if
negotiations have been completed with nursing home people etc.

The DOHC have indicated that they will be taking the response on this; however the following details on the
operationalisation/implementation of the scheme are relevant.

The Scheme
The Nursing Homes Support Scheme is a scheme of financial support for people in need of
nursing home care. The legislative basis for the scheme is the Nursing Homes Support
Scheme Act 2009. The Scheme is expected to commence in the last quarter of 2009.

Applicants to the scheme must undergo a care needs assessment to determine whether they
need nursing home care and a financial assessment to determine their ability to contribute
towards their own care. Based on the outcome of both these assessments, the HSE will
decide on the payment of financial support.

The scheme involves a co-payment arrangement between the person and the State.
Essentially, the person will contribute up to 80% of assessable income and up to 5% of the
value of any assets they own towards the cost of their care. The State will then pay the full
balance of the cost. It is important to note that a person will never pay more than the cost
of their care regardless of the level of their means.

The new scheme will replace the existing Nursing Home Subvention Scheme. The scheme
will be budget-capped.

1
Care Needs Assessment
A person or a family member/ guardian can apply to the HSE for an assessment of care
needs. The needs assessment will be carried out by healthcare professionals using a common
summary assessment record (CSAR), which is a document setting out a summary of the
applicant’’s needs and the determination of care needs. If the applicant is assessed as needing
long term residential care, a decision can then be made in respect of the provision of
financial support under the scheme.

Financial Assessment
The Financial Assessment works out how much the applicant shall contribute to the cost of
their care by taking into account their income and assets.

The assessment will establish a person’’s ability to contribute to their care costs based on
80% of their assessable income and 5% of the value of their assets, including their principal
residence. It contains safeguards to ensure that the spouse or partner remaining at home
keeps a minimum retained income. No one shall pay more than the agreed cost of care
applicable for the facility. The person’’s principal residence will be excluded from the
financial assessment after 3 years from the date on which the person entered care including
time spent in care before the commencement of the Scheme. The person’’s farm and
business may also be excluded from the assessment after 3 years in certain circumstances.
This means that the deferred contribution from such assets may in certain circumstances be
capped at a maximum of 15%, i.e. after three years of care, the applicant will not be liable for
any further contribution in respect of such assets.

Contribution to Care
During the applicant’’s stay in long term residential care, they shall contribute the amount
determined in the financial assessment based on 80% of their assessable income and 5% of
the value of any cash assets (i.e. effectively savings) over the asset disregard per annum. The
annual contribution will be advised to the applicant in weekly terms also.

2
If their assessed means includes land and property, the 5% contribution based on such assets
may be deferred. This means it may not have to be paid during the person’’s lifetime and
may be deferred (‘‘Deferred Contribution’’) and collected from their estate. In order to
facilitate payment of the fees in such cases, a Nursing Home Loan/Ancillary State Support
will be provided by the HSE. This loan will be released to the nursing home on a weekly
basis. The applicant cannot assume that ancillary state support (the nursing home loan) will
be approved but must await formal notification of the outcome of the application. This
benefit is referred to as the Nursing Home Loan (““Ancillary State Support””) and must be
applied for.

This Deferred Contribution will be up to 5% of the value of certain chargeable assets per
year. It will apply only to each year of care and will be charged on a pro rata basis for any
period of care of less than one year. If there is a spouse or relatives (as defined in the Act)
living in the principal residence, the charge may be further deferred.

Selection of Nursing Home


The applicant can choose care in any designated long stay facility (i.e. in a private nursing
home or in a public / voluntary facility) –– subject to availability and suitability of the home
to meet the applicant’’s care needs. Local staff are available to assist applicants in accessing
suitable placements. However, the principle of patient choice is legally enshrined in the Act
and staff may only direct applicants, and recommend facilities, where there are clear medical
criteria for same which can be absolutely defended.

State Support
State Support will be provided as follows:
x For residents in a private nursing home, they will make their co-payment to the
nursing home and the State will meet the balance of the agreed cost of care to
provide the service
x For residents in public nursing homes, the State will collect their co-payment and
provide the service
x For residents in voluntary nursing homes, the voluntary agency will collect their co-
payment and the State will meet the balance of the agreed cost of care.

3
Care Representative
In order to benefit from the Nursing Home Loan, a person needs to consent to a Charging
Order being placed against the asset in question. The Charging Order is a simple type of
mortgage which provides the security for the loan advanced by the HSE. If a person is
found to lack capacity under the functional assessment, they will not be able to consent to
the creation of the Charging Order. For this reason, they will require a care representative to
act on their behalf.

The care representative must be appointed by the Circuit Court. Their role is set out in
section 21 of the legislation and is limited to:-

(a) making an application for the Nursing Home Loan,


(b) consenting to the creation of a Charging Order in relation to the asset concerned, and
(c) taking necessary actions in connection with the application for the Nursing Home Loan,
the creation of the Charging Order and the registration of the Charging Order in the Land
Registry or the Registry of Deeds.

While the role of, and requirement for, the care representative is clearly limited to the actions
listed at (a) to (c) above, a care representative may assist an applicant to the scheme with any
matter in the same way that a non-court appointed representative may.

A care representative is required where a person lacks the capacity to make a decision in
relation to the matters listed at (a) to (c) above.

PCCC
Services for Older People
September 2009

4
Question 5 on National Issues –– 7.10.09 –– CEO’’s File only

Brief for Brendan Drumm, CEO:

Inspection of disabled children’’s residential facilities:


To ask the Minister for Health and Children and the HSE Chief Executive
when will residential services for children with a disability be inspected and
registered.

The Department of Health and Children will lead the response to this question.

The decision on whether and when to register and inspect facilities for children with
disability is for the Department of Health and Children, the Minister for Health and
Children and for HIQA. The HSE has no decision in this matter.

The HSE was co-operating with HIQA in developing standards for children's services which
will include residential services for children with disabilities. We are also working with HIQA
and DoHC on identifying the number and location of residential centres for children with
disabilities.

The timing of when centres will be inspected will be determined by HIQA and the DoHC.
Question 6 (National Issues) Symphysiotomy in Ireland (CEO’’s File only)

Joint Oireachtas Committee for Health and Children

Note on services offered to all symphysiotomy clients to date:

x Medical assessment
x Gynaecological assessment
x Counselling
x Reflexology (GP to recommend)
x Physiotherapy (GP to recommend)
x Osteopathy (GP to recommend)
x Acupuncture (GP to recommend)

Independent clinical advice is available, on request, through the local liaison officer to
patients who have undergone symphysiotomy.

Individual pathway of care for symptoms directly related to symphysiotomy recommended


for patients by their GP and/ or consultant are fast tracked.

Applications for home help and home modifications are responded to on an individual basis
and applications fast tracked, if necessary. Clinical assessments and/or advice will be offered
to symphysiotomy patients where requested, including a home assessment by an
Occupational Therapist or Physiotherapist.

A refund of medical expenses related to symphysiotomy is made where necessary to patients


in respect of medication/private treatments required to address the effects of
symphysiotomy.

Once an individual patients condition has been confirmed they have automatic entitlement
to a medical card without a financial assessment being carried out.
Joint Oireachtas Committee for Health and Children

What protocols are currently in place to deal with people who present themselves at
psychiatric units with suicidal tendencies and if there are procedures in place to
contact the family of psychiatric patients when they are being discharged from
hospital.

Psychiatric Units accept referrals from Community Mental Health Teams and General
Practitioners. In some instances, clients self refer and in these circumstances staff perform
an assessment on the patient. If there are concerns in relation to the patient’’s health, the
Consultant on call will undertake a psychiatric assessment and depending on the outcome,
invite the patient to stay if clinically indicated or offer an early appointment at an appropriate
community facility. These facilities may include an outpatient clinic, day hospital or follow
up home care.

With their expressed permission, family members and carers of the patient can be invited to
become involved in the care programme. This is the HSE preferred model and indeed is the
model recommended in ““A Vision for Change”” to work with, but this is dependent on the
agreement of the individual concerned. We are bounded by patient confidentially which we
must respect.
QUESTION

The vast majority of expectant women experience an uneventful pregnancy


requiring no or minimal intervention antenatally, during labour and in the
postnatal period. Pregnancy is a normal life event and despite the fact that
delivery normally takes place in a hospital based maternity unit here in
Ireland, the fact is that pregnant women are not ill.

Will the Minister/HSE acknowledge that to provide care in a holistic and


women centred way, we must move away from the idea that a ““centre of
excellence”” is necessary for all pregnant women and, in fact, if implemented
would ultimately only increase the amount of interventions made through
increased inductions/instrumental deliveries/caesarean sections etc as a
result of facilitating the increased numbers passing through such a unit.

RESPONSE
The HSE is committed to extending and enhancing primary and community service
models as a preferred approach to providing care to mothers and babies with
uncomplicated pregnancies and treatment needs. We recognise the centrality of clinical
involvement and leadership in the design provision and improvement of care. The role of
the midwife is recognised as being fundamental to delivering women and baby-centred
maternity services.

The provision of maternity care is constantly evolving to respond to the changing needs of
women in Ireland and their families. The Primary Care Strategy (2001) highlighted the
need to develop national community midwifery schemes to align with the development of
primary care schemes nationally. Midwives provide care in maternity hospitals/units,
recently developed midwifery-led units and increasingly through the provision of
midwifery-led services in the community. Midwives work in partnership with obstetricians
and other members of the healthcare team in the provision of care, particularly to women
with complicated pregnancies.

The HSE has made a commitment in its Transformation Programme to develop its
strategic approach to Maternity Services nationally and this started in 2007 with the
Independent Review of Maternity & Gynaecology Services in the Greater Dublin Area.
The HSE/KPMG report on the Review of Maternity & Gynaecology services in the
Greater Dublin Area was published in February 2009 and is available on www.hse.ie. The
report is an integral blue print for maternity and gynaecology services. The review
provided an opportunity for organisations and individuals to debate and exchange ideas
for positive change maximising improvement for mothers and babies in terms of the
model of care and choice/safety agenda.

The report concluded that Dublin’s current model of stand alone maternity hospitals is not
the norm internationally. It is well recognised that for optimal clinical outcomes maternity
services should be located with adult acute services. This allows the mother to access a
full range of medical and support services should the need arise for (for example) cardiac
and vascular surgery, diabetes services, intensive care facilities, haematology services,
psychiatric services among others.

The development of co-located Midwifery led Units (MLUs) alongside obstetric units is a
key recommendation for the Greater Dublin Area. Pilot co-located MLUs were established
in 2004 in the North East area in Cavan General Hospital and Our Lady of Lourdes
Hospital in Drogheda and are still ongoing. These units are currently being evaluated by
the School of Nursing and Midwifery Trinity College Dublin and early indications are that
they are popular with women. Formal evaluation of these MLUs is imminent.

We are aware of the desire of all parties to progress the implementation of the
HSE/KPMG report recommendations and we are arranging to put in place appropriate
national, regional and local level supports for the work streams identified across service
redesign, workforce needs, clinical governance, teaching and training and physical
infrastructure requirements.
JOINT OIREACHTAS COMMITTEE

ON

HEALTH & CHILDREN

7th October, 2009

Local Issues for the Quarterly Meeting

with the Minister for Health and Children

and the

CEO of the Health Services Executive


1. To ask the minister for Health and Children and the HSE Chief
Executive if they will restore to Monaghan General Hospital the
acute services removed on 22nd July 2009 and which removal has
already proven to be a major threat to patient safety and a
severe strain on services at Cavan General Hospital.
North East Transformation Programme
The Transformation Programme for the North East region involves widespread
and fundamental change. It is designed to build a health system that is in line
with the model of care emerging internationally. This can be achieved by
centralising acute and complex care so that clinical skill levels are safeguarded by
ensuring access to a sufficient throughput of cases.
This was highlighted, along with identified patient safety and quality of care
issues, in the 2006 Teamwork Report to the HSE - "Improving Safety and
Achieving Better Standards - An Action Plan for Health Services in the North
East".
The first step in the development of a fully integrated regional health service is to
ensure that the people of the North East have local access to both routine
planned care and immediate life saving emergency care.
A series of focused service changes are planned for the region. The immediate
focus of the Transformation Programme is to reconfigure services by moving
acute and complex care from 5 hospital sites (Cavan, Monaghan, Drogheda,
Dundalk and Navan) to 2 (Cavan for Cavan/Monaghan and Drogheda for
Drogheda/Dundalk/Navan) and to ensure that services in the region are
organised to optimise patient safety.

Since the 22nd July services have been centralised from Monaghan to Cavan as
part of the NE Transformation plan, a number of staff have been redeployed to
support the enhanced services in Cavan General –– MAU, ICU, addition
ambulance personnel. To enable this in some instances there has been a direct
discipline specific transfer, however in other cases where a grade for grade
transfer has not been feasible posts freed up from the transfer of services are
being reconfigured and redeployed in the region to address identified quality and
risk issues. In particular the identified 50 priority Transformation posts to
address the following long standing priority objectives:

x Progressing full implementation of the Lourdes Inquiry Report -


x Establishment of High Dependency Unit within Maternity Services
x Key support posts including MIS system, CNS Pain management, Audit
Facilitator
x Progressing Harding Clarke & Anaesthetic review report requirements in
respect of
x Moving to full consultant anaesthetist separate 24 hour obstetric rota at
OLOL
x Improving the on call cover for Consultants and NCHD’’s.

Page 1 of 17
x Meeting Birth Rate Plus best practice midwifery staffing levels at Cavan
General Hospital (CGH) and OLOL i.e. 1 midwife to every 37 births ( based
on 1,957 and 4,331 births respectively in 2008)
x Meeting British Association of Perinatal Medicine guideline for nurse staffing
in Neonatal Intensive Care within CGH (+2 ) and OLOL (+14)
x Moving towards Irish College of Obstetrics and Gynaecology standard of 1
Consultant obstetrician / gynaecologist to every 500 births ( 4th Consultant
CGH and 8th OLOL)
x Implementing FS report recommendations re 1 paediatric registered nurse on
each shift in ED at CGH and OLOL
x Progressing the initial strengthening of medical services in the areas of
Cardiac and the nurse manager for the Medical Assessment Unit
x Progressing the opening of the new ED Department at OLOL Drogheda

In relation to services in Cavan, there has been a decrease in the number of


patients per day attending the Emergency Department at Cavan General Hospital
since the transfer of acute medical services from Monaghan Hospital.

An analysis of patients presenting at Cavan General Hospital pre and post


Monaghan coming off call has been carried out. Dates used for comparison were
the 7 weeks before Monaghan went off call 4th June - 22nd July 2009 and the 7
weeks after the introduction of the changes i.e. July 23rd to 9th September 09

This analysis found that the there has been an overall decrease in daily
attendances at the Emergency Department by an average of 2 per day as patients
with medical needs are being treated in the Medical Assessment Unit (MAU)
which provides a more appropriate alternative for many patients who typically
attend Emergency Departments.

It also found that an average 1.5 extra patients are requiring admission per day
from the Emergency Department. The average number of patients waiting for
admission to a bed from the Emergency Department at 2pm each day has
increased slightly from 0.5 to 1, this anticipated rise in activity is catered for by
the extra capacity in the observation ward which accommodates all patients who
require observation for a period of 24 hours, and admission ward which
accommodates patients in an appropriate environment to await beds from the
time of decision to admit is made until an inpatient bed is available.

There has been an expected increase in numbers attending the medical


assessment unit in this 7 week period. This increase in MAU attendances is an
average of 1 patient daily, admissions from the MAU in this period has increased
by 1 patient daily.

Page 2 of 17
2. The Future of the HSE services in the South East, particularly
St. Luke’’s Hospital, Kilkenny and Wexford General Hospital.

The HSE future strategies for health service delivery are now proceeding to
implementation through the Transformation Programme. The aim is to
substantially align Irish health services with recognised international best practice.

The HSE is now seeking the implementation of these strategies across the South
East. Other factors including the cost of service provision and the
implementation of the European Working Time Directive for Non Consultant
Hospital Doctors will influence the implementation of HSE strategies.

A steering group was established in April 2009 to lead the project to plan and
implement the acute hospital transformation programme in the South East. The
title of the project is ““Future Development of Acute Hospital Services””. In the
process of defining and planning the future Organisation of services the Steering
Group has established three Regional Specialty Advisory Groups to provide
specific advice and information on individual services. This advice / information
will advise the strategic plan for a revised model of care.

All hospitals in the South Eastern Hospital Group - consisting of Wexford


General Hospital, Waterford Regional Hospital, South Tipperary General
Hospital, and St Luke’’s Hospital Kilkenny - will be included in the plan for the
revised model of care.

In this regard, no decisions regarding the roles of services of any hospitals will be
taken until this plan is completed through a process of broad based consultation
within the services.

It is anticipated that the role of the 4 hospitals in the South East including
Waterford Regional Hospital will change substantially in the future.

It is likely to be the end of 2009 before this review is completed. The review will
be published in the first quarter of 2010.

3. To ask for an update and commitment in respect of plans to


develop and open an urgent care and ambulatory care centre at
Tallaght Hospital in advance of the paediatric hospital
development at the Mater site.

The RKW Consultants High Level Framework Brief for the new Paediatric
recommended, along with an ambulatory and urgent care centre on the Mater
campus, that the first such centre be developed at Tallaght Hospital. Many
parents who currently access urgent care type services at Tallaght, will be able to
continue accessing these services, but will do this via the new Ambulatory Centre
–– a separate dedicated facility that will be constructed. Discussions have
commenced with management at AMNCH to cede a suitable site.

Page 3 of 17
4. To ask for confirmation of future plans for the delivery of cancer
services to the catchment area of Tallaght Hospital.
In relation to Symptomatic Breast Care Services, all new referrals to the AMNCH
Unit ceased on 31st August 2009. General Practitioners were informed of this by
both the NCCP and by the CEO of AMNCH. Referrals are now directed
towards St. Vincent’’s and St. James’’s Hospitals, the two Cancer Centre’’s for the
Tallaght catchment area.

The NCCP and all three hospitals are now working together to manage the care
of current Tallaght patients. Appropriate arrangements will be made for their
ongoing care and follow up. Patients and GP’’s will be communicated with if it is
necessary to transfer their care to St. James’’s or St. Vincent’’s. Medical Oncology
will continue to be provided in Tallaght for patients who prefer to avail of the
service closer to their home.

In the NCCP Service Plan there are plans to transfer other surgical services of
significant volume from Tallaght in the coming year. These are currently under
discussion. The next service likely to transfer will be pancreatic cancer which
affects a low number of patients (approximately 25 per year). It is anticipated
that this transfer will happen in January 2010. Rectal Cancer Surgery will also
transfer later in 2010 (approximately 40 cases per year).

Pancreatic cancer will move to St. Vincent’’s University Hospital and Rectal
Cancer will move to St. Vincent’’s University & St. James’’ Hospitals.

5. To ask for a detailed report on plans for the further


development of community health services in Tallaght and the
general Dublin South West constituency area.

The following is the position with regard to Dublin South West Primary,
Community & Continuing Care

Tallaght
Tallaght has a population of some 90,000 people and the profile is younger than
the national average. There are large pockets of social disadvantage and a large
immigrant community from African and Eastern European countries.

The HSE, either directly or through funded local organisations, provides a full
range of services to the people of Tallaght, including the full range of Primary
Care services, Child, Youth and Family Services, Disability Services, Older
Persons’’ Services, Mental Health Services, social inclusion, and addiction services.

Primary Care Developments


In line with the Primary Care Strategy multi-disciplinary Primary Care Teams are
being developed to serve local populations of 8,000 to 12,000 people. We are
developing 18 Primary Care Teams, supported by four Health and Social Care
Networks for the Dublin south west area, including Tallaght, serving a
population of approximately 148,000:

Page 4 of 17
Teams functioning or in active development in 2009:
Brookfield / Fettercairn (Tallaght west)
Killinarden / Oldbawn (Tallaght west)
Jobstown / Citywest (Tallaght west)
Springfield / Belgard (Tallaght west)
Cashel Road (Crumlin/Drimnagh)
Curlew Road (Crumlin /Drimnagh)
Old County Road (Crumlin / Drimnagh)

Teams for development 2010


Kilnamanagh (Tallaght east)
Tymon (Tallaght east)
Millbrook (Tallaght east)
Parnell Road (Crumlin)

Teams for development 2011:


Firhouse-1
Firhouse-2
Limekiln (D6w / D12)
Templeogue (D6w / D12)
Terenure (D6w / D12)
Walkinstown (D12)

As of August 31st this year, a total of 80 WTEs have been reconfigured into
Primary Care Teams, The majority of these staff are Clinical (eg. Nurses,
Physiotherapists and Occupational Therapists etc).

The initial focus of development in this LHO area has been on the Tallaght west
Network, which has the highest profile of social disadvantage. Currently four
Primary Care Teams are in development to serve the communities of Jobstown-
Citywest, Brookfield-Fettercairn, Springfield-Belgard and Killinarden and the
Minister for Health and Children has agreed to open Community Information
Days for these teams before the end of November.

These teams which include GPs, Nurses, Occupational Therapists and


Physiotherapists will be the first port of call for people from the local community
who require health or social services. The teams will be supported at Network
level by additional services including Social Work, Psychology, Speech and
Language Therapy, Mental Health and specialist services for older persons or
children with a disability. A community consultation process, designed to work
towards ensuring strong community participation in the further development of
services provided by Primary Care Teams in the area, is underway. This process is
being enhanced by special funding jointly provided by the HSE and the former
Combat Poverty Agency.

Strong links continue to be forged between Primary Care Team members and
voluntary and community groups working in the Tallaght West area, striving
towards an integrated approach to serving local communities.

A suitable premises was identified (Chamber House) by the HSE in the heart of
Tallaght to accommodate the social and care network services and the Springfield

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/ Belgard PCT and was included in the HSE Capital programme for 2009.
However due to the reduction in capital provision for this year it is not possible
to proceed with this development at this time.

Other sites in the Tallaght area, Kilnamanagh, Firhouse and Citywest are being
considered for primary care developments. These are being considered under the
term of the Public Private Partnership process. Negotiation in relation to some of
the sites is ongoing and subject to relevant approvals delivery of new sites is
expected in 2011 and 2012.

The existing health centre at Millbrook Lawns has been substantially refurbished
and was completed earlier this year to a high standard.

The Brookfield / Fettercairn PCT has been leading in the development of a


shared approach to the management of chronic conditions in partnership with
AMNCH staff at Tallaght. The initial focus for this project is in the management
of diabetes.

In addition to the general development of primary care, the following


developments in children and family services, older persons services and
addiction services are highlighted to give an indication of ongoing service
development.

The HSE is chairing the multi-agency South Dublin Children Services Committee,
one of four pilots nationally being developed under the Towards 2016 Agreement.
This innovative project involves interagency cooperation involving all the main
agencies that impact on the lives of children, with a view to coordinating services
and working together to ensure best outcomes for their work.

Some of the initiatives include developing alternative responses and enhancing


the multi-agency response to critical incidents. The HSE is also an active
participant in the Childhood Development Initiative (CDI) in Tallaght West.

The Knockmore Child and Family Centre, Tallaght, Dublin 24 is primarily a joint
venture between the HSE, South Dublin County Council and Barnardos. The
Child and Family Centre is part of the Knockmore Mixed Use Project, which is a
multi-agency, multi-use project enjoining the objectives of a number of
Government policies and departments. All elements of the project received the
requisite statutory approvals. The development of the Centre is on hold pending
the availability of capital monies from the various partners involved in its
development.

Developments in services for Older Persons include the delivery of core


community services and the expansion of home care services, including home
care packages and home help services. The HSE is providing capital funding a
new day care centre for older persons, in partnership with St John of God
Hospitaller Services, as part of a new supported housing development at
Cookstown Way, Tallaght. Construction is well underway on this major
infrastructural project.

Page 6 of 17
The HSE participates in the RAPID developments across the area and is actively
involved in the work of local Drug Taskforces.

In the Tallaght area, the Belgard Road Treatment Centre provides a range of
treatment services including community alcohol services, assessment, nursing,
medical, counselling, psychiatry, treatment, dispensing, education, liaison
midwife, outreach and community welfare services. There is a specialised service
for under 18’’s (YODA) based in Belgard Road. The team includes a Consultant
Child & Adolescent Psychiatrist, Registrar, Specialised Nurse, Counsellor and
Family Therapist.

The HSE provides wide range of services to adults who have mental health
difficulties with a strong emphasis on delivery of these services in the community
and the consequent reduction in dependency on institutional care. The Dublin
South West area is particularly well developed in this field where a significant
home care service is provided in the community.

6. To ask the Minister for health and Children if she will consider
appointing a Consultant Endocrinologist at Letterkenny
General Hospital.

There is no Consultant Endocrinologist at Letterkenny General Hospital. One


of our Consultant Physicians run specialised diabetic clinics and another
Consultant who retired this year comes in to run a specialised diabetic clinic.
Also, 1 of our 2 Consultant Geriatricians runs a monthly diabetic clinic. The
Consultant Endocrincologist/Diabetologist is on our list for future Consultant
requirements at LGH

7. What is the current situation regarding the transfer of Breast


Cancer services from the South Infirmary Victoria University
Hospital (SIVUH) to Cork University Hospital (CUH). Are the
Consultants and Medical staff fully supportive of the move and
what discussions have taken place with GPs regarding the
aftercare they will be expected to provide for patients of the
Unit.?

Cork University Hospital is one of 8 dedicated cancer centres established in line


with the National Cancer Control Strategy and is committed to responding to the
continued priority for the centralisation of cancer services in these centres of
concentrated expertise.

The relocation and development of Symptomatic Breast Cancer services in the 8


Centres was identified as the first cancer service to be enhanced under the
National Cancer Control Programme (NCCP). In the South (Cork/Kerry) this
initially involved the successful relocation of diagnostic and surgical symptomatic
breast services from Kerry General Hospital to CUH in October 2008. The
transfer was progressed via a Breast Care Planning Team who met on a weekly
basis to ensure that the infrastructure, staffing and care pathways were in place to
accommodate the move. To facilitate the transfer and to support the further

Page 7 of 17
development of the service, the appointment of additional Consultant, Nursing,
Allied Health Professional and Administrative staff was approved and funded by
the NCCP.

To afford all patients across the South a high-volume quality service, the next and
final step in the centralisation of the symptomatic breast disease service is the
amalgamation of the Cork University Hospital (CUH), South Infirmary Victoria
University Hospital (SIVUH) and Mercy University Hospital (MUH) (Pathology)
breast disease services at Cork University Hospital by late 2009. To progress the
move, and to ensure wide-spread engagement and consultation, a joint
governance programme between NCCP, HSE, CUH, SIVUH and MUH has
been set up to afford all stakeholders, including frontline Consultant medical and
other clinical staff on the 3 sites, the opportunity to participate in the planning
and development of the service. This includes:-

(a) An over-arching High Level Steering Group


(b) A Cancer Centre project implementation group which meets
fortnightly and is actively working on actions required to progress the
amalgamation
(c) 7 sub-groups with multi-disciplinary staff membership from the 3
sites who are working collaboratively on the detailed planning for the
future service using the national standards on Symptomatic Breast
Disease developed by the Health Information and Quality Authority
(HIQA) and NCCP. Of note, the membership of these groups
includes Consultant medical staff.

In conjunction with this work, the following key infrastructural issues are being
addressed to ensure adequate capacity for the amalgamated service:-

x Radiology/Mammography/OPD capacity
x Inpatient and Day Bed requirements
x Theatre Capacity
x Pathology service
x Multidisciplinary meeting facilities and office accommodation

To support the Cork University Hospital Cancer Centre programme, NCCP has
provided capital funding of €€5.750m set to develop an integrated diagnostic
centre which will accommodate the symptomatic breast service along with
planned rapid access clinics for lung, prostate and colo-rectal patients. This
funding will support the development of full diagnostic clinics and treatment
facilities and will significantly enhance cancer service provision within the South.
Revenue funding of €€1.476m has been provided for additional posts of
Consultant in Radiology and Consultant Anaesthetist, along with support staff
for the Cancer Centre at CUH.

One of the sub-groups mentioned above was established to enable NCCP/HSE


to jointly address Human Resource issues/queries via a HR Framework
agreement, pre transfer of the service. This includes Consultant medical staff
reservations/questions on:

Page 8 of 17
x Contractual issues
x Patient care pathways
x Transfer arrangements
x Sessional commitments etc

and any issues that arise are being actively pursued and addressed. As part of this
process, a joint HR meeting was held with all relevant SIVUH Consultant
medical staff on Friday, 18th September, 2009 at the South Infirmary Victoria
University Hospital.

Communication with General Practitioners is taking place at national and local


level to further open dialogue with all primary care givers. Dr. Marie Laffoy has
been appointed as Community Oncology Advisor to the NCCP and she and her
staff have:-

(a) Prepared a work plan which includes the development and embedding of
the usage of standardised breast cancer guidelines and referral forms.
They are progressing this via ongoing training days for GPs and other
health professionals (one was done in Cork in April)
(b) Developed and are putting in place clear and consistent patient pathways
that will enable cancer patients to continue to receive appropriate
elements of their treatment, care/after-care and support from their family
doctor, local hospitals and community services staff. They are working
with specialist services to examine the best way that patients with early
stage breast cancer can be followed up which includes the review of best
evidence in this regard and a draft protocol for follow-up of these
patients has been prepared. They are currently consulting with patients,
GPs and the specialist services in relation to protocol before finalising
this.
(c) Set up a Community Oncology Liaison Group, chaired by a Local Health
Manager from PCCC services in Cork, with GP representation on the
group.

8. In the light of the absolute unavailability of funds for the capital


development of the new major hospital in the North East,
would it not be better, in the South East, to allow the present
successful and excellent sector hospitals in Wexford, Kilkenny
and South Tipperary continue their work without interference,
as it seems extremely unlikely that the massive capital
developments required by the reconfiguration of services
proposed by Prof. Brendan Drumm and the HSE could be put
in place before 2020 at the earliest.

The capital requirements in the South East are not the same as the North East.
While there is a requirement for a completely new hospital in the North East, this
is not the case in the South East. As no decisions have been made about the
future model of care in the South East it is premature to make any detailed
comment on Capital Infrastructure. This will be assessed as part of the planning
process and all factors will be taken into consideration before a final decision is

Page 9 of 17
made on the future organisation of services in the South East. The provision of
Health services in the South East will be continued in the existing hospital
facilities.

9. In South Tipperary General Hospital, Clonmel, last year, 1149


children were seen in the Day Ward and in excess of 4000
children were seen in the Paediatric Unit. 1647 children were
admitted for continuing treatment and of the more than 2,500
children seen in the Emergency Room, the vast majority were
treated to discharge avoiding admission to the Unit. This is by
far the most satisfactory way to treat children ensuring
minimum disruption and psychological upset to the child.
What assurance can the Minister/HSE give that the quality of
the service being provided in Clonmel will not be eroded should
it be decided to transfer to a site that is already working to
capacity?

The vast majority of sick children are treated for discharge in the 4 hospitals in
the South East, thus avoiding unnecessary admissions to the 4 units. There is no
argument against this current model of ambulatory care. The Women and
Children’’s Specialty Advisory Group is currently advising the Steering Group on
the future organisation of paediatric services.

10. Can the Minister provide an update on the Cystic Fibrosis unit
in St Vincent’’s Hospital?

St. Vincent’’s Hospital currently treats over 50% of the CF adult population.

The HSE is now working with St. Vincent’’s to identify opportunities for patients
who do not require tertiary level care to be treated close to home where adult
services have been developed in the other specialist centres.

2.1.1 Staffing Enhancements

Additional funding enables the recruitment of up to 19.0 wte additional


staff across the full range of disciplines for the specialist treatment of
CF.

2.1.2 Infrastructure

x Ambulatory care for CF patients at St. Vincent’’s is provided in the


new building opened in 2006.

x Eight new single en-suite rooms (St. Christopher’’s Ward) for the in-
patient treatment of CF were opened at the hospital in August 2008.
This brings the total level of in-patient accommodation for the
treatment of respiratory patients (including people with CF) at the
hospital to 63 beds.

Page 10 of 17
x A new ward block to replace existing accommodation is being developed at
the hospital. This facility will provide single room en-suite inpatient
accommodation (100 rooms) and a dedicated day unit for people with CF,
including 10 single day treatment rooms with en-suite sanitary facilities. It is
intended that construction will commence in 2010 and the building will be
operational by mid 2011. Site clearance work has already commenced.

x The HSE is arranging to commence a contract for enabling and decant works
on site and is completing tender documents for the ward block in order to
ensure earliest possible commencement of construction in 2010. It expected
that the development will become operational in mid 2011

11. 1,100 medical card holders in the south of the country who are
seeking routine renewals have been turned down by the HSE
even though their economic circumstances haven’’t changed or
in some cases have worsened –– has a policy decision been
made to cut down on the number of medical card holders?

There has been no change in medical card assessment procedures in the HSE
South area. This area has been implementing the National Medical Card
(MC)/GP Visit Card (GPVC) Assessment Guidelines since they were introduced
in December 2005 (and updated in March 2007 & May 2009). The national
document gives very clear guidance on eligibility based on financial assessment.
The document also gives guidance on determining entitlement to persons whose
income exceeds the financial guideline i.e. where medical or other exceptional
circumstances may result in undue hardship.

Due to the changes in our economic environment, changes in household


circumstances have been noticed generally. Mortgage rates have reduced and
rent charges have been substantially reduced. Persons previously on low earnings
are now working reduced hours and qualifying for Social Welfare payments and
their combined income from earnings and Social Welfare is greater then when
they were working full time. In addition the medical card financial guidelines
have not increased with a number of years.

In response to queries received from Public Representatives, information on the


number of applications for medical cards approved and refused in the HSE
South area was put into the public domain. This was reported on in a national
newspaper where the report generated some confusion between normal
applications for new medical cards and reviews of existing cards. The position
can be clarified as follows:

From January to June this year, 93,114 applications for medical cards were
processed by the HSE South, with 80,977 approved and 11,228 refused. The
HSE also processed 13,345 applications for a GP visit card in that period,
refusing 2,892.

In addition cards have been reviewed throughout the year and the suggestion has
been made that a more onerous approach was being taken than in previous years.

Page 11 of 17
In this regard a comparison has been made between 2008 & 2009 and the
position is as follows:

In 2008, of the total number of cards reviewed in the South West (former SHB
area) 90.24% were granted cards with 9.76% being refused.

In 2009, of the total number of cards reviewed in the South West (former SHB
area) 88.64% were granted cards with 11.36% being refused. This represents an
increase of just only over 1% and does not reflect a significant change in the
approach to dealing with applications.

In 2008 In the South East (former SEHB area) the total cards reviewed 75%
were granted cards with 25% being refused.

In 2009 In the South East (former SEHB area) the total cards reviewed, 85%
were granted cards with 15% being refused. This represents a reduction in the
number of cases being refused in the South East.

The HSE trusts that the figures demonstrate overall how HSE South continues
to apply the medical card guidelines in a standardised way and continues to take
account of individual circumstances as heretofore.

Page 12 of 17
12. Could the Minister give an up to date statement on the
reconfiguration of acute hospital services in the Greater Cork
area involving Cork hospitals, Mallow and Bantry.

A three phase consultation process comprising of the following is in place for


the reconfiguration of hospital services in the south.

1. Broadly based consultation leading to the public launch of the


Horwath and Teamwork Report (2008)
2. Establishment of subgroups to conduct a detailed examination of
each aspect of clinical services, and
3. The synthesis of an integrated plan for the reconfiguration of services
in Cork and Kerry

Establishment of subgroups
A total of 47 specialty and functional subgroups have been established. A chair
and project manager (in some cases two) have been appointed for each,
reporting templates have been issued, and arrangements have been made with
all six hospitals in the region and the HSE’’s Performance Management Unit to
gather as much factual data as possible to inform the work of the subgroups. It
is hoped that most, if not all, of the subgroups will report back by the end of
October.

Each subgroup will include key members of its service delivery team, a patient
advocate representative, a PCCC representative, a representative from
University College Cork, a General Practitioner and a representative of each
hospital where the service is delivered and/or required. The subgroups are as
follows:

Medical Surgical Subgroups Laboratory Functional


Subgroups Subgroups Subgroups
1. General Internal 20. General Surgery 37. Clinical Lab 40. Human
Medicine Subgroup 1 Resources
2. Medical 21. Colorectal 38. Clinical Lab 41. GP Referral
Assessment and Subgroup 2
Admissions Unit
3. Cardiology 22. Breast 39. 42. Single
Haemochromatosis Patient Chart
and Number
4. Dermatology 23. Upper GI 43. ICT
5. Endocrinology 24. Anaesthetics 44. Finance
6. Gastroenterology 25. Anaesthetics/ 45. Primary
Critical Care Care Liaison
7. Infectious 26. Anaesthetics/ Pain 46. Education
diseases medicine and Training
8. Medicine for the 27. Orthopaedics 47. Theatre
Elderly Utilisation
9. Oncology and 28. Cardiothoracic
Radiation

Page 13 of 17
Oncology
10. Clinical 29. Plastics
Haematology
11. Paediatrics 30. Maxillofacial &
primary dental
12. Palliative care 31.
Otorhinolaryngology
13. Radiology 32. Ophthalmology
14. Renal medicine 33. Urology
15. Rehabilitation 34. Vascular
medicine
16. Respiratory 35. Neuroscience
medicine (including
neurosurgery,
neurology)
17. Rheumatology 36. Gynaecology and
Obstetrics
18. Mental Health
19. Emergency
Services

Haemochromatosis testing
The Haemochromatosis subgroup was established early on to address the
specific issue of haemochromatosis testing. New protocols were developed that
allowed the introduction in recent weeks of an in-house testing regime at CUH
that replaced proposed outsourcing thereby creating significant savings to
patients and the taxpayer.

Emergency Services Review


The Emergency Services subgroup has completed its work and its draft
recommendations are being discussed with interested groups in Mallow, West
Cork and Kerry. An initiative has been commenced in West Cork to introduce
a team of six Advanced Paramedics (AP) and a fully equipped vehicle based in
Bantry to provide an additional response capability, tasked by ambulance
control, on a 24/7 basis. The team is currently engaged in an extensive
awareness programme in local schools, to voluntary groups and at public
gatherings to inform the public about the new service.

The team is frequently accompanied by Professor John Higgins, Dr Gerry


McCarthy or Dr Stephen Cusack who take questions on reconfiguration and
emergency medical services. The programme of meetings is being arranged by
the Communications Department of HSE South. The 8th September draft is
attached to this response to demonstrate the comprehensive nature and reach
of this programme. The AP personnel will work in close collaboration with
hospital physicians in Bantry General Hospital and will be in 24/7 contact with
the Emergency Department in Cork University Hospital through a special
hotline. Prior to the introduction of this service, pre-planned scenarios will be
conducted to test the functionality of the new service in different circumstances
and at different locations.

Page 14 of 17
Another recommendation is the establishment of special Medical Assessment
and Admissions Units in each hospital in the region. Dr Jennifer Carroll, a
consultant in the HSE South East who successfully introduced a similar Unit in
St Luke’’s Hospital Kilkenny, is advising the Reconfiguration Forum on this
project. Quality standards and operating protocols will be introduced
throughout the region so that each unit provides similar levels of service to a
similar quality standard and each relates effectively to the hospital in which it is
based.

Another recommendation, already in train, involves the addition of


intermediate care vehicles for inter-hospital transport. Additional vehicles are
being commissioned and these will relieve pressure on the existing 24/7
ambulance service.

Fundamental to the recommendations of the subgroup is the development of a


regional team of emergency medicine consultants who will develop regional
standards and a role for each hospital in a regional strategy.

The Cork city hospitals, and Mallow General Hospital, will act collectively to
provide a co-ordinated emergency service for the city and for North Cork. This
will include a co-ordinated approach to bed management and the phasing out
of trolleys. In this respect, the recent publication of a strategic plan for the
Mercy University Hospital, is in line with the subgroup’’s recommendations and
has been warmly welcomed by the Reconfiguration Forum.

The subgroup review deals at some length with the role of pre-hospital care in
an integrated emergency service, including potential enhanced roles for the
general public as first responders providing basic life support using Automatic
External Defibrillators (the Ambulance Service already has a programme
underway that has trained over 5,000 community first responders). Prof
Higgins has met with a wide range of political representatives and community
groups, and this engagement is ongoing.

Implementation of the subgroup’’s recommendations has already commenced


where this is possible through taking specific actions and this will continue.
Steps requiring greater integration, or those requiring recruitment or retraining
of staff, will commence when the overall plan for the reconfiguration of
services is clear and priorities can be set. It is planned to upload the review on
to the HSE website as ““work in progress”” in October.

The Development of Community-based health facilities


Members will be aware that the business plan for 2009 which was presented to
the Forum in January this year, set out a range of measures for development of
community based health facilities across a range of care groups including
primary care, mental health & older people. I do not intend to restate all the
above measures but I can confirm for Members that progress with
implementation is in line with our plan. Given the importance of integrating
primary care as part of the overall re-configuration programme I wish to
confirm for Members that the HSE South is on target for the implementation
of 63 primary care teams across the South by the end of this year.

Page 15 of 17
When the overall programme is completed, in Cork and Kerry there will be 82
primary care teams and 21 primary and social care networks –– this will involve
a workforce of over 260 GPs working in teams with over 450 community
professionals i.e. nursing, physiotherapy, OTs, speech and language therapy &
social work staff across the region.

The teams will be supported through the 21 primary and social care networks
where over 4,917 staff will provide specialist services such as the 31 community
hospitals / residential centres for older people, which deliver over 1800 long
stay, rehabilitation and community support beds, 8 consultant geriatrician
teams, 30 day care centres for older people as well as 19 adult community
mental health teams and 7 child and adolescent teams.

All of these services will be linked together in a far more integrated way across
the community and linked to the acute hospital sector ensuring a more
seamless and responsive service for the public.

In relation to Southdoc I can confirm that they have been fully involved in this
overall process and the HSE south continues to liaise closely with them to
ensure that the services provided continue to meet the needs of the population.
Most recently Southdoc have extended their out of hours service in Cork City
to Saturday mornings commencing at 8.00 a.m. in response to increased service
needs.

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