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Dáil Éireann debate -
Thursday, 1 Jul 2010

Vol. 714 No. 2

Adjournment Debate

Suicide Incidence

I appreciate the opportunity to raise on the Adjournment the frightening increase in the rate of suicide. The provisional suicide figures for 2009 show that the number of deaths by suicide has increased by 25%, from 424 in 2008 to 527 last year. I suggest the real figure is much higher because there is a serious level of under-reporting of suicide. Experts estimate that the true figure is as high as 650. It is worth noting that 239 people died in road accidents last year. In 2008, the level of HSE funding to the National Office for Suicide Prevention was €5.1 million and the State grant to the Road Safety Authority was an inadequate €40.4 million. Figures will be published tomorrow to confirm that 11,966 people presented to hospital in 2009 having attempted suicide or engaged in self-harm. For every person who presents at hospital, at least six more people are thought to engage in self-harm. Therefore, the true figure for self-harm is approximately 70,000. The Government must recognise and respond to the level of suicidal behaviour, which requires an emergency response.

I wish to outline why I think this profound increase in suicide is taking place. During recessionary times, there is a sudden gap between material needs and resources. In economic downturns, frustration increases as an increasing proportion of people fail to meet their financial goals. There is clear evidence that suicide is linked to financial difficulties. The WHO has identified that the potential psychological impact of economic recession on public health is severe. Job loss, job insecurity, job uncertainty, economic strain, loss of income, home repossession and restricted access to credit lead to a reduction in mental well-being, an increase in mental health problems and mental ill-health, increased substance misuse, especially alcohol and drugs, and intimate relationship breakdown and divorce. There is a loss of perceived social worth, purpose and daily structure, a reduction in social contact, an increase in social isolation, and an increased risk of suicidal behaviour, non-fatal self-harm and completed suicides. A protracted period of unemployment, especially at a young age, seems to have a particularly deleterious effect on the mental health of young men, regardless of their social background. Rates of suicide are three to four times higher among those who are unemployed.

The Minister for Health and Children and the HSE must respond to the changes in society that are leading to higher rates of suicide and problems associated with mental illness. The failure of the Government to invest resources in mental health services, including suicide prevention, is one of the main contributory factors. I will set out a hypothesis relating to why the Government may be choosing not to invest in this social health issue. The stigma surrounding mental health issues and suicide is a barrier to the Government meeting the demands of society. Each Government responds to the expressed demands of the electorate. The demand for the Government to deal with suicide and mental health problems is not expressed due to the stigma associated with such matters. We hear about many problems when we knock on doors, but hear little about mental health. As we wish to protect ourselves and others from this stigma in some way, we do not demand the services that are badly needed for us or our family members. True political leadership must respond to the politically unexpressed needs of society. The Government is not doing this because there are no votes in it.

I thank Deputy Neville for raising this matter on the Adjournment. I compliment and commend him on the work he is doing in this area. The Government is aware that suicide continues to be a significant public health issue. Its prevention is a major challenge for health and social services at all levels. Suicide is one of the most tragic events a family can experience. The heartache of a family's grief cannot be underestimated or ignored. As a nation, we must continue to ensure we take all steps to prevent suicide. I am conscious that a discussion on figures, rates of suicide and policy strategies can seem detached from the individual tragedies represented by such statistics. The provisional figures presented for 2009 show a 24% increase over the 2008 figures. Caution should be exercised when comparing the 2009 statistics with those for 2008, however, as both figures are provisional. Nevertheless, the increase in the rate of suicide in 2009 is of great concern. The Department of Health and Children is consulting the HSE to consider what measures can be taken to counteract this worrying trend. The largest increase has occurred in the 25 to 44 age group. We will need to target this group to stop the continuing rise in suicide.

It may be too early to quantify the effect of the current economic climate on mental health, but there is no doubt the crisis is placing a greater strain on many people and their families. As public representatives, we meet individuals and representatives of various groups every day. In the course of such meetings, people express concerns and fears about the impact the recession is having on their lives and their work. Mental health promotion is key to minimising the consequences of the recession. In 2009, the National Office for Suicide Prevention launched two worthwhile initiatives which highlight the practical things we can do to protect our mental health — an information booklet, Suicide Prevention in the Workplace, as well as information leaflets and wallet cards on the theme of "looking after mental health during tough economic times". Other initiatives developed by the office include the development and implementation of national training programmes; the development of a training strategy under the direction of a training and development officer; the progression of the availability of self-harm services through hospital emergency departments; the implementation of recommendations arising from a review of bereavement services; the appointment of dedicated suicide resource officers; the provision of funding to the National Suicide Research Foundation; the roll-out of support to voluntary organisations working in the field of suicide prevention; and the development of mental health awareness campaigns.

The elimination of the stigma associated with mental illness is key to good mental health. Stigma can affect all aspects of life, limit access to employment and housing, harm social relationships and reduce self-esteem. Fear of being labelled as having a mental health problem reduces the likelihood of individuals with mental health difficulties seeking treatment.

As many Deputies will be aware, the Minister of State with responsibility for disability and mental health, Deputy John Moloney, recently launched See Change, the national stigma reduction campaign. The aim of this campaign is to reduce the stigma people feel and to encourage them to seek help. The campaign will inspire people to challenge their beliefs about mental illness and to be more open in their attitudes and behaviour. It will also encourage people to support a friend or loved one who is experiencing a mental health problem. Our vision is to achieve a change in Irish social attitudes and behaviour and to reduce the level of discrimination and prejudice. In order to help make that vision a reality and to positively change attitudes, it is proposed to develop a range of national and local activities aimed at giving focused messages to the general public and target groups. The campaign will include radio programmes, media interviews, a new website, newspaper articles and school presentations.

The tragedy of suicide affects every community in the country. The Government is firmly committed to reducing suicide, as part of a whole community effort to ensure that people in distress do not feel isolated and alone. While a discussion on figures, rates of suicide and policy strategies can seem very detached from the individual tragedies represented by these figures, I assure Deputy Neville that the Government is firmly committed to tackling suicide in this country.

Hospital Services

I wish to raise an issue which I feel will have a deep impact on the ability of hospitals like Mallow General Hospital to deliver acute services.

For the past five years we have been through a number of processes in relation to Mallow General Hospital, including the Horwath, Wrixon and Teamwork reviews. Now, through a new national reconfiguration process, the HSE will seek, in an underhand and surreptitious way, to undermine the ability of the hospital to deliver acute services.

I have before me a document in respect of this matter. The people who represent the interests of the hospital and who live within its catchment area are undergoing a reconfiguration process, headed up by Professor John Higgins. There is general agreement that change is needed within the hospital and that there will be implications for the delivery of acute services, but that the capacity of the hospital should not be undermined in any way. In other words, if there is to be a loss or diminution of acute surgical services, they would be buttressed by acute medical services.

We have bought into that process and have been given assurances in relation to it. We now discover documentation emanating from the HSE showing that it seeks to assign to every hospital in the country a new modelling system ranging from 1 to 4, depending on the category of hospital, and which will put Mallow into the No. 2 category. The document states that this hospital will not have an ICU so the patients and doctors need to be made aware that the resources are not in place to provide the full spectrum of an acute hospital resuscitation, that is, intubation, ventilation and resuscitation, IVR. The patient must give informed consent and have knowledge of this prior to admission. A ceiling of care discussion needs to take place and be documented with appropriate patients prior to admission to this facility. The document goes on to say that standards of care should be measured and comparable to those delivered at a model 3 and model 4 hospital. A model 3 or 4 hospital would be the equivalent of Cork University Hospital, which is a tertiary centre and the nearest geographically to Mallow.

I demand a meeting with Mr. Pat Healy, regional director of operations for the HSE south region. I demand respectfully, as is my right as an Oireachtas Member, a meeting with Ms Laverne McGuinness and Mr. Brian Gilroy, who are in charge of efficiencies, and I demand that the Joint Committee on Health and Children discuss this document because it will have serious implications for the delivery of acute care. By a surreptitious and secretive method, the HSE will seek to diminish the ability of Mallow to deliver acute care. If a ceiling of care discussion has to take place on every admission, most people will not be admitted to the hospital and will have to go to CUH, thereby reducing the ability of Mallow General Hospital to deliver services.

There are many scenarios where resuscitation might be appropriate for an individual on whom a "do not resuscitate" order has been placed, for example, anaphylactic reaction to an infusion. Such a notion has major consequences for the status and reputation of a hospital and for the esteem of those working there. Discussion about ceilings of care as espoused in this process is, in most clinical situations, unnecessary and often inappropriate and counter-productive. I wonder if dividing patients into categories of access with regard to resuscitation is unconstitutional, in that it would negate the rights of a patient.

Numbers in the hospital would be so reduced that it would not be viable. That is what is at play here. This is an attempt by the HSE at national level to undermine the local reconfiguration process which all of the stakeholders have bought into. We recognise that change is needed but it seems the HSE is trying push through a plan whereby hospitals like Mallow will no longer be able to provide acute care, whether medical or surgical, and the 4,500 people who are served in an acute setting in Mallow will have make their way through CUH, which does not have the capacity to deliver those services because the capital investment has not been made there.

We need transparency. I am asking, as is my right as an Oireachtas Member representing the people of Cork East, for a meeting with the HSE at national level so that I can learn what plans are afoot and what surreptitious methods are being employed in the downgrading of hospitals like Mallow.

I am replying to this Adjournment matter on behalf of my colleague, the Minister for Health and Children, Deputy Mary Harney. Patient safety is central to the delivery of health services. Ensuring patient safety is of paramount importance, so people can have confidence in the care they receive and have the best possible outcomes. The overwhelming consensus among clinical experts is that demonstrably better outcomes, as seen in cancer care, are achieved for patients if delivery of complex care takes places where the necessary staff and equipment are available and where there are sufficient volumes of activity. The evidence also emphasises the need to provide timely emergency care to patients in an appropriate setting. To achieve better outcomes for patients, hospitals will need to fundamentally change the types of service they deliver to their communities and how those services are delivered.

The reconfiguration of services in the HSE south area, when implemented, will result in an improved service. The clinical benefits for patients will be significant and the treatment offered will be of the highest standard. Mallow General Hospital is one of six acute hospitals covered by the 2008 Horwath and Teamwork review of acute services in Cork and Kerry. The task of reconfiguring acute services is informed by the principles stated in that review, as well as by the extensive consultation processes that have been carried out with stakeholders.

The reconfiguration process is based on all hospitals delivering acute care within a national framework that is clear, safe and transparent. The quality and clinical care directorate of the HSE has established a number of national programmes of care designed to lead to improvement and standardisation in health delivery outcomes. Discussions are ongoing about developing a national framework for acute medical care in our hospital system that gives clarity to hospitals, ambulance staff and patients on how acute medical emergencies will be dealt with. These discussions are clinician-led and include the active engagement of the management and staff of Mallow General Hospital.

The overall reconfiguration plan for Cork and Kerry will consist of a comprehensive set of proposals, encompassing all acute services across the six Cork and Kerry hospitals. The contribution that Mallow General Hospital makes to the people of north Cork and the importance of its capacity to the acute hospital system of Cork and Kerry is recognised in this context. I understand that elements of the plan are still under discussion and, accordingly, they should not be taken out of context. What can be said at this stage is that the plan will seek to use all hospitals in the region in an integrated manner, to provide better access to and improved capacity in all types of hospital care, both acute and less complex, and ultimately to provide a more equitable health service for all the people in Cork and Kerry.

I hear what Deputy Sherlock is saying. I will ask the Minister to organise the meeting he mentioned in his speech and I am sure that his office and the HSE will come back to Deputy Sherlock as quickly as possible.

Medical Cards

I presume I am not the only Deputy who thinks people in his constituency are experiencing considerable delays in the processing of medical card applications and renewal applications. I have not seen anything like it in my life as a public representative. The delays are horrendous. Sick, old and disabled people are suffering because the Minister for Health and Children and the HSE decided to impose a system of processing medical card applications on top of a system designed to process the primary care reimbursement service, PCRS. The Minister should have learned from what she did with the HSE, imposing that layer of bureaucracy onto the health board system which, in itself, has been a disaster. She has now combined with the HSE to place this tier of centralisation of medical card applications and renewals on top of another system designed for an entirely different purpose.

There have been long delays, files have gone missing and there is chaos in the system. In the last analysis, the most vulnerable people suffer because they are the ones looking for medical cards and renewals; they are those left waiting and under stress, strain and anxiety because of the mismanagement and insensitivity in the way the HSE and the Minister for Health and Children have dealt with this matter.

There is a great lack of information for applicants. The actual service being provided in the PCRS is amazingly secretive. It is almost like Fort Knox. A person cannot simply turn up. The place is guarded by dogs and security personnel and ordinary members of the public cannot go near it. I understand the centre is in the Minister of State's constituency but people must deal with it as if it was a limbo situation. It is non-personal and there is no opportunity for a person to speak with personnel to ask how his or her application is processing. It has gone into the secretive centralised centre to which nobody has access — not a good approach in terms of transparency and dealing with the public. I understand the PCRS was not consulted about this plan but that it was simply announced and then imposed on that body which did not have the services, personnel or resources to cater for this. Belatedly, the Minister has begun to provide some resources.

As early as 19 January, the Minister told the Oireachtas she fully supported the centralisation of the medical card application process and that centralisation would make the whole system more efficient. She said at the time it would take only 15 working days to process an application. That is cloud cuckoo land. The situation has not improved. I will be interested to hear whatever figures the Minister of State will trot out but six months later there is no sign of any improvements or improved efficiency in the system. It still takes months to process applications and renewals and many of the files go missing in transit.

I must agree with the statement of the Ombudsman, Ms Emily O'Reilly, who said the HSE is living in another world. The Minister is also living in another world; it certainly is not one related to reality. The Ombudsman was speaking about her own dealings with the HSE which she described as being from Alice in Wonderful. We all experience this.

I do not know whether the Minister of State has a hot line to deal with medical card applications for his constituents but the system is not working satisfactorily. It may be that only my constituency is experiencing this dire service. However from comments I have heard from colleagues it seems this is a universal problem throughout the country. I noted many cases that I have forwarded to the HSE and to the Minister. The Minister acknowledges them and says she must send them to the HSE. The HSE come back to me after a long time with replies. It is very unsatisfactory and everything is in process. It is in a state of chassis and it does not reach a conclusion.

I would like to know whether there will be any improvements in the existing system and why there are so many people in my constituency who find this dire situation in regard to their applications for new medical cards or renewals.

I am taking this Adjournment matter on behalf of my colleague, the Minister for Health and Children, Deputy Mary Harney. The determination of eligibility of applicants to medical cards is a matter for the Health Service Executive as provided for under the provisions of the Health Act, 1970. Medical cards are provided to persons who, in the opinion of the HSE, are unable without undue hardship to arrange general practitioner medical and surgical services for themselves and their dependants. Prior to January 2009, local health offices provided the public with advice and assistance in regard to applying for medical cards and processed medical card applications in more than 100 offices around the country.

As part of the HSE's ongoing programme to provide a more responsive and cost effective service, the HSE is centralising the processing aspect of medical card applications to its facility at the primary care reimbursement service in Dublin, as Deputy Costello noted. Under the centralisation plan, the HSE's local offices will continue to provide the public with assistance and information locally in regard to medical card eligibility and making an application, and the current status of their application or review.

From the customer's perspective, this means that at all times he or she will be able to seek advice from his or her local health office. Local health offices have access to the national system to help clients with inquiries about their application or review and can also deal with queries of a general nature regarding the medical card scheme.

On 11 June, the HSE launched a new website — - where individuals can make a medical card application online, track the status of their application or review and access a simple eligibility checker to check the current eligibility status of a medical card. There is also a new on-line feedback and inquiry facility for the public to communicate directly with the PCRS. Since the processing of medical cards for persons aged 70 and over was centralised in January 2009, the HSE has processed 2,801 renewal applications from clients aged 70 or over in Dublin North Central, the local health office area which covers the constituency area of Dublin Central, of which 2,673, or 95%, resulted in a new medical card being issued. A total of 106 or 3.8% of applications were submitted without the necessary supporting documentation and the HSE is working with those applicants so that their applications may be completed. A very small proportion — less than 0.32% — of applicants were unsuccessful following review.

In regard to persons aged 70 years and over, the HSE recently introduced a new simplified declaration process for reviewing those cards so that the vast majority of persons aged 70 years and over do not have to undergo the more onerous review application form. The new declaration comprises a single page form that can be completed with a single entry, signed and dated, in the event that the circumstances of the medical card holder and his or her dependants have not materially changed since their last review. In respect of clients under 70 years of age in Dublin North Central, the HSE has processed 8,341 reviews, of which 6,946, or 83%, resulted in a new medical card being issued. Some 1,125 or 13.5% of applicants are in communication with the HSE as their applications were submitted without all of the necessary documentation. In this case, less than 2.5%, 205 applications, were unsuccessful following assessment in line with the national medical card-general practitioner visit card guidelines.

English Language Programme

I thank the Leas Cheann Comhairle for giving me the opportunity to raise the very difficult issue of the senior primary school, Mary Mother of Hope national school, in Littlepace in Clonee, Dublin 15. This is about the situation in Dublin West, where the vast bulk of primary and secondary schools have high numbers of international children. A number of primary schools have over 70% of international children, and some schools have up to 40 different nationalities.

The critical education support for education in this case has been English language teachers. These are now under review, even though officials in the Department of Education and Skills know that the Dublin 15 area includes many children who do not have English as a mother language. The decision by the Department and the Minister to cut further the teaching allocation to Mary Mother of Hope senior national school may result in very serious long-term consequences for the 107 international children who do not have English as their mother tongue and who desperately need English language classes to ensure that they can participate and prosper in the education system.

Mary Mother of Hope senior national school will have only one English language support teacher for its 400 pupils from next September, compared to the three teachers it had for the 300 pupils it had only two years ago. The school caters not just for the local Irish population, but for a very large population of international children. It finds that because it is a senior cycle school, it is now suffering severe cuts because the Department officials argue that children only need two years of English language support.

To date, schools, teachers, boards of management and patrons in Dublin West, and other areas with high numbers of international children, have done fantastic work in developing the children's language skills. However, unless language skills are a specific focus over the entire course of a child's education, the child may well acquire speaking fluency without acquiring the academic fluency he or she needs to pursue further education.

It is incredibly important that we do not create a situation where because newcomers lack English language skills, they begin to fall back on academic achievement in schools because they simply have not acquired academic fluency in English. They become disaffected in secondary school and they drop out. We are then in serious danger of repeating the pattern with which the Minister is all too familiar, where young boys drop out because they cannot connect with achievement in their schools. If we do that, we are on the road to ghettoisation and to producing very large numbers of disaffected teenagers. Some of that is already happening to some extent.

There are two ways to approach this. The Department needs to keep supplying English language teachers, or allow school principals more flexibility in using and distributing resources. I go to places like Dublin 4 and Dublin South and the school children are all Irish and all white. If people come out to my constituency, 25-30% of the children are international. That has been very successful, but the key to the success is that children in school need a chance at success and they have to be able to integrate. Language is the bedrock of integration. It is extraordinarily short sighted for the Government to deprive children of English language education. It will cost an incredible amount in social and economic integration in the long run.

I am replying to this Adjournment matter on behalf of the Minister for Education and Skills. I thank the Deputy for raising this issue as it affords me the opportunity to outline the position on language support teachers. I want to provide an overall context on the language support provision and I will return to the issue of the aforementioned school.

There has been a large influx of newcomers to Ireland in recent years and into schools and the Department recognised this through the provision of significant additional supports by way of English as an additional language, or EAL, support teachers. The ongoing requirement for current levels of language support teachers in schools should start to reduce in line with lower levels of immigration and in line with improvements in the levels of proficiency of those pupils for whom this resource has been available.

In the 2009-10 school year, there were over 1,500 language support teachers in our schools, of which 1,185 were employed at primary level, providing support to approximately 30,000 eligible pupils. I realise that standards are not simply achieved by supplying teaching resources and that the quality of the supports the child receives and the inclusive atmosphere cultivated in schools are important factors influencing the quality of learning achieved by migrant children. The Department of Education and Skills recognises that it must monitor and review the educational experiences provided to newcomer students so that it can improve the quality and effectiveness of its provision and, therefore, it is undertaking a range of research to consider the question of integration in schools.

The inspectorate of the Department of Education and Skills conducted an evaluation of the provision of English as an additional language in a number of schools in 2008-09. This evaluated the quality of teaching and learning of English as an additional language that students experience in mainstream education and in support contexts in schools. The findings of the research are currently being collated so that they can be analysed and a report prepared. They will help to inform policy in the area of supports for students learning English as an additional language. The inspectorate will draw up best practice guidelines and define what is needed with regard to teaching English as a second language.

Since 2008, the Department has been providing specialist continuing professional development for EAL teachers, for school leaders and whole school teams, at both primary and post-primary level, through the primary professional development service and the second level support service. There is a range of resource material available to schools which has been produced with the Department's support, including assessment toolkits for language proficiency and the National Council for Curriculum and Assessment's intercultural guidelines.

The Department recognises that there are language and integration challenges for schools with significant numbers of students for whom English is not their first language. The current pressures on the public finances mean that it is not possible to provide additional resources to schools over and above what has been agreed by the Government as necessary to cater for demographics and to deliver on the commitments in the renewed programme for Government. Significant resources are already given to these schools and the challenge is to ensure that they are used to maximum effect. The research projects being carried out will help to guide and develop Department policy into the future.

The level of extra teaching support provided in respect of language support to any school is determined by the numbers of eligible non-English speaking students enrolled and the associated assessed levels of these pupils' language proficiency. It is an annual allocation process that begins in the spring of each year when schools apply to the Department. Language support posts are approved on a provisional basis initially and will be confirmed following clarification of actual enrolments on 30 September.

Under current arrangements set out in Department Circular 0015/2009, a school would be allocated up to four language support teachers. Additional support is also available for those schools which have at least 25% of their total enrolment made up of pupils who require language support. Such applications for additional language support are dealt with through the staffing appeals process.

The school to which the Deputy refers is entitled to a provisional allocation of one full-time temporary teaching post in respect of EAL support, based on its application to the Department. This allocation is provisionally sanctioned until 31 August 2011 and is subject to the EAL pupils for whom support is sought remaining in attendance in the school on 30 September 2010. The school submitted an appeal to the primary staffing appeal board which was considered by the board at its meeting on 21 June 2010. The board decided that a departure from the staffing schedule was not warranted in this case and the school has been notified in this regard. The appeal board operates independently of the Department and its decision is final.

I wish to thank the Deputy once again for raising this matter.

The Dáil adjourned at 10.40 p.m. until 10.30 a.m. on Friday, 2 July 2010.