Dáil Éireann debate -
Tuesday, 4 Nov 2014

Vol. 856 No. 1

Topical Issue Debate

Neuro-Rehabilitation Services Provision

Deputy Maureen O'Sullivan

Ba mhaith liom buíochas a ghabháil leis an Cheann Comhairle as ucht an deis seo a thabhairt dom an cheist seo a ardú. I know this matter was selected before the recess but I waited so that the Minister could address it in the Chamber.

Like me, I am sure she has had family and friends who have suffered strokes. We know not just about the medical side of stroke, but the psychological and emotional effects it has on the victim and on those who love them. We know also that there are personal, emotional and psychological costs along with the physical ones. Stroke is a life-changing experience.

Every year, the financial cost of strokes comes to over €550 million with €400 million of that going on nursing home care. Up to 75% of stroke victims never go back to work and there are major difficulties for them and their families. When the HSE, Health Service Executive, launched the national stroke programme four years ago, the death rate from strokes fell by 13% while the rate of discharge of patients from hospitals to nursing home care was down 28%. The savings from the reduced requirement for nursing home care are conservatively estimated at €22 million. These are positive results which came about because the HSE invested in a stroke network and took account of reports that stated better acute stroke services would save lives and money on a significant scale.

Better community rehabilitation services can maximise recovery, however. I acknowledge the work of the Irish Heart Foundation and its research in this area. Up to 44% of all stroke sufferers, more than 3,000 people every year, are in the mild to moderate stroke category. They could benefit from early supported discharge programmes. The idea is to get them home earlier. The Government’s health policy in many areas is about getting people back to their families and communities. We are very much in favour of that with mental health issues. This would be particularly valuable also in the stroke rehabilitation area. It is estimated that €12 million could be saved by such a move and it would free up 24,000 hospital bed days which are in demand. It is expected that an initial outlay of between €5 million to €10 million would be the annual cost to resource community therapy and services to stroke victims. The cost to implement this would be considerably less than the cost of inpatient stay. With so much going into nursing home care, those in the mild to moderate range are losing out when they leave hospital because they need physiotherapy, occupational and speech and language therapy. It would be better for them to be at home where they would have services and a greater delivery of care in the community.

The 2014 Irish Heart Foundation, the Economic and Research Institute of Ireland, ESRI, and the Royal College of Surgeons in Ireland, RCSI, report stated:

Clinicians engaged in stroke care in 24 out of 28 acute hospitals agree that inadequacies in community services lead to referrals of patients post-discharge for rehabilitation services in hospitals or other inpatient locations such as nursing homes, who could be treated at home by community services if these were more readily available.

Nursing home costs would be reduced if more stroke patients were able to live independently at home. I hope there will be a positive response to a small outlay of funding to bring this about even on a pilot scheme to show it will work.

Minister of State at the Department of Health (Deputy Kathleen Lynch)

I thank the Deputy for raising this issue. I am glad to be here as I have a particular interest in this area due to family circumstances. Since the introduction in 2010 of the national cardiovascular health policy, significant improvements have been made with regard to access to acute treatments for coronary heart disease, as well as the development of stroke units. Key elements of stroke care now available include new and existing stroke units provided with additional therapy, nursing and consultant posts. Thrombolysis is now available to acute hospitals admitting stroke patients, 9.5% of whom are being thrombolysed which compares well with the best European figures.

The aims of the national stroke programme are to provide national rapid access to best-quality stroke services including acute care and the implementation of early support discharge, ESD, services. The implementation of ESD services is within the context of the wider range of rehabilitation services required by stroke patients. The stroke programme estimates the number of people with enduring disabilities as a result of stroke has decreased as the percentage of patients with stroke discharged from acute hospitals to nursing homes dropped from 17.3% in 2009 to 14.5% in 2012. It has gone down again since then. The percentage of patients discharged directly home increased from 49.4% in 2009 to 51.1% in 2012. A certain percentage of stroke patients will be suitable for ESD which involves intensive specialised stroke rehabilitation provided in the patient's home for up to eight weeks. I agree with the Deputy that the notion of taking up a hospital bed when one can have treatment in the comfort of one’s home makes no sense. This reduces the length of hospital stay, long-term dependency and the risk of further disability after six months, as well as reducing the number of patients requiring long-term care.

ESD services are funded in several locations. The feasibility of implementing this model in geographically dispersed populations is limited. The national clinical programme for stroke, NCPS, continues to provide funding to these sites. During 2013, a total of 90 patients were discharged home via an ESD service across three ESD service sites - the Mater Misericordiae University Hospital, Galway university hospitals and Tallaght hospital. Patients requiring more intensive rehabilitation are referred to the nearest available rehabilitation service. The establishment of managed clinical rehabilitation networks for neurological and prosthetic rehabilitation services in each of the four HSE regions contributes to rehabilitation services. The National Rehabilitation Hospital provides specialist stroke rehabilitation as a national hub and links in with regional services.

The Department of Health's national policy and strategy for the provision of neuro-rehabilitation services in Ireland, in collaboration with the national clinical programme for rehabilitation medicine, provides for improved access to and quality of services for patients requiring rehabilitation. The rehabilitation medicine clinical programme and the HSE’s disability services division are developing an implementation plan for the neuro-rehabilitation strategy.

Primary care also plays an important role in stroke rehabilitation. As of 6 September 2014, some 229.5 of the 264.5 primary care team posts have been filled or start dates agreed. The HSE is striving to have the remainder of the posts filled as soon as possible in 2014.

Taken together, all these developments show we have made significant progress in preventing stroke and its complications. The issue of how best to further develop and support early stroke discharge is under consideration by the HSE stroke programme.

A friend of mine recently had a stroke. A lot depends on how quickly one gets to a unit that has the capacity to deliver the relevant treatment.

Deputy Maureen O'Sullivan

I thank the Minister of State for that reply. We are saying the same. It is opportune because World Stroke Day was on 29 October. The reports, findings and the opinions of people who work with stroke victims all say the same thing: proper consultation, organisation and better community therapy services for stroke survivors will improve their quality of life on a major scale. We would see more cost savings than under the current system; therefore, there is an economic justification for the rapid development of community rehab and care services. We are also talking about international best practice. Above all, however, there is a greater justification on the personal side. It is about making a difference in the lives of those who suffer stroke and those who love them. My own recent experience involved someone who had a stroke. He was quickly admitted to hospital, where the care was excellent. He then went to a nursing home but spent far too long there. The care and therapy there was too intermittent and too short. If that person had been at home receiving community care with his family and friends around him, encouraging him, that informal therapy would have been much more valuable. If we are going to make a difference, we must deal with the matter urgently. The services are not seeking a blank cheque, and while it is not an astronomical amount of money, it can make a big difference.

Deputy Kathleen Lynch

I could not agree more with the Deputy. The joining up of posts we are putting into the community provides that sort of interconnection between primary teams and community intervention teams. I have first-hand experience showing that when strokes are treated quickly and in the correct location, the outcome can be as though the stroke had never occurred. It is incredible. I credit the last Government and ourselves for identifying that system and making it work.

I was hugely impressed recently by a normal gym that had equipment everyone could use for balance and muscle capacity in terms of stroke. The general population also uses that gym. It was not a matter of having different equipment, but equipment that could be used by both able-bodied people and those who need additional help. We are on the right track but we need to do more.

Home Care Packages Provision

Deputy Seán Ó Fearghaíl

I thank the Ceann Comhairle for allowing me to raise this matter. To revert briefly to the previous issue, I salute the Minister of State and her predecessors for what has been done in terms of stroke treatment. Real and meaningful progress has been achieved.

On a number of occasions, my colleague, Deputy Billy Kelleher, and I have raised the issue of children with life-limiting conditions both on Leaders' Questions and as Topical Issues. It goes without saying that providing care for a child with a life-limiting condition is highly challenging for families, both physically and emotionally. Some 1,400 children in the country have life-limiting conditions. Unfortunately, about 350 of those die each year due to their conditions. The life expectancy of many of those children is just one year.

All studies have clearly shown that the majority of parents want to care for their children at home. Our party has recently been informed of difficulties arising following the failure of the HSE to take over home care plans for children currently supported by the Jack & Jill Children's Foundation who will soon reach the age of four years. There are three such children in north Dublin. One of them - a little girl who was four last August - has Ohtahara syndrome, a rare infantile epilepsy with seizures, which results in a limited life expectancy. Indeed, David Cameron's son died of the same condition aged six years. This girl cannot walk, talk or feed herself and is totally dependent on others. Up to now she was receiving 40 hours of support monthly from the Jack & Jill Children's Foundation, which made all the difference to her family. The HSE met this girl's family in July after the Jack & Jill Children's Foundation and the public health nurse had done an assessment. The HSE assured the parents that the matter would be sorted out on or just after her fourth birthday. It has not been sorted out.

Another child, a boy who will be four years old on Sunday week, has a diagnosis of West syndrome and chromosome 8 and 9 abnormality. Like the little girl I mentioned, he cannot walk, talk or feed himself and is totally dependent on others. He sleeps for only about four hours a night. His mum and dad are understandably up with him on those occasions. The family use their 44 hours of Jack & Jill Children's Foundation support over four nights, giving them one night a week of guaranteed sleep and a few free hours each day. The public health nurse has told the boy's mother that she will not get a nurse, which she desperately needs. Therefore, the mother will have to continue to meet his needs 24/7.

Another little boy who was four years old last week has a diagnosis of trisomy 7p, which is associated with severe to profound developmental delay. He needs 24 hour care as he is gastrostomy-fed. He also requires suctioning and continuous positive airway pressure, CPAP - a treatment that uses mild air pressure to keep the airways open at night - due to his sleep apnoea. He also needs numerous medications daily. In June this year, a referral was sent to the HSE for a home care package to replace the nursing hours that the Jack & Jill Children's Foundation has provided over the last four years. An assessment was carried out and the family was told that their hours could I hope be replaced. However, at the end of October the HSE has not made a decision about this home care package. The little boy left hospital this week and his parents are very worried about how they will cope with his needs. I understand the Jack & Jill Children's Foundation has set up a temporary emergency fund to cover these hours over the next month, hoping that the HSE will make a decision about replacing them. The parents' wish in this case is that funding will continue to run through the charity so that the same nurses can continue to care for the little boy at home.

Will the Minister of State examine these three particular cases, which are part of a much bigger scenario? In the interests of human decency, will she direct the HSE to take action on these three specific cases?

Deputy Kathleen Lynch

The Deputy has known me long enough. I am always loath to direct people to do something unless I consider there is belligerence there and do not think there is in these cases. However, I will undertake to examine the matter and make inquiries about what can be done concerning the three children the Deputy has mentioned. We must remember that they are children.

I am pleased to take this opportunity to outline the current position in relation to home care plans for children supported by the Jack & Jill Children's Foundation on reaching their fourth birthday. The Jack & Jill Children's Foundation offers a care package to families in respect of palliative care nursing and home care for children with life-limiting conditions. This funding is provided to families following assessment by a member of their home nursing team.

The Jack & Jill Children's Foundation, along with other contracted service providers, is part of a range of services that receive funding from the Health Service Executive to provide services to families with children who have life-limiting conditions. Many children availing of services provided by the Jack & Jill Children's Foundation also avail of other specialist hospital-based and community-based health supports and disability services. In those circumstances, it is always preferable for the child to be at home as far as possible.

Each HSE area has a home care co-ordinator who has responsibility for the planning and provision of all home care packages in their area, including for those children receiving supports from the Jack & Jill Children's Foundation who are reaching their fourth birthday. Home care packages are delivered based on assessment of the applicants and their families. This assessment takes into account all services being provided by all agencies to ensure the delivery of an integrated package to meet the assessed needs. A care plan is then agreed and delivered by the HSE, voluntary or private providers, or a combination thereof. This process ensures that all children with life-limiting conditions receive services on an equitable basis and through a standardised approach. The HSE's disability services provide annual funding to the Jack & Jill Children's Foundation under section 39 of the Health Act 2004. In 2013, the foundation received funding of just over €630,000. The foundation also raises additional finance through fund-raising activities. It gets that money because it is a good foundation - it is as simple as that.

The Jack & Jill Children's Foundation also engages with the primary care division of the health service, which was given an additional budget of €1.2 million in the 2014 national service plan to address specific service challenges in areas such as the discharge of special care babies from hospital who have tracheotomies and require packages of care in the community. My Department is following up with the HSE in respect of one family with a child who has just reached four years of age. I assume that is one of the children Deputy Ó Fearghaíl is talking about and if the Deputy has a particular case in mind I would appreciate the details in order that we can pursue the matter with the HSE.

Deputy Seán Ó Fearghaíl

I will supply the information requested. I have confidence in the Minister of State in so far as her commitment to intervene is concerned.

Deputy Kathleen Lynch

The Deputy should not say that.

Deputy Seán Ó Fearghaíl

There is a broad issue. The Minister of State suggests there is a natural follow-on from the care provided by the Jack & Jill Children's Foundation with very little State subvention when one considers the amount of work done by the foundation. The €630,000 it received in 2013 is a small percentage and a far smaller percentage than sums made available to many section 38 organisations. There is not the sort of follow-on from the HSE described by the Minister of State because, time and again, we hear from the Jack & Jill Children's Foundation and at our clinics from parents of children with these life limiting conditions that the expected continuity of care, which we aspire to, does not happen. That I must come onto the floor of the House and instance these examples is proof positive that the system the Minister of State aspires to is not working.

I heard the Minister of State speak eloquently about the problems with senior citizens in hospital while awaiting stepdown facilities. There is a major cost to the Exchequer and the health services in meeting the demands of older people. These children's needs are so complex that for them to remain in hospital involves expenditure far in excess of anything that might be spent meeting the needs of older people. From an economic perspective, we all have a vested interest in ensuring the objective of the parents, which is to care for the children at home, is realised.

Deputy Kathleen Lynch

There is no disagreement. The ideal is a seamless service that is not interrupted just because the child reaches a particular chronological milestone. Circumstances might not permit it but the ideal is that the nurses providing the home care will continue to do so. That is the argument I will make and I am sure I will be told there are 100 reasons that it cannot happen. Others who deliver services are anxious to deliver it but the ideal is that the child and family can continue with the service they are receiving. I will inquire about this. It should not be happening but I will do my very best to ensure a resolution is found to these cases. It is not just about these three children, but about the broader problem.

Nursing Homes Support Scheme Administration

Acting Chairman (Deputy Olivia Mitchell)

The next issue will be raised by Deputies Mattie McGrath, John O'Mahony and Denis Naughten.

Deputy Mattie McGrath

The situation is out of control. I watched the Minister of State, Deputy Kathleen Lynch, with Deputy Denis Naughten on television recently and the answers given were not answers. I watched the Minister of State when she was in opposition and she must know the hardship and anguish caused to families who must make a decision after trying their best to care for their families at home for as long as they can. When people make the decision to go into the fair deal scheme, they must wait up to 16 weeks to get a placement. I want to kill the myth that there is no capacity in nursing homes, as portrayed in the television programme by the Minister of State and the Minister. It is untrue. In south Tipperary, 12 beds are taken up by patients who are not fit to go home. The families are traumatised because they cannot take them home and they are waiting for nursing homes to go to. The patients are in long-stay beds, which is having a major knock-on effect on hospitals throughout the country. There is one hospital in Clonmel and there are stepdown facilities in Carrick-on-Suir, Clogheen and Cashel.

I ask the Minister of State to take her head out of the sand and deal with the issue. Talking about capping in this issue is the cruellest word she can use. People are at the end of their lives, having given service to the State and paid their taxes, as have their families, while the Minister of State talks about capping the funding. It is totally insensitive and it is a different Minister of State from the person I saw in opposition for four years. The Rottweiler was over here but now she reads out speeches prepared by the HSE and the Department of Health. The Minister of State should hang her head in shame because of the crisis, the trauma caused and the waste and occupancy of beds being held up for so long. I beg the Minister of State to do something. We are in the winter months and hospitals will get busy. Families are traumatised, having made the decision to care for the family properly. The system is cruel, ineffective and inept in sorting out the problem. It is another crisis and it is a fine mess the Government has created.

It was a good scheme set up by a previous Government but let us imagine using the term capping in this context. The Minister of State can throw her cap at it or throw her hat at it. She should have some dignity and, if she cannot sort it out, she should resign as Deputy RóiinShortall did.

Deputy John O'Mahony

I do not know how I will follow that.

Deputy Mattie McGrath

Deputy John O'Mahony knows the truth.

Deputy John O'Mahony

This is an issue for all Deputies in the House. It is a very good scheme, but it is a major issue for families with elderly parents waiting on the list, some of whom have taken out loans to pay €800 or €1,200 in some parts of the country. Last February, the waiting time was four weeks and it has grown rapidly to 16 weeks.

The health service plan is coming out in the next few weeks. The question is how a demand led scheme will be dealt with in that plan. There is a 4% increase annually in the number of people over 80 years and the issue is to try to find a solution. It is causing trauma and people who cannot care for the elderly at home want to try to get into the scheme. Four or five weeks was acceptable but 16 weeks is unacceptable. I want to hear that there is some plan to deal with it. This is clogging up beds in acute hospitals and it costs far more than beds in nursing homes. The argument put by nursing home owners and families is that rolling out the scheme could save money. I hope there is some way of dealing with it in the coming weeks and months. Will the waiting time increase to six months, eight months or 12 months? It can be argued that we are in crisis now but the longer timeframes would be unacceptable. There must be a reduction to reasonable waiting times.

Deputy Denis Naughten

If someone applies for the fair deal nursing home scheme, the first payment will not be received until 13 March 2015. That leaves three categories of people, one of which is those who are in nursing homes. The families of these people must find a minimum of €13,000 to fund the nursing home stay between now and when the payment kicks in. The other group of people involves those who, according to HSE medical staff, can only be cared for in a private or public nursing home and are remaining in their homes because families cannot afford to put them into nursing homes. It is leading to two problems, one of which is the potential risk of neglect to the person, through no fault of the family, by remaining at home when the person needs to be in a nursing home. The second is that many of the people will end up back in hospital with preventable conditions.

I know an elderly person in my own constituency who had to be taken from a private nursing home because the family could not afford it. That person was admitted into an acute hospital pending approval of an application to the fair deal scheme.

A third cohort consists of more than 700 people who are fit to be discharged from hospital but must remain there. This is effectively taking 250,000 hospital bed nights out of the system. The only way to effectively tackle the congestion is to ring-fence the €25 million announced in the budget specifically for that purpose. That should be ring-fenced to treat older people before they need to go into hospital, and for those who end up in hospital, it should be used to get them well and out of hospital as soon as possible. The way to do this is threefold. We must increase long-term care capacity in the form of long-stay beds and the community care model by extending the fair deal scheme to include community supports. We need to reduce the number of older people attending our emergency departments by opening medical assessment units and urgent care centres in smaller hospitals, as well as maximising the use of technology for remote consultation. We also need to increase the rate of discharge into long-term care and the provision of short-term beds. This will unlock the capacity problem within our acute hospital system.

Deputy Kathleen Lynch

I have distributed a note which will tell Members everything they need to know. The Government did not cap the fund referred to by Deputy Mattie McGrath. Fianna Fáil did so and he was a member of that party.

Deputy Mattie McGrath

The Government has been happy to keep the cap.

Deputy Kathleen Lynch

No; Fianna Fáil capped the fund and he was a member of the party.

Deputy Mattie McGrath

Why is the cap not raised? If the cap fits, wear it.

Deputy Kathleen Lynch

The Deputy agreed to it.

Deputy Mattie McGrath

Lift the cap.

Deputy Kathleen Lynch

He was warned about it. As people listen to the Deputy, we can answer him.

Deputy Mattie McGrath

It should be the same as mental health funding.

Deputy Kathleen Lynch

Deputy Dennis Naughten must have got hold of the plan, because everything he suggests needs to be done.

Deputy Denis Naughten

Good.

Deputy Kathleen Lynch

The €25 million in question is ring-fenced. I agree with Deputy John O'Mahony's comments; it would be unsatisfactory for the process to run to six months. The only way people would wait until March of next year after having applied now would be if we did nothing. It will happen if we do nothing, but that is not what we will do. We are committed to acting; it is not as if this issue is going away. This is not a problem that can be resolved in a week. It will continue and worsen, which is why we need a plan. We are not at the point of crisis, which can only occur if we do nothing about the issue and allow it to continue. There must be a plan to deal with an issue coming down the road. There are families suffering badly and, equally, there are people in hospital of a later vintage who do not want to be in there. They are conscious that this matter is being discussed in the media and in here, so we should not add to their distress. Deputy Mattie McGrath may not like to hear that fact.

There are just over 2,000 people awaiting approval for the Fair Deal scheme, but these are not the same 2,000 people every month. There are 788 people in acute hospital beds, and these are not the same people every month. Every month we issue 515 allowances to people who are awaiting approval for the fair deal scheme, and these people come off the list. They get a bed in a long-stay care home or a type of step-down respite. We need more of this.

Mount Carmel is part of the process and it will be the first community hospital in Dublin city. There are community hospitals around the country and Deputies Mattie McGrath, Denis Naughten and John O'Mahony all know them. In Cork we have a substantial community hospital that deals with old-age psychiatry and all it entails. Mount Carmel will deal with long- and short-stay cases as well as providing the intensive rehabilitation that people need after hip or knee procedures. There is also scope for intensive physiotherapy.

There is a plan, but it must be put into action. Deputy Denis Naughten spoke of a delay, but this will only happen if we do nothing, which is not an option. It is not as if this will go away. We know the number of people over 65 is increasing every year by 20,000, with the number of people over 80 increasing by 4% every year. Those people will need more services. There is a big difficulty with our acute hospitals and it is not just about people who are inappropriately placed. Accident and emergency departments are clogged because there is nowhere in a hospital for people to go. As there is a knock-on effect throughout the system, we must act. We have a substantial plan, which we have discussed in great detail.

Deputy Mattie McGrath

My goodness, how would one follow that? The Minister of State will certainly have a place in the Cork Opera House after the next election. She will be there, or a place like it, if she acts as she has done. She stood up and said she had a plan. Was it Abraham Lincoln who said he had a plan or a dream? The Minister of State does not have a plan, a dream or a vision for sorting this out. The Government closed our hospital for psychiatric services in Clonmel. The Minister of State knows where I am talking about. She promised all the plans in the world and the rolling out of community services, but that has not happened. The Minister of State may read out figures, but when will the plan be implemented? For example, when will Mount Carmel come on stream?

The Minister of State has listened to us this evening and may hear of this issue every day of the week. If she is honest with herself and looks into her heart, she will realise that although the Government has had five-point and three-point plans in the past, all of them were for naught and they have gone up in smoke. Nobody believes the Government, as it has no plan, vision or idea. I salute the manager of South Tipperary General Hospital, as well as the people of Clogheen and Carrick-on-Suir, for the work being done. They are under pressure trying to do deals with nursing homes that are offering places. These people want to free up beds while the Minister of State is rubbing her hands and talking about a plan. The opera house will welcome her with open arms after the next election. It is where she will end up with that kind of talk.

Deputy Kathleen Lynch

The Deputy will do anything to get elected.

Deputy Mattie McGrath

I was elected.

Deputy John O'Mahony

I thank the Minister of State for her explanation and I am glad to hear there is a plan. We will all watch it very closely. The key point is that the system is capped but demand is increasing. Will the 2015 allocation, in addition to the measures mentioned by the Minister of State, reflect the increasing demand that is evident each month?

Deputy Denis Naughten

It will not. There are two separate issues. As the Minister of State has admitted, there are 788 people fit to be discharged from hospital tonight and there is a cost to the health service of approximately €700,000 every night. The €25 million must be ring-fenced, and it could be the most radical reform in our health service during the term of the Government if this process is implemented properly. The difficulty is that such action will only deal with approximately one quarter of people on the waiting list for the fair deal nursing home scheme. We need additional money put into the scheme for the 1,500 other people; this should be the €23 million taken from the scheme last year. I can tell the Minister of State where to get the money. If the Government rolls out the national stroke programme and removes the seven telemedicine stroke machines that are currently in a warehouse in the Minister of State's home county of Cork, it would save the health service €55 million per year. Based on the ESRI report, it is estimated that the additional impact of the complete roll-out of the national stroke programme would be to reduce nursing home admissions, saving €23 million per annum. That is the same amount of money taken from the system last year. I urge the Minister of State to implement the stroke programme, save the money and ensure these older people have access to nursing home beds.

Deputy Kathleen Lynch

There was a recent Topical Issue dealing with stroke care. The stroke programme is being rolled out.

We reduced the percentage of people moving from acute hospitals to nursing homes from 17.3% in 2009 to 14.5% in 2012. The percentage of patients discharged directly home has increased from 49.4% to 51.5%.

Deputy Denis Naughten

The Minister of State refers to phase one - much more can be done under phase two.

Deputy Kathleen Lynch

The neurological strategy is being rolled out. The one point on which I do not agree with the Deputy concerns the €23 million to which he referred. We must ensure older people have a choice in where they stay. A great number have expressed a preference to stay at home or, failing that, in their own communities. The figure of €23 million relates to this.

I wish to inform Deputy John O'Mahony that the fair deal scheme is not demand-led and this presents a difficulty. He is right to be concerned about this because it places great pressure on families. The sustainability of the scheme also presents difficulties. The report on the review of the scheme will be ready around the end of January next year and will tell us much but not everything. It will say much about the sustainability of the scheme. Families are paying nursing home fees out of their own pockets and the average cost is around €800 per week. In places where demand is highest and beds are relatively scarce such as in Dublin, Galway, Cork and Limerick the costs can be even higher. Sustainability will be a difficulty if the contribution from the person in need of care is to be between €280 and €290 and the State is to pick up the rest. This applies to public and private nursing homes. If needs increase, sustainability will present a difficulty. The fair deal scheme is not demand-led, which presents another difficulty.

I do not agree with Deputy Denis Naughten on the figure of €23 million.

Deputy Denis Naughten

Additional money will have to be made available.

Deputy Kathleen Lynch

The fund should be increased, although not necessarily by taking money from the fair deal scheme, as it stands.

Deputy Denis Naughten

I would have no difficulty with that.

Deputy Kathleen Lynch

We should increase the fund for home help and enhanced home care packages.

Deputy Denis Naughten

The Minister of State's predecessor refused an amendment I tabled last July on that very issue.

Deputy Kathleen Lynch

I cannot do anything about that now, but I only approach things in the way I would like them to be dealt with.

Deputy Mattie McGrath

The Minister of State should remove the cap.

Deputy Kathleen Lynch

That is how I judge myself, which is why I am not as abusive to Deputy Mattie McGrath as he is to me.

Acting Chairman (Deputy Olivia Mitchell)

I thank the Minister of State. The next Topical Issue is to be raised by Deputy Dan Neville on the need for a bypass at Adare, County Limerick. Is the Minister of State, Deputy Kathleen Lynch, taking this matter?

Deputy Kathleen Lynch

Yes, I am on the rota today.

Deputy Michael McGrath

I thought only senior Ministers were to take Topical Issues.

Deputy Denis Naughten

We had the senior Minister already.

Acting Chairman (Deputy Olivia Mitchell)

Deputy Kathleen Lynch is a senior Minister.

Deputy Kathleen Lynch

The other Topical Issues related to my Department.

Road Projects

Deputy Dan Neville

I welcome the opportunity to raise this issue which is important in my locality. The Minister for Transport, Tourism and Sport, Deputy Paschal Donohoe, recognises it is not only a constituency issue but a regional one. I refer to the N20 Limerick to Kerry road.

The road into Adare has been named by AA Roadwatch as one of the worst in the country in terms of traffic tailbacks. It also appears on the AA's list of the country's seven slowest roads. The list was based on the findings of the AA and information from An Garda Síochána and the bus companies. None of this comes as a surprise to the people of Adare or those who use the road to commute because tailbacks have delayed traffic entering and leaving the town for a number of years. Traffic increased over the summer for several reasons, including the upturn in economic activity and the general attractiveness of the Kerry region, particularly when the weather is fine.

I wish to raise a number of issues related to this matter. Commuters travelling west experience great frustration. Many commuters live in the west of the county but work in Limerick city and county roads can become problematic rat runs. Some 133 people signed a petition on the speed limit on such roads, but the council will not consider the matter as the difficulty only arises at certain times of the day. There are serious concerns about the safety of children and at certain times people cannot walk on these roads owing to vehicles taking short cuts. Many of the byroads in question are very narrow and one is especially dangerous.

This has been a problem for almost 30 years and several bypass routes have been proposed during that period. We were extremely disappointed when An Bord Pleanála rejected the last route proposed by the council as the National Roads Authority, NRA, and the previous Minister agreed with it. The rejection was based on the excuse that the delay in the construction of the motorway from Limerick to Cork was partly due to this project. The NRA has stated it is extremely concerned about the condition of the road from Patrickswell towards Cork because of its dangerous narrowness. Trucks create difficulties on this road and there have been many fatalities. The road from Patrickswell to Charleville should be developed as it is an extremely dangerous stretch of road and this development should include the Adare bypass, which was destined to be the case.

I am making a case for Adare to be bypassed, which has happened in the case of many other towns, including Castleisland. Like any other bypass, the project to bypass Adare must stand on its own. It has cost over €5 million to date all relating to plans - not one sod of earth has been turned. There is much tourist activity in Adare which could be enhanced by removing traffic from the village and facilitating local and tourist traffic. I put the case for a bypass to the Minister of State as there are strong feelings on the issue in Adare. The demand for a bypass has been supported by Limerick County Council, the National Roads Authority and the previous Minister for Transport, Tourism and Sport, Deputy Leo Varadkar. When I raised the issue recently, the current Minister stated it was not just a local issue but one of regional importance. I have raised the matter on several occasions and do not wish to do so indefinitely. The current approach could see the project stall for decades. Traffic chaos is not enhancing one of the prettiest villages in the country - in fact, the opposite applies.

Deputy Kathleen Lynch

I am taking this issue on behalf of the Minister for Transport, Tourism and Sport, Deputy Paschal Donohoe. All Members of the House will be well aware that the Minister has responsibility for overall policy and funding of the national roads programme.

The planning, design and implementation of individual road projects are matters for the National Roads Authority, NRA, under the Roads Acts 1993 to 2007, in conjunction with the local authorities concerned. Within its capital budget, the assessment and prioritisation of individual projects are matters, in the first instance, for the NRA in accordance with section 19 of the Roads Act. Because of the national financial position, public funding for Ireland's roads has fallen radically since reaching a peak of €1.75 billion in 2007. The allocation for the NRA for improvement and maintenance works in 2014 is €371 million, including recent stimulus funding of €23 million, which is comparable to that available for national roads in 1998.

The reality is that the available funds do not match the amount of work required. For this reason, it has not been possible to progress a range of worthwhile projects and the main focus has to be on the maintenance and repair of roads. As the Deputy will appreciate, the Minister will have to continue to prioritise the maintenance and upkeep of existing infrastructure and the scope for progressing new projects will very much depend on the level of future funding available.

The N21 Adare bypass route was intended to run to the south of Adare. The compulsory purchase order and environmental impact statement documentation were submitted to An Bord Pleanála for approval on 4 March 2010. On 18 October 2012 An Bord Pleanála made a decision to refuse the proposed road scheme to bypass Adare. Principally, although not exclusively, the decision was based on the fact that the Adare bypass route would:

...if permitted and constructed, constitute isolated infrastructure, would not represent a coherent approach to the provision of major roads infrastructure and, furthermore, would not have the potential to fulfil the functions envisaged for the scheme. The proposed development would, therefore, be contrary to the proper planning and sustainable development of the area.

While it cannot be argued that traffic is not an issue for residents and businesses in Adare, given the rejection of the preferred route by An Bord Pleanála, the National Roads Authority and the local authority have to assess options on the basis of that decision. The scheme will have to return to route selection stage and the Minister understands Limerick City and County Council has removed planning restrictions on the southern route. The council has initiated a study to examine the various options to better connect Foynes Port to the wider road network. This study is ongoing and the council is likely to be in a position to confirm the preferred route by mid-2015, at which time it will be able to confirm whether Adare will be impacted on by the scheme.

One concern raised by the Deputy in discussions with the previous Minister, Deputy Leo Varadkar, was related to the need for pre-planning application consultation with An Bord Pleanála on major road projects. There is no provision in either the roads Acts or the planning Acts for the NRA or road authorities to enter into pre-planning application consultation with An Bord Pleanála on proposed route development. However, the planning Acts make provision for pre­planning consultation on various other strategic infrastructural developments, including transport related projects, with An Bord Pleanála prior to the submission of a planning application. As indicated to the Deputy in June, the Minister is considering the inclusion of an amendment to the Roads Bill 2014 on Committee Stage relating to the proposed merger of the NRA and the Railway Procurement Agency. This would enable the NRA and road authorities to engage in pre-planning consultations with An Bord Pleanála on proposed road developments. It would provide the NRA or the road authority, as the case may be, with a formal mechanism to obtain the preliminary views of An Bord Pleanála on a proposed road development before submitting an application to An Bord Pleanála for approval under section 51 of the Roads Act 1993, as amended.

I am uncertain whether that answers all of the Deputy's questions, but I imagine the proposed amendment would be helpful.

Deputy Dan Neville

The amendment would be helpful for certain. There has been a pick-up in the economy and there will be capital spending. We must plan for the construction of this road. The Minister of State has said the money is not available to construct it, but there will be a long lead-in period. We must be ready when the opportunity arises or when capital spending is provided for. If the economy keeps growing as it is, it will only be a short number of years before this happens. At that point, while we may have the funding available, the plan will not be in place. We are, therefore, calling for planning of the bypass to commence immediately.

The Minister of State referred to the road to Foynes. That would be a good project, if it were to place, but I have been listening to talk about that project for 30 years. I joined the council over 30 years ago and it was being discussed then. It will continue to be discussed in the future. We do not have funding for a stand-alone bypass project in Adare, but the Minister of State is suggesting there is funding for a project ten or 15 miles down the road in Foynes.

The statement was critical of stand-alone bypass projects but most bypass projects are stand-alone. Any bypass project of which I know is stand-alone. The most recent bypass constructed in our area at Castleisland was a stand-alone project. Will the Minister of State point to a bypass project that is not stand-alone? They were constructed where they were obviously needed. It is a new spin to suggest that because a bypass would be a stand-alone project, it cannot be constructed. Most bypasses of which I know were constructed to relieve congestion in towns and villages. There are two bypasses in my area, one in my village of Croagh and the other in Rathkeale. They are stand-alone. Now the Minister of State is telling us this cannot be done in the case of Adare because it would be stand-alone. That is not acceptable.

There must be a level of urgency created to commence the planning of a bypass route. Must we wait another 30 years for a new road to Foynes? What will Adare be like in three, five or ten years with the growth in traffic through the town and the development of the tourism industry in Limerick and the Kerry region? Inaction could seriously damage prospects because people will begin to be concerned about the delay in travelling to some tourist resorts in west Limerick and County Kerry.

Deputy Kathleen Lynch

The National Roads Authority is suggesting having isolated and disconnected infrastructure is not a good idea. I imagine the authority is right, but I am equally certain that the Deputy is right. The proposed amendment to the roads Act would have a significant impact. All of the points raised by the Deputy are valid. I am pleased that the Minister for Finance has joined us because Adare is probably in his constituency also. As we all know, funding is a key issue, especially when it comes to road construction. I will ensure all of the points the Deputy has raised will be relayed to the relevant Minister.