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Wednesday, 14 Jan 2015

Written Answers Nos. 664-682

Medical Card Administration

Questions (664)

Pat Deering

Question:

664. Deputy Pat Deering asked the Minister for Health the position regarding the new medical card system; and the way these changes will impact on patients. [1360/15]

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Written answers

In the light of the conclusions of the Expert Panel on Medical Need and Medical Card Eligibility and the external review of the Medical Card Process, ten key actions have been identified to improve the operation of the medical card system, particularly for people with significant medical needs. To deliver on these, the following are examples of a range of actions that are being put into effect immediately or in the short-term by the HSE.

The HSE is putting arrangements in place for a more integrated and sensitive processing of medical card applications involving significant medical conditions to ensure greater interaction between the central office regarding the assessment of a person’s eligibility and the local health office regarding the person’s medical condition and the services that they may require. The HSE has appointed a senior manager to lead the reform of the systems for handling medical card application and reviews.

The HSE is developing a single, integrated process for people to apply for a medical card, a GP visit card, the Long-Term Illness Scheme and the Drugs Payment Scheme. Access points will be established around the country in health offices to support and assist people to make applications.

A clinical advisory group will be established by the HSE to develop guidance on assessing applications involving significant medical conditions so as to take account of the burden involved and the needs arising from the condition and to ensure that appropriate services are provided to people who need them.

The Minister and I have asked the HSE to examine, with the Department of Health, the best way to meet the needs of people with significant medical conditions who need the support of the public health system. This work includes considering the best way to make medical aids and appliances available to persons who do not hold a medical card, the provision of services to children with severe disabilities, and to enable people with particular needs to have these met on an individual basis rather than awarding a medical card to all family members.

Nursing Homes Support Scheme

Questions (665)

Pat Deering

Question:

665. Deputy Pat Deering asked the Minister for Health the position regarding nursing home support, fair deal; the current waiting time; and his plans to reduce this [1361/15]

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Written answers

As of the 5th of January 2015 (latest figures available) there are 1,188 people on the national placement list for the Nursing Homes Support Scheme (NHSS). The HSE controls the release of funding to manage the funds that are available across the course of the year. Funding is released to approved applicants according to their place, in order of their approval date, on the National Placement List. Over recent months, demand for funding has exceeded what could be released and the national placement list has grown as a result.

In July 2014, the HSE allocated €5m for an initiative to improve access to appropriate care for older people. To date this has funded over 300 transitional care beds for patients in acute hospitals who are on the national placement list and over 200 home care packages to assist patients in the acute hospitals who require a home care package to be discharged.

In Budget 2015 a further €25 million was allocated to alleviate the problem of delayed discharges, €10m of this amount has been allocated to the Nursing Homes Support Scheme which has allowed the HSE to reduce waiting times for funding from circa 15 weeks to circa 11 weeks now.

The Review of the Nursing Homes Support Scheme, which will be completed in the coming months, will include consideration of the future balance between community and residential services and the longer-term sustainability of the Scheme.

Services for People with Disabilities

Questions (666)

Finian McGrath

Question:

666. Deputy Finian McGrath asked the Minister for Health his views on correspondence (details supplied) regarding support required in respect of a person in County Monaghan; and if he will make a statement on the matter. [1376/15]

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Written answers

As the particular issue raised by the Deputy relates to an individual case, this is a service matter for the Health Service Executive. Accordingly, I have arranged for the question to be referred to the HSE for direct reply to the Deputy. If you have not received a reply from the HSE within 15 working days please contact my Private Office and they will follow up the matter with them.

Inniúlacht sa Ghaeilge sa Státseirbhís

Questions (667)

Éamon Ó Cuív

Question:

667. D'fhiafraigh Deputy Éamon Ó Cuív den Aire Sláinte bunaithe ar an treoir a thug an Roinn Caiteachas Phoiblí agus Athchóirithe do gach Roinn, cad é líon agus cad iad gráid na bpost dá mbeidh státseirbhísigh atá inniúil sa Ghaeilge agus sa Bhéarla ag teastáil; cad é líon na bpost sin a bhfuil duine leis an gcumas cuí Gaeilge agus Béarla iontu cheana féin, arna bhriseadh síos de réir gráid; cén cháilíocht Ghaeilge atá riachtanach do na poist sin; i gcás nach bhfuil an treoir ón Roinn Caiteachais Phoiblí agus Athchóirithe comhlíonta, cad é údar na moille agus cén uair a dhéanfar an scrúdú; agus an ndéanfaidh sé ráiteas ina thaobh. [1433/15]

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Written answers

Tá seachtar ball foirne i mo Roinn, nó beagnach 2% den líon iomlán fostaithe sa Roinn, in ann a gcuid dualgas a chur i gcrích sa Ghaeilge agus sa Bhéarla araon. Tugtar freagra sa Ghaeilge ar an gcomhfhreagras ar fad a sheoltar don Roinn sa Ghaeilge and cuirtear aon cheisteanna teileafóin ar aghaidh chuig duine de na baill foirne atá inniúil sa Ghaeilge.

Agus aird á tabhairt ar bheartas Rialtais le haghaidh soláthar feabhsaithe seirbhísí sa Ghaeilge agus de réir Scéim Teanga bheartaithe na Roinne do 2015-2018 a cuireadh faoi bhráid an Aire Ealaíon, Oidhreachta agus Gaeltachta lena formheas, tá an Roinn tiomanta do scrúdú a dhéanamh, faoi dheireadh na chéad bhliana den scéim, ar an ngá le haon phoist bhreise a bhféadfadh inniúlacht sa Ghaeilge a bheith ina riachtanas bunriachtanach ina leith a shainaithint.

Tuigeann an Roinn go gcuirfear san áireamh i bpainéil na Seirbhíse um Cheapacháin Phoiblí don bhliain 2015 daoine ag a bhfuil inniúlachtaí sonracha sa Ghaeilge (ceadaithe ag an Roinn Caiteachais Phoiblí agus Athchóirithe) agus bheadh sé mar rún ag an Roinn aon bhearnaí a shainaithnítear inár soláthar foirne reatha sa réimse seo a líonadh ó na painéil sin agus/nó seirbhísí oiliúna na Gaeilge ceadaithe ag an Roinn Ealaíon, Oidhreachta agus Gaeltachta a úsáid chun na hinniúlachtaí atá ag ár bhfoireann reatha a fhorbairt .

Departmental Expenditure

Questions (668)

Barry Cowen

Question:

668. Deputy Barry Cowen asked the Minister for Health if he will provide in tabular form the total photography costs for his Department per annum in 2011, 2012, 2013 and 2014; the costs incurred from use of the ministerial allowance; a list of occasions for which photographers were booked; the photographers used; a breakdown of costs associated with each occasion that a photographer was used; and if he will make a statement on the matter. [1439/15]

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Written answers

Details of Photography costs for the Department from 2011 to date are shown in the table below.

It is the policy of my Department to keep costs in relation to the use of photographers to a minimum. Photographers are usually booked through the Press Office. From time to time individual units may incur other photography costs. I will advise the Deputy separately if any such payments were made.

No photography costs are met from my Ministerial Allowance.

Year

Occasion

Name

Cost €

2011

Seminar: Parental Substance Misuse - Addressing its impact on Children. A review of the literature

Conor Healy

800

2012

2nd National Patient Safety Conference

Derek Speirs

318

2012

Consultation Day Rare Disease Plan for Ireland

Conor McCabe Photography

431

2012

Closing Conference to mark the end of the European Year for Active Ageing and Solidarity between Generations 2012 in Ireland

Tommy Clancy Photography

584

2013

Symposium for Senior Pharmaceutical Policymakers on 29 - 30 August 2013

Robbie Reynolds Photography

738

2013

Joint Meeting of Chief Medical Officers and Chief Nursing Officers

Fennells

105

2013

National Drugs Coordinators Meeting April 2013

Fennells

117

2013

NPHDB/CHGB Joing Induction Day Photo Session October 2013

1Image Photography

314

2013

Photography Costs for John Higgins Chair of the Strategic Board on Hospital Groups

Donagh Glavin Photography

234

2013

Tobacco Free Ireland Launch

Conor McCabe Photography

554

2013

First National Clinical Effectiveness Symposium

Derek Speirs

437

2014

Stakeholder Consultation: September 2014

Conor McCabe

308

Public Relations Contracts Data

Questions (669)

Barry Cowen

Question:

669. Deputy Barry Cowen asked the Minister for Health if he will provide in tabular form the use of external public relations firms employed by his Department per annum in 2011, 2012, 2013 and 2014; a list of uses of the external public relations firm; and if he will make a statement on the matter. [1447/15]

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Written answers

As indicated on 18 December last, between March 2011 and July 2014, the Department did not spend any money on PR or communications consultants. The Department does not generally use their services. The Press and Communications Office in the Department liaises with the media on my behalf, the Minister of State and the Department. I will revert to the Deputy with details should there be any such expenditure since July 2014.

The Department's policy on engaging external consultants is to only so do where it is felt to be appropriate and cost effective, taking into account Government policy and Government decisions.

Information and Communications Technology

Questions (670)

Barry Cowen

Question:

670. Deputy Barry Cowen asked the Minister for Health if he will provide in tabular form per annum the total cost of external IT contractors incurred by his Department in 2011, 2012, 2013 and 2014. [1455/15]

View answer

Written answers

My Department operates a shared ICT service which, in addition to supporting the business of the Department of Health, also provides IT support for the Department of Children and Youth Affairs, the Adoption Authority of Ireland and the Office of the Ombudsman for Children. My Department engages external IT contractors for specific services such as software, helpdesk, security and network support and the total cost for these services is outlined in the following table.

2011

2012

2013

2014

€562,020

€627,892

€648,420

€736,435

Hospital Appointments Status

Questions (671)

John McGuinness

Question:

671. Deputy John McGuinness asked the Minister for Health when a person (details supplied) in County Carlow will be assessed for a hip operation; and if he will make a statement on the matter. [1458/15]

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Written answers

The scheduling of appointments for patients is a matter for the hospital to which the patient has been referred. Should a patient's general practitioner consider that the patient's condition warrants an earlier appointment, he or she would be in the best position to take the matter up with the consultant and hospital involved. In relation to the particular query raised, as this is a service matter, I have asked the HSE to respond to you directly. If you have not received a reply from the HSE within 15 working days please contact my Private Office and my officials will follow the matter up with them.

Hospital Services

Questions (672)

Fergus O'Dowd

Question:

672. Deputy Fergus O'Dowd asked the Minister for Health his views on correspondence regarding hospital treatment of a person (details supplied); and if he will make a statement on the matter. [1459/15]

View answer

Written answers

The Deputy's question relates to service delivery matters and accordingly I have asked the HSE to respond directly to him.

If you have not received a reply from the HSE within 15 working days please contact my Private Office and my officials will follow up the matter with them.

Services for People with Disabilities

Questions (673)

Michael McCarthy

Question:

673. Deputy Michael McCarthy asked the Minister for Health the recommended case load that the Health Service Executive operates for therapists, included occupational therapists, speech and language therapists, physiotherapists and psychologists in respect of children under the age of 18 years; the current adherence levels to these recommended case loads; and if he will make a statement on the matter. [1460/15]

View answer

Written answers

As this is a service matter, it has been referred to the Health Service Executive (HSE) for direct reply to the Deputy. If you have not received a reply from the HSE within 15 working days please contact my Private Office and they will follow up the matter with them.

Dental Services Provision

Questions (674)

Brendan Griffin

Question:

674. Deputy Brendan Griffin asked the Minister for Health if funding is available for dental treatments for medical card holders who require additional treatment which is not covered under the general medical services scheme; and if he will make a statement on the matter. [1479/15]

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Written answers

The Dental Treatment Services Scheme (DTSS) provides access to dental treatment for adult medical card holders. The service is provided by contracted dentists. The HSE prioritises for treatment patients with special needs, high risk patients and those who have greater clinical needs. A free oral examination every calendar year and free emergency dental treatment with a focus on relief of pain and sepsis are available to all eligible patients, regardless of their medical condition. This includes 2 fillings per year, all extractions, including surgical extractions, and a number of complex treatments. Additional treatments are available to persons with specific medical conditions including persons in receipt of care or services for a disability and persons on a register of disability. €76 million is being provided for the DTSS in 2015. The HSE will continue to monitor the operation of the DTSS to ensure the most beneficial, effective and efficient use of available resources.

Accident and Emergency Services Provision

Questions (675)

Seán Ó Fearghaíl

Question:

675. Deputy Seán Ó Fearghaíl asked the Minister for Health if his attention has been drawn to the situation at Naas General Hospital, County Kildare, where continuing overcrowding exists at the accident and emergency department and where in recent times record numbers of patients have been treated on trolleys; if he, his Department and the Health Service Executive have identified the cause of this problem; if he will provide the details of those causes; the measures he will take to address the situation; his views that the position of the accident and emergency department of the hospital is unacceptable for patients and represents a totally unsatisfactory environment for HSE staff to work in; and if he will make a statement on the matter. [1506/15]

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Written answers

The Department of Health and Health Service Executive regard trolley waits as unacceptable and acknowledge the difficulties which the current surge in ED activity is causing for patients, their families and the staff who are doing their utmost to provide safe, quality care in very challenging circumstances. It is anticipated that the figures will continue to fluctuate, but the collaborative arrangements now in place with the professional bodies and management are having an impact. All hospitals have escalation plans to manage not only patient flow but also patient safety in a responsive, controlled and planned way that supports and ensures the delivery of optimum patient care.

Triage is operated to prioritise patients so that those with most acute needs are seen and treated as soon as possible. Hospital EDs seek to manage any possible risks for patients so as to minimise any safety issues and keep risk to an absolute minimum in what are very difficult circumstances in many EDs at present. Senior clinicians are part of this system and the responsibility to minimise potential risk and ensure the safest possible care is a responsibility they deal with as part of their duties every day in hospitals.

Measures to manage ED surges involve the full health system including primary, community and continuing care services to ensure that all available capacity and options are utilised and brought to bear on the situation. HSE have advised that at present:

- Additional beds to cope with surge pressures are open

- All non-urgent elective procedures have been cancelled but urgent and cancer surgeries will continue

- Day surgery facilities are in use to provide additional capacity for overflow purposes

- Ambulance bypass cover arrangements will be invoked in exceptional circumstances and with the prior agreement of the Group CEO and participating hospitals

- The role of consultant doctors in terms of ensuring additional ward rounds and patient transfers has been emphasised with the aim of discharging patients as soon as they are fit and well enough to go home or to other care facilities.

- The use of additional capacity in non-acute hospitals, particularly to provide rehabilitation care, is being expedited where possible (e.g. St. Luke's/Cappagh/Navan)

The Government has provided additional funding of €25 million in 2015 to address delayed discharges. This funding is being targeted at hospital and community services which can demonstrate initiatives to address specific needs of delayed discharge patients most positively and therefore improve timeliness for admissions from Emergency Departments and waiting lists.

As this is a service matter, I have asked the HSE to respond to you directly in relation to the situation at Naas General Hospital. If you have not received a reply from the HSE within 15 working days please contact my Private Office and my officials will follow the matter up.

Proposed Legislation

Questions (676)

Jerry Buttimer

Question:

676. Deputy Jerry Buttimer asked the Minister for Health the range of measures being considered for inclusion in the public health (alcohol) Bill; when the general scheme of the Bill will be published; and if he will make a statement on the matter. [1509/15]

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Written answers

The Government has approved an extensive package of measures to deal with alcohol misuse to be incorporated in a Public Health (Alcohol) Bill. These measures are based on the recommendations contained in the Steering Group Report on a National Substance Misuse Strategy, 2012. The package of measures to be implemented will include provision for minimum unit pricing, regulation of the marketing and advertising of alcohol, regulation of sports sponsorship, structural separation of alcohol from other products in mixed trading outlets and labelling of alcohol products. Work on developing a framework for the necessary Department of Health legislation is continuing and is hoped to publish a General Scheme of a Bill early this year.

Accident and Emergency Services Provision

Questions (677)

Bernard Durkan

Question:

677. Deputy Bernard J. Durkan asked the Minister for Health the extent to which the throughput of patients and procedures has been maintained at all public hospital accident and emergency departments, all fully operational primary care centres throughout the country on a daily basis for the months of December 2014 and to date in January 2015; if any particular issues relating to overcrowding have been noted; if arising therefrom his proposals to address any such issues; and if he will make a statement on the matter. [1564/15]

View answer

Written answers

As this is a service matter, I have asked the HSE to respond to you directly. If you have not received a reply from the HSE within 15 working days please contact my Private Office and my officials will follow the matter up.

Nursing Staff Provision

Questions (678)

Michael Healy-Rae

Question:

678. Deputy Michael Healy-Rae asked the Minister for Health his views on a matter (details supplied) regarding the shortage of nurses here; and if he will make a statement on the matter. [1574/15]

View answer

Written answers

I am aware that some nursing homes are experiencing difficulties in recruiting nurses reflecting to a degree the fact that opportunities within the Acute sector have improved. Historically a large number of Irish graduate nurses have found posts in acute hospitals in Ireland or abroad more attractive and the sector has relied on attracting nurses from abroad to fill these posts.

The six weeks adaptation course (for overseas nurses) referred to is not a matter for the Department but a matter for the Nursing & Midwifery Board of Ireland (NMBI). The central tenet of the NMBI is the protection of the public and as such the NMBI must be fully satisfied that each application for registration is fully reviewed and decisions reached are in full compliance with the requirements and standards for registration. Individuals who have queries regarding the application process or outcome of an individual assessment should contact the NMBI directly.

The Health Information and Quality Authority is the independent authority established under the Health Act 2007 to drive continuous improvement and to monitor safety and quality in Ireland’s health and personal social care services. Since 2009 all nursing homes - public, voluntary and private have been registered and inspected by HIQA. The Health Act (Care and Welfare of Residents in Designated Centres for older people) Regulations, 2013 contain provisions for the purpose of ensuring proper standards of care in nursing homes and include a requirement that the number and skill mix of staff is appropriate having regard to the assessed needs of the residents, and the size and layout of the centre in question. There is also a requirement that the staff of a designated centre includes, at all times, at least one registered nurse.

With regard to pressures in the health system, the budget for the Nursing Home Support Scheme in 2015 is €948.8m. This includes an increase of €10m allocated to the initiative related to delayed discharges. This increase will allow for the provision of an additional 300 long stay care places under the NHSS. In 2015 the HSE's National Service Plan's projected target of people in receipt of financial support for long term residential care is 22,361. In light of the recent pressures in Emergency Departments the HSE is accessing all suitable non-acute accommodation to the maximum extent possible to allow those who have been clinically discharged to leave acute hospitals.

National Dementia Strategy

Questions (679, 680, 681, 682)

Billy Kelleher

Question:

679. Deputy Billy Kelleher asked the Minister for Health in view of the recently published national dementia strategy indicating that up to 29% of all patients in a typical general hospital may have dementia while the Irish national audit of dementia found that 94% of hospitals have no dementia pathway in place, the actions that have been put in place to ensure that dementia patients are provided appropriate care and that hospital beds are therefore available for those patients currently in accident and emergency on trolleys; and if he will make a statement on the matter. [1575/15]

View answer

Billy Kelleher

Question:

680. Deputy Billy Kelleher asked the Minister for Health in view of the acknowledgement in the national dementia strategy that the average cost to the State per person with dementia here is €40,500 per annum as the bulk of the care for persons with dementia is provided free of charge by their family care-giver and that the informal cost of dementia to family caregivers is estimated to be €807 million per annum, if he will provide a breakdown of the €27.5 million allocated to fund the strategy; and the financial support that will be provided to family care-givers who are burdened with the most significant proportion of the cost of dementia. [1576/15]

View answer

Billy Kelleher

Question:

681. Deputy Billy Kelleher asked the Minister for Health if the national dementia strategy monitoring group has been established to monitor progress towards implementation of the strategy; the details of membership if already established; and details of the members' remit in terms of ensuring that all actions are successfully implemented. [1577/15]

View answer

Billy Kelleher

Question:

682. Deputy Billy Kelleher asked the Minister for Health regarding the assignation of the overall responsibility for the implementation of the national dementia strategy within the Health Service Executive to the office of services for older people and the 4,000 persons currently affected by early onset dementia, if he will indicate the specific programme of care for these persons under the management of that office; if his attention has been drawn to the specific challenges for persons with early onset dementia are compounded by the lack of a specific care programme in terms of attaining funding for carers, nursing homes and the additional financial struggles affecting these particular groups of persons [1578/15]

View answer

Written answers

I propose to take Questions Nos. 679 to 682, inclusive, together.

A Monitoring Group, chaired by the Department of Health, is being established to assist with and advise on implementation of the National Dementia Strategy, including the National Dementia Strategy Implementation Programme. This Group will again include health professionals, administrators, researchers, and advocates. In addition, the Group will include a number of new members including a person living with dementia and a representative of those who care for people with dementia.

With one exception (because the relevant person is directly involved in implementing elements of the Strategy and is therefore unavailable), all the members of the expert Working Group which assisted in formulating the Strategy have been invited to join the new Monitoring Group. In addition there will be a number of new members, as follows:

- Ms. Helen Rochford-Brennan, who will represent people living with dementia.

- Dr. Richard Aboud, who is a General Practitioner.

- Professor Eamonn O’Shea, who is an expert on ageing issues and will represent Atlantic Philanthropies.

- Mr. John Linehan, Head of HSE’s Dementia Strategy Implementation Office.

The Monitoring Group’s remit is as follows:

- To monitor and assess progress on the implementation of the recommendations in the National Dementia Strategy;

- To identify any factors with the potential to affect the delivery of the Priority Actions, including the three Priority Activities within the Implementation Programme agreed with The Atlantic Philanthropies;

- To make recommendations in relation to the manner in which the Strategy is implemented;

- To advise on the establishment of a monitoring and reporting framework (to include key performance indicators) which is valid both nationally and locally to track change and improvement over the agreed period in respect of dementia services,

- To advise on the commissioning framework for Strategy evaluation following from the Expert Advisory Panel ( This is a small technical group to advise specifically on evaluation issues),

- To report to the Minister of State for Older People twice yearly on progress made towards implementing the recommendations of the National Dementia Strategy. The Minister will in turn report to the Cabinet Committee on Social Policy and Public Service Reform .

The Strategy specifically acknowledges the fact that many people under the age of 65 are living with dementia, and both the members of the Monitoring Group and those leading the Strategy’s practical implementation are very conscious of the particular challenges posed for younger people by dementia, and of the need to respond to those challenges

A number of the priorities identified within the Strategy will be of benefit to people under 65 with dementia. Early diagnosis will assist in ensuring people under 65 will be diagnosed earlier. A key aim of the Strategy is to identify the services currently available to people under 65, and to plan to address gaps that may now exist. The Dementia Awareness and Stigma Programme element of the National Dementia Strategy Implementation Programme will seek to increase awareness of dementia in this age group, and to provide more age specific information for them. Six Dementia Advisors (under the aegis of the Alzheimer's Society of Ireland) are also in place in various locations and will support people with a diagnosis of dementia, including those under 65. Early onset dementia may cross a number of care groups, and a HSE Cross Departmental Group will work to integrate service provision for people under 65 with dementia. Consideration will also be given to providing tailored packages of intensive home supports that are appropriate to younger people with Dementia, as part of the National Dementia Strategy Implementation Programme.

The Strategy’s objectives include the need to make hospitals dementia-friendly from admission to discharge or death, which includes environmental aspects as well as clinical support. There is a commitment to the development by the Health Service Executive of a dementia and delirium care pathway, which can be fitted to existing acute care pathways and implemented on a local level in each acute hospital. In addition the HSE will assign responsibility within its own facilities and elsewhere will encourage the assignment of responsibility to a senior clinician within each hospital to lead the development, implementation and monitoring of the care pathway.

Hospitals will be required to ensure that people with dementia have a specific pathway through Emergency Departments and Acute Hospital Medical Units that is appropriate to their particular sensory and psychosocial needs. The HSE will develop guidelines on dementia-friendly ward specification to be taken into account at the design stage of all refurbishments and new builds. Elements to be considered should include safe walking spaces and the use of colour, lighting, signage, orientation cues and space used to promote social interaction.

Hospitals will prioritise the assessments of social and environmental supports to meet the needs of people with dementia and their carers, including access to appropriate social work support.

While exact financial allocations will be firmed up as implementation progresses, our agreement with the Atlantic Philanthropies provides that the €27.5m which is available for the National Dementia Strategy Implementation Programme will broadly be allocated as follows:

Provision of intensive home supports ~ €22.1m

Dementia Awareness Programme ~ €2.7m

Education programme for GPs/Primary Care teams ~ €1.2m

National Dementia Strategy Implementation Office and supports ~ €1.5m

Financial supports for Carers are mainly provided through Schemes administered by the Department of Social Protection. Details of these supports are available on that Department’s website (www.welfare.ie), these include - Carer’s Allowance, Carer’s Benefit, Respite Care Grant, and Domiciliary Care Allowance.

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