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Dáil Éireann díospóireacht -
Tuesday, 13 May 2008

Vol. 654 No. 1

Health Services.

I wish to raise with the Minister of State the wide disparity in average waiting times in the Dublin area for 4,136 children who urgently require speech and language therapy services which vary from as low as three months in Dublin North-Central to 31 months in south Dublin and 32 months in Dublin west.

I have been following up on this matter now for more than 12 months. The situation in the south Dublin area, which includes my constituency, is going from bad to worse. It is extraordinary in that in the Dublin area there are 4,136 children urgently seeking speech and language therapy. The number involved is frightening when one considers the consequences for each child who does not receive early attention.

The Bacon report, published six years ago, recommended that the number of speech and language therapists be increased four-fold to 100 per annum to attain a total of 12,085 therapists by 2015. Those who have qualified are not being employed on the basis that they have no experience. I do not understand how a person can gain experience without being given the opportunity to do so. As a consequence, a number of young children in particular are waiting substantial periods for treatment.

I raised on the Adjournment in January or February this year the situation in respect of a five year old child living in my constituency. I contacted the HSE about this child on 10 November last and was told that having waited 12 months for assessment he had been assessed as an urgent case but that it would be at least a year before he obtained treatment. Children are having to wait one year to be assessed and, having been assessed as in need of urgent treatment, must wait another year for it.

In April, I decided to follow up on the matter to get the latest position in respect of this child. I received a reply which stated that things were worse and that it would be at least another 12 months before got treatment. Despite this child having been assessed as an urgent case, he will have to wait 18 months for treatment.

In Dublin North-Central, there is a three month waiting period for assessment with 207 children on the waiting list. In south Dublin, which includes Dun Laoghaire, there are 598 children on a waiting list and the waiting period is 31 months. These figures were supplied to me by the HSE. I cannot understand this. In Dublin west, for example, the waiting period is 32 months. Surely, something can be done about children five years old and upwards having to wait for up to 31 months at a minimum before they receive treatment. I hope the Minister of State can explain to me this evening on what basis such disparity exists.

I take this Adjournment on behalf of my colleague, the Minister for Health and Children, Deputy Mary Harney.

I emphasise the Government's commitment to providing a high quality service to all people with a disability. This commitment is illustrated by the substantial investment in disability services in recent years. The national disability strategy launched in September 2004 reinforces equal participation in society of people with disabilities and provides for a framework of new supports for people with disabilities. This strategy, together with the enhancement of other key support services, are key factors in building the additional capacity required to ensure that services best meet identified needs.

The strategy builds on a strong equality framework, which is reflected in equality legislation. It puts the policy of mainstreaming public services for people with disabilities on a clear legal footing. The main elements of the strategy are the Disability Act 2005, the Education for Persons with Special Educational Needs Act 2004, EPSEN Act, sectoral plans published in 2006 by six Departments, Citizens Information Act 2007 and the multi-annual investment programme 2006-2009 for disability support services.

An integral part of the national disability strategy is the multi-annual investment programme, MAIP, announced in the 2005 budget, which gives a commitment to a cumulative capital and revenue programme of €900 million with the bulk of this funding being spent on health services for people with a disability during the period 2006 to 2009. These commitments include the development of new residential, respite and day places for persons with intellectual disability and autism in each of the years covered by the programme.

As the Deputy is aware, an additional €50 million was allocated by the Government for the provision of disability services in budget 2008 of which €9.8 million was allocated for the provision of 140 additional therapy posts. These 140 posts are being allocated to disability services in 2008 to provide assessment and ongoing intervention services to children with a disability and in particular with reference to the implementation of the Disability Act for children under five years of age, which commenced on 1 June 2007.

By the end of the current multi-annual investment programme in 2009, it is expected that 1,235 new residential places, 398 new respite places and 467 new day care places will have been commissioned for intellectual disability services in addition to 380 new residential places and 1,150,000 extra personal assistant-home support hours for people with physical and sensory disabilities.

With regard to the matter raised by the Deputy on the Adjournment, the HSE has informed the Department of Health and Children that speech and language therapists are concerned with the assessment, diagnosis and management of communication and swallowing disorders. Children referred to speech and language therapy services undergo an initial assessment to identify the existence and severity of the need for ongoing therapy. The priority for ongoing intervention is dependent on the nature and severity of the disorder, following assessment.

The HSE has consistently endeavoured to prioritise the provision of speech and language therapy to children with speech and language delay or disorders. The development of additional primary care services, through the establishment of primary care teams, has led to the creation of several additional speech and language therapy posts. In addition, funding allocated for the development of disability services in line with the multi-annual investment programme and the national disability strategy also allowed an increase in speech and language therapy resources. This prioritisation of speech and language therapy is evidenced by an increase in the number of speech and language therapists employed by the HSE and by agencies funded by the HSE from 498 in December 2004 to 724 in February 2008. However, the HSE states that notwithstanding the 45% increase in speech and language therapy posts, some individual local health office areas have experienced difficulties in replacing staff members who have left the service.

In addition the complexity of service delivery, including the way in which services have been managed by a range of agencies and funded across different care groups, has not resulted in a cohesive approach to service provision. These factors have a bearing on the waiting times for services as raised by the Deputy in this Adjournment debate. As part of its transformation programme, the HSE is developing co-ordinated early intervention services in each local health office. This will ensure that all resources available to each local health office, including those in non-statutory agencies, work as part of a cohesive single service to address the needs of all children.

The HSE states that it is also planning to improve the range and effectiveness of services to children from five to 18 years. These plans are being developed in co-operation with the Office for Disability and Mental Health in the context of preparation for the implementation of the EPSEN Act and the extension of the Disability Act for this age cohort. The Office for Disability and Mental Health was established in January of this year with a remit, inter alia, to facilitate the delivery of integrated health and education support services for children with a disability.

Hospital Services.

I thank the Ceann Comhairle for providing me with the opportunity to raise this important matter regarding the uncertainty about patient care for the people of Monaghan in light of the commitment of the Minister for Health and Children, Deputy Harney, and Professor Drumm to wind down services at Monaghan General Hospital. On Saturday, at least 5,000 people met in Monaghan Church Square to protest regarding their fear for the future.

On Saturday morning, my colleague and Fine Gael health spokesperson, Deputy James Reilly, together with Senator Joe O'Reilly and myself, paid an arranged visit to Cavan General Hospital to see for ourselves what preparation, if any, has been made to cope with the downgrading of Monaghan General Hospital and the further proposals to take Monaghan General Hospital off call. It was blatantly obvious that no such structure is available or likely to be available for the foreseeable future. While some planning was explained to us, it was made clear that no additional budget has been granted and funding is already under severe pressure.

We subsequently visited Monaghan General Hospital and met with the consultants and GPs to see at first hand the facilities available in Monaghan accident and emergency treatment room. However, we were advised that no more than three patients are allowed to remain on trolleys in Monaghan under the so-called "protocol" whereas they can be transferred to the trolley system in Cavan or Drogheda, mostly against the wishes of the patients. The treatment room at Monaghan General Hospital is fabulous and equal to none.

The consultants in Monaghan have made every effort to work within the system to provide a safe and quality service to our patients. An independent survey has shown that their delivery of service is of an extraordinarily high nature and better or as good as any other in the country. I will quote a recent letter to the programme manager for the north-east transformation structure from the consultants who made it clear that "it is apparent to us following our meeting with the Cavan consultant physicians, that the availability of a critical care bed for a patient from Monaghan Hospital cannot be guaranteed. We believe therefore, that the Protocol outlined is intrinsically unsafe and we hereby formally put that on the record."

They also made it clear that:

no extra resources have or will be provided at Cavan General Hospital to provide for 3,000 extra patients from Monaghan. It is also apparent to us from our contact with our General Practitioner colleagues that no extra resources have been provided for care in the community.

They further state: "if you discontinue the coronary care/acute care facility at this hospital you are compelled to show provision of a similar quality service elsewhere to which our patients can have recourse".

I will provide the Minister of State with the full content of the letter sent to the HSE by the four Monaghan General Hospital consultants. It is clearly one of a series of letters being sent to the Department and the HSE. The situation in Monaghan General Hospital is at crisis level where the knowledge and ability of consultants is being ignored and ambulances are being advised to travel directly to Cavan by administrative staff rather than to Monaghan, in spite of the fact that the patients are almost certainly likely to finish up on trolleys.

With a clear indication that no money is available for the necessary restructuring and provision of services in Cavan or elsewhere, it is vital that the Minister for Health and Children uses her influence to stop the lunacy of withdrawing an excellent service until, as she has previously promised, a better or as good alternative services is available. This has been put on the record several times but it has been completely ignored.

At least 17 people lost their lives unnecessarily as a result of Monaghan General Hospital being off call on a previous occasion. If similar happens again, I will personally hold the Minister for Health and Children responsible along with the Taoiseach and those who support them. I do not mean this as a threat but I want to make it absolutely clear. Mr. Finbarr Lennon, a consultant at Our Lady of Lourdes Hospital, was a special adviser to the health board. Once again, he has written to the HSE explaining how unsafe the situation is and begging it to step back

I will take the Adjournment on behalf of my colleague the Minister for Health and Children, Deputy Mary Harney.

The teamwork report, prepared for the Health Service Executive, has helped to inform the approach being adopted with regard to the transformation programme. The report clearly indicated that the current service configuration in the north-east region is unsustainable and recommended a reconfiguration of hospital services across the existing five hospital sites to ensure the highest level of patient safety. The report also identified a future role for all five hospital sites in the provision of acute hospital services.

The transformation programme for the north-east region involves widespread and fundamental change and is designed to build a health system in line with the model of care emerging internationally. In progressing the programme, the HSE has repeatedly emphasised its commitment that existing services in the region will remain in place until they are replaced with higher quality, safer or more appropriate services. The overriding aim of the programme, which has the full support of the Minister, is the need to improve safety and achieve better standards of care for patients in the region.

The transformation programme is approaching the end of its initial phase of detailed planning and is moving towards detailed design and implementation. The initial focus of the programme has been to have acute and complex care transitioned from five to two hospital sites by 2010. In determining the future capacity of each hospital in the region, the HSE will need to have regard to the findings of reviews which it commissioned and which highlighted the potential to use the existing bed complement in a more efficient manner. The reviews confirmed, for example, that acute hospital admissions and length of stay could be reduced if access to a range of support services is improved.

The HSE has advised the Department that a draft interim report for the north-east transformation programme has been produced primarily to facilitate engagement and meaningful input, via the partnership process, with staff and unions. This interim report addresses many of the key short and medium-term planned service changes in Cavan and Monaghan together with a number of the initial changes proposed for Louth and Meath and lists the supporting changes that need to be in place in advance of or parallel with the centralisation of acute care. These include enhanced ambulance services, medical assessment units——

There are none of these either.

——rehabilitation and non-acute services, packages of primarily community-based care and additional long-stay services.

It is not possible until the current detailed planning phase is complete to be definitive as to what aspects of north-east transformation can be implemented during this year and what can be achieved in 2009. In its draft capital plan, the HSE proposes to spend approximately €100 million additional capital funding up to 2013 in the north east to progress the transformation programme. The HSE intends to make a capital allocation available in respect of each of the five hospitals in the region to meet the cost of interim infrastructural works necessary in each facility.

The HSE envisages that the role of Monaghan General Hospital in the future will be to provide a range of diagnostic, outpatient, day cases and some in-patient treatment services within clinical networks. Significant developments have also taken place with regard to the provision of surgical services across the Cavan and Monaghan hospital interface. Emergency surgical services on a 24-hour, seven day basis are provided on the Cavan site while significant elements of diagnostic, outpatient and day case services are provided on the Monaghan Hospital site. This has resulted in lower waiting times for out-patient appointments and in-patient elective services. Since the reconfiguration of Cavan and Monaghan surgical services, patients can be seen by the visiting consultant surgeon on the day of referral by the GP.

Monaghan Hospital will continue to have an important role to play in the provision of health services in the north east. This view was confirmed in the teamwork report and also in the north-east transformation programme. The reconfiguration of services in the north east in a way which demonstrably delivers safer and more effective services for people in that region will continue to have the full support of the Minister.

Child Care Services.

While I welcome the Minister of State, Deputy Hoctor, I wonder why, when all the questions on the Adjournment pertain to the Minister for Health and Children, she is not here herself.

I thank the Ceann Comhairle for the opportunity to address the important issue of the need for immediate action by the Minister for Health and Children to address the crisis in child protection by appointing additional social workers and other community care and health professionals. The section is required without delay to fulfil the State's responsibility to children known by the HSE to be at serious risk of abuse or neglect, or being abused and neglected but who are receiving no assistance because of the recruitment embargo and the restrictive appointment controls.

Last night's "Prime Time Investigates" programme revealed the horrific extent of the child protection crisis in this State. Children are being abused and neglected or left at risk of abuse and neglect, even though their files are in the hands of the HSE and they are known to be in these situations. We were faced in that programme with the chilling prospect of dozens of files on children at grave risk in filing cabinets with no action being taken because there are not enough social workers to deal with the massive caseload. This is the devastating result of the cap on recruitment implemented by the HSE, for which the Government is ultimately responsible. The report confirms the repeated warnings from social workers and others working with children and for children's rights that the under-resourcing of child protection services, social work, community care, family support and psychological and therapeutic services is having terrible consequences. To make a bad situation worse, the current regime of cuts is being imposed by the HSE.

We are all too familiar with waiting lists in our health services, but the waiting list of children in need of immediate intervention in crisis situations must surely be the worst. It is appalling that there are waiting lists of more than a year for access to child mental health services and family support services. The Irish Association of Social Workers, IASW, stated that its members are concerned, angered and frustrated that the right of children to effective protection and community care is being infringed. On many occasions it has warned that children are at huge risk because of HSE failures. The association said the programme drew attention to the realities faced by social workers and families attempting to access social work services.

Many social workers experience stress, burn-out and exhaustion as they struggle to respond to an ever-increasing need with inadequate resources. I join the association in its call on the Government and the HSE to act immediately to lift the current employment controls on social work posts and to fully resource community care social work teams throughout the country. Declan Coogan of the IASW stated:

Children at risk of abuse and neglect are among the most vulnerable group in our society, yet judging by the lack of provision of funding for community care social work services, little consideration is given to their welfare. We demand that the HSE fully resource community care social work child protection and welfare teams and fully resource community mental health services. No child should have to wait for essential social work and therapy services because someone somewhere has said there is no money. It seems that the protection of children is at the bottom of the list of priorities of those who make decisions about funding but are remote from the consequences of these decisions.

The Government cannot credibly claim that it did not know the extent of the problem as again and again it has been warned. For example, last December the Minister for Finance, now the Taoiseach, attended the launch of Barnardos' 2006 review, which stated that 91% of the children who came to Barnardos had family and relationship needs ranging from family discord to domestic violence. The response to this crisis by the new Minister of State with responsibility for children, Deputy Barry Andrews, on "Morning Ireland" this morning can only be described as totally inadequate. He was in automatic defence mode and he could not possibly have fully briefed himself on this crisis in the short time since he was appointed. I am also disappointed at the response of the Taoiseach in the Dáil today. Neither he nor the Minister of State treated the matter with the sense of urgency that is required. They seemed not to recognise the justifiable outrage among people throughout the country that the most vulnerable of children in our society are being let down in such an appalling manner.

I urge the Minister of State strongly to take immediate action to address the crisis to ensure that essential social workers are appointed and to ensure that those children most at risk are assisted with all possible speed.

I thank the Deputy for raising this issue and I welcome the opportunity to respond to the debate on behalf of my colleague, Deputy Barry Andrews, the Minister of State with responsibility for children and youth affairs.

In all cases where there is a serious and immediate risk to the health or welfare of a child, the HSE responds immediately and takes appropriate action. All child abuse reports to social work departments are subject to a phased process of initial screening and assessment, aimed at providing appropriate interventions. Legislative mechanisms are in place which also allow for additional responses from the Garda.

Increases in resources for child care and family support services have continued in recent years. The HSE informed the Minister of State that a significant number of additional social work posts have been created since 2005 and funding of family support services has increased by 79%, from €45.7 million in 2003 to €81.8 million, in 2008. This reflects the commitment of the Government and the HSE to the ongoing implementation of the national children strategy and, most recently, the overarching policy of the Office of the Minister for Children and the agenda for children's services. The HSE has made significant advances in many areas of children's services. For example, a well managed national approach is in operation in regard to special care and high support, dealing with the most needy children in HSE care.

Developments in services provided through the HSE have, in more recent years, refocused on community-based family support sector targeting children and families at risk. In many cases this is done in partnership with non-governmental agencies where the focus is building capacity in vulnerable communities. This reflects the Government's policy of emphasising a preventive and supportive approach to child welfare. The shift in emphasis towards community-based services and the increase in the HSE's staff complement in respect of new service developments are to be welcomed in this regard. In addition, the inter-agency work promoted by the Office of the Minister for Children has led to improved co-operation in the delivery of children's services.

The HSE's budget for 2008 is €14.2 billion, an increase of 8% on 2007. Employment in the health sector must reflect the funding available and the HSE is responsible to live within the funding voted by the Oireachtas to deliver its service plan commitments. As regards employment control issues, the HSE has received ministerial approval for a revised ceiling of 110,600 for the end of 2007, with an additional 1,050 posts for new developments announced in budget 2008. Within this overall employment ceiling, it is the HSE's responsibility to deploy resources in line with priorities identified in its service plan. Total numbers employed at end March 2008 are 110,156 compared to the ceiling of 111,650. The temporary pause in recruitment, initiated as part of the HSE's financial break-even plan, ended on 31 December 2007. Posts vacant since 1 January 2008 can, therefore, be filled subject to the provisions of the HSE's employment control framework for 2008, which provides for an assessment of the vacancy by HSE area monitoring groups, the protection of employment in frontline services and the reconfiguration of employment to meet the primary objectives of integrated service delivery and a fundamental shift in the delivery of health and personal social services from the hospital sector to primary, community and continuing care. In this regard, 47 social worker vacancies are in the process of being filled by the HSE.

The HSE successfully intervenes with children and families at risk on a daily basis. There remains a concern that any diminution of public confidence in the child protection system, for any reason, could result in individuals being reluctant to report child protection concerns. There is an onus on us all to ensure this does not happen. In this regard, it is imperative everyone is aware of their own and the HSE's responsibility under Children First — the National Guidelines for the Protection and Welfare of Children. My colleague, the Minister of State and his office will continue to work with the HSE to monitor and review services for children and families and to ensure the available resources are applied to greatest effect, leading to improvements in child welfare and protection services.

Protection of Animals.

The need for the establishment of a working group to examine legislation for the regulation of dog breeding establishments is borne out of a concern for an area that falls outside mainstream animal breeding, which is open to much abuse. In the same way as turkey and brussels sprouts farmers, many of these people see Christmas as the golden time to sell. We see what happens when dogs are given to children as Christmas presents and end up on the road, in the wild or in animal welfare pounds by the middle of January.

With that in mind, a working group was set up in October 2004. It brought together many of the people involved in dog breeding establishments to try to bring to heel those who abuse animals purely for unscrupulous commercial purposes in the same way as dog fighting, which was carried out in the past and probably continues under the radar in the black economy. The group held four meetings over a two-year period and came up with draft recommendations. Since the autumn session, I have asked the Minister when he was going to publish those recommendations and his own recommendations.

One thing was clear. In its deliberations, there were areas that were outside the terms of reference which came up for discussion, one of which is the need to introduce microchipping to assist gardaí and dog wardens in identifying animals. This may present problems for legitimate breeders who want to sell their animals abroad.

The group identified the need for but did not have the authority to recommend that the Department of the Environment, Heritage and Local Government carry out a review of the Control of Dogs Act and that the Department of Agriculture, Fisheries and Food carry out a review of the Protection of Animals Act and the duty of care associated with that in the same way as for mainstream farming. It also identified the need for better education. This goes back to the Christmas or birthday buzz people get from buying their children a dog they are unable to take care of. It also looked at ways of reducing the number of animals that must be put down annually by way of spaying and neutering and highlighted the need to encourage that.

We do not want to see this legislation brought in purely on foot of the recommendations because it is not the complete picture. This area is to be transferred to the Department of Agriculture, Fisheries and Food. In reality, that may not happen before these regulations are put in place. This must be brought back before the House to be debated because all of those other areas must be brought into the pot before we get proper legislation.

There are people out there who have large-scale puppy farms with thousands of animals. I am not exaggerating. If this was implemented as legislation, it would not be possible to control these people. The ISPCA says that it cannot take the animals into its care, while the gardaí say it is the responsibility of the ISPCA, which does not have the resources. If there is an outbreak of disease or other animal welfare issue affecting large animals, we are able to organise a cull for the greater good of animals and animal welfare.

We must bring the recommendations of this committee back to the House for further discussion to try to fine tune them and make it a comprehensive piece of law before it is put on the Statute Book. Is it the aim of the Minister for the Environment, Heritage and Local Government to bring it back here to be discussed? What is the timeframe for transferring responsibility in this area to the Department of Agriculture, Fisheries and Food? Will the Departments of Agriculture, Fisheries and Food and the Environment, Heritage and Local Government set up an interdepartmental think tank because that is needed? Will this happen before legislation is introduced? We do not want to see these regulations published one day, which the Minister seemingly has the right to do, without coming back here to be discussed as primary legislation.

I thank Deputy Andrew Doyle for raising this issue. The role of the Department of the Environment, Heritage and Local Government relates primarily to dog licensing and controls on dangerous dogs in the interest of the protection of the public and other animals, i.e., the Control of Dogs Acts 1986 and 1992 along with associated regulations.

In the light of a number of reports about substandard "puppy farms", the Minister for the Environment, Heritage and Local Government undertook in 2006 to consider regulation of dog breeding establishments in the interest of animal welfare. A working group was established to review the management of dog breeding establishments nationally. The group, which included a cross section of people with professional and welfare involvement with dogs, produced a majority report for the then Minister with a set of recommendations. However, three minority reports were also presented by bodies represented on the working group. In light of that, a period of public consultation followed and while there was not universal agreement with the recommendations, the then Minister concluded that there was sufficient agreement that they should be implemented.

The Department of the Environment, Heritage and Local Government is currently finalising a set of draft regulations in accordance with current control of dogs legislation which will give statutory effect to most of the recommendations contained in the majority report of the working group. This majority report contained a set of recommendations which are set out as follows. It was recommended that dog breeding establishments be defined based on the number of female dogs with breeding potential present on the premises. A dog breeding establishment would be defined as "a premises containing more than five female dogs, aged over four months, with breeding potential". In respect of the funding of the regulatory system, it was recommended that the new regulatory regime be self-financing and be funded by increasing the general dog licence fee for dogs kept in breeding establishments. In respect of permanent identification, it was recommended that all dogs kept in breeding establishments, including their offspring, be electronically microchipped to ensure traceability and assist the enforcement of the registration system. The group also recommended that greyhounds be exempted where they have already met the Irish Greyhound Board's identification requirements. In respect of the transportation and export of dogs, it was recommended that the Department of Agriculture, Fisheries and Food implement regulations for the transportation of consignments of dogs within the State and for export. These regulations would cover transportation standards, minimum space requirements, ventilation, route plans, journey durations, feeding and watering intervals. It was agreed that every dog owner and dog breeder has a "duty of care" in respect of animals kept by them and it was recommended that this be enshrined in all animal welfare legislation. In respect of lead-in time, it was recommended that the new dog breeding registration system be introduced on a phased basis using an improvement notice model to avoid the creation of a surplus of dogs caused by the closure of substandard dog breeding establishments.

Since the working group's report was issued, the Department has undertaken extensive consultation with relevant central and local authorities and a large number of interested organisations. In finalising the regulations, a comprehensive round of discussions took place between the Department and a range of veterinary, dog welfare and other interested bodies. Guidelines will also be introduced in conjunction with the regulations which will focus strongly on the welfare requirements of dogs in these establishments. These guidelines have been extensively informed by discussions with, and valuable input from, leading veterinary and animal welfare organisations.

Certification of registration of dog breeding establishments will be undertaken by local authorities as part of their dog control responsibilities. It is intended that a registration fee graded in accordance with the size of the establishment will apply in order to finance the scheme.

In general, while there remains some opposition to the recommendations, there is general support for regulation in this area. It is a complex area with a very large and diverse number of interested parties and stakeholders. It is not considered practical to introduce interim arrangements for the regulation of puppy farms in advance of these new regulations and I understand that it is the Minister's intention to finalise matters in the coming weeks. The regulations represent one aspect of reform in regard to dog control. Other issues raised in the course of discussions with interested parties will be examined with a view to introducing additional reforms in the future.

The Dáil adjourned at 9.10 p.m. until 10.30 a.m. on Wednesday, 14 May 2008.
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