Dáil Éireann díospóireacht -
Thursday, 16 Feb 2023

Vol. 1033 No. 5

Ceisteanna Eile - Other Questions

Mental Health Services

Mark Ward

Ceist:

87. Deputy Mark Ward asked the Minister for Health if he will set out a timeframe for completing a review of all open and lost to follow up cases in child and adolescent mental health services to address matters raised by the interim report of the Mental Health Commission arising from an independent review of such services; if he will publish a multi-annual funding plan for improving child and youth mental health services; and if he will make a statement on the matter. [7554/23]

Deputy Mark Ward

I will speak about the Mental Health Commission's report into CAMHS. One of the concerns escalated relates to the 140 children who were lost to follow up. Will the Minister of State set out a timeframe for completing a review of all open and lost cases in CAMHS? Will she publish a multi-annual funding plan for improving CAMHS, including to extend access to CAMHS to young people up to the age of 25?

Minister of State at the Department of Health (Deputy Mary Butler)

I will respond to the Deputy's third question first. As he will be aware, the national implementation and monitoring committee, NIMC, is the oversight body in charge of ensuring Sharing the Vision: A Mental Health Policy for Everyone is delivered. A sub-committee which reports to me every three months has recently been formed. Its reports are on the NIMC website. The sub-committee was in place before this report was published. It was asked to look at children ageing-out of CAMHS at 18. We are looking at extending the age to 21, 23 or 25. I am open to all suggestions. A body of work is being done by public, private and voluntary stakeholders on this.

I will now respond to the Deputy's first question about the timeframe for completing a review.

All areas of concern identified by the commission in carrying out its interim report were escalated immediately by the HSE for immediate action and resolution, including the review of open patient cases which the HSE is undertaking. Several meetings were held with the Minister, Deputy Donnelly, and I and I met all the stakeholders in the HSE.

All CAMHS teams nationally have been asked to conduct a review of all open cases. For the purpose of this review, an open case is defined as a referral that has been accepted and the patient seen for initial assessment and where the patient is currently under the care of CAMHS. A guidance pack and associated documentation has been sent out to all chief officers and heads of service for mental health in the CHO areas this week requesting details on the number of open cases identified through this phase. Each area has been asked to report back on this by 17 March 2023. This is to identify the open cases. Once CAMHS teams have assessed and prioritised those cases that have not been seen within the past six months and have no follow-up appointment scheduled, the HSE has confirmed that a number of steps will be undertaken. I will come back with the details on these. The complete audit will be concluded by the end of May 2023.

Deputy Mark Ward

I thank the Minister of State. As I said I have met the HSE numerous times. It came before the Oireachtas Sub-Committee on Mental Health on Tuesday. It was probably one of the more positive meetings we have had with the HSE. I acknowledge the work done by the staff in CAMHS. They are doing their best. It seemed to be systemic failures that impeded them from doing their best for the children they look after.

An issue that came up at the meeting, about which I was concerned, is that CAMHS has said it has identified 140 children lost to follow-up but it has yet to meet these children and their families. This is the answer that I got on Tuesday. Will the Minister of State give us a timeframe on when this will be carried out? It is of utmost importance that these children and their families are sat down and a plan is put in place for them. It is all right to identify them in paper files but seeing people face-to-face needs to happen.

Deputy Mary Butler

In total there were 168 children lost to follow-up. There were 140 in CHO 3 in the Limerick area. They were identified by the team there before the Mental Health Commission had come in. It was a result of a lack of staff. There were only three consultant psychiatrists working there and at present there are seven. The other 28 were between three other CHOs. My understanding is that the 168 cases, some of whom have been identified, will form part of the review.

Contact will made with the young persons and their parents to invite them to a review appointment with a member of the CAMHS team within the timeframe I have set out, unless urgent concerns are indicated in which case they will be called in much sooner. In relation to expediting urgent cases, the severity of presenting symptoms as well as an assessment of risk is always taken into account. If they no longer need the support of CAMHS, or have aged out, the children should be discharged and care transferred back to the GP. If, despite all attempts, the team cannot make contact with the young persons or their parents the files will be closed and referred back to the GP or referral agent.

Deputy Mark Ward

I thank the Minister of State. Is it possible for the Minister of State to indicate the number of open cases that need to be reviewed? If she has any figures on this I would like to get them.

There is a gap in the system when young people turn 18 and go into adult mental health services. The Minister of State mentioned referring them back to GPs. I do not know whether that is appropriate in all cases. We probably need to extend CAMHS to the age of 25. One of the responses I received from the HSE on Tuesday was with regard to it being a medium- to long-term plan of the HSE to extend CAMHS. Is there a timeframe on this? Is there any way it can be sped up and put in place a lot quicker? The report is of great concern but it could be a catalyst for the substantial changes needed in CAMHS. I will work 100% with the Minister of State to get these changes made.

Deputy Mary Butler

I thank Deputy Ward. I agree that it will be a catalyst. I want to make several points. I asked for all of these audits and reviews to be put in place 12 months ago, as a result of the Maskey report in Kerry. The main concern I had after the report was for the 240 children in Kerry at risk and the 48 who had significant harm caused to them. There were many challenges but the overprescribing did not come through in the report. This has to be looked at. It is something we were worried about.

There are 73 CAMHS team and a 74th team will be put in place in the Wexford area very shortly. The last one we put in place was in Donegal. I met all of the stakeholders last week in Leinster House. Dr. Amir Niazi, of whom Deputy Ward is aware and who answers all of the parliamentary questions, has put great effort into this. I look forward to the final outcome. The seven audits and reviews are under way. We must be aware that they place a large amount of pressure on the teams. My focus and the focus of the Deputy is that the child will be looked after first. There are a lot of pressures on the teams to respond to all of these reviews and audits.

Bereavement Counselling

Duncan Smith

Ceist:

88. Deputy Duncan Smith asked the Minister for Health for an update on the provision of bereavement counselling services; and if he will make a statement on the matter. [7764/23]

Deputy Duncan Smith

I am looking for an update on the strategy for counselling and bereavement services throughout the State. The two areas I will focus on in my contributions are bespoke supports for people who lost someone during the Covid crisis and bereavement and counselling supports for young children.

Deputy Mary Butler

I thank Deputy Smith. I am delighted that he has raised this issue. It is not something that we get to discuss very much. It is only when people are bereaved that they use these supports. It is important that people know they are available.

Responsibility for bereavement counselling and associated services lies across a variety of services areas. This is why it can be confusing for people. The national counselling service, NCS, is an essential part of the HSE's mental health provision and provides a professional and confidential counselling and psychotherapy service. The service is available in all HSE community health areas and operates from more than 240 locations throughout Ireland.

In 2021 I launched the national suicide bereavement support guide. Developed by a working group of individuals bereaved by suicide and HSE resource officers for suicide prevention, the guide is now a cornerstone of informative level 1 bereavement support. Counselling support is provided at four different levels. Level 1 is HSE public health information campaigns. The HSE website details useful information and resources for the general public on grief and bereavement. Level 2 is the Irish Hospice Foundation's bereavement support line. This is staffed by trained volunteers to provide a listening and support service. The service is available from Monday to Friday between 10 a.m. and 1 p.m. The NCS has collaborated with the Irish Hospice Foundation, which can signpost callers to HSE counselling services where appropriate.

Level 3 is counselling in primary care. The HSE NCS counselling in primary care, CIPC, service is available in each county in Ireland. It provides generic counselling for mild to moderate psychological distress. It is accessible only to GMS patients who are referred by GPs and other health professionals. A contract for an initial assessment and eight counselling sessions is offered. Bereavement loss is a significant reason for referrals to CIPC. I will come back on the rest of the questions the Deputy has asked.

Deputy Duncan Smith

Level 3 is where we find that people are unable to access the service, particularly young people. Phoneline support is not something that young children need. They might need group therapy or one-to-one therapy. Rainbows Ireland is a wonderful organisation that provides counselling and bereavement services and services for children whose parents have separated. It provides public and school-based services but it is not in every school. It is very difficult to get its public service for children in a school where it does not operate. There are gaps. If we are to focus on the emotional and social development of children who have lost a parent we need more one-to-one and group therapy services for them. We need services such as Rainbows Ireland to be more widespread.

Deputy Mary Butler

I thank Deputy Smith. He is aware of Rethink Ireland, which is an organisation that funds various supports. Recently I visited the Solas Centre in Waterford. One of the programmes it runs is to provide information and supports for teachers in schools with a child in the class who has lost a parent to cancer or where a child has died of cancer. We have found this to be very effective. The Children's Grief Centre in Limerick is a very important initiative. The Minister of State, Deputy Rabbitte, works very closely with it and I believe she will have a positive announcement for it very soon with regard to capital funding. Pieta House also provides this type of support. I know the point Deputy Smith is making with regard to specific supports.

In one of the other areas, the counselling in primary care, CIPC, service supports are there but it is only if people have a medical card.

Deputy Duncan Smith

Upskilling teachers in terms of being aware when children are bereaved is important but is still not the primary function of a teacher's job, and probably will not provide what the child needs in terms of bereavement and counselling support. There might be a need at some point for the Government to review our policy and strategy on this.

With regard to Covid, I am still contacted by people who lost loved ones during the height of the crisis, when there was separation and they could not say goodbye, and there were incredible situations in nursing homes, in hospitals and at funerals, which we all remember. There are still people living with that. Within the HSE national counselling strategy, if there was some element or focus on those who lost someone during Covid, that would be a great help.

Deputy Mary Butler

I do not disagree with the Deputy. With regard to the level 4 specialist trauma informed bereavement counselling, the NCS provides trauma informed bereavement counselling for more complex cases in some CHO areas, so we have that in CHOs 1, 8 and 9, although not in the other six areas. This service is available to both medical card and non-medical card holders, which is very important, and clients can self-refer or be referred by a GP or health professional.

I agree with the Deputy on this. Since I started back visiting day care centres, I see the number of older people who were bereaved during Covid who did not get that opportunity to go to the funeral. We all remember that maybe only 20 were allowed to go to a funeral initially. For those who were bereaved and who specifically were not able to say goodbye, and who stood at a window outside and watched their loved one dying, that is very difficult.

There is a myriad of supports there. The Deputy has got me thinking today that it might be no harm to do more information profiling and get it out to the public that these supports are in place.

Cancer Services

Pa Daly

Ceist:

89. Deputy Pa Daly asked the Minister for Health when oncology services in University Hospital Kerry will have a permanent location. [6697/23]

Deputy Pa Daly

When a patient has been diagnosed with cancer and their life is in turmoil, the first thing they need is a bit of stability. Oncology patients who have to attend University Hospital Kerry have been at various stages in the palliative care unit, then there was a proposal to send them to a private hospital and they are currently in the day ward. What plans does the Minister have to give oncology services a permanent home?

Deputy Stephen Donnelly

I acknowledge that the current situation for cancer services and the location of those at University Hospital Kerry is not sustainable and is not what anybody wants to see. I visited the hospital just last month and discussed this with the senior management in the hospital. The priority is that every patient in Kerry receives the best possible care in the right environment. The solution to this is the new oncology unit, which will greatly increase capacity at the hospital. The project is going through the various capital stages. I am happy to say it completed appraisal last year, the design team has been appointed and the project is being advanced this year. I have made it clear to the Department, the HSE and the team in Kerry that this is a priority.

The chemotherapy services operate on a hub and spoke model nationally, providing patients with treatment closer to the home where that is appropriate, including in Kerry. Over the course of the cancer strategy, there has been an increase in the number of patients receiving chemotherapy. The developments are taking place under the strategy, which has received significant investment in recent years, with €20 million in new development funding and capital funding for exactly this situation. We do not want a situation where chemotherapy services are being delivered while displacing other parts of the patient service. As the Deputy referenced in his opening remarks, they are currently co-located with palliative care, as they have been in the other places, and I am told there has been a knock-on effect, for example, on day case procedures as well.

The focus here is on progressing the new unit as quickly as possible. It has been approved and the design team is in place. What I want to see now is a rapid conclusion of that as we move to build. As I discussed with the team when I was there, we would also like to take a modular build approach, which we know can put these facilities in place a lot quicker than the traditional approach that has been used.

Deputy Pa Daly

I have also been in contact with the new general manager and I wish her well in her endeavours over the next few years. However, while I hear what the Minister is saying in regard to capital stages and the design team, the Minister still has not given a date as to when he expects the new permanent unit to be completed. He is right in referencing palliative care but, from 1 March, I understand that, quite rightly, patients have to leave the palliative care section and move somewhere else. Unbelievably, there was a proposal to move them to a private hospital on the other side of town, which would have involved a €50,000 investment by the private hospital and a €2 million investment by the HSE. At least someone saw sense and decided that moving patients to the other side of town and that type of spending was not a good idea, to put it mildly, while only a fraction of the cost was paid, which is a familiar theme across healthcare, where the public has been subsidising the private. It is now in the day surgery space and, as the Minister mentioned, 20 operations have been cancelled.

Deputy Stephen Donnelly

We need to get this sorted as quickly as possible. The new unit is going to make a big difference. It will have 14-day treatment cubicles, two treatment isolation rooms and seven outpatient consultation rooms, so it is going to make a big difference in terms of the experience that patients have and, indeed, that clinicians have in providing what is world-class oncology treatment to patients. I am advised that to facilitate palliative care being reinstated, the Department has been told by the HSE that the oncology services will move for a period of four months to facilitate the reconfiguration of the palliative care unit and to provide adequate interim capacity but, ultimately, the solution is to finalise this design and then crack on.

I appreciate the Deputy’s very reasonable question, which is whether we have a date for when the new services will be in place. That cannot be answered until we have the final design because, obviously, the design that is come up with will, to some extent, determine how long the build will take.

Deputy Pa Daly

Can the Minister even give a year as to when he expects this to be open? He mentioned the problem with day surgery. The problem in the last three or four years has been that whenever there is a surge, whether due to Covid or otherwise, elective day surgeries are the first to be cancelled. On any given day, University Hospital Kerry cannot guarantee that an elective surgery will actually take place because it does not have the beds or it is using the day wards as surge capacity for the emergency department. They are the low hanging fruit; they are the ones that are always getting cancelled.

What plan does the Minister have to deal with this? He mentioned rapid modular builds such as the ones that were built in Clonmel and Limerick. One of those needs to be put in place, at the very least. We have a problem with ratcheting up hospital capacity. One of the solutions was community recovery beds. It was said two or three years ago that an extra 70 would solve the problem with regard to step-down beds. A new building is being constructed in Killarney but, unfortunately, there is not one extra bed there.

Deputy Stephen Donnelly

We are looking at modular builds. My view is that the capital process is not working; the capital process is broken. There are internal processes within the HSE and processes between the Department of Health and the Department of Public Expenditure, National Development Plan Delivery and Reform. There are far too many layers and far too many people who can say “No” who need to say “Yes”. As an example, I was checking in recently on a very modest project that I sanctioned a year and a half ago which still has not happened. I got a note to say it had been through four separate committees and was working its way to the board for a review, on a piece of healthcare infrastructure that should have taken a matter of months to sanction. I am working with the Department of Health, the HSE and across Government to call this out. The current process is not working for patients or for our healthcare professionals, so we need to substantially overhaul it to be able to make these decisions quicker - either yes or no – and then drive on with the build. As I said, we are looking at modular build approaches right across the board in terms of surgical hubs and new bed blocks. The Deputy rightly referenced that University Hospital Limerick put in its new oncology suite in four months during Covid.

Home Care Packages

Fergus O'Dowd

Ceist:

90. Deputy Fergus O'Dowd asked the Minister for Health to provide an update on the expected timelines on the establishment of a new statutory home support scheme; the way he intends to scope and plan for such a scheme; and if he will make a statement on the matter. [7520/23]

Deputy Fergus O'Dowd

Many more people are living longer in our society. The latest census indicated there are over 1 million people aged over 60 years in the State, of whom 150,000 are aged over 80 years. I am thankful that hundreds of people are reaching the celebration mark of 100 years of age every year. Older people want to age in place, not in nursing homes or institutions. Will the Minister give an update on the Government commitment to establish a new statutory home care support scheme? I welcome the work the Minister of State, Deputy Butler, is doing on this matter.

Deputy Mary Butler

I thank the Deputy for raising this issue. He is correct that we have an ageing population. It is something we must endorse and embrace and that is what we are doing. The World Health Organization, WHO, has determined that we have the highest life expectancy in Europe, at 82 years of age. I am conscious of the Minister's comment a few minutes ago that we hear a lot of negativity but to have the highest life expectancy in Europe means we are doing something right.

Deputy Fergus O'Dowd

Absolutely.

Deputy Mary Butler

Work is ongoing in the Department to progress the development of the new home support scheme. This involves a lot of complicated work, as the Deputy will understand. There is a regulatory framework comprising primary legislation for the licensing of home support providers, secondary legislation in the form of regulations and HIQA national standards that are in development. All this has the aim of ensuring all service users are provided with high-quality care.

Two Bills are being worked on and I hope to have them in the House before the summer recess. These relate to the licensing of home support providers and the HIQA national standards that are in development. In order to put the scheme in place we need regulation, funding and reform of service delivery.

We commenced a pilot in November 2021 in east Westmeath in community healthcare organisation, CHO, 8. This was the first of the four pilot sites. The three others came into operation in January 2022 in Tuam, Athenry and Loughrea in CHO 2, in Bandon, Kinsale and Carrigaline in CHO 4 and in Ballyfermot and Palmerston in CHO 7. They all started but because we were in the throes of Covid at the time, we allowed the pilot to operate for longer than initially expected. The data collection phase of the home support pilot concluded in August 2022 and I expect that report in the next couple of weeks.

Deputy Fergus O'Dowd

I thank the Minister of State for her reply. One of the biggest problems we have is getting people to work in the home care area. The Government is dealing with that in some respects. I welcome that over 1,000 visas are being issued to people to come to work in Ireland as healthcare assistants and healthcare workers. Would it not also make sense to look at the thousands of people who are in this country seeking international protection? If they have qualifications in healthcare, home care or in the health field generally, we should fast-track them into the vacancies that exist in our system. That is a constructive engagement the Government must make. It does not make sense that many of the thousands of people staying in our country and who could work usefully in an area they are qualified to work in are not doing so. I welcome the initiatives for people who can speak Ukrainian and have medical and other qualifications, for example, in dentistry, to work in our healthcare system because of the shortage of GPs and other qualified people.

Deputy Mary Butler

The Deputy makes a valid point. There are many people in our country who are not in a position to work and are highly qualified and skilled. They can work now after six months but we are sitting on a lot of people who have expertise.

Deputy Fergus O'Dowd

Hear, hear.

Deputy Mary Butler

We want to promote home care as a viable career opportunity. I worked very closely with the former Minister of State, Deputy English. On 1 January this year - we are six weeks into the process now - 1,000 permits were issued for people from outside the EU to come here and provide home care. We hope they will do so. This approach worked in the nursing home sector, where 2,640 permits have been issued. That is important.

On the Deputy's initial question, in order to put in place this statutory home care we need the interRAI assessors. We have funding for 128 of them and we are currently recruiting them.

Deputy Fergus O'Dowd

The future for older people is ageing in place and ageing at home and I welcome the Minister of State's commitments in that regard.

I will comment on the criticism by nursing homes of the regulator, HIQA, and the Department of Health. They claim there is over-regulation. I have examined the homes that have closed recently. Fire has been a big issue, in that fire hazards cannot be, and are not being, dealt with. There are governance issues that are not being addressed. There are significant concerns about infection control and also shortages of staff. There are huge criticisms being made of the appropriate and proper regulation of homes by professional organisations out there that do not add up or make sense.

We need greater involvement by the State in overseeing and helping out nursing homes. I think the Minister of State said as much herself. I do not mean the State should be running homes but it should be providing governance, which is a big issue, especially in smaller homes. It is about keeping smaller homes open. If possible, we should offer interest-free or low-interest loans to deal with structural issues. In a county that has many smaller nursing homes, such as Galway, we could have combined purchasing. We could have people who work for a group of nursing homes, be they private or whatever else, who can go in and offer the additional expertise and support that the smaller homes cannot provide. However, HIQA-----

An Cathaoirleach Gníomhach (Deputy Denise Mitchell)

The Deputy is over time.

Deputy Fergus O'Dowd

-----red-risks homes where there is a risk to the safety, health and welfare of people. It is right those homes are brought to account and, if necessary, made to account for what they are not doing.

An Cathaoirleach Gníomhach (Deputy Denise Mitchell)

I thank the Deputy but we are way over time.

Before the Minister of State replies, two other Deputies are indicating. Deputies Cullinane and Ó Murchú have 30 seconds each.

Deputy David Cullinane

Gabhaim buíochas leis an gCathaoirleach Gníomhach. I want to see the statutory home care scheme put in place as quickly as possible. That is one of the things we must do to reduce pressure on emergency departments and hospitals, as the Minister of State knows. In addition to the issues she identified, such as regulation and other measures that need to be put in place to make this happen, the main measure we need to take is increase capacity because if we put this scheme in place, more people are going to be looking for more hours because that is the nature of it.

Deputy Mary Butler

Yes.

Deputy David Cullinane

What we do not want is to provide a statutory scheme where there is an entitlement but people cannot access it. Capacity, therefore, is going to be the biggest issue and that means more staff and resourcing of both public and private providers to deliver the service.

Deputy Ruairí Ó Murchú

We all welcome and see the need for a legislative framework to deal with home support and give people the capacity to live in their own homes. We have dealt previously with the matter of recruitment and know the issues in that regard. We have had the strategic workforce advisory group. I want a timeline for the recommendations it has proposed and how we can ensure we have, as Deputy Cullinane said, the capacity to be able to deliver what needs to be delivered.

Deputy Mary Butler

I thank Deputy O'Dowd for his comments. I am on the same page as him. I will never compromise on standards.

Deputy Fergus O'Dowd

Hear, hear. No compromises.

Deputy Mary Butler

We never want to see a Leas Cross again. There is no compromise and I will be bringing in more regulation for HIQA later this year as part of the statutory home care scheme. I also agree with the Deputy that the State must take a more active role in the care of older people and I said so at the weekend. I think all the Deputies present agree with me on this. As they are aware, the care of older people is outsourced, with 80% private and voluntary - just under 4% is voluntary - and 20% provided by the State. We are supporting 22,500 people under the nursing home support scheme every year. That is a position that evolved over many years. I have had many conversations with the Minister on this and I would like to see the State becoming much more involved.

I agree on the strategic workforce advisory group. We put it in place to see if we could build capacity. I am looking forward to seeing how many permits are issued over the next couple of months. There are timelines on all that and I can come back to the Deputy again on it.

Medicinal Products

Aindrias Moynihan

Ceist:

91. Deputy Aindrias Moynihan asked the Minister for Health the process by which pregnant women experiencing extreme nausea and vomiting, hyperemesis gravidarum, can obtain the drug Cariban; the reason the drug cannot be prescribed by GPs through the drugs payment scheme; the number of Cariban prescriptions that have been processed through the drugs payment scheme to date, in tabular form; and if he will make a statement on the matter. [7436/23]

Deputy Aindrias Moynihan

Extreme nausea and vomiting can be so debilitating for a pregnant woman. There are various therapies available to support such women but having easy and affordable access to them is very important. Will the Minister outline how women can access the various therapies available?

Deputy Stephen Donnelly

I thank the Deputy for his question. He will be aware that I secured funding of €1.3 million in budget 2023 to provide reimbursement support for Cariban, which I think is at the heart of his question. Cariban has been available since the beginning of the year for women suffering from hyperemesis, which is a severe form of nausea and vomiting during pregnancy that affects about 1% of pregnant women. I believe the number of women who have been approved for the product is 144 as of today.

This is slightly ahead of projections in terms of the funding allocated. Because Cariban is an unlicensed it is being handled in line with the established procedures around clinical governance. This is that the initial prescriber of Cariban to the patient must be a specialist or a consultant and subsequent prescriptions can come from a GP.

It has been brought to my attention, very reasonably, that some women are saying they need access to some form of treatment, be it Cariban or something else, before the 12-week appointment with an obstetrician. There is a request it would simply be a GP who would provide the initial prescription. I have gone back to the Department with that suggestion. The initial response I got back from the Department and the HSE was for unlicensed products. Cariban is an unlicensed product and the company has never applied for it to be licensed in Ireland. Personally I think it should do this as a priority, but the company has not done so, and because of that for clinical governance reasons it falls within the established framework, which is prescription by a consultant. Nonetheless, based on the obvious issue raised concerning access and timing to see an obstetrician, I have asked that this be reviewed to see if there is a clinically appropriate formula that can be put in place to provide access quicker when pregnant women need it, rather than when they can get access to an obstetrician.

Deputy Aindrias Moynihan

I acknowledge the different initiatives the Minister has been undertaking for women's health. The funding and access he has already been putting in place for Cariban is proof of this and demonstrates the commitment. As the Minister outlined and as so many people have been raising with me, there are these difficulties. Having timely and affordable access is so important. As the Minister is aware, many people will not expect to be seeing a consultant until they have reached about the 12-week stage and they would have a need ahead of that. Also, a GP can follow-up on issuing further prescriptions. I understand this is for approved patients. Can the Minister clarify who exactly GPs can follow up with and issue prescriptions for? Is it everybody that would be getting a prescription from a consultant or is there some subset involved?

Deputy Stephen Donnelly

I will get the Deputy a detailed note to ensure this information is correct. My understanding is that once a woman has a prescription from her obstetrician that the repeat prescriptions can then be filled by the GP. Under the scheme introduced this year, the product is provided completely free of charge. I will, however, get the Deputy a detailed note just in case there are some nuances involved.

What we should be doing now is looking to the company. Under the Health Act 2013, the onus is on the company to apply to the HSE to have a new medicine added to the reimbursement list. That would, in fact, solve this problem. Cariban would then be a licensed product and it would fall within the normal reimbursement scheme, which would then make it very easy for any GP to prescribe. GPs would have the comfort of knowing that this was a licensed product, with all the various clinical checks and governance associated with that. Obviously, we cannot compel the company to do this. Anecdotally, I am also hearing that Cariban is much more expensive here than it is in some other countries. If the company was to apply to have this product licensed and added to the reimbursement scheme, then the HSE would be able to negotiate, I would imagine, a much more competitive price to facilitate making it more widely available again.

Deputy Aindrias Moynihan

For women to be able to access Cariban via their GPs would be so much more affordable, practical and accessible than going through consultants. I am glad the Minister is taking steps in this direction. It is so important that this is followed through on and this type of access is created. I understand that a number of different drugs offer the same benefits and that the market authorisation holders for those have not sought to get approval. I acknowledge that an initiative was taken with Cariban. Is the HPRA going to follow through with Cariban? Is the aim to try to get this product to a stage where it would be GP prescriptionable, if such a word exists? Given that the Minister originally took the initiative on it, is the aim to continue with this process or is there a stand-off with these market authorisation holders?

Deputy Stephen Donnelly

I do not know if "prescriptionable" is a word. It is now and will be forever recorded as such. My understanding is that it is up to any company to apply for market authorisation and to apply to be added to the reimbursement list. I think this would be the best solution to this. We have well established processes, clinical governance, safety reviews and contract negotiations in place, which work very well. In fact, the reason we are in this situation is because Cariban is not a licensed product and this means there was no normal mechanism to make this drug freely available. We cannot compel the company to do this. Indeed, we cannot compel any of the other companies, which the Deputy referred to, that have other products which are also seen to be very good to do this either. What we can do is to ask that there be engagement from the HSE with these companies to see if they would like to begin the process. This is certainly something I would support.

Question No. 92 taken with Written Answers.

Medicinal Products

Aindrias Moynihan

Ceist:

93. Deputy Aindrias Moynihan asked the Minister for Health the measures his Department are taking to ensure our competitiveness in securing medicines that are currently experiencing supply issues; and if he will make a statement on the matter. [7670/23]

Deputy Aindrias Moynihan

Many pharmacists and members of the public seeking to fulfil prescriptions are finding time and again that the various different drugs are not available. There are supply issues which are causing a need for a switchover from one product to another, if it is possible for people to get these products at all. While there are always similar issues, the situation seems to be much more intense now. What kind of measures are being put in place to ensure that prescribed drugs are available to people?

Deputy Stephen Donnelly

I thank the Deputy for the question. He will be aware that many of the recent medicine shortages were caused by an exceptional increase in demand for certain products to treat winter illnesses; in some cases this demand was two to three times greater than the same period in previous years. This demand was seen right across Europe and around the world. I am pleased to be able to inform the House that the level of demand for products to treat winter illnesses has levelled off and the problems with the supply for most of these products have eased to some degree. To combat the recent supply issues a number of initiatives were undertaken via the medicines shortages framework, including extensive engagement with manufacturers to increase supply to Ireland, the provision of updated clinical guidance for prescribers, the creation of a web page with up-to-date information on shortages and, critically, alternative products being made available. My Department continues to work closely with the Health Products Regulatory Authority to ensure that the medicines shortages framework is fully utilised. This is there to ensure that everything possible is done to mitigate the impact of medicines shortages when they do occur.

It is important to highlight that in the case of medicines used most often in Ireland there are typically multiple alternatives available from various sources that remain available to ensure continuity of treatment. For example, while one strength of ezetimibe only containing medicines is currently in short supply, 49 other products authorised by the HPRA can be generically interchanged, and often without the need for prescriber involvement. Another example would be if there was a shortage of supply of the nasal spray used to treat hay fever. In this case there are multiple other non-prescription treatments for hay fever available.

Deputy Aindrias Moynihan

There is nothing unusual about different supply issues, but it is so much more intense now in respect of the breadth, number and range of drugs under pressure, for various different reasons, being so much wider now than what it would have been in other years.

Many pharmacists tell us they have seen different issues over the years. Regarding the steps that would need to be taken, there is not one quick fix because there are many causes. Could we put in place a serious shortages protocol such as there is in the UK? Have alternative therapies been looked at rather than always replacing with a drug? Another possibility is generic substitution for all molecules that are in short supply, and not just those on the list designated by the HPRA. It is hugely important that we look at all the different options. Has the Minister thought about the possibility of having a chief pharmaceutical officer, a champion across Departments who would be able to advise and offer support on such matters?

Deputy Stephen Donnelly

The Deputy asked if Ireland was more affected than other countries. This is something we have been looking at. There are some commercial entities that have been suggesting it, linking it to them potentially getting paid more money for their products. There is no evidence to suggest that Ireland is more adversely affected by the current global medicine shortage than anywhere else. The HPRA has said we are experiencing fewer shortages than many other European countries, despite the fact that demand for some medicines has been two or three times greater.

The Deputy's question about a protocol makes a lot of sense. Pharmacists in Ireland already have more flexibility than UK pharmacists in certain areas around generic substitution but there is a lot of merit to bringing in a medicine shortages protocol as a standing protocol within the pharmacies. Considerable work is required to do it in terms of clinical governance and relationships with GPs. Legislative changes may be required as well. I am looking at all of that with the Department at the moment.

Deputy Aindrias Moynihan

I must take the Minister up on the point that it does not seem to be affecting us worse than other places. Given all the different causes we are hearing about, whether Covid or the war or various others, we would expect that to be impacting across the board. Brexit was expected to impact access to medication in the UK, yet there are medications available in the UK market that are not available here in the Republic. People would quite readily cross the Border to get access to them or fill a prescription. That is a big step for people coming from Cork. They are doing it because they know they can get access to different prescriptions in the North that are not available here. It is not only prescription medications that are involved; it is also over-the-counter medications. Where some of those over-the-counter medications are not available, say Brolene eye drops-----

An Cathaoirleach Gníomhach (Deputy Denise Mitchell)

The Deputy is over time.

Deputy Aindrias Moynihan

-----people end up having to go for GP appointments to get a prescription as a result. We need to look across the board and at all options.

An Cathaoirleach Gníomhach (Deputy Denise Mitchell)

Deputy Cullinane has indicated he wishes to come in. He has 30 seconds.

Deputy David Cullinane

There is no doubt that global supply chains have had an impact on the availability of certain medications, which has resulted in medications not being available to the extent we would have wanted in some areas. There are things we can do. There are other reasons for it as well but there are things we can do. Other countries have serious shortages protocols where pharmacists can substitute alternative medications without the patient having to go back to a GP. Is that something that will be examined? The HPRA should also have a greater role in looking at supply, particularly as we track illnesses. If we know we are going to have a spike in respiratory illnesses or the flu, we should be looking at the corresponding medications. There is a greater role for the HPRA there.

Deputy Stephen Donnelly

The HPRA is doing a very good job. It is very actively engaged in this and I am open to seeing if there is a wider role it can play or more it can do. The HPRA publishes a list of shortages. It would be useful if it could show that in many of these cases, for example, it might be that the 12-pack of a medication is not available but the 24-pack is. The real squeeze is therefore substantially less than the list might suggest. We were just discussing the medicine shortages protocol. There is merit to it but there is a lot of work required. It might require legislative change and I have asked the Department to progress thinking on that to see if it is something we can bring in as a permanent change in terms of enhanced pharmacy care.

Disability Services

David Cullinane

Ceist:

94. Deputy David Cullinane asked the Minister for Health when he will publish an implementation plan for the disability capacity review; when he intends to transfer functions for specialist disability services to the Minister for Children, Equality, Disability, Integration and Youth; and if he will make a statement on the matter. [7557/23]

Deputy David Cullinane

We kind of touched on this earlier. There are two aspects to this question. The first is about the transfer of the functions for special disability services from the Department of Health to the Department of Children, Equality, Disability, Integration and Youth - that is a mouthful - and the second relates to the resourcing of the disability capacity review. I ask the Minister of State to give an update on both those issues.

Minister of State at the Department of Health (Deputy Anne Rabbitte)

I thank the Deputy for raising this two-pronged question this morning. Hopefully, on 1 March, I will be transferred. However, we have had a number of dates in the past so if the Deputy is writing it down I would write it in pencil. I hope it will happen on 1 March. That is a piece of work that is going on at the moment.

Regarding the disability capacity review action plan implementation, the Department of Children, Equality, Disability, Integration and Youth will be doing the heavy lifting on that. We will be finalising the report. Most of the team are coming across with me from the Department of Health. The enabling works are under way with regard to finalising the disability capacity review. It is a ten-year plan but it is my ambition to launch it in phases, with the first in 2023-26. That will address the under-resourcing, the gaps and the unmet need within disabilities and particularly in disability specialist services right across the country.

Deputy David Cullinane

The disability capacity review set out the need for €750 million of investment over ten years. The problem is that two years on, there is still no implementation plan and certainly still no funding plan. As the Minister of State will recognise, we need to support complete decongregation of people with intellectual disabilities into more appropriate facilities, which is part of the plan. We also have to ensure we have the investment needed for additional personal assistant, PA, hours and additional home care packages to serve distinct needs and support independent living. We also have a severe shortage of respite care services. Less than a third of carers for adults with intellectual disabilities can avail of respite care. There are lots of pieces to this. There are lots of elements to that disability capacity review. The overall funding ask of €750 million is significant but it is less significant over ten years. The problem is that I have not seen any funding plan or implementation plan. We cannot simply put in place capacity reviews and then not resource them and not put plans in place. Two years on, we need to see the colour of the Government's money.

Deputy Anne Rabbitte

The colour of the Government's money has already been shown in the previous budgets. While the disability capacity action plan has not been published, funding has been put in place. The years 2020, 2021 and 2022 saw significant investment in disability. What has been put into disability for the last two years is actually record-breaking and we have addressed the issues the Deputy raised, which needed the investment, including the respite piece and the PA piece. In the most recent budget, the PA piece was allocated ten times the funding it had received in the previous number of years. On respite, every single year since I became a Minister of State it has been my ambition, on which I have delivered, to have a respite house in every county in the country by the time I am finished. In the first year, we put €6.5 million into respite and in the second year, it was €9.5 million. This year's service plan is yet to be finalised but it will match what has gone in previously. Children's respite has been a priority of mine coming out of Covid to ensure families are supported. I am now moving on to adult respite but, at the same time, respite is not all about putting a head on a bed. It is also about looking at alternative forms of respite and PA support.

Deputy David Cullinane

I recognise that additional funding has been made available for disability services over the last number of years.

Unfortunately, a lot of the additional funding - we had the same debate in the area of mental health - is eaten up by existing levels of service, which means that it does not provide additional capacity. I accept that additional capacity has been put in place, but it is nowhere near what is required to meet the capacity review. The only way we will make sure that is done is to have a comprehensive plan set out over a reasonable time period. The plan was meant to be a ten-year one. We are two years in, but we do not have sight of a plan or a costing model. There is also the accountability element. The advocate groups I meet tell me they do not believe the additional funding that was made available in recent years, which the Minister of State described as record-breaking, is anywhere near enough to start addressing the deficits and difficulties we have. We are still way behind where we need to be on decongregation and many other critical elements of that capacity review. I look forward to the publication of the plan. I will judge it when I see it. I hope we can see it as soon as possible.

Deputy Jennifer Murnane O'Connor

I hope the Minister of State's functions are transferred to the Department of Children, Equality, Disability, Integration and Youth by 1 March. I think she will play a significant role there. I say that as a member of the Joint Committee on Children, Equality, Disability, Integration and Youth. There seems to be a significant issue with recruitment in this sector. I met with Down Syndrome Carlow last week. The group is waiting on occupational therapy and speech therapy services. I welcome the funding, but how can we work faster to ensure that children in need, who have a disability, will get the services they deserve?

Deputy Ruairí Ó Murchú

The disability capacity action plan is needed. We know the unmet need in disability is for specialist services. Could a certain level of flexibility be shown? We know the silo issues that exist in the sense that a ping-pong game is sometimes played between CAMHS and children with autism who require services but cannot get them. We must deal with the issue across the board.

Deputy Anne Rabbitte

I will start with the final question and work my way back. Deputy Ó Murchú referred to a ping-pong game. The HSE has a national access policy, NAP, which promotes an integrated approach between primary care, disability and mental health. It might not be done fairly or equally across all CHOs but there are some very good CHOs that are practising that model.

In response to Deputy Murnane O'Connor, I accept there has been an unmet need in terms of the number of therapists. When I was appointed, only 3% of the overall budget was left for therapy services. Since then, every single year, with the help of the Minister, I have secured serious funding to resource therapies. The Deputy is correct that there is an issue with recruitment, but we have a progressing disability services, PDS, roadmap that we will launch fairly soon. That will show the Deputy the way forward in that regard.

I acknowledge, as should Deputy Cullinane, that a lot of money has gone into new developments in the disability area. I hope that funding will be a foundation for the disability action plan when it is published. I look forward to his feedback on it.

Dental Services

Alan Dillon

Ceist:

95. Deputy Alan Dillon asked the Minister for Health the steps being taken to alleviate the backlog for patients of all ages to access dental services; and if he will make a statement on the matter. [7725/23]

Deputy Alan Dillon

The lack of dental services is causing severe problems for men, women, and children across the country. Numerous contracted dentists have withdrawn from the dental treatment services scheme, DTSS. Primary schoolchildren are not receiving dental treatment until they reach secondary school. What steps are being taken to alleviate the backlog for those on waiting lists to access dental treatment?

Deputy Stephen Donnelly

There are challenges in the provision of dental services and patients of all ages are waiting longer than they should to access care. This is not acceptable, but we are responding. This year, an additional €15 million was allocated in the budget to specifically deal with the issue. It is an unprecedented increase. Some €4 million of the allocation will target orthodontic care, prioritising those who have been waiting the longest to access treatment. Another €5 million is being invested to address backlogs in the public dental service, which invites children, usually in second and sixth classes, for a check-up with a HSE dentist, who will then provide further treatment if it is needed. The €5 million also supports the HSE to provide emergency care for adult medical card holders who are having difficulty accessing care under the DTSS.

Last May, I introduced additional preventative treatments to the DTSS and increased fees by between 40% and 60% per item across most items. This has led to an increase in the numbers of treatments provided and the number of patients being seen. We are pursuing fundamental reform of dental services, through investment in implementation of the national oral health policy, Smile agus Sláinte. As well as all that investment, my Department is supporting the HSE to put clinical leadership roles in place. These have not been in place so far. The chief dentist in the Department made a very strong case for it as part of his budget. We saw recent coverage of CAMHS, where the Minister of State, Deputy Butler, has agreed with the HSE that there will be both an administrative national lead and a clinical national lead. The national oral health policy is another national strategy were we are putting in place a similar approach to drive it on. I accept that the waiting lists in the children's service, orthodontics in particular, are too long. Significant money is being put in place and we must ensure that waiting lists reduce.

Deputy Alan Dillon

I thank the Minister for his response. On a weekly, if not daily, basis, we receive representations from people of all ages who are unable to access dental treatment. We must ask why contracted dentists are withdrawing from the DTSS. Dentists in Mayo say the DTSS is outdated in its scope and that it is so burdened with bureaucracy that most of them would not accept the contract regardless of the fees being offered. They need to be consulted when it comes to reforming the scheme. What engagement has the Minister had with dentists to see what can be done to encourage them back into the DTSS?

Deputy Stephen Donnelly

I will make two points specifically on the DTSS. The first is that the fee structure did not keep pace with inflation and we saw a lot of dentists leave the scheme as a result. There are issues related to the administrative burden of the scheme but they have been a factor for a long time. In response to that, we significantly increased the fees paid to dentists, by between 40% and 60% per item. We did that in a single year. Any dentist who chooses to leave the DTSS can do so, and dentists can also choose to rejoin it. When we discussed this recently in the Chamber, one Member of the House gave an example of a constituent whom a dentist refused to treat under the DTSS and when the person came back some time later in agony, the dentist agreed to do the treatment privately. I do not believe that is acceptable behaviour from the dentist. The State has a role to play. We are significantly increasing fees. There are two parties to this arrangement. It is not acceptable for dentists to pull out of the scheme and refuse to treat patients under a publicly funded scheme but then to be willing to take their money some time later as private patients.

Deputy Alan Dillon

I thank the Minister for his response. We have similar examples in Mayo where elderly people had to look for appointments in Sligo to fix their dentures, which is completely unacceptable.

On another point, the lack of access to dental treatment for young people is causing great difficulty for primary schoolchildren who are to be examined and treated by the HSE dental services in second, fourth and sixth class, before the age of 12. We are having significant problems with many checks coming after significant developmental milestones. It is a major issue. Additional supports must be put in place. There is a large backlog of 13,000 children who are waiting for orthodontic treatment for grades 4 and 5 on the HSE eligibility criteria. That must be addressed. We must also put in place supports for parents if they cannot get access to the HSE service and have to go privately for treatment. How can we support families in that regard?

Deputy Stephen Donnelly

There was an issue with regard to young people which was driven in part by Covid. The school-based schemes were affected by Covid. Money is being put in to catch up on those schemes. The Deputy will be aware that, critically, I funded a new scheme this year. That will be very important in years to come. Almost €5 million has been provided for a preventative scheme for children aged from birth to seven. We will see the benefits of that in years to come.

There are 30% more dentists in Ireland now than there were ten years ago, so the number is increasing.

The population is increasing, and the burden of care is increasing as well. I encourage dentists who have left, on the basis of a very significant increase in fees, to rejoin the scheme. Is it perfect? It is not. Does it need to be upgraded? It does. We are talking to the Department about a more streamlined and modern scheme but, right now, there are people with medical cards throughout the country who could and should be treated under the DTSS. I would love to see those healthcare professionals signing back up with an understanding that we will reform the scheme.

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