Joint Committee on Disability Matters díospóireacht

Progressing Disability Services: Discussion (Resumed)

An Cathaoirleach

We have received apologies from Senator O'Loughlin. We are now resuming discussion on the Progressing Disability Services for Children and Young People. On behalf of the committee, I welcome from the HSE: Mr. Bernard O'Regan, assistant national director of disability services; Mr. John Fitzmaurice, chief officer of CHO west; Ms Ann Bourke, national service improvement lead at children’s disability services; and Dr. Rosie Gowran, clinical lead for the national clinical programme for people with disability.

Before we begin, all witnesses are reminded of the long-standing parliamentary practice that we should not comment on, criticise or make charges against a person or entity in such a way as to make him, her of it identifiable, or otherwise engage in speech that might be regarded as damaging the good name of the person or entity. Therefore, if your statements are potentially defamatory in relation to identifying a person or entity and you are directed to discontinue your remarks, it is imperative that you do so. Members are also reminded of the long-standing parliamentary practice that they should not comment on, criticise or make charges against persons outside of the Houses or an official by name or in such a way as to make him or her identifiable. Members must be within the confines of Leinster House if they are contributing to the meeting remotely. If they are speaking, they must confirm to the team that they are within the confines of Leinster House.

Without further ado I call on Mr. Bernard O'Regan to make his opening statement.

Mr. Bernard O'Regan

I thank the Chair and members of the committee for the invitation to meet them today. I welcome this opportunity to engage with the committee on progressing children's disability services. I am joined, as the Chair has outlined, by Dr. Rosie Gowran, Clinical Lead for the national clinical programme for people with disability; Ms Ann Bourke who is the national service improvement lead for children’s disability services and Mr. John Fitzmaurice, chief officer for CHO west.

The HSE prioritises the development of supports and services to children with disabilities. At the outset I wish to acknowledge that these services still fall short of what children and families need and I apologise profoundly for these shortfalls. In October 2023, we launched the Roadmap for Service Improvement 2023-2026: Disability Services for Children and Young People. While implementation of the roadmap was impacted by industrial action, which is now suspended, we have been able to make progress on a number of critical actions. The suspension of the industrial action enables us to drive the implementation of all of the 60 measures in the roadmap, including but not limited to; the standing up of the delivery structures at both governance and working group levels involving service managers, parents, Departments, unions, mental health, CAMHS and primary care colleagues; a recruitment campaign that resulted in 495 applications for therapy posts that are currently progressing through the interview stage; the development of a dedicated recruitment campaign for therapy assistance, which will go live in the coming weeks; and engagement with the wider community and voluntary sector to identify a range of supports and services that can be provided to children and families while they await CDNT services. The measures also include workshops led by the national team and involving chief officers, heads of service, lead agencies, children's disability network managers and their staff to ensure everybody understands their roles and responsibilities in delivering on roadmap actions and importantly, harnessing existing good practice models that will help to achieve roadmap actions. Further workshops with children's disability network managers, CDNMs, are planned.

Work is under way in each area to develop a roadmap implementation plan for that area. Guidance has been developed and issued, including at a workshop, on how the initial contact with all children currently on waiting lists will be addressed in the context of the roadmap. Significant work has been undertaken on workforce strategy for disability services, including dedicated working groups within the HSE and a cross-sectoral group chaired by the Minister of State, Deputy Rabbitte, which the HSE is actively participating on and which has a focus on rebuilding, extending and planning sustainable recruitment and retention initiatives for health and social care professionals and therapy assistants, education and practice education places. The measures also include strong oversight and support by the CEO and board of the HSE. Moreover, 69 of the 91 family forums and five of the nine family representative groups are now up and running and have nominated their two family representatives for the CHO CDNT governance group. We will run an independent review on the experience of this model of engagement to ensure it is the optimal for family input on the development of children's disability services.

A national tender process for assessment of need, AON, has been completed to maximise private provider provision of AON, supporting public services to meet their legislative responsibilities. A total of 45 new psychology trainee placements commenced in September 2023, with an additional 45 due to commence in September 2024 and September 25 for the health services from which disabilities will seek to attract to CDNT services both for placement and post graduate on-boarding.

Recruitment and retention is the most significant area for improvement. We need to ensure a sustainable model for recruitment and retention is put in place. The HSE is offering all new graduates permanent positions, similar to the programme for nursing. The development of additional capacity through the third level institutions to increase the number of graduates across all of the disciplines is critical. It would be useful to revisit the Bacon report from 2001 to ensure the targets are reviewed and revised to reflect the increased population.

The HSE recognises that it must do more to provide and support the necessary student practice placements. We are currently gathering data on the number of placements that have been provided in the last academic year across all CDNTs in order to set targets for all teams, based on staff in post. We have developed guidance to support this, along with additional staffing capacity at national and CHO levels. Consideration of short-, medium- and long-term sustainability for education, recruitment and retention and clinical governance, ensuring staff well-being and safety and, in turn, delivery of the best services for children and families, are our priority.

While there are challenges, we should also note that approximately 46,000 children are on CDNT caseloads with approximately 16,000 currently receiving a service from the CDNTs every month. In addition, based on each individual team’s capacity, a significant number of children on waiting lists are also receiving interventions. We will have national data on this once the CDNT information management system has been fully rolled out. The CDNT service provides supports on an interdisciplinary basis, in group work for children with common needs and through individual supports, as required. It is delivered across a multitude of settings and a key component of the child’s programme is training and capacity building for families, provided both in-person and remotely. It also includes the provision of the legislated for assessment of needs.

The increasing demand for assessment of need continues to be very challenging. The number of applications in 2023 was 8,472, an increase of 1,717, or 25%, over 2022. This reflects population increase and families who we believe are exploring every avenue to access services for their child. Of the total assessments of need completed in 2023, 849, or 36%, were found not to have a disability. This time could have been more productively used to provide additional assessments of need or other services. As of December 2023, there were 8,893 assessments overdue. On an average of 36 hours of clinician time required for each assessment, these would take 334 full-time health and social care professionals 12 months to complete, again diverting scarce resources from service provision.

An AON is not required to access primary care, children’s disability services or mental health services providing services including assessment, goals setting, intervention and follow-up services. This direct access ensures more efficient and timely access for many families and it is important that we highlight the statistics regarding the appropriateness of the number of people that go through the AON process. In 2023, the HSE spent approximately €10.5 million commissioning AONs from the private sector. We will continue to secure any available capacity but we are of the view that the available capacity is being maximised. We are concerned that the impact of this direction also serves to further deplete the development of public services.

The situation in relation to AONs is not the same in every area. The numbers of applications in some areas have historically been significantly lower than other areas. This reflects a service model used in those areas to engage with families and support them to access services without them having to resort to the assessment of need legal route. This will be explored in detail by the roadmap working group focusing on service access and improvement with the objective of spreading this good practice across all teams nationally and rebalancing the demand for AON with CDNT service provision, including workshops with families and staff on how this can be achieved.

In conclusion, the challenges continue to be demanding. However, there is scope for some optimism as we build momentum through the delivery of the roadmap, both through the specific actions set out in it and in the way that we seek to harness the support and involvement of all stakeholders, including staff, families, providers, all relevant services of the HSE and the Government. Working collectively to meet these challenges is critical. We will be happy to answer any questions the committee may have.

An Cathaoirleach

Thank you very much, Mr. O'Regan. There are votes in the Dáil but I am not sure what the outcome will be. We may have to suspend for them. I do not think there will be a voting block so it might only be for ten or 15 minutes. We will see how it goes. Deputy Feighan is here in place of Senator Seery Kearney and is first on my list.

Deputy Frankie Feighan

I thank Mr. O'Regan for his presentation which was very interesting and informative, as usual. The roadmap highlights the key metrics that will be collated and reviewed each month from each CDNT and CHO, with reports published quarterly on the HSE website. One of the metrics is the number of children discharged during the month. Will discharge plans be put in place and will reviews be undertaken to inform the process into the future? Is there a standard and accessible complaints process? What are the plans for when staff have to take maternity leave across CDNTs and how will this be resourced, as standard?

The disability action plan aims to address unmet needs as highlighted by the disability capacity review. I ask the witnesses to outline funding commitments and any shortfalls for the disability action plan that could impact this.

Mr. Bernard O'Regan

I will take some of those questions and pass others to my colleagues. I will take them in reverse order, if that is okay. The disability action plan is set out to cover the period from 2024 to 2026 and the only dedicated funding is what is committed to in 2024, as set out in the HSE service plan. We will need to engage with the Department of Children, Equality, Disability, Integration and Youth as part of the Estimates process on the funding that is needed for the next stages. Given the level of vacancies that we currently have in children's services - which we need to fill - we need to make progress on those before we could legitimately go back to the Government asking for more money. That said, the Government has indicated that it understands that more money would be needed and it did provide additional funding for therapy assistants in 2024. There are challenges in the scale of ambition in the action plan. It will require significant investment over the next two years if it is to realise the ambition that is set out in it but that ambition reflects the scale of need that exists. The ambition was not just picked out of the air but was based on the data that was available to us and the Government. It is important that there is a level of commitment.

The other part to this is that it is not just about the money, although that will be a critical enabler. It will also involve a huge amount of additional recruitment. We need to know that we have the pipeline of additional staff across all services, including children's, residential, respite and day services. We must be sure that if we can secure the money, we have a way of spending it and are able to recruit the staff we need. That will be part of the ongoing work between us and the Department.

On maternity leave, there are two parts to the answer. No specific funding is available for maternity leave replacements. Any time maternity leave arises, we have to look at it on a case-by-case basis and see what we can do. The difficulty we have at the moment in children's services is that if we cannot fill the core posts where there are permanent, full-time contracts available, maternity leave cover is difficult to manage. Sometimes, it is about trying to move people around, if we can, but often it results in gaps for the duration of the maternity leave. There are other parts of the disability services where replacements are funded and have to be in place, for example, in residential or respite services, where it is required to have replacement staff to maintain the service. We look at maternity leave in the children's services on a case-by-case basis and try to manage it as best we can.

My colleague, Ms Bourke, may come in on the metrics. We have set out the metrics we will measure in the roadmap. It is coming on the back of industrial action so the roll-out or gathering of metrics is at early stages because we are still picking up following that industrial action. It is our intention that those will be published as set out.

When individual children are discharged from the service, there should be a discharge plan. No child should be discharged from any service without a plan. Discharges from children's disability services are often to primary care. It is not a discharge from services altogether and there should be a pathway. We have policies and pathways to guide that. How that operates in practice can always be improved but no child should fall off a cliff from being discharged from one service and admitted into another.

Ms Ann Bourke

Looking at the figures, they are not validated yet but they will be. According to the most recent figures we have from the 91 teams across the nine CHOs, there were 650 discharges in the past month and 822 new children coming in. Some of those children may in fact be returning. A good thing that came out of the new teams, the children's disability network teams, is that we now have consistent policy across the country so that a child and family will be discharged at a point in time when their goals have been met and they have access back into the service under our national policy. Most important, they do not go back on a waiting list. They come back in on the referral date they originally came in on. That is important.

On discharge plans, every family leaves with one, including whatever training is required. They will have a point of contact and they come back into the service if and when they need to. Sometimes, it might be to touch base and they do not need to come back in but need some information. That will be challenged when there are gaps in staffing. There is no doubt about that.

On the complaints process, there is a structured process nationally. Section 38 and 39 organisations, under their service arrangement, have to report on the number of complaints quarterly, whether they are resolved and the percentage that are not resolved. Within the HSE, there are also named complaint officers. Like any good policy, you start at the closest person. If you report on it but you do not get satisfaction there, you can go higher up until you get your complaint answered.

Deputy Dessie Ellis

I thank Mr. O'Regan and the rest of the team for their input and for coming in. Early intervention is important when it comes to children in particular. My experience in CHO 9, Dublin north west, is that there are huge waiting lists. We have one of the worst waiting lists in the country. I can give examples. I am aware of a four-year-old child who is waiting for speech and language therapy and there is no sign of it. The parent was told they will have to wait until the child is assessed. That has been going on for months and there is still no word back. Another example is a man who had a stroke 18 months ago. His speech and cognition are such that you cannot make him out. He is badly affected. During that 18-month period, he has had four speech therapy sessions. It is expected that he will have to wait nine months to get another session. That is outrageous. The lack of speech therapists in Dublin north west is a serious matter. There seem to be huge discrepancies across the different teams for assessments. Even in CHO 9, there are discrepancies. I think I am correct in saying that, in the north-central area, people were put in to assess. I think there were about six people, from what I can recollect. Yet, there are little or no waiting lists in one section and in another there is a huge waiting list. I find it hard to understand how that can happen. There is something like 15,000 children awaiting initial contact from the CDNT and almost two thirds of them are waiting for more than 12 months. My experience is that they are waiting for a hell of a lot more than 12 months.

The service improvement plan states, "Over 16,500 children are awaiting their first appointment with a CDNT". I would love to know the progress on this, the waiting lists and what targets are being set. Of course, with population growth, is that being assessed properly? How will the national framework of service providers be rolled out so that CDNTs can offer appropriate supports to wait-listed children and families based on needs support? What is the progress on this framework? I do not know what assistance is being given to some of these families. I know there are changes in Dublin north west. I think there was a change in the management there. Something is not working right. That is a serious issue.

What about the private sector? Mr. O'Regan mentioned there was so much money and it is probably maxed out. That is the impression I got from what he said. Surely, there must be some more scope for families who are waiting for so long. Can we source in the North? Can we do something? Can we source some way of dealing with these cases? It is just wrong that a child of four years cannot talk properly, although certain words can be understood. We have to be able to address that. I ask for some answers.

An Cathaoirleach

I thank Deputy Ellis. A vote has been called in the Dáil Chamber on the Research and Innovation Bill 2024. We will suspend and reconvene shortly.

Sitting suspended at 5.59 p.m. and resumed at 6.17 p.m.

An Cathaoirleach

I ask Mr. O'Regan to answer Deputy Ellis's questions.

Mr. Bernard O'Regan

I thank the Chair and the Deputy for his questions. I agree that early intervention is critical and must be a priority. In all aspects of what we do across disability services and the wider HSE, the earlier the intervention for people with a need is, the better the outcomes often are, especially for children. When we can get it right as early as possible, the outcomes for the individual child and family are better. Also, as regards services, as the child goes through life stages, he or she will be impacted by what happens early on. There is no doubt, therefore, that early intervention is critical.

Deputy Ellis rightly highlighted some of the challenges around the variations in staffing levels. In the roadmap and some of the work streams, we set out to improve our recruitment and retention. At the same time, we will continually explore other and smarter ways in which we can provide services, whether that is through increased use of online and virtual supports or anything else that we can do to improve families' situations.

As for the framework the Deputy asked about, that is a grant scheme for which we put out a call to organisations in the community and voluntary sector. There were nearly 500 applications for funding which totalled €45 million. We had to work through those. We now have a shortlist and we are engaging with the Department to sign off on that. I hope to be in a position to make announcements on this shortly. This is not an alternative to therapy services. We are trying to harness whatever supports there are to provide something that will improve things for children and families while they wait for access to therapy services.

As for Deputy Ellis's local area, the challenges and variations there are reflective of most of the CHOs. It just happens that the Deputy's area is a tighter geographical area-----

Deputy Dessie Ellis

It seems to be worse in CHO 9.

Mr. Bernard O'Regan

CHO 9 has a number of unique challenges to it, both in terms of population and the profile of that population.

To be fair, extraordinary work is being done in trying to organise and increase the resources it has, including by additional recruitment, where possible. However, it is also facing challenges. It is an expensive place to live and when people have options, it is necessary to find as much as possible to make the roles as compelling as possible. We are doing a lot to try to support sponsorships and to incentivise people as much as possible to come and work on the teams, but I cannot say it will be resolved tomorrow, next month or in the next six months. All I can say is that the work we are doing is intended to improve that on a continual basis. The Deputy's colleagues from another area will ask about another part of the country where there are significant staffing gaps we have to try to address. Mr. Fitzmaurice, as chief officer, has a perspective on managing that across a CHO area.

Mr. John Fitzmaurice

I am happy to contribute. One of the key elements of the roadmap for each CHO is that we will be developing our own service improvement plan. A key part of that, as we have already mentioned, will be recruitment and retention. One of the key priorities for us all is to retain the staff we have currently because we have simply lost too many staff. We all acknowledge that we are falling short of the expectations of members of the public and people with a disability. There is no doubt about that.

One of the key opportunities available to us is to show evidence of the progress we are making. That is important from a staffing and public confidence perspective, in respect of the inroads we are making. Having dedicated recruitment specific to disability will enhance the level of service we will be able to provide. That is important. No more than CHO 9, my area, CHO 2, experiences discrepancies from area to area. For example, I find it easier to recruit in Galway city than in north Mayo. We have particular challenges in places like north Mayo for certain professions, such as psychology and so forth. They are the challenges we experience. One of the key points under the roadmap is that we have a uniform approach and targeted recruitment. The focus on retention is really important for staff because they need to see a vision for how we will deliver our services into the future. They will see evidence and need to see incremental evidence of improvement. That will help in our efforts to retain the staff we have and to recruit people to key positions where we currently have vacancies.

Mr. Bernard O'Regan

Dr. Gowran might comment on speech and language therapy and the development that is needed to create additional capacity.

Dr. Rosie Gowran

Yes. Across the health and social care sector there are major issues in workforce capacity. We are in a state of recovery now after the pandemic and we need to rebuild the capacity in the system. There are major shortfalls that need to be addressed. A number of initiatives need to be looked at to entice people to come into the sector to work in CDNTs and practice education, such as finding ways to support student placements in the sector. We are working closely with higher education institutions, HEIs, to look at how we can develop supports to progress student placement in the sector because that will encourage people. If they have experience in the sector, they will be more likely to apply for posts in it. That is one aspect, but it is across all health and social care professionals, including speech and language therapy.

We have to look at some short-term responses to developing posts in the sector. We have talked about retention and supporting staff with clinical supervision and looking at the whole area of clinical governance, which is critical and has been highlighted as an area of concern. We are looking to address it in detail.

Mr. O'Regan mentioned in his opening statement the Bacon report of 2001 which brought into play the higher education programmes for speech and language therapy, physiotherapy and occupational therapy. We need to revisit that and either increase the number of places on some of the programmes - which is challenged by being able to access practice education so we also have to look at supporting practice education, as I said - or consider the potential for new programmes to come on stream. That needs to be investigated, looking at exactly what is needed in that area so we can build capacity and ensure people are available to fill the posts that are currently vacant and additional posts, if they are needed.

In addition to thinking about recruitment and retaining people, we are aware there are major challenges in the system. There is a lot of negative media coverage about the delivery of services and it is important from a staff morale point of view to ensure we hear the good news stories about the excellent work that is happening on the ground. That is important so that people feel valued and want to go work every day, that they know their work is valued and that they are doing a good job. If people are constantly hearing negative stories across the whole media spectrum, it does not encourage them to apply for jobs in the sector so we need to look for ways to demonstrate the great work that is happening in the sector.

Deputy Dessie Ellis

I do not mean to come across as being too critical. I know the staff and the work they are doing is tremendous. I am just trying to highlight what I am seeing on the ground. Once people get into the system and when the teams are in place everything is really good. My focus, in mentioning two specific cases, was on Finglas and Ballymun. I found a discrepancy between one section of CHO 9 and another and I could not get my head around it. It was not down to geography in the sense that both area are fairly working class, so why is one functioning very well and the other is not? These things need to be looked at. The plan the HSE has set out to examine the whole system might show up some of what I am saying and that is why I am saying it.

Mr. Bernard O'Regan

We will be happy to come back to the Deputy with a note. We can link in with CHO 9 and follow up.

Deputy Dessie Ellis

I thank Mr. O'Regan.

Deputy Jennifer Murnane O'Connor

I thank all the witnesses for coming. It is important that we highlight our issues. We have spoken about recruitment and retention. CHO 5 covers the Carlow-Kilkenny area. I understand the CDNT in Carlow is very understaffed. It is one of the worst in the country, but I also understand that we have to be mindful of the staff who are there. There is such a thing as burnout. I also understand that because staff are under fierce pressure. However, the number of families this has affected is unreal. A large number of families are coming to me who are upset. When I say upset, I mean it in the sense that they are crying. That is how bad it has got. I met the special educational needs organisers, SENOs, in Carlow because of the autism spectrum disorder, ASD, classes the Government is looking at, which is good. It will make sure schools are able to build ASD classrooms, if they have room to do so. My issue is that there are children in the system who are waiting to be assessed. My fear is that we will come into a new school year in September, while children are on a waiting list to be assessed and it will not happen.

This is a huge issue. We spoke about the importance of everybody working together, be it special educational needs organisers, SENOs, the HSE, the bodies on the educations side and also through whatever legislation is passed. If there is not early intervention we will end up with a huge, long-term problem. That is what I think is happening at the moment. I feel that I have never seen as many families visit my clinic as I have in the past two years. Their children are waiting for assessments. As I said, there is no door that I am not knocking on between CHO 5 and the HSE. I go to anyone I can who can do the work.

I welcome Mr. O'Regan's opening statement. He mentioned engagement with the wider community and voluntary sector to identify a range of supports and services that can be provided to children and families while they await the CDNT services. What supports and services is the HSE providing? I mean this question very nicely. People call me to tell me that their calls to the HSE are not returned. That is my first point.

Regarding the strong oversight and support by the CEO and the board of the HSE, Mr. O'Regan's opening statement states:

69 of 91 Family Forums and 5 of the 9 Family Representative Groups are now up and running, and have nominated their two family representatives for the CHO CDNT Governance Group. We will run an independent review on the experience of this

[...].

Will Mr. O'Regan explain that to me? There is a little bit of confusion about that and I will explain that in a second.

There are challenges, as Mr. O'Regan has mentioned. Some 46,000 children are on the CDNT caseload, with approximately 16,000 currently receiving a service from the CDNTs every month, based on each individual team. Will Mr. O'Regan provide a breakdown of these figures because I am a little bit confused by them?

I have worked very closely with the Minster of State, Deputy Rabbitte, how has Mr. O'Regan seen the transfer of the functions and in what way has this affected the services? What has been done through the Minister of State? I know how passionate she is but I want to know what the gain has been and what is the roadmap going forward?

What does the HSE believe are the key supports that parents with a child with a complex or non-complex disability need? How is the HSE rolling out those supports? The reason I ask this question, is that while we have complex or non-complex disabilities, I need to know because I am working with some families.

How are the Irish sign Language, ISL, supports being rolled out in the CDNTs to support cases of services for deaf children? I know this is part of something that is being worked on. On the delivery of supports, the HSE roadmap states:

Establishing SEED (Sharing Experience and Expertise in Disability) centres, as virtual interconnected national network of practice - in Motor Management and Feeding, Eating Drinking and Swallowing (FEDS).

Do parents have access to this? I have one or two issues in this regard that I want to have looked at.

Carlow CDNT needs more staff. I am not here to criticise any staff member because I know everyone is burnt out. I work very closely with the HSE and with SENO regarding ASD classes or if someone needs a carer. I am very mindful of this but I believe we are starting to hit crisis point now. This is just my opinion, but we need to start providing services more quickly. Children are losing out and families are at breaking point. We need to do something urgently. I believe at one stage it was mooted that with the waiting lists for CDNT services there might be the possibility of considering the use of private occupational therapists, with the cost to be refunded by the HSE. At the moment, I have two cases of children who need urgent treatment. I checked the cost of using a private occupational therapist for them. The cost per child is from €1,200 to €1,600. Many families simply do not have that kind of money. What can we do in the interim to help these children and their families who are at breaking point? Again, I welcome the representatives from the HSE here. I know they are here to try to solve the problems that exist. I am not saying they are not. I am glad the HSE appears before the committee so often. I am simply wondering how we can find some kind of a solution here.

Mr. Bernard O'Regan

I will start with the transfer of functions because it creates a context for the work we are doing, which is different from how things were before the transfer. The Department we are now engaging with has a very specific focus on and commitment to disability services. The Department is engaging with all levels of the HSE. While it is doing so, it is mindful of the other pressures like the emergency department issues and the hospital challenges, but is very focused on disability services. I mean no disrespect to the Department but when we were in the Department of Health, disability was one part of a wider issue. The pressures in acute services often trumped the focus on disability and other areas. It has certainly brought more focus. When we look at the outcome of the last budgetary process, it would be fair to say that disability services probably got more money, relatively speaking, than the rest of the HSE. Disability services have probably benefited because of the single focus. In terms of the engagement with other Departments to try to solve problems, there is a lot of potential there.

Yes. I will go to vote and then return for my answers.

An Cathaoirleach

Next is Senator Flynn, who is taking Deputy Gannon’s place.

Senator Eileen Flynn

I thank the witnesses for once again appearing before us. I will start by saying that this committee visited the national learning services that are available for people with disabilities in Rehab’s care. It was an eye opener for us as a committee and for me as an individual. A week later, I visited the national learning centre in Sligo. I do not know whether the witnesses can address public transport in the CHO 1 area, but I will ask the question anyway. People with disabilities have to pay for their Local Link service in the CHO 1 area. I had thought that, if someone had a disability pass, it would cover him or her on any public transport. Unfortunately, that is not the case, which stops people with disabilities from accessing the service. They would be out €2 per day. That might “only” be €20 or €30 per week to the witnesses or me, but not to a person who is already struggling, given how we know that having a disability increases costs. If the witnesses have information on this matter, it would be welcome.

The extra hours for the personal assistance service are positive. Can the witnesses give more information on whether access to services will be expanded to those who identify themselves as needing them as opposed to just those with diagnoses?

I have raised a matter at this committee more than once, and the witnesses have probably heard me discussing it previously, that being, the lack of mental health supports for people with special needs. Yesterday, Down Syndrome Ireland, AsIAm and Inclusion Ireland appeared before the education committee. The term “complex needs” came up at least 20 times. A bit like the word “disadvantaged”, there is something negative when we use the term “complex needs” to describe someone who has greater needs. This committee needs to consider changing the language from “complex needs”. People with disabilities are not the problem or should not be the issue. The system is the problem. I mean no disrespect to any of the witnesses, as this system existed long before they entered their roles. Do they have data on how many people from the age of 18 years to 64 years are waiting to be diagnosed with ADHD or autism? I know many people who have ADHD or may be on the spectrum but cannot get a diagnosis. If someone is from a marginalised community, he or she will already be afraid because of that, never mind being labelled with a disability, too. While it is difficult for some people, it is even more difficult for people from underprivileged backgrounds.

In some cases, the Government’s Green Paper on changes to disability payments would only divide people more and increase the cost of living. We all understand that the cost of living is tough for everyone currently, but a person with a disability would be genuinely worried about the Green Paper. I appreciate that there are different forms of disability, but people with disabilities should receive the same disability payment and it should not be means tested. Something I have seen numerous times is the pressure on people because of their addresses and because they are from marginalised communities, for example, the Traveller community. There is a stigma, as some would call it, of being seen as being on the sick book when it is actually a disability payment and not just a case of being off work for two or three weeks because they are sick. I would like to know the witnesses’ thoughts on the Green Paper. My opinion and that of many activists is that we should get rid of it and not have means testing. Having a disability is already a challenge. People would be intimidated and patronised if they had to go into social welfare offices and so on.

Voluntary organisations provide up to 70% of disability services nationally and are finding it difficult to recruit staff. This committee has discussed the recruitment of staff in the CHOs. It is difficult to work for a sector where people are underpaid. Without comparing it directly, it is a bit like child care, in that no one wants to be a child care worker. Someone puts his or her life and soul into a job for which he or she is getting very little wages. It is the same for people working in the disability sector. For SNAs and people like the witnesses who are working in the regions, it is a tough job. In some cases, the money might be there but the people to fill the roles are not. When I was studying social science in university, I wanted to be a nurse so badly because a nurse gave something back to society. I never had the qualifications to do that. Whenever I tell someone I studied social science, I feel straight away in my gut that what I did was not valued. That is okay, but we need to recognise people who work with persons with disabilities as professionals in their roles and that they should be on good wages. Most importantly, people with disabilities should have equality of pay within Irish society. I do not know whether the witnesses have any solutions to the recruitment issue. What would that look like?

I believe we should be recruiting people who are able for these jobs and who have disabilities. Sometimes people with disabilities can work in the regional organisations. It is first and foremost about that positive discrimination. We have seen it in Ballyfermot, where people with disabilities work in recycling, and how it gives people a sense of life. Just because somebody has a disability does not mean they are stupid or do not have the capacity to hold down a job. That is far from the truth.

Sorry, I have gone on a wee bit. I would welcome any comments back or suggestions around going forward. Even yesterday, in the education committee, it was a bit disheartening. Whatever it is about today, I am having a bit of a disheartening day. We have been sitting here nearly three years now - I have been for two years anyway - and we are talking about women's rights coming up to International Women's Day. As regards disabled women's rights, women with disabilities also should have spaces around these kinds of tables and spaces in the chambers.

On that note, I welcome two students in with me today, Nora and Lucille. The two young women have been here since 1 o'clock today and are really getting to know the place and committees like the disability committee. It is brilliant to share the experience of these Houses with our young students.

An Cathaoirleach

Nora and Lucille, you are very welcome. I hope you find this enjoyable and of benefit. Over to you, Mr. Regan. Do you want to take the Senator's questions?

Mr. Bernard O'Regan

Again, I will ask colleagues to come in on a few of the issues the Senator has raised. First, the HSE cannot comment on the Green Paper. We might have personal views on it, but I am not sure I can represent a HSE perspective on it.

As regards the transport issue in Sligo, there is an innovative component to what they have done. The use of the Local Link transport scheme as a kind of local community mainstream transport is a really good approach to take and one we have been talking about to the Minister of State, Deputy Rabbitte, and the Department to see if there are ways it could be further developed. The issue as regards people being asked to contribute to it is a decision that was taken a number of years ago because there was a funding gap and people at the time could not figure out any other way than to look for a contribution from people. It is something we are looking at. I cannot say today that we have a solution to it, but we are coming at it from the perspective that if people are living in an urban area where there is a public transport system, they have a travel pass that they would be able to use and they would not be asked to make any contribution. We do need to find a way that that same equity of access is available if it is a Local Link service, but we have a piece of work to try to figure that out. It is something that, as recently as last Friday, I was discussing with the managers in CHO 1, so it is on our radar. I do not know what the timeframe is as to when we will be able to find some solution to it but we do recognise the inequity of it while recognising at the same time that the use of Local Link offers a lot in terms of access to transport.

As regards the employment of people with disabilities, as a State we are not achieving what we need to do. We have many thousands of people who attend day services every day. They are very good services and supports to people, but we also know that many people attending those services want to and would benefit from being able to get into the workplace. The interesting thing - and I think the Senator alluded to it - is that we have vacancies all over the country in respect of a wide range of jobs and we have people with the skills who could do them or who have the capacity to be taught the skills with the right coaching and mentoring. We absolutely agree that that is an area that should be addressed. Within the national disability inclusion strategy, the comprehensive employment strategy sets out a very useful and helpful framework for how that might be addressed. It includes the question of how we address the benefits trap that can be there. I might want to work and I am on the disability allowance, but if I work too much and get paid too much, my allowances will be impacted.

Senator Eileen Flynn

And your medical card.

Mr. Bernard O'Regan

Yes, and my medical card and things that can be hugely valuable to people in just maintaining a reasonable standard of living. There are a range of things that need to be addressed in order to make work really possible. There is also the expectation we have for people. It has been raised by a number of organisations, and I understand that some progress will be made on this through the Department of Education around having guidance counselling available in special schools, for example. That is really important because it creates an expectation and an ambition beyond day services only and that there are other options, whether third level education, additional training, apprenticeships or getting into the world of work.

The last comment I will make on it is that over the years a lot of work has been done with the Department of Social Protection to create supports for disabled people to go to work. I think there is a group of people in the middle who do not meet the threshold for those supports and who need more intentional support. We need to develop something as a State to assist with those.

I acknowledge the language issue the Senator has raised. I think we constantly fall into traps as regards the language we use, and sometimes we need people to call it out because it is not that anybody intends anything; it just becomes the language. It is important that when it is seen it is called out and we pay attention to it.

As regards the personalised budgets and personal assistance, we have a working group on PA at the moment that is working on clarifying definitions, differentiating between PA and home support and so on. It is also looking at the access criteria. That work is progressing at pace, and I hope that by the end of the year that group will have something out of it that will help to clarify both the definition and the access to it.

John, do you want to comment on accessing diagnosis? Rosie, you might also want to come in on that as well as the project that is happening under the autism programme board.

Mr. John Fitzmaurice

Yes. As regards the numbers the Senator asked about, we do not have the numbers in terms of those with ADHD over the age of 18 who have not been diagnosed. What is important at the moment is that there have been a lot of stories and a lot of narrative in the public about people who have been diagnosed late in life. It is important for others to hear that because it allows those who have been undiagnosed to come forward. We hope that journey will be easier for people.

One of the things we are currently going through is a pilot. We have stood up a programme board which is looking at autism assessments and pathways specifically. It is a tiered approach, and the focus is on ongoing intervention that is not dependent on assessment. They go hand in hand. There has been a lot of discussion about how an assessment is a gateway to intervention. We have to focus on the journey, being focused on intervention and ongoing assessment being part of that journey. Phase 1 of that has been completed and we are in the latter stages of completing phase 2. The primary focus is on children. We also have a number of adults who have gone through that process. That allows for assessments and intervention to happen right throughout our system, not just within disability but across primary care and within mental health as well. I know there has been some discussion about mental health. If somebody is in receipt of mental health services, it allows for that assessment to be undertaken within mental health. For some people it can be very obvious that they have autism and so forth, but for others it may not be, so that tiered model of intervention allows for a more timely focus on that and, as I said, a focus specifically on intervention.

We hope we will conclude that. It was held up by the Fórsa direction on non-compliance but that has been lifted, so we will be able to conclude that, I hope, in the coming months. That will be positive and will certainly streamline the way we do our work and carry out our assessments and interventions.

Dr. Rosie Gowran

I think Mr. Fitzmaurice covered most of the question about the autism assessment. To go back to the question on employment for people with disability, it is critical we ensure there are supports for people to access employment. Under the national clinical programme for people with disability, my role is to ensure the implementation of the UNCRPD and to ensure supports are developed appropriately and are effective, efficient and evidence based. Mr. O’Regan mentioned looking at PA supports and home supports and ensuring necessary supports are available to people in order that they can access employment and can get out of bed in the morning, do the things they want to do and live a life of their choosing. A lot of work is happening to establish supports for the appropriate provision of aids, appliances and technology, and developments are happening in that area in order that we will build sustainable infrastructure to support people with disabilities to live their lives and be included as they wish to be.

Senator Eileen Flynn

I know that not every disability is visible. I understand that, but we need diversity both in these Houses and throughout employment. We talk about the gender gap but we are leaving cohorts of women behind, namely, women with disabilities, women from the Traveller community and black or Muslim women. People with disabilities can participate in Irish society and that is so important.

An Cathaoirleach

I thank the Senator. We might go back to Deputy Murnane O’Connor’s questions, which we paused because the vote was called.

Ms Ann Bourke

On the question about the 69 out of 91 family forums and the five out of nine family representative groups, we have planned one family forum in each of the children's disability network team areas. Sixty-nine was the figure before the industrial action. We understand, although we are awaiting validated information, that figure has increased. The intent is 91 family forums. Most of the forums have been run three or four times and this is where all families, both of those children in service and of those wait-listed children, are invited to participate. The manager of the team, that is, the children's disability network manager, attends as a partner on a level playing field and they are independently facilitated. That family forum then nominates two people to the family representative group. There is one of those per CHO, and that is independently facilitated as well. From that family representative group, those family representatives nominate two people onto the CHO children's disability network team governance group, so they have a say at that CHO level.

At national level, under our roadmap structure, we have five working groups and a service improvement programme board sits above that. The board has met and includes two parents. We have had our first workforce working group meeting and it is the only group where we do not have a parent represented. It met yesterday and the working group has voted to the effect it must include a parent as well. We will, therefore, have a parent on all the groups.

Deputy Pauline Tully

I welcome our guests. I am contacted by parents probably every week about access to the CDNT and there is a mixture of distress, anger, frustration and disheartenment. Some have more than one child with additional needs, and while they may be on the list, they may have had no intervention whatsoever. Some parents of older children would say the last time their child had any intervention was before the progressing disability services programme and before the CDNTs were established, when there were early intervention teams that saw all children up to six. Since they aged out of that, they have had no services whatsoever. We have got to the stage where the CDNTs are not providing any information on children, which is why the complex needs aspect was removed from the set hours going into schools, because they do not have the information anymore. I recall teaching and getting vital information from what was then the child development team about children coming from primary school into secondary school who were on the list. That is greatly missed.

The Minister of State, Deputy Rabbitte, has indicated that there is a recruitment drive and that a lot of interviews are coming up. We all hope that will work but there are huge numbers on the list, as our guests identified in their statement. The HSE used to carry out a census every year of the CHOs and the vacancy rate among them. Is that being produced again this year? I think it was around this time last year that it was published. Even if the recruitment drive is successful, the core registration was holding up people. Has that eased, especially for people who trained outside this jurisdiction? Has the regulation of psychology moved on at all or are we any nearer to that being registered?

Staff on maternity leave have not been covered up to now. I know that the acting manager in the CDNT in Cavan is currently on maternity leave and I am hearing different names as to who is responsible now. Will team members, whether management or therapists, be covered if they are on maternity leave?

It remains the case that children with complex needs are being abandoned in hospitals, respite centres and schools. I had thought there was a better working relationship between the CDNTs and Tusla but my party colleague Deputy Daly indicated to me recently that a child in a Kerry hospital had been left in a side room for a number of weeks, if not longer, because, again, there was disagreement between who was supposed to be responsible for taking care of him. I believe a residential placement has been found in Cork for that child, but he spent quite a number of weeks without support. Does the HSE reach out to families who are in crisis or when it realises they are in crisis, and has co-operation with other agencies improved?

Is there any oversight as to whether the CDNTs are more effective than the previous teams? I appreciate that is difficult to tell. They replaced the previous structure, which applied up to the age of six and then from six to 18, but it is probably hard to tell without them being fully staffed. Will that be looked at?

Our guests spoke about the almost 9,000 people on a waiting list for an AON and, in a lot of cases, it is probably not necessary but, unfortunately, they are necessary for schools. How can we get away from that? It makes sense that if a child goes into the CDNT, there is an ongoing assessment while they are getting the supports and services they need, but if the parents wants the best and most appropriate placement for the child and if that child needs a special class, special school or autism class, the school demands a report. Until we move to a more inclusive form of education where every child is accommodated in their local school and the supports are there, I do not know how we can get past that. It is something we need to address. A parent contacted me recently who is looking at accessing private supports for her child, even though she can barely afford it, but that provider has said it needs an assessment from the CDNT and the CDNT has said it has not seen the child and cannot assess them. She has been left in a quandary whereby even if she could afford to get the private support for her child, which they badly need, she cannot because the private practitioner is looking for an assessment.

In respect of section 39 organisations, such as Enable Ireland in Cavan, the pay parity agreement is welcome, although I do not know whether it is going to fully bridge the gap. I do not know whether section 39 organisations have received that back pay. That is going to be an issue as well. I understand KOSI is now being asked to deal with the pay.

I am concerned about that because organisations are still waiting for the Covid payment, which was administered by the same organisation. Why do such payments have to be outsourced at all? I appreciate that there is a good deal in what I have raised.

Mr. Bernard O'Regan

As with others, I will cover some of the queries and ask colleagues to come in on the others. The staff census for CDNTs is being carried out. We identify a date in October and do the annual data capture on that day. It was affected by the Fórsa industrial action, which meant nobody was in a position to do returns to us. Since that industrial action was suspended, it is progressing. We are working towards trying to have a report in next month. Once we have completed that report, we will share it with the committee.

I will have to come back to the Deputy regarding any specifics on CORU registration. The indications we are getting is that where somebody has made an application, where all of his or her information is together and he or she puts in a full and frank application, it works through reasonably quickly. Many of the issues and delays seem to arise where CORU has to chase information or there are inadequate applications and so on. CORU and the Department of Health have also been reviewing jurisdictions. They have made some changes recently and added some countries where the training in those countries is recognised, which aids and speeds up the CORU registration process. I am not sure whether that is the cause or excuse for the delay, notwithstanding the fact there are challenges in it. I cannot comment on the registration of psychologists. I will follow up on it and come back to the Deputy. It is piece of work that is going on between the Department and CORU. I just do not know where it is at as of now.

I mentioned that we are not funded for the replacement of staff who are on maternity leave, except for some aspects of service, such as residential services. However, we make every effort, where we can, to try to provide cover. If a manager is out, we have to put arrangements in place. Somebody has to be able to co-ordinate the team. Sometimes, that involves moving people around from other roles so we are robbing Peter to pay Paul, which has consequences. It is something we are very mindful of. It has an impact. The solutions are even harder in circumstances where a team might be depleted. To be honest, it can be challenging enough. If a staff member is being asked whether he or she will take on the children's disability network manager, CDNM, role for a period, for example, it is a hard job. It is not always attractive to as many people as we want. That is something we are very conscious of in trying to make those roles as attractive and satisfying as possible.

On children in hospitals, while I cannot comment on an individual case, we have a joint protocol with Tusla, which we are reviewing at present. The initial feedback is that by and large the protocol works well. A lot of very collaborative work is done and there are very speedy responses to many children's needs. There is good co-operation between the HSE and Tusla in responding to those children's needs. There are circumstances where it can be quite challenging. Sometimes, the challenge is not necessarily the relationship between the HSE and Tusla, or who pays or who is the clinical lead for a service. Those things can often be worked out very quickly. It is finding a suitable place that the child can transfer from. This is against a backdrop where we absolutely agree that a child in an ED, who does not need to be there, is completely inappropriate. Any day or night that a child is spending there is a day or a night too long, and a speedy solution needs to be found.

The review of the protocol is with a view to us improving it and finding ways to improve it. Some things will emerge out of the review that will inform some steps we can take to make sure it works as effectively and efficiently as possible, primarily for the children but also for the staff who are involved in it. Tusla has done its review. In the context of the HSE component, we are working towards completing our review later this month. We will then work with Tusla and the Department to review and update the protocol.

Deputy Pauline Tully

The preference for most families would not be to leave their children anywhere, but the intervention needs to be much sooner. A mechanism needs to be worked out to see how distressed a family is. Often, if they got the supports at home, they would not need the residential place.

Mr. Bernard O'Regan

Absolutely. The point we tried to make earlier was that early intervention is right for the child, has better outcomes for the child and family, prevents or reduces the demand for other types of services into the future, and supports a child to remain at home, which is what we want to happen.

On section 39 pay and the involvement of an external organisation to assist us, the pay agreement was agreed in November. The HSE has been working with the Department on a mechanism to release the funding. We released a once-off part of the 2023 payment in January as a way of getting it going. Organisations are being written to this week with details of the data they need to submit in order for the payments to be released to their staff. We have asked KOSI, in this instance, as part of a procurement process, to assist in the administering of it. KOSI is not setting the rules around it. All it will do is administer the data gathering and the administration that is needed. Ultimately, the payments will still go through the HSE.

On the point the Deputy made about the pandemic payment, there were undoubtedly some challenges. I am not a defender of KOSI but I am not sure it was necessarily down to it. Many queries came at KOSI, which it needed to come to us and the Department about in order to get clarification on them. KOSI were not the ones making the decisions around what the parameters of the payment were. Undoubtedly, there was learning for us on how that scheme was administered in order to try to get this one right.

Does anybody want to comment on the assessment of need piece?

Ms Ann Bourke

Sure, and the CDNTs.

Mr. Bernard O'Regan

Sorry, yes.

Ms Ann Bourke

It was asked whether the CDNTs were more effective. The question we continue to ask ourselves is whether the policy is correct. The PDS policy is the foundation of the children's disability network teams. In its simplest form, it is about equity of access for all children, regardless of where they live, or whether they have complex or non-complex needs. Going back 12 years, prior to PDS, children may or may not have got access to services. I will take one county as an example. I am from County Meath and was there before PDS service level. Some children, depending on their diagnoses, may have got access to a service, while other children did not. As publicly funded services, we have an obligation to bring all the resources from 18 different organisations providing children's disability services, including the HSE, pool those resources, including staff, equipment, buildings, etc., and set up teams comprising staff from all those different agencies. Most importantly, those staff brought their individual skill sets. The Deputy mentioned Enable Ireland. It deals with physical and sensory disability. It does not do autism. The Brothers of Charity are very good at intellectual disability but do not deal with physical and sensory.

By pooling all of those into one team in a county, children get access to a local team regardless of what needs they have. When the teams were reconfigured, what we could not predict in advance was how many children who did not have access to a service before the advent of PDS would have access to these teams. This is because it is based on need. Most CHOs indicated that what was done brought in hundreds of children who did not have services before.

An Cathaoirleach

Ms Bourke can come back in again. There is a vote in the Dáil. The meeting will continue regardless. Senator McGreehan is next to speak. I am sorry for interrupting Ms Bourke. I just wanted to bring that to the attention of members. She may continue with her reply to Deputy Tully's questions.

Ms Ann Bourke

First and foremost, once the teams were set up, at least each child was being dealt with on the basis of his or her needs. Most importantly, what we said we would do was signpost families to the right service, namely, primary care - and forgive me for the language we have currently - non-complex needs and CDNT complex needs. The demand for services has risen significantly. If we look at the mid-west, it has had teams in place for more than 20 years. It built that service and developed family centred practice, which is a very different way of working from how our clinicians work, how Dr. Gowran and i were trained and how clinicians are still mostly trained today in a single-discipline manner.

This approach involves working together in order that when the family and the child come to meet us for the first time, we have a blank sheet. It is strengths-based approach. We ask them what the strengths are within their family and with their child and then what their biggest bugbears are and what is destroying the family. We then ask how we can support them to develop their own strategies to implement in the home and how can we give them strategies. It is a three-tiered model, although "tiered" is the wrong word; we see it as circular. We provide universal supports that are targeted and individual, depending on the child's needs. Universal supports are the types of supports that are common for most children or families coming to our services. Targeted supports are more for groups of children - maybe it is toileting, sleep or adaptational behavioural supports. That is for smaller groups of children within the overall groups that come to us and are eligible for access to our teams. There is also one-on-one support for children with very specific needs. This is what is presented and offered to families and taken up when teams are full. Obviously, it is a challenge in view of the staffing levels we have talked much about at this meeting.

Does it work? We have the evidence from the mid-west and from the teams we configured in 2014 that it does work. The mid-west is also now challenged, although it is probably the best staffed model in the country because it has the history to which I refer and because it is bedded in. This is not to say that there are not waiting lists in the mid-west. There are waiting lists because the growth in demand for services has increased. In the past three years, the region has reported an 8% year-on-year growth in the number of referrals. Children with disabilities and complex needs are living much more than they would have in the past, and there is more complexity involved. I left front-line services 14 years ago. In that time, the profile has changed dramatically. Fourteen years ago, the profile of children with ASD presenting to a team in County Meath would have been. Teams are telling us that it is up to 80% now. That is a significant change. We need to continue growing and developing our teams to meet that need.

In the context of feedback from families, the biggest complaint we hear about consistently is the waiting list. However, the biggest compliments are from families within the service.

Deputy Pauline Tully

I am not hearing it. None of the families I talk to is very satisfied with the service. Even the family forum was very poorly attended on the last occasion. Parents are becoming so disheartened.

With regard to the figure for autism, we are severely below the national European average. It is something above 2% here, whereas it is above 4% in Europe. My figure could be a little off, but I know from talking to representatives from AsIAm that the figures are much higher than we actually see them as yet. That is what I am saying. We need to plan for more services in our education system and in the disability system. It is not that every autistic child is going to need support; many of them get on perfectly well in life.

Ms Ann Bourke

Absolutely.

Deputy Pauline Tully

Often, it is when it is combined with ADHD or something else that an issue arises.

Mr. Bernard O'Regan

It is a whole-of-system lead. It is not just what the HSE or the Department of Education do; it is about the collaborative and parallel development that both Departments are doing.

Ms Ann Bourke

We had an interesting meeting with the Department of Education on 1 March at which we looked at the prevalence of autism, what is driving this and, more importantly, what we can collectively do about it, which will be very positive.

An Cathaoirleach

I call Senator McGreehan.

Senator Erin McGreehan

The witnesses are very welcome. In the context of PDS, it is all about access or lack of access. We speak to parents whose child is at home and they are not getting any services. They can see their child regressing. They can see their child not doing well in school and not developing. It is such a travesty.

We are causing bigger problems because of that lack of services. Obviously, we need vacancies. As has been rightly said, anyone who gets care in the HSE gets good care. We have really good healthcare professionals. We just do not have enough of them. As Mr. O'Regan said, that does not do any parent any good. They do not care where the care comes from. If they can scrape money together, they will do so. I know parents who were getting loans from grandparents and siblings and scraping to get some sort of care and therapy for their children. That regression causes the child to have more needs. Parents have come to me. Mothers have given up work. As a result, the family is further impoverished. We have such a desperate cycle. It is so heartbreaking when mammies and daddies talk to us about their gorgeous little person who is not being given the ability to thrive.

With regard to vacancies, we say we have a big recruitment plan. In the past 12 months, let us say, how many vacancies have been filled? Are any of the CDNTs fully staffed at this stage? In a reply to a parliamentary question last year, the Minister indicated that the vacancy rate in Louth was 50%. If we can only field half a football team, we are not going to be able to win. We need to get staff. Where do matters stand in the context of recruitment? Where are we at when it comes to attracting people? If people are leaving, are we doing exit interviews to see what we can do better? Have proposals regarding disability services been put to those in the higher echelons of the HSE, the Ministers, the Department of Health or whomever? They need different terms and conditions and we can fight for those, but have there been any proposals? As Mr. O'Regan said, being a CDNT lead is quite a difficult job. They are all difficult. How do we entice people to take up these roles? What is being done in that regard? Mr. O'Regan mentioned that there will be a roadmap and implementation plan in each area. When will we see that? Will there be so many vacancies?

Will the roadmap be any good? Are there implementation plans to be made? Are they cognisant of the fact that there are so many vacancies that we cannot field a full team?

I understand the potential value of a family forum, but so many people are just exhausted. I have spoken to some individuals. The last thing they have time for is the idea of taking part in a family forum, particularly if they are not getting any interventions. They are only getting scraps, and going to a family forum to hear the heartache of other families is not what they want. If someone does not want to engage with a family forum, what else is there? Some people would not like that sort of thing or would not feel they have the capacity to be able to do it. What other options are there for a family that does not want to take part in a family forum? It could be that a parent has had enough of engagement, wants to get their child a service and learn a new skill to allow them to care for him or her. Is there is a plan for these parents?

I hear so many times that children are ageing out of services but that they have not received any care for years. Families do not trust the system. They disengage and have no faith in contact with the HSE when it comes to adult services. One cannot blame them. They are fearful of putting their 18- or 19-year-old child into a service. Their child may be an adult, but his or her capacity is not that of an adult. Families are given the option of placing their children into day services with loads of adults who are much older and who have completely different needs. How does the HSE plan for families to be able to move on to suitable day services? Eighteen-year-olds are coming to that point and are in services that are not suitable. It is not fair on them. A young girl with the capacity of a ten-year-old could be in with adult men. That is the only service they are given.

Regarding long-term planning, our population is growing, the needs of our communities are growing and there is far more awareness and understanding of what is needed, so that puts pressure on the HSE in the context of those therapies. What is the long-term planning regarding respite services? We are continuously putting things like that out to private tender. In this State, we are fantastic at putting out our most vulnerable people to the private sector and there are so many private providers of respite services. Where is the long-term plan for the HSE taking ownership of long-term respite places or day services or will we always rely on private providers for this? Perhaps it is HSE policy, but I do not think we should be allowing our most vulnerable to be at the mercy of private services. We saw it recently with St. John of God. We are putting so many people under pressure and causing them fear. Thankfully, the matter with St. John of God was resolved. If the State planned to take care of people, we know how many children are in the service. Thankfully, they will be here in 18, 40 or 50 years' time, so where is the HSE with regard to future plans for those 70,000 children?

Mr. Bernard O'Regan

Regarding future planning, the capacity review report the Department published in 2022 set out a ten-year analysis based on the data available at the time, including projections in terms of population growth. We have a framework that sets out for the State what needs to happen in terms of development of services. In some cases, it is able to be reasonably specific about what is needed, for example, with residential services but also a place for people to live at home because I do not think it necessarily translates into everybody living in a four-person group home. It is about people being able to have a home and having support and respite with a range of options on respite.

We have a roadmap that sets out what we need. That will need to be continually reviewed. We have seen extraordinary population growth over the past number of years. We have set out a ten-year plan but that will need to be updated as we go, as census data becomes available and in light of the national database, which is being rolled out, because that is a very important tool for us in terms of future planning. As that is increasingly populated, it will help us plan for future needs of services.

Meeting that need is not solely the responsibility of the Department of Children, Equality, Disability, Integration and Youth or the HSE. The efforts of the Departments of Social Protection, Transport and Housing, Local Government and Heritage need to be aligned. I understand that this was an important part of the context of the development of the capacity was to allow all Departments to be able to see what the population need is and what our role needs to be. The action plan set out for this year and the next two years seeks to bring those Departments into the frame so that it is not just about the Department of Children, Equality, Disability, Integration and Youth and ourselves planning for the supports for people in residential services, for example, it is also about the Department of Housing, Local Government and Heritage knowing the housing need that will need to be aligned with those things.

Senator Erin McGreehan

The HSE is working in an interdepartmental way.

Mr. Bernard O'Regan

Yes. There is a great deal of work in that, but that is part of it. Regarding the structure for the delivery of services, we have always had a thriving and really important voluntary sectors, for example, organisations like St. John of God, Western Care Association and St. Michael's House, all of those-----

Senator Erin McGreehan

They are fantastic.

Mr. Bernard O'Regan

I listened to what the witnesses said about all of the things like remodellings and doing reviews. Ms Bourke mention how these forums will go into something else, and they go all the way up to the top. It is exhausting even listening to it because the parents do not give two damns about all of that. They want a service for their child. The other thing that is wrong is that if the HSE cannot provide the service and it can be provided privately, that service should be obtained for the child irrespective of what the problems are with regard to how funding is organised. The primary thing in this is to get the child sorted out. I am ranting but I do not know if there is a review going on of what is happening in Tuam. However, from all of the parents who have come to me since that protest, I am overwhelmed by the number of people who are coming with complaints. There is no doubt that if somebody gets a service, it is a good service but there is something completely amiss somewhere in that system because it is just not working for the majority. I have parents coming into my office or ringing me and they are crying. They are looking for help, guidance and somebody to talk to, and they tell me about the money they are spending on trying to get private assessments. We all talk about early intervention and how it is the most important thing, and I know children who cannot get any kind of an assessment. They are brought in and they are registered but that is it. They are not getting the assessments or the service. They are more or less brought in to say, "You are in our network now" but they are not getting it.

It is a failure, and I think that what happened was that when that forum meeting was held, parents went to it and thought they had a particular problem but when they discussed it around the room and they realised, there was nearly open revolt. All of a sudden they realised this is what is happening. I know Deputy Tully talked about not getting any positive feedback into her office. I certainly am not getting any. I am getting so much of the negative. I worry about the parents and their mental health. We can talk about it forever but I would ask the witnesses to go, really and truly and as a matter of urgency, and find out what is going on, what is there and give us the accurate information as to what is missing. When you get two different sets of figures on a spreadsheet like I have there, parents who asked me to find out point it out to me, and that drives them to worse states. That is the kind of stuff that is going on.

I am not being critical of the staff that is there. Actually, there is a speech and language therapist leaving now. The parents hear all of this first, and then they contact me and say, "Seán, do you know what is happening today?" I was looking through my phone there at messages I have been getting from parents. It really erupted when that forum meeting happened. It might be the best thing that happened because we might now open up the envelope and see what is inside it. It cannot be covered in on procedures and all of that kind of thing. It is something that worries me for the sake of the parents and the children. I could go on about services going into adulthood. I could talk about respite services where I had a poor woman who has a son aged 45, and he needs respite services. She had to go to England for a funeral. She was told she had the respite services, and two days before she went she was told the services could not be delivered because they were doing some work on the house. There was another person who asked to go in and get a knee operation. She came to me and she was crying because her daughter, who is an adult, would not have anybody to mind her while she was in the hospital. She was going to postpone the knee operation on the basis that she could not leave her daughter on her own, and she was waiting about three years to have the knee operation.

I could go on and on but what I am saying is that there are problems with CDNT 7. There is no denying that there are problems, and I would like the HSE to look at it. The witnesses do not need to respond to me now but genuinely, I would like them to seriously put someone in there and do a root-and-branch review of what is actually going on. I thank the witnesses.

An Cathaoirleach

Does any of the witnesses want to respond?

Mr. Bernard O'Regan

I will make a couple of comments, and Mr. Fitzmaurice might want to comment as well. He will comment specifically on the Tuam service, and I take on board what the Deputy is saying about the experience for families, their frustration in not being able to access a service, and then the compounded frustration of getting mixed messages, different data, and not being clear on what the picture is.

Regarding our intention in the family forums, I think the Deputy is right. Sometimes you do need to----

Deputy Seán Canney

I would not even talk to the parents about that. They do not want to know about the family forums. We need to know about the service.

Mr. Bernard O'Regan

I understand that but it is also important that we have places where families can come and voice that. That is part of the function of the family forums. Previously, families were also saying that they had nowhere to go to talk to us. As Ms Bourke said, we want to make sure we have good communication with families. If they are not the right mechanism, or we need to do more, that is some of the learning we need to do.

On the challenges that are there for other services, the Deputy is absolutely right. There are circumstances were families are not able to access respite, or access it when they need to. There are thousands of respite services being provided. We have provided more respite in each of the last two years than we did in the years before. However, it is not enough to meet the needs that are there. There will be significant investment this year in additional respite. That still will not meet all of the need but it is part of a multi-year commitment that the Minister of State, Deputy Rabbitte and the Department have made with regard to increasing funding. It is an area where there will be improvement, although we still have a way to go in meeting the needs that are there. Does Mr. Fitzmaurice want to comment on the Tuam service?

Mr. John Fitzmaurice

I am happy to speak on a couple of things. First and foremost is the forum being cancelled in January. The facilitator was unavailable for genuine reasons. There is a date for the second meeting to proceed. The Deputy mentioned the new building, which is welcome, because previously, we had staff located in two different buildings, but it is only a building and, as the Deputy says, it is about the services that come out of it. We need to ensure that we do better. We need to do better. There is no question about that.

The Deputy mentioned the announcement about the number of staff. The person speaking that day made a mistake and announced the total quantum of staff that we have across the CHO. I appreciate that was upsetting for everyone who was there because we talked about staff who did not exist in the network. That was across our nine networks. We have since apologised for that.

The issue with network 7 is in my area. I have somebody who is doing a 360 degree review of that network at the moment. It started last Monday. It will take six weeks. It is to look at our systems and processes, how we do our work and whether we can do it more efficiently. We need to work with the team there to enable it to provide the best services possible. The Deputy mentioned the speech and language therapist. I am not aware of the speech and language therapist who is leaving. That would be unfortunate because we need to retain the staff. Our focus has to be on supporting the team, making sure that we maximise the potential, and also recruiting to those vacant positions.

I acknowledged the difficulties. I think the whole team, to be fair, acknowledges them. It has been a difficult time for the team. Nobody wants to see a protest outside the office in which they are working. We have a deeply committed group of staff who are doing their best. We need to work with them to ensure we support them in that. I fully accept the frustration and anger of the families. I will not dismiss that for a second. I know about it because those same complaints and frustrations come in to my office. Our intention with the family forum is to work together with families to try to resolve those issues. We intend to do that. I accept that on occasions we have fallen short of the engagement and communication that we should have with families. We intend to rectify that because some of that will help us all to work together and come up with a better product for families.

Deputy Seán Canney

I thank Mr. Fitzmaurice. I do not for one minute question the staff. I worry about them. The issue of whole-time equivalents needs to be addressed. I can send on the two different spreadsheets that I have to try to get to a position where parents know what is supposed to be coming, what they have and what is missing, so that they can understand things. I accept that the witnesses are trying to do their best but, at the end of the day, whatever we are doing, we are not doing the service right for the parents and especially for the children. As Mr. Fitzmaurice said, it is a new building. It had been vacant for 20 years. Much money has been spent on it. It is a credit to everybody but the problem is that, to make the service functional, there is a hell of a lot of work to do in a short time to try to restore confidence to the parents.

Deputy Violet-Anne Wynne

I thank the witnesses. I listened to their opening statements at the beginning. I noted something very interesting. They gave a statistic about those found not to have a disability. They might expand on that. I think they said it was 36%. There is also the 8% year-on-year increase in demand in the mid-west region.

I wanted to raise respite services in Clare specifically. I know there is a good bit of work being done to locate additional space and capacity. At a recent UL Hospitals Group briefing, we were told there was possibly a need for four additional respite homes. I wanted to see if that is being planned or if it is something the witnesses are working on. A number of people who are in need of respite are facing difficult situations and end up in the emergency department, which is not ideal for them either.

I got a parliamentary question response about assessments of needs, which outlined the number of children on the waiting list. It specified that progress was made, even with those who were waiting. It was noted that initial contact was made with that child in particular. I wanted to ask about the process of how that is decided. I noticed at the beginning that there were two children who have been waiting for 457 days. There was nothing about initial contact or anything like that with those two. When I skipped down, there were children who had been waiting for only 15 or 20 days and had received initial contact. Is work needed on how initial contacts are decided or delivered?

A few parents have contacted me to say they got the initial contact but two years have gone by and they have not received any further assessment. It can make things tricky, especially for those who absolutely cannot get a loan for private assessments. That is just not an option for them. They are feeling very hopeless in that situation and cannot actually do anything about it. I know the Minister said she was hoping to secure additional funding to be able to do that. I know there is the matter of regulating the private sector, including psychiatrists and so on. It would be great if the witnesses had anything to mention on that.

I note that there were 120 additional posts for speech and language provision. Do the witnesses know if any of that was delivered for CHO 3? I would be interested in that. That is pretty much it.

Mr. Bernard O'Regan

In response to the Deputy's specific question about the posts in CHO 3, I do not have that information. I will try to get it if we can. We are updating our census and will have a report on that in the next few weeks. That may be the best way that I can at least provide part of an answer to the question the Deputy raises.

Regarding the issue of the no disability data, when an assessment application comes in, the first thing the assessment officer has to do is make a judgment about whether certain criteria are met for whether the child may have a disability or not and if the criteria meet the threshold for the assessment. The assessment is then done. The data I included in the opening statement was based on 2023. I can tell the Deputy how much time was put into that number of more than 800. It highlighted that a significant number of children are part of the assessment of need process who subsequently turn out not to have a disability. That is a good thing. I hope that outcome is reassuring for families and helps them to have a different direction for them and their child. On the other hand, we are using a cumbersome, time-consuming process to get to that outcome. We need to look to see if there is another way of doing that which is better for the child and is also a more effective use of the scarce resources available to us.

We have funding this year of €15 million to commence additional respite services. That will grow to a full-year budget of €25 million. It recognises that some services will only start part-way through this year but they will have access to the full funding of €25 million the following year.

We are finalising the allocations to the CHOs and we will be asking each area to come back to us indicating what its priorities are. Every area will have a portion of the budget and each area will be asked to prioritise in its area. They will not have enough to meet all of the need but it is an essential increase on what was available in previous years.

We have to acknowledge, certainly in each of the years I have been in this role, that we have added to the respite budget. We are building capacity. There are delays sometimes in implementation, which is a frustration for everybody. Sometimes the length of time it takes to buy a house, renovate it and get it registered with HIQA takes too long. We are in a market where this is a challenge and we are trying to manage it as best we can. We will see growth in respite services this year, building on previous years. There are commitments in the disability action plan to further grow respite services. Each area will have the opportunity to develop on this.

In terms of initial contact, Ms Bourke has been leading out on some work with colleagues on guidance on this and I will ask her to comment on it.

Ms Ann Bourke

To clarify, there are two elements. One of the metrics we have been gathering from teams manually for quite some time is on initial contact. When a child and-or family receives initial contact they become an open case for the team from that point onwards. Again, this data is fresh and not yet validated but the figures are that 14,200 children are awaiting initial contact. This is against the active caseload of 42,000. A number of children who did not need services have been discharged and this figure for the past month is 650. There are 822 children who are new to the services, or returning to them having been in previously, had their needs taken care of and were discharged.

With regard to initial contact, we have a national prioritisation policy which has been in place for several years. It is going under review at present with a multi-stakeholder group including, importantly, front-line staff members. Initial contact is based on need. We do not have enough staff or staff hours. Mr. O'Regan mentioned that 849 assessments of need were completed for children who did not have a disability. On a quick calculation, and forgive me for my maths, that amounts to 29,000 hours of clinical time lost for children's interventions, which is significant.

It is a constant balancing act for the children's disability network manager and the individual disciplines when they have a child with an identified need for speech and language therapy, physiotherapy or occupational therapy. They have to prioritise their available time based on the children's needs. This is where some children may be perceived to jump above other children. It is based on greater need.

Deputy Ruairí Ó Murchú

Throughout the Houses this week, there have been multiple mentions of CDNTs. I will speak about the particular case of a 12-year-old and his diagnosis of autism. There is no need to worry; I will not name anyone. Over the years, his presentation has changed. There have been difficulties as he has got bigger as there are elements of violence. How could the parents not be in some element of crisis? I will not get into the full issue but the family has been to private psychologists, paediatricians and whatever else. The boy has also presented with ADHD multiple times. The family have gone back to the CDNT but are not getting any hope there. They are looking to get referred to CAMHS. They are not looking for a referral for anything other than an assessment but they are not getting anywhere.

I am always slow to call out anybody who has far more medical experience than I have. I accept a great amount good work is being done by those who work in primary care and CDNTs. I will speak to the witnesses later on the specific issue I have raised. There needs to be some means of providing the family with a solution. They are looking for an assessment and then a strategy to deal with it. There are always multiple other issues. There is an issue with people being forced to get assessments privately which are then not always accepted. It is farcical that these private assessments are sometimes done by people who previously worked in CDNTs or the HSE. What do I do with the particular case I mentioned? What does the family do? What do others who find themselves in this set of circumstances do?

Mr. Bernard O'Regan

Unfortunately, that is the reality. Deputy Ó Murchú has given an example of one case but we know there are multiple children and families this situation. This reflects the challenge we are trying to address through the roadmap to improve staffing and services so the experience for these children, this child and this family is improved.

That is it. To refer again to the child with ADHD, his parents are looking for some sort of strategy.

Adaptation grants fall directly within the remit of local councils. We sometimes interact with parents whose children, as they get older, become more difficult to deal with logistically. In those cases, an adaptation grant of €30,000 or maybe €6,000 will not cut the mustard as regards what needs to be done. The grant is being reviewed across the board. Has the HSE had any engagement on that? I have always had the view that the HSE needs a separate funding scheme to deal with these particular children who should not be in the same group as those who get older and need stair lifts, shower units and so on.

Mr. Bernard O'Regan

I have not had any direct involvement with the adaptation grants. I do not know if anyone else has had direct involvement with them. They are administered through the local authorities.

Dr. Rosie Gowran

I have not had any direct involvement with them but we are looking at housing and access to adaptation and accessible housing in relation to the rehabilitation sector to ensure that people have appropriate access. There are grant systems and schemes that are not necessarily adequate. When we are thinking about planning for children across the life course and ensuring they have what they need as they grow and develop, we need to put a system in place for that. It is something we are looking at. It is about the cross-departmental discussion to ensure that we are meeting people's needs across the life course and taking a whole-systems approach. It is something that is on our radar and we are definitely looking at it.

Mr. Bernard O'Regan

I will check with colleagues, particularly on the primary care side, who are involved in the whole area of aids and appliances and adaptations. There may have been some HSE involvement from that side but just not with us. I will check and come back to the Deputy.

An Cathaoirleach

Deputy Dillon is next. I think we may be out of danger as regards votes

Deputy Alan Dillon

I thank the Cathaoirleach for accommodating me and members for allowing me to contribute. I am a member of the Joint Committee on Children, Equality, Disability, Integration and Youth, with which the HSE has engaged extensively. I know Mr. Fitzmaurice and Mr. O'Regan from their days in CHO 2. It is good to have them back.

My questions are focused on autism. We have all seen a rise in the rates of autism in our own areas. When it comes to the HSE's method for accurately determining the prevalence rate, why has a national model or method not been agreed? The Department of Health issued a report in 2018, over five years ago, on the increasing prevalence of ASD in the Irish population. It stressed the importance of a national prevalence rate but to date the HSE has failed to have a register of persons with ASD. Why has a register not been implemented yet? We need such a register to implement proper planning of resources and services, whether in social services, education or health, but we have nothing to go on. I am very concerned. In other areas such as diabetes and cancer, there are registers and adequate resourcing and funding focused on where they need to be targeted. I would like an honest explanation for that.

Mr. Bernard O'Regan

On the database, the direction currently in place is to use the NASS. I can never remember what the acronym stands for-----

Ms Ann Bourke

It is the national ability supports system.

Mr. Bernard O'Regan

On the family forums, there is a need to engage with families collectively and to provide families with a support base or forum. Judging by the feedback I have had, these could be developed like focus groups, with themes and questions given out to participants. A format is needed for these and in large counties like Cork, for example, they would need to be fairly central. The point was made by Senator McGreehan that families are exhausted and the last thing they want to do is get involved in a family forum but there is a need for it. There is also a need for it to work so that people get something out of it. Sometimes rather than asking questions, a general talk or discussion can be better and can provide better feedback.

On recruitment and retention, it is fair to say that most of us, on most days, go into our jobs and feel a certain level of satisfaction having done some good. Some days we might be banging our heads on the table. I asked the team in my office in Kanturk one day if banging my head off the table would work. We all have those days but those who work with people with disabilities are providing one of the greatest services to the State. However, some of the people working in certain disability units do not seem to be getting job satisfaction. Is that because of frustration or complaints? There needs to be real engagement between the HSE with the staff to figure out where the challenges lie. As someone said to me once, if everyone did his or her job, we would have a great country. We need to find out what the staff think. If staff are dealing with children with different levels of disability and are dealing with same issues in an occupational therapy session with a ten-year-old as with a four-year-old, that is disheartening. I am sure people working in the sector are utterly frustrated. Can the HSE find out what are the frustrations for staff? How can we make it better? There was a protest in Tuam recently. Nobody wants to see a protest but there is a level of frustration among families, employees and also among HSE managers, all of whom want to better the services.

Members mentioned adaptation grants. We need to move that process on and get that grant scheme changed to take account of people with sensory difficulties, for example. Questions have been asked about the privatisation of services. The HSE is buying services from the private sector but forward planning is essential. We had a great service up to 20 years ago because we had a smaller population and services had been developed by charitable bodies, including section 39 organisations. Our population has grown by 17% or 18% and so has the level of need. We are going to have that higher level of need into the coming decades and we must try to build up capacity. A lot of people would say that the State, through the HSE, should do it but the only place where there is capacity to do it is in the section 39 organisations.

The HSE is trying to put a plan in place but in terms of recruitment, we must seek out ways to ensure that everybody who is taken on gets job satisfaction, whether they are engaging with young people or adults. They are doing good but we must find out the source of any frustration. When the HSE goes to the Departments of Children, Equality, Disability, Integration and Youth and Public Expenditure, NDP Delivery and Reform in the next round of negotiations, it must stress the fact that serious resources are needed. It is not just a question of a percentage increase here or there under certain headings; there is a serious need for more money. We know that a serious amount of extra money has been invested in the past three or four years but we will need nearly as much again. That will go a long way towards solving the problems.

I have summed up most of what was said this evening. There is an awful lot of anxiety and frustration among the parents of young children regarding the services they are getting. Some are borrowing money to pay for occupational therapy at €60 or €70 per week. They are doing everything they can. In one case that I am dealing with, a mortgage is not being paid as the parents try to fund services for a family member. The other issue is the assessments of need. The HSE is buying in assessment of need services but that is only the first step. There is a lot of work to do and I know that the HSE is engaging very hard on it.

Do any of the witnesses wish to comment on my observations?

Mr. Bernard O'Regan

I would like to acknowledge the points made. The Cathaoirleach summed up our discussion well. Members of the committee, throughout this evening and at previous meetings, have been reflecting the experience of the parents who are coming to their door and telling them about their experience of the services. He is correct that nobody in the public service comes to work other than to do the job he or she wants to do. When we talk to staff we hear them say that the greatest job satisfaction they get is from the work that they do with the child and the family, where they can see that they are making some contribution to that child's development, opportunities and potential. The things that they find the most challenging are the fact that they are not able to meet the needs of the children and families they come in contact with and that they are constantly trying to decide whether to help this child or that child. These are the real decisions they are having to make. Sometimes the physical environment in which they are working is not great, they cannot get access to something they need, or there is no budget available for some of the stuff they need to do. These are the issues that make work really hard and that take away from any sense of job satisfaction that they might have. I appreciate that the Cathaoirleach said the frustration is for everybody. Nobody wants to be at this committee explaining or trying to set out what we are doing to address the scale of the problem we have. We would much prefer to be here talking about the success of it and hopefully, some day, we will get to that point. The roadmap offers a pathway for us to improve things. It will not happen overnight but the roadmap provides a structured way for us to improve things over the next number of years and in a way that is accountable, reportable and transparent. In that way, parents and families will be able to see that there is some light at the end of the tunnel.

An Cathaoirleach

Thank you very much to our guests. It was a long evening and I thank them for their engagement. I also thank members for their attendance, as well as the non-members who attend our meetings quite regularly and who are very welcome. I also thank the committee secretariat, who do an excellent job. Again, I thank all of our guests for their ongoing work. I have no doubt we will be in touch with them again in the future.

The joint committee adjourned at 8.49 p.m. until 5.30 p.m. on Wednesday, 20 March 2024.

Joint Committee on Disability Matters díospóireacht - Wednesday, 6 Mar 2024

Progressing Disability Services: Discussion (Resumed)

Mr. Bernard O'Regan

Mr. Bernard O'Regan

Ms Ann Bourke

Mr. Bernard O'Regan

Mr. Bernard O'Regan

Mr. John Fitzmaurice

Mr. Bernard O'Regan

Dr. Rosie Gowran

Mr. Bernard O'Regan

Mr. Bernard O'Regan

Mr. Bernard O'Regan

Mr. Bernard O'Regan

Mr. Bernard O'Regan

Mr. Bernard O'Regan

Mr. Bernard O'Regan

Mr. John Fitzmaurice

Dr. Rosie Gowran

Ms Ann Bourke

Mr. Bernard O'Regan

Mr. Bernard O'Regan

Ms Ann Bourke

Mr. Bernard O'Regan

Ms Ann Bourke

Ms Ann Bourke

Ms Ann Bourke

Mr. Bernard O'Regan

Ms Ann Bourke

Mr. Bernard O'Regan

Mr. Bernard O'Regan

Mr. Bernard O'Regan

Mr. Bernard O'Regan

Ms Ann Bourke

Ms Ann Bourke

Mr. John Fitzmaurice

Mr. John Fitzmaurice

Mr. Bernard O'Regan

Mr. Bernard O'Regan

Mr. John Fitzmaurice

Mr. Bernard O'Regan

Ms Ann Bourke

Mr. Bernard O'Regan

Mr. Bernard O'Regan

Mr. Bernard O'Regan

Mr. Bernard O'Regan

Mr. Bernard O'Regan

Mr. Bernard O'Regan

Mr. Bernard O'Regan

Dr. Rosie Gowran

Mr. Bernard O'Regan

Mr. Bernard O'Regan

Ms Ann Bourke

Mr. Bernard O'Regan

Mr. Bernard O'Regan

Mr. Bernard O'Regan

Mr. Bernard O'Regan

Mr. Bernard O'Regan

Mr. Bernard O'Regan

Mr. Bernard O'Regan

Mr. Bernard O'Regan

Mr. Bernard O'Regan

Mr. Bernard O'Regan

Mr. Bernard O'Regan

Mr. Bernard O'Regan

Mr. Bernard O'Regan

Mr. Bernard O'Regan

Mr. Bernard O'Regan

Mr. Bernard O'Regan

Mr. Bernard O'Regan

Joint Committee on Disability Matters díospóireacht -
Wednesday, 6 Mar 2024