Questions Received from Joint Committee on Health

Meeting 9th May 2018

Deputy Margaret Murphy O’Mahony

Q1. What strategies do the HSE South West Group have in place to deal with the

chronic staffing shortages across key disciplines i.e. consultants, doctors, nurses,

healthcare professionals at University hospital Kerry?

The South/South West Hospital Group (S/SWHG) is working in partnership with University

Hospital Kerry (UHK) to address staffing shortages at the hospital via local, national and

international avenues.

For Nursing and Midwifery specifically, this includes utilising the services of the

International Recruitment Agency appointed under the HSE National Framework. For UHK

we are actively recruiting through local advertising which is proving successful in attracting

nursing staff, national advertising and national job fairs. S/SWHG participated in a health

sector jobs fair specifically targeted at nursing and midwifery candidates in Dublin in March

2018 and Senior Management UHK, participated as part of a group representation on the day.

UHK is an approved site for training of nursing students and will be offering all of the

Hospital’s graduates permanent contracts following successful completion of the nursing

degree programme.

For Consultants we are working with the Consultant Appointments Advisory Committee

(CAAC) and the Public Appointment Service (PAS) for the approval, recruitment and

advertising of all new and replacement Consultant Posts. The S/SWHG are reviewing the

potential to promote recruitment in specialities which to date have failed to attract candidates.

This will include advertisements in Medical Publications and Social Media as part of a

targeted recruitment drive to include UHK. Approval has also been received to fill Training

Lead positions across the S/SWHG at Consultant level which will support this initiative.

For all other staff groups, we continue to run campaigns with the recruitment body of the

HSE Health Business Services (HBS). Campaigns are updated to reflect additional

opportunities unique to the hospital, including any opportunity for training and further

development. Social Media is also fully utilised to communicate such opportunities.

The S/SWHG acknowledge that there are challenges in recruitment however the Group and

the Hospital are actively continuing to recruit for suitably qualified staff from all available

avenues to ensure that staffing levels are safe and reflect patient centred care.

Senator Colm Burke

Q4. The need for the Minister for health and the HSE to outline what work has been carried

out in respect of progressing the plan for a new hospital for Cork.

(a) Has a working group been established to help identify a suitable site

(b) Has any discussion taken place with the voluntary hospitals in Cork on this project

(c) What target date has been set for identifying the site and proceeding to design stage

On 24th October 2017, the Chair and the Chief Operations Officer of the South/South West

Hospital Group wrote to me as Minister for Health, attaching a copy of a Business Case for

an Elective Hospital for the South/South West Hospital Group.

The Government's new National Development Plan includes a new acute hospital for Cork

among its proposals. Further planning to progress investment in this new facility will now

be undertaken, including full evaluation of local capacity and infrastructural needs and a

framework for decision-making on the optimal location from a clinical and population

needs perspective. The National Development Plan also identifies Cork as being a suitable

location for a new ambulatory elective-only centre. It is envisaged that both consideration

of the question of a new hospital and an ambulatory elective only facility will be addressed

in conjunction with each other.

It is important to recognise that the National Development Plan is a long-term plan which

provides for a large number of health developments across the country, including both

national programmes and individual projects, across acute, primary and social care. We

must ensure that we carefully plan the use of this capital funding so as to meet the

population needs and achieve value for money. Health capital projects and programmes

currently underway will continue. As is to be expected with a ten year plan, many

proposals, including the new hospital in Cork, are at an early stage and will require to

progress through appraisal, planning, design and tender before a firm location, timeline or

funding required can be established.

Q5. The need for the Minister for Health and the HSE

(a) To set out in detail the number of hospital beds which were taken out of use since the 1st

of January 2010 and the location of the hospitals where this occurred

(b) The number of beds that have come back into use since the 1st of January 2016 and the

hospitals where this occurred

(c) The number of beds which are not in use but which could be brought into use if facilities

were brought up to the required standard and the hospitals where this increased bed

capacity could be made available

Given the detailed information required to answer this question it was not possible to

have it available for today’s meeting. It is being collated and we will get it to the

Committee as soon as possible.

Deputy Louise O’Reilly Q8. To ask the Minister for Health what is the current status of the proposal for a modular cath

lab for University Hospital Waterford?

Following an independent review of the need for a second cath lab in University Hospital

Waterford (UHW), the Herity report concluded that the needs of the effective catchment

population for Waterford University Hospital could be accommodated within a single cath

lab. Funding has been provided to support extension of the existing cath lab operating hours

to 12 weekly sessions per week, or by 20%, as recommended in the Herity Report.

Initial recruitment efforts were made in 2017 to recruit posts including a senior cardiac

physiologist, radiographer and staff nurse, to support extension of the hours of the existing

cath lab. However, these initial efforts were unsuccessful and the fact that posts were part-

time was identified as one of the challenges. A renewed recruitment effort is now ongoing,

with posts now structured as whole-time with the aim of ensuring they are attractive to

candidates with suitable skills and experience. It is hoped that these posts will be in place in

the near future.

In the interim, a mobile cath lab service has been provided. The mobile cath lab was initially

deployed in October 2017 and will stay in place for a further number of weeks to allow time

for UHW to complete recruitment of the additional staff required for the service extension to

the existing cath lab.

A modular cath lab has also been proposed, as an interim solution pending the outcome of the

National Review of Specialist Cardiac Services, and the Department of Health is currently

examining this proposal at my request.

Q9. To ask the Minister for Health how long will the public consultation take with regard to the

National Review of Specialist Cardiac Services?

It is expected that the public consultation will begin in June 2018 and will remain open for

two months. The public consultation will be carried out via a web-based survey. Analysis of

the submissions to the public consultation will be one of the main elements informing the

final report of the National Review.

Further detail, including the precise dates, will be publicised closer to the time.

Q10. To ask the Minister for Health how long the National Review of Specialist Cardiac

Services is expected to take?

When the Steering Group of the Review had its first meeting on 31 January 2018, the Chair

anticipated that it would take approximately 18 months to produce a comprehensive and

robust final report. However, all efforts will be made to conclude the Review at an earlier

date if feasible. While the Review is still in its early stages, it should be noted that the key

targets in the anticipated timeline are currently being met.

Q11. To ask the Minister for Health for a breakdown of the reported 650 doctors operating as

consultants but who are not on the specialist register operating in private and public

hospitals be provided?

1. Context

In March 2008, the HSE amended the qualifications specified for consultant posts to require

registration in the relevant specialist division of the Register of Medical Practitioners at the

Medical Council. The Consultants’ Contract 2008 reflects this requirement, the details of

which were contained in HSE HR Circular 021/2017 re: Qualifications required for

consultant posts.

The effect of this is that applicants who are not registered in the relevant specialist division

cannot be appointed to a permanent consultant post in a HSE hospital or service or in a

Section 38 agency funded by the HSE.

The rationale for the change was the imperative to ensure that consultants employed in the

public health system have the appropriate training, skills, competences and qualifications to

deliver care as assessed by the Medical Council which has the statutory role of protecting

the public by promoting the highest professional standards amongst doctors practicing in

the State.

2. Current position

It remains the case that there are number of consultants employed who are not registered

in the relevant specialist division. As at 14 April, this number stood at 127 out of a

consultant workforce of 2977 wte or 4.3% of the workforce. This number can be broken

down into two main cohorts as follows:

2.1. Consultant employed pre-2008

There are 52 consultants in permanent employment who took up post before the

introduction in 2008 of the contractual requirement to be registered in the relevant specialist

division. This represents 1.7% of the consultant workforce. Of this number, 49 are

employed in acute hospitals, one in the IBTS and two in mental health services.

2.2. Consultant employed post-2008

There are 75 consultants in employment currently employed who took up post since the

introduction in 2008 of the contractual requirement to be registered in the relevant specialist

division. They represent 2.5% of the consultant workforce. By definition, these cannot

be in permanent employment, and are instead on a short-term specific purpose contract

(SPC) basis or on a short-term locum basis or are engaged through an agency. SPCs are used

to fill permanent vacancies pending the filling of a new or replacement consultant post on a

permanent basis after the necessary approval from the HSE’s Consultants Appointments

Advisory Committee.

The selection process at the Public Appointments Service for HSE posts or within the

Section 38 agency, and the post-recruitment formalities of reference-checking, Garda

vetting, and pre-employment occupational health status assessment. Short-term locums are

either employed directly by the HSE or Section 38 agency or are engaged through an agency

in instances where cover is required for the annual leave of permanent consultants or for

other temporary absences.

It can often be the case that appropriately qualified consultants registered in the relevant

specialist division do not present as applicants for short-term locum posts or for SPC posts

pending the filling of a new or replacement permanent post. Service requirements have

therefore led to the engagement of the consultants in this category. Fourteen consultants

registered in the general division have been engaged on a non-permanent basis with the

last 12 months.

3. Breakdown by Hospital Group and CHO

Breakdown by Hospital Group and CHO

consultants in

general division at 17

April 2018

consultant complement at

Feb 2018

consultants in general division as

%age of total

CHO 1 5 34 14.7%

CHO 2 5 40 12.5%

CHO 3 0 27 0%

CHO 4 1 51 2.0%

CHO 5 5 30 16.7%

CHO 6 0 51 0%

CHO 7 1 56 1.8%

CHO 8 9 42 21.4%

CHO 9 0 68 0%

CHO total 26 399 6.5%

Children's Hospital Group

3

177

1.7%

RCSI HG 10 408 2.5%

Saolta 23 406 5.7%

South South West HG 33 451 7.3%

Ireland East HG 9 496 1.8%

Dublin Midlands HG 16 429 3.7%

UL HG 6 154 3.9%

Hospital Groups total

100

2521

4.0%

IBTS 1

Grand total 127 2920 4.3%

NB total consultant complement of 2977 wte includes consultants in Health & Wellbeing

4. Measures to address the issue

4.1. Risk mitigation measures

The National Clinical Adviser and Clinical Programme Group Lead for Mental Health has

sought and received assurances from the Executive Clinical Directors in mental health

services of risk mitigation measures to include oversight of the practice of post-2008

consultants not in the specialist division. Similarly, within acute services, hospital managers

and clinical directors have put in place monitoring arrangements appropriate to the

circumstances of the practice of post-2008 consultants not in the relevant specialist division.

4.2. Incentivising eligible pre-2008 consultants to apply for specialist registration

The acute services division and the mental health services division are working to establish

which of pre-2008 consultants would be eligible for registration in the relevant specialist

division on the basis of their having completed higher specialist training. As a once-off

measure, the HSE will fund the Medical Council directly for the cost of the application

process such that the consultant will not incur any personal expenditure.

4.3. Up-skilling post-2008 consultants who have not completed higher specialist

training

Colleagues in mental health are engaging with the Royal College of Psychiatrists to explore

additional competence-based training for consultants to allow them to apply for specialist

registration. This approach will be a more complex issue in acute services, given the

greater numbers of consultants involved, the greater number of specialties, the procedure-

based nature of training in some of those specialties, and the greater number of training

bodies (Royal Colleges etc).

4.4. Minimising the timeline for filling new or replacement permanent consultant

posts

Clinical Directors in mental health services and acute services are seeking to clarify the

position with each post-2008 consultant post currently filled, by definition, on a non-

permanent basis in order to establish where the post is on the continuum from approval at

the CAAC for a new or replacement post, to advertisement, to short-listing and interviewing

at the Public Appointments Service, to post-selection formalities undertaken by HBS Recruit

prior to the offer of a contract. The aim is to identify any impediments at any stage of this

process with a view to elimination of these or otherwise to minimise the impact on the

timeline for filling new or replacement permanent consultant posts.

The hospital groups’ HR leads will work with the HSE National Doctors Training and

Planning’s Doctors Integrated Management E-System (DIME) to access real-time data

contained within DIME to allow full compliance with consultant specialist registration

requirements, and to ensure in the interim 100% compliance with the matching of approved

posts on DIME to all occupied posts in the hospitals.

Q13. To ask the Minister for Health his views on waiting lists for children with scoliosis needing

surgery; if new targets will be forthcoming for 2018; and if he will make a statement on the

matter.

The target waiting time in 2018 for children requiring surgery for scoliosis is 4 months from

the date of listing and where the patient is clinically indicated as requiring surgery. It is

recognised that the decision to schedule for surgery is a clinical decision and must have

regard for the patient’s age, condition and any other clinical factors that may be relevant.

Surgery can be postponed at the request of parents in order to work around family schedules

and exams. Patients will only be listed for surgery when they are considered to require the

surgery and this is clinically appropriate in all the circumstances.

The focus for 2018 is on continuing to reduce the backlog for children and young people

awaiting scoliosis surgery and ensuring that patients in the future who require surgery receive

it in a timely manner.

The number of children currently awaiting scoliosis surgery is 141.

70 of whom are waiting 0-4 months

51 of whom are waiting 4-12 months

20 waiting over 1 year

The patients waiting over 1 year have been offered the option of treatment abroad but have

declined this offer so far.

Significant progress has been achieved in relation to the Scoliosis waiting list since 2016.

Increased investment has provided additional theatre capacity at Our Lady’s Childrens

Hospital Crumlin, Cappagh National Orthopaedic Hospital and the Mater Misericordiae

University Hospital. Surgery has also been offered to patients at overseas centres such as

Stanmore and Portland Hospitals in the UK and at St Franziskus Hospital in Germany.

The plan for the year ahead in partnership with the clinicians and all other stakeholders is to

drive further progress in reducing waiting times by developing a long term sustainable and

safe paediatric model of care for paediatric orthopaedic services which will ensure that

clinical criteria will determine the timeframe for the delivery of care.

The expectation is that the waiting time target of four months for 2018 will be achieved by

year end.

Q16. To ask the Minister for Health how access to abortion services will work and the rollout

plan if the 8th

Amendment is repealed?

The provisions of the General Scheme of a Bill to Regulate Termination of Pregnancy,

published on 28 March on the Department of Health's website, are based on the

recommendations of the Joint Committee on the Eighth Amendment of the Constitution and

also include consideration of a number of additional issues which were not addressed in the

report of the Joint Committee but which are provided for in the Protection of Life During

Pregnancy Act 2013.

The Government could only seek to introduce legislation to regulate termination of

pregnancy if the Referendum on Article 40.3.3, scheduled to take place on 25 May 2018, is

passed by the people.

It would be premature for the Department of Health to undertake a detailed examination of

issues, such as those raised in the question, in advance of the Referendum. In the event that

the Referendum is passed by the people, the Department of Health would, in considering any

new legislation on the area, meet with all key stakeholders on the details of the legislative

proposals and possible service implications.

Q17. To ask the Minister for Health for a breakdown of inpatient/day case treatments provided

in private hospitals under the newly announced inpatient/day case action plan compared to the

same treatments provided in public hospitals; and if he will elaborate on the cost benefit

analysis and make a statement on the value for money of the action plan?

Inpatient Day case Action Plan 2018

Reducing waiting time for patients for hospital operations and procedures is a key priority for

the Government. In 2017, through the work of the NTPF and the HSE, the annual increase in

the overall number of patients waiting for a hospital procedure was halted.

The Inpatient/Day Case Action Plan 2018 is a joint initiative between the HSE, the NTPF and

the Department of Health. Under the Plan, the HSE will, in this year, deliver approximately

1.14 million hospital operations or procedures and the NTPF will deliver 20,000 Inpatient

Day Case treatments and 4,000 Gastro Intestinal Scopes.

The NTPF will provide the majority of the 20,000 procedures through outsourcing. This

involves commissioning treatment in private hospitals through tender following procurement

processes through e-tender. It is important to note that HSE insourcing, which supports the

public system, is also an important element of the waiting list action plan. Based on

experience in 2017, it is projected that insourcing arrangements could account for 4,000 of

the 20,000 treatments.

The overall number of patients waiting for an inpatient or day case procedure is projected to

fall to below 70,000 by year end, from a peak of 86,100 in July 2017.

Breakdown of inpatient/day case treatments provided by the NTPF:

In the Action Plan, the NTPF commits to offer treatment to all clinically suitable patients

waiting more than 9 months for treatment in a number of high volume specialities - including

cataract, hip and knee replacement, tonsils and scopes. The following sets out a breakdown of

this activity between the HSE and NTPF:

Procedure NTPF Activity

(both outsourcing and

HSE insourcing)

Cataracts 5,000

Hips/Knees Replacements 800

Tonsillectomies 1,200

Varicose Veins 1,650

Angiograms 650

Cystoscopies 2,500

Lesions 2,000

Other Treatments 6,200

TOTAL 20,000

*Case Authorisation Number – The NTPF issues a CAN for each patient identified to the hospital on whose list the patient is

waiting specifying the patient, the procedure and the proposed treating Hospital.

Breakdown of inpatient/day case treatments provided by the HSE:

The HSE inpatient/day case activity in 2018 is in line with their commitment in the National

Service Plan (NSP) will deliver approximately 1.14 million elective inpatient and day case

discharges in 2018.

The HSE advise that the National Service Plan NSP 2018 provides for a volume of activity

and a casemix value in line with 2017 activity. It does not commit to the volume of activity

by specialty or procedure. However, Table 1 (overleaf) provides a breakdown of 2017

inpatient and day case activity by the HSE. The HSE advise that this provides an indication

of anticipated activity levels by specialty for 2018. In addition, Table 2 (overleaf) provides an

overview of HSE IPDC Activity by Specialty from the Waiting List for year to date to April

2018.

Role of the NTPF

The waiting list initiatives set out in the Action Plan strikes the appropriate balance between

maximising the number of patients treated in both public and private capacity, as appropriate,

and ensuring the best return for the taxpayer.

This approach will support HSE activity and performance management, with additionality

provided by the NTPF.

As outlined, during 2017, 2,000 patients were removed from the Active IPDC waiting list

having accepted an offer of insourcing treatment from the NTPF. It is proposed to double the

number of patients removed from the list through insourcing in 2018.

Based on experience in 2017, it is projected that insourcing arrangements could account for

4,000 of the 20,000 treatments and €7m of the €47m expenditure.

More broadly, the NTPF has a number of insourcing arrangements in place. For example:

• Cataract surgery in the Royal Victoria Eye and Ear Hospital

• Cystoscopies in Nenagh General Hospital

• Lesions in Roscommon General Hospital

• Orthopaedic Surgery in Cappagh National Orthopaedic Hospital

It is expected that NTPF and HSE will continue to engage to identify further potential

insourcing to be put in place over the course of the year, with a particular focus on long

waiters and complex cases.

Strengthened governance by Department with HSE and NTPF

The Government has placed particular priority on performance improvement in unscheduled

and scheduled care in order to improve access for patients. Progress against the targets of the

Action Plan will be reported upon by the NTPF and HSE throughout the year.

Table 1: 2017 All Elective HIPE discharges from NQAIS

Specialty Total Specialty Total

Nephrology 174,469 Paediatric gastro entero 1,652

General surgery 117,160 Paediatric respiratory

med 1,600

Radiotherapy 116,388 Paediatric cardiology 1,257

Oncology 107,013 Paediatric nephrology 1,222

Gastroenterology 62,417 Hepato biliary surgery 948

Haematology 61,473 Paediatric orthopaedic

surg 728

Opthalmology 56,836 Obstetrics 620

General medicine 50,509 Neuroradiology 541

Orthopaedics 46,007 Paediatric neurology 467

Dermatology 44,323 Oral surgery 417

Urology 38,405 Paediatric

endocrinology 367

Gynaecology 36,906 Paediatric radiology 302

Otolaryngology 30,808 Paediatric ENT 270

Plastic surgery 23,931 Neonatology 235

Cardiology 21,526 Accident & emergency 196

Respiratory medicine 16,899 Immunology 184

Pain relief 14,606 Paediatric metabolic

med 181

Rheumatology 12,267 Metabolic medicine 158

Radiology 11,697 Paediatric infectious dis 149

Neurology 11,565 Paediatric neurosurgery 144

Paediatrics 11,095 Renal Transplantation 112

Gastro intestinal surger 7,983 Paediatric Urology 109

Vascular surgery 7,654 Substance abuse 102

Paediatric haematology 6,662 Psychiatry

Total of 238 patients

(total is rounded as some

treatments involve small

numbers of patients)

Geriatric medicine 5,549 Palliative medicine

Maxillo-facial 4,467 Diabetes mellitus

Dental surgery 3,843 Paediatric dermatology

Anaesthetics 3,826 Paediatrics

development

Genito urinary medicine 3,282 Histopathology

Infectious diseases 3,213 Paediatric A/E medicine

Clinical neurophysiology 3,086 Clinical (medical) genet

Cardio thoracic surgery 2,813 Nuclear medicine

Paediatric oncology 2,719

Endocrinology 2,535 Total 1,147,259

Breast surgery 2,478

Obstetrics/gynaecology 2,410

Paediatric surgery 2,194

Clinical Immunology 2,041

Neurosurgery 2,005

Table 2: HSE IPDC Activity by Specialty from Waiting List Year to date - April 2018

Specialty Total Specialty Total

General Surgery 18,506 Oral Surgery 660

Orthopaedics 11,565 Neurosurgery 632

Ophthalmology 11,055 Paediatrics 495

Urology 10,420 Rheumatology 375

Gastro-Enterology 8,123 Cardio-Thoracic Surgery 340

Otolaryngology (ENT) 6,505 Paed Gastro-Enterology 312

Plastic Surgery 4,885 Neurology 290

Gynaecology 4,278 Anaesthetics 286

Pain Relief 4,173 Dental Surgery 275

Cardiology 4,133 Paed Cardiology 229

Vascular Surgery 3,046 Clinical Immunology 214

General Medicine 2,729 Paediatric Respiratory Medicine

204

Respiratory Medicine 1,109 Immunology 166

Maxillo-Facial 1,100 Hepato-Biliary Surgery 159

Gastro-Intestinal Surgery

827 Paediatric ENT 152

Dermatology 671 Geriatric Medicine 108

Other Specialties including: Paediatrics Haemotology Breast Surgery

Total of 343 patients (total is rounded as some treatments involve small numbers of patients)

TOTAL 98,373

Table 1: Breakdown of inpatient/day case treatments provided by the HSE: National

Expected Activity/ Target 2017

National Projected Outturn 2017

Children’s University Hospital Temple Street

National Children’s Hospital at Tallaght Hospital

Our Lady’s Children’s Hospital Crumlin

CHG Expected Activity/ Target 2018

National Expected Activity/ Target 2018

Daycase Cases (includes dialysis)

1,062,363 1,049,851 7,648 2,169 18,220 28,037 1,056,880

Elective Inpatient Discharges

94,587 92,172 1,975 619 3,455 6,049 91,427

Dublin Midlands Hospital Group

National Expected Activity/ Target 2017

National Projected Outturn 2017

Coombe Women’s and Infants University Hospital

Midland Regional Hospital Portlaoise

Midland Regional Hospital Tullamore

Naas General Hospital

St. James’s Hospital

St. Luke’s Radiation Oncology Network

Tallaght Hospital - Adults

DMG Expected Activity/ Target 2018

National Expected Activity/ Target 2018

Daycase Cases (includes dialysis)

1,062,363 1,049,851 7,776 6,558 32,989 7,654 50,322 72,501 46,686 224,486 1,056,880

Elective Inpatient Discharges

94,587 92,172 679 523 2,535 645 5,115 1,144 2,811 13,452 91,427

Ireland East Hospital Group

National Expected Activity/ Target 2017

National Projected Outturn 2017

Cappagh National Ortho Hospital

Mater Misericordiae University Hospital

Midland Regional Hospital Mullingar

National Maternity Hospital

Our Lady's Hospital Navan

Royal Victoria Eye and Ear Hospital

St. Columcilles Hospital

St Luke's Hospital Kilkenny

St. Michael's Hospital

St. Vincent's University Hospital

Wexford General Hospital

IEHG Expected Activity/ Target 2018

National Expected Activity/ Target 2018

Daycase Cases (includes dialysis)

1,062,363 1,049,851 7,332 55,042 10,656 2,664 5,523 11,584 2,744 9,868 6,051 69,969 9,246 190,679 1,056,880

Elective Inpatient Discharges

94,587 92,172 2,924 4,504 973 463 1,097 1,614 230 540 1,039 4,098 846 18,328 91,427

RCSI Hospitals Group

National Expected Activity/ Target 2017

National Projected Outturn 2017

Beaumont Hospital

Cavan General Hospital

Connolly Hospital Blanchards -town.

Louth County Hospital

Monaghan General Hospital

Our Lady of Lourdes Hospital Drogheda

Rotunda Hospital

RCSI Expected Activity/ Target 2018

National Expected Activity/ Target 2018

Daycase Cases (includes dialysis)

1,062,363 1,049,851 87,645 18,061 14,375 8,912 3,612 9,546 9,345 151,496 1,056,880

Elective Inpatient Discharges

94,587 92,172 5,766 1,054 1,796 73 1 1,344 445 10,479 91,427

Saolta University Health Care Group

National Expected Activity/ Target 2017

National Projected Outturn 2017

Galway University Hospitals

Letterkenny University Hospital

Mayo University Hospital

Portiuncula University Hospital

Roscommon University Hospital

Sligo University Hospital

Saolta Expected Activity/ Target 2018

National Expected Activity/ Target 2018

Daycase Cases (includes dialysis)

1,062,363 1,049,851 84,921 30,015 25,544 9,576 7,690 31,825 189,571 1,056,880

Elective 94,587 92,172 8,610 1,929 1,731 561 830 2,217 15,878 91,427

Inpatient Discharges

South South West Hospital Group

National Expected Activity/ Target 2017

National Projected Outturn 2017

Bantry General Hospital

Cork University Hospital

Lourdes Othopaedic Hospital Kilcreene

Mallow General Hospital

Mercy University Hospital Cork

South Infirmary/ Victoria University Hospital

South Tipperary General Hospital

University Hospital Kerry

University Hospital Waterford

SSWHG Expected Activity/ Target 2018

National Expected Activity/ Target 2018

Daycase Cases (includes dialysis)

1,062,363 1,049,851 2,724 78,767 1,471 4,563 22,773 33,721 6,313 18,598 43,442 212,372 1,056,880

Elective Inpatient Discharges

94,587 92,172 210 6,392 850 449 2,477 3,718 1,270 1,419 2,968 19,753 91,427

University of Limerick Hospital Group

National Expected Activity/ Target 2017

National Projected Outturn 2017

Croom Hospital

Ennis Hospital

Nenagh Hospital

St. John’s Hospital

University Hospital Limerick

University Maternity Hospital Limerick

ULHG Expected Activity/ Target 2018

National Expected Activity/ Target 2018

Daycase Cases (includes dialysis)

1,062,363 1,049,851 3,025 7,141 7,640 5,250 37,071 112 60,239 1,056,880

Elective Inpatient Discharges

94,587 92,172 1,301 222 406 1,690 3,855 14 7,488 91,427

Senator John Dolan

Q19. Can the Minister outline where the process to deal with the Section 38/39 employment

retention/pay issue is currently at and how soon there will be a satisfactory solution?

As employees working in section 39 organisations are not public servants, they were not

subject to the provisions of FEMPI legislation nor were they a party to the Public Service

Agreements. As such, they are not covered by the pay restoration provided for in these

Agreements. While it is understood that pay savings were made by the organisations, the

precise mix of pay cuts or other savings measures will have varied. Also, where there were

pay cuts, it is not at all clear that they were applied in a universally consistent manner, as is

the case in the public sector. As a result, the cost of restoring pay will also vary between

these organisations, depending on the actions taken.

To address this, the Government has put in place a process to establish a deeper

understanding of the funding position in 50 of these grant - aided organisations. Also, the

true extent of the pay reductions applied needs to be clear. The HSE has been asked to

engage with the Section 39 organisations to establish the facts around what cuts were applied

and how and when they were implemented. When these facts are established, it will inform

the assessment of the costs involved. A plan will then need to be developed by Government

in relation to possible solutions and their implementation.

The Department of Health is expecting an interim report on this matter from the HSE shortly.

Q20. The HSE has recently confirmed that the average number of weekly hours for those in

receipt of the Personal Assistance Service, PAS, is less than 12 hours. This gives a daily average

of one hour and 42 seconds per person.

Given the definition of PAS used by the HSE, can the Minister explain how that service

definition could credibly be delivered within the above average hours per person?

The HSE provides a range of assisted living services including Personal Assistant and Home

Support services to support individuals maximise their capacity to live full and independent

lives. While the resources available for the provision of assisted living services are

substantial, it must be noted that they are finite.

Personal Assistant Service (PAS)

The role of a Personal Assistant (PA) is to assist a person with a disability to maximise their

independence through supporting them to live in integrated settings and to access community

facilities.

The PA works on a one-to-one basis, in the home and /or in the community, with a person

with a physical or sensory disability. A vital element of this personalised support is the full

involvement of the individual (service user) in planning and agreeing the type and the times

when support is provided to them; in this way the service user is supported to maintain

personal control over their own life.

Services are accessed through an application process or through referrals from public health

nurses or other community based staff. Individuals’ needs are evaluated against set criteria

for prioritisation for particular services and resources are allocated accordingly.

The HSE has consistently, year on year, increased the number of PA service hours delivered

to people with a disability. The target for 2017 was 1.4 million hours; however, in excess of

100,000 additional hours was provided in 2017 to almost 2,500 people.

The HSE is committed to protecting the level of PA supports available to people with a

disability. While the average number of PA hours per person is currently approximately 12

hours per week, it should be noted that some service users are in receipt of more hours.

The need for increased PA services is acknowledged and the HSE continues to work with

agencies to explore various ways of responding to this need in line with the resources that are

currently available.

PA Services Delivered to People with a Disability; 2013-2017

The following table provides data for PA services delivered to persons with a disability in the

years from 2013 to 2017; data for Quarter 1 2018 will not be reported until April 2018.

2013 2014 2015 2016 2017

PA Services –

Number of Hours 1,291,070 1,335,759 1,482,492 1,510,116 1,516,727

PA Services –

No. People availing

of services

2,057 2,224 2,369 2,427 2,470

PA Services delivered in 2017

The following table outlines the PA services delivered in 2017 broken down by the number of

support hours provided per week per individual.

1-5 PA

hours per

week

6-10 PA

hours per

week

11-20 PA

hours per

week

21-40 PA

hours per

week

41-60 PA

hours per

week

60+ PA

hours

per week

No. People

availing of

service

1,097 570 419 241 67

65

Deputy Louise O’Reilly Q24. To ask the Minister for Health if he has received a report on the ‘loco parentis’ rule from

his colleague, Minister of State Jim Daly, if he is aware of the hurt this issue is causing to

already extremely stressed families and what actions he intends taking to provide a solution.

I am aware that Minister of State Daly met your party colleague Deputy O’Caolain recently to

discuss the provision of paediatric homecare packages and the application of the in loco

parentis rule, and I would stress that both the Minister of State and myself are very aware of

this issue and understand how important it is for parents.

Children with complex medical conditions have significant healthcare needs, and paediatric

homecare packages are designed to maximise a child’s quality of life and developmental

opportunities, while also helping to keep children out of hospital as much as possible. These

homecare packages are required when a child has medical and/or nursing needs that cannot be

met by existing Primary Care services.

However, the Nurses and Health Care Assistants who deliver these packages are responsible

only for the clinical care of the child. As such, they cannot assume sole responsibility for a

child in the child’s home. Therefore, where parents may not be available it is required that a

designated and competent individual be appointed to act in loco parentis. This requirement

ensures that a second person will be present in the event of an acute emergency such as

respiratory arrest, decanuation of a tracheostomy or status epileptus.

It is essential that parents have the opportunity to contribute to the development of services

for their children. Many parents have already contributed to a Quality Assurance Process for

Paediatric Home Care Packages (PHCPs) commenced by the HSE in 2017. This process will

inform how PHCPs should be delivered, including the operation of the in loco parentis

provision, and I understand that further engagement with parents will take place in the

coming weeks and months.

In addition, the HSE intends to establish a Parental Reference Group in order to provide

parents with the appropriate forum to identify and discuss issues of concern in relation to the

provision of these packages. It is intended that this group will be established by the

beginning of July.

I believe that the processes outlined above will ensure that we deliver the best possible care to

children with complex medical needs and that this care continues to be managed as a

partnership between parents and the specialist medical staff who work together to help

children lead as normal a life as possible.

Q26. To ask both Minister Harris and Mr Tony O’ Brien what steps have been taken at this

point in time by both the Dept. of Health and the HSE to provide for the rights contained in the

recently ratified UN Convention on the Rights of Persons with Disabilities.

Ireland’s ratification of the UN Convention on the Rights of Persons with Disabilities came

into force on 19 April 2018. By ratifying the Convention, this Government has reaffirmed its

commitment to the protection of the rights of persons with Disabilities.

While significant progress has been made on the required legislative change, for example,

through reform of the law on decision-making capacity, there still remains some legislation to

be enacted to ensure that we meet our obligations under the Convention. From my

Department’s perspective, this includes legislation on the issue of deprivation of liberty

safeguards. The central issue to be addressed in these new provisions is that existing

legislation in the form of the Assisted Decision Making (Capacity) Act 2015 and the Mental

Health Act 2001 do not provide procedural safeguards to ensure that people in residential

settings are not unlawfully deprived of their liberty.

My Department published draft Heads of Bill on deprivation of liberty safeguards for public

consultation last December. This consultation process formally closed on March 9th

but a

number of late submissions have been accepted. Some 50 submissions have been received to

date. The consultation submissions on the draft Heads of Bill are currently being analysed and

the findings will be published as soon as possible. My Department will amend the draft

Heads as necessary with a view to submitting them to Government for approval as quickly as

possible.

Q27. To ask both Mr Tony O’Brien and Minister Harris what budget provisions are being made

respectively by the HSE and the Dept. of Health for 2019 in order to provide for the

commitments involved following ratification of the UNCRPD.

Decisions in terms of the funding that will be made available in 2019 for the provision of

health and personal social services have yet to be taken and will be made within the context

of the Estimates Process for Budget 2019. This process typically involves detailed

discussions between the Department, the HSE and the Department of Public Expenditure and

Reform in the months leading up to Budget Day.

Pending the conclusion of these discussions, I am not in a position to comment on any

budgetary provisions that will be made to ensure our statutory obligations under the

UNCRPD are met.

Q29. To ask the Minister for Health to advise what steps he intends taking to address the wholly

inadequate ambulance provision in the Cavan Monaghan area and to advise the criteria

employed in determining at ambulance control what ambulance and from what centre would be

deployed in any given situation.

The Ambulance Service for the Cavan Monaghan area operates from locations in Cavan Town,

Monaghan Town, Castleblayney and Virginia. Ambulance resources from neighbouring counties e.g.

by Meath, Louth and Westmeath can also be dispatched to calls in these counties depending on the

closest resources to the call at any point in time. This dispatch approach also includes the use of air

assets if necessary as a primary or secondary response.

The NAS Emergency Operations Centre dynamically deploys resources to areas where cover is

required or to respond to incidents as they arise to ensure the nearest available ambulance responds to

emergencies. Care begins immediately from when the emergency call is received, where lifesaving

pre-arrival assistance is given by the emergency call takers directly to the patient or any third party

that is available to assist. This pre-arrival care can include the delivery of medications, CPR, use of

defibrillator, haemorrhage control, childbirth and many other emergencies that present.

This care is then transferred to the arriving paramedics, where it is followed through to the safe

transportation and handover of the patient to the clinical team at the receiving hospital. NEOC utilises

an Advanced Medical Priority Dispatch System (AMPDS) which utilises international standards in

triaging and prioritising emergency calls. This system ensures that life threatening calls receive an

immediate and appropriate response, while lower acuity calls may have to wait until resources become

available.

These arrangements are seeking to ensure that timely and safe patient care is being delivered in this

area, similar to other parts of the country, as far as possible within the resources available.

The National Ambulance Service capacity review undertaken in 2016 identified a number of key areas

for development which include:

The continuous monitoring of service delivery and the transition of communications from

analogue to digital (voice and data).

The implementation of the Advanced Medical Priority Dispatch System (AMPDS).

The establishment of 3 clinical layers of care delivery, (EMT’s, Paramedics and Advanced

Paramedics) and the continuous upskilling of all three grades.

The introduction of an Intermediate Care Service to provide for inter facility transfers.

The introduction of the Emergency Aeromedical service.

The development of the Community First responder Scheme.

Substantial progress has been made in relation to these key service enhancements in the period since

2016. The Strategic plan for Ambulance Service (published in 2017) is also informing the

development programme for the Ambulance Service at local and national level.

Q33. What plans are in place to build a new hospital on the grounds of Merlin Park in Galway?

The Government's new National Development Plan includes three new elective facilities, in

Dublin, Cork and Galway, among its proposals. Further planning to progress investment in

these new facilities will now be undertaken, including full evaluation of local capacity and

infrastructural needs and a framework for decision-making on the optimal location from a

clinical and population needs perspective.

It is important to recognise that the National Development Plan is a long-term plan which

provides for a large number of health developments across the country, including both

national programmes and individual projects, across acute, primary and social care. We must

ensure that we carefully plan the use of this capital funding so as to meet the population needs

and achieve value for money. Health capital projects and programmes currently underway

will continue. As is to be expected with a ten year plan, many proposals, including the new

elective facilities at Dublin, Cork and Galway, are at an early stage and will require to

progress through appraisal, planning, design and tender before a firm location, timeline or

funding required can be established.

Q39. Can you provide an update on the new application to have Translarna, the drug treatment

for Duchenne Muscular Dystrophy?

Translarna (Atlauren) is manufactured by PTC Therapeutics and was developed for the

treatment of a subgroup of patients with Duchene Muscular Dystrophy. The medicine has

conditional market authorisation for Europe - (the condition being that the company carries

out further clinical trials to determine the clinical efficacy of the drug). Market authorisation

in the US has been refused to date due to the absence of substantial evidence of effectiveness.

Translarna is a high cost medicine – costing in the region of €300,000 per patient per annum.

Applications for reimbursement were considered by the HSE Drugs Committee and

Leadership Team in 2016 and 2017. The applications were considered very carefully,

however the final outcome was that the HSE was not in a position to fund the medicine on the

basis of the current clinical evidence of effectiveness and the price charged by the

Pharmaceutical Company.

The company has initiated high court proceedings against the HSE in relation to the decisions

taken regarding these applications, and these proceedings are still the subject of the legal

process.

The HSE has informed the company that it will consider any further new information in

relation to clinical effectiveness or price that would warrant further consideration of the

reimbursement application.

Deputy Michael Harty

46. What is the present position regarding the drug Translarna used for Duchene

Muscular Dystrophy and if the HSE intends to set up a patient access programme for

the small number of children involved?

Translarna (Atlauren) is manufactured by PTC Therapeutics and was developed for the

treatment of a subgroup of patients with Duchene Muscular Dystrophy. The medicine has

conditional market authorisation for Europe - (the condition being that the company carries

out further clinical trials to determine the clinical efficacy of the drug). Market authorisation

in the US has been refused to date due to the absence of substantial evidence of effectiveness.

Translarna is a high cost medicine – costing in the region of €300,000 per patient per annum.

Applications for reimbursement were considered by the HSE Drugs Committee and

Leadership Team in 2016 and 2017. The applications were considered very carefully,

however the final outcome was that the HSE was not in a position to fund the medicine on the

basis of the current clinical evidence of effectiveness and the price charged by the

Pharmaceutical Company.

The HSE has informed the company that it will consider any further new information in

relation to clinical effectiveness or price that would warrant further consideration of the

reimbursement application.

The feasibility of an access programme is being examined, but may not be practical in this

instance due to the very small number of patients involved.

The company has initiated high court proceedings against the HSE in relation to the decisions

taken regarding these applications, and these proceedings are still the subject of the legal

process.

47. Foreign trained doctors from outside the EU and certain named countries are

precluded from accessing training schemes thus making it less likely that they will stay

in Ireland. This is contributing to the manpower crisis in our health service. What

measures can you take to address this issue?

The Medical Practitioners Act 2007 currently provides that doctors whose qualifications are

from non EEA countries require the equivalence of a certificate of experience (internship) to

access specialist training in Ireland. The Medical Council has established an Adjudication

Group which decides if internships completed in non-EEA jurisdictions satisfy the Medical

Council’s standards for training and experience. The Medical Council currently recognises

internships from Australia, New Zealand, Pakistan, South Africa, Sudan and Malaysia as

being equivalent to Irish internships. A doctor whose qualification is from a country other

than one of these cannot access specialist training in Ireland.

I do acknowledge the valuable contribution made by doctors who are from outside the

European Union to the Irish public health system, and the role they play in Irish health care. I

am also aware that specialist medical training may be an important career pathway for these

doctors, but that some are unable to access this training. I have therefore decided to amend

the Medical Practitioners Act to remove the requirement to hold the equivalence of the

certificate of experience to access specialist training.

The amendment will be introduced by a Regulated Health Professions (Amendment) Bill,

which is amending the five health profession regulatory Acts in relation to a number of areas.

It is a large and complex Bill, and is currently at an advanced stage of drafting by the Office

of Parliamentary Council in liaison with my officials. I expect to publish it in this Dáil

session, subject to no major issues arising.

With regard to manpower, recruitment and retention of consultants is challenging at present,

particularly in certain specialties, including psychiatry and paediatrics. Notwithstanding these

challenges, the number of consultants has increased by 110 in the 12 months to end March

2018 and by 462 in the past five years. This is against a backdrop of global shortage of health

workforce workers, including doctors. The HSE is committed to improving the training and

career pathways for doctors in training with a view to maximising retention.

I feel it is important to mention that Ireland is also committed to a national policy of health

worker self-sufficiency, and has signed up to implementing the WHO Global Code of

Practice on International Recruitment of Health Personnel. The Code establishes and

promotes voluntary practices for the ethical international recruitment of health personnel and

the strengthening of health systems. The Code recommends that Member States ‘strive to

create a sustainable health workforce and work towards establishing effective planning,

education and training, and retention strategies that will reduce their need to recruit migrant

health personnel.’

Deputy Louise O’Reilly

Q48. Can the parents of a young adult (over 18) diagnosed with autism have access to the case

file relating to their son or daughter.

As a matter of policy, the health service supports an individual’s right to see what information

is held about them within its service. Administrative access involves a written request for

information made to the appropriate Centre of service. Generally, access to your own health

record should be provided administratively (subject to exceptions). You can also give your

authorization for someone else to access them on your behalf. However, access to records in

respect of any adult (with capacity) is not permitted without that person’s authorization.

If the personal records sought relate to an adult who does not have the capacity to give

authorization, then it may be more appropriate to request access under Freedom of

Information legislation (FOI Acts 1997, 2003 and 2014). Requests of this nature are dealt

with on a case by case basis.

Deputy Alan Kelly

Q49. Has the Minister for Health or the Director General of the HSE liaised with the

Department of Justice & Equality regarding the provision of Naloxone to members of An Garda

Síochána for use in opioid overdoses and if this will now be considered for implementation?

Department of Health Response

There has been no liaison between the Department of Health, the HSE and the Department of

Justice and Equality in relation to the provision of Naloxone to members of An Garda

Síochána.

Background

Naloxone is an opioid antagonist which is used to reverse the effects of overdose of opioids

such as heroin, morphine and methadone.

While injectable naloxone has been used extensively for decades, there are currently a

number of clinical trials taking place in the United States and in Europe on the use of

intranasal naloxone. In advance of the clinical trials phase, the HSE has decided on grounds

of patient safety, to roll out the demonstration project using the naloxone injection. Once an

authorised intranasal spray is available, the HSE hopes to replace the injection with the

intranasal product.

The HSE’s Naloxone Demonstration Project involved 600 patients receiving take-home

Naloxone and the provision of training to lay persons, such as the family and friends of a drug

user, in the administration of a Naloxone injection to overdose victims.

The demonstration project has already prevented a number of fatal overdoses for the

individuals involved and it is anticipated that many more lives will be saved as a result of this

initiative. The HSE is working to expand the Naloxone programme and will work on training

more people in the use of Naloxone, increasing its accessibility and availability.

Reducing Harm, Supporting Recovery contains a specific action to continue to target a

reduction in drug-related deaths and non-fatal overdoses by expanding the availability of

Naloxone to people who use drugs, their peers, and family members. The HSE plans in 2018

to expand Naloxone Training and distribution to target a reduction in drug-related deaths and

non-fatal overdoses.

Q50. To ask the Minister for Health and the Director General of the HSE for an update on the

oral question I asked the Minister in the Dáil on February 8 in relation to the publication of an

FOI disclosure log on the Beaumont Hospital’s website

(Deputy Alan Kelly asked the Minister for Health the status of the work being carried out at

Beaumont Hospital in respect of publishing a freedom of information disclosure log, as per the

Freedom of Information Act 2014, on the hospital's website; if this process will be expedited; the

timeframe for completion; if he will direct the hospital to publish as much information as

possible in an open and accessible manner on a routine basis outside of freedom of information;

and if he will make a statement on the matter. [6097/18])

My Department wrote to both the Chairperson and the Chief Executive Officer of Beaumont

Hospital asking them to ensure that work on the Publication Scheme, which includes the

Disclosure Log, be expedited and that as much information as possible be provided outside of

Freedom of Information.

The current status is that the Beaumont Hospital Model Publication Scheme, can now be

found on the Beaumont Hospital website in tabular form under the tabs;

Information about Beaumont Hospital

Services provided by Beaumont Hospital or to be provided to the public

Beaumont Hospital’s decision making process for major policy proposals

Beaumont Hospital’s financial information

Procurement

Beaumont Hospital FOI disclosure log and other information to be published routinely

Within each tab, there is a link to the relevant information under the corresponding heading.

Sub-headings are also provided where necessary in order to make the information more

accessible. Work is still underway, particularly for the final tab which is the FOI disclosure

log with the aim of having this finalised by 30 June 2018.

Q51. To ask the Minister for Health and the Director General of the HSE the status of the

rollout of the drug entyvio in Tallaght Hospital, if its availability will be expanded at that

hospital and rolled out more widely in hospitals across the country.

Vedolizumab (Entyvio) is manufactured by Takeda Pharmaceuticals and was developed for

the treatment of adult patients with moderate to severely active ulcerative colitis (UC) and

Crohn’s disease.

Vedolizumab was approved for reimbursement by the HSE in September 2017 and is in use

in Tallaght Hospital and other hospitals in Ireland where clinically required. The Acute

hospitals drugs management programme has published guidance on its use on the HSE

website –

https://www.hse.ie/eng/about/who/acute-hospitals-division/drugs-management-

programme/drug-approvals/.

As this is an expensive medicine, hospitals have also been advised on the availability of a

significantly cheaper alternative product (Infliximab) which can be prescribed both as a

biosimlar and as an original medicine. Vedolizumab has not demonstrated clinical superiority

when directly compared to other anti-TNF (Tumour necrosis factor) therapies (of which

infliximab is one).

The appropriate use of these medicines is carefully managed by specialist physicians taking

into full account the evidence to support their treatment choice for patients.

Deputy Margaret Murphy O'Mahony Q52. Are the Government going to give the go-ahead to allow the use of orphan drugs such as

FreeStyle Libre and Respreeza in circumstances where they are still being used on a trial basis

thus prolonging uncertainty for patients?

The HSE has statutory responsibility for decisions on medicine pricing and reimbursement,

under the Health (Pricing and Supply of Medical Goods) Act 2013. The 2013 Act sets out the

criteria for making decisions on the reimbursement of medicines.

The 2013 Act requires the HSE to have regard to both clinical benefits and cost effectiveness.

It does not include provision for a different rule set for orphan drugs.

However, while orphan drugs are assessed in the same way as other drugs, the HSE is

mindful of the differences and challenges in terms of patient numbers.

The Medicinal Products Review Committee, which will be chaired by Professor Michael

Barry, will consider whether there should be a separate rule set for orphan drugs.

In looking at whether a new set of entry and exit criteria is warranted for drugs to treat rare

diseases, the Committee will also consider the question of managed entry for orphan drugs.

The Department will consider the need for a separate approval process for orphan drugs, in

the context of the evaluation of the committee’s report. There is merit in seeing what comes

out of the work of the new review committee before considering whether changes to the

existing legislation might be required.

The current system, which is in place since 2013, supports a rigorous, transparent assessment

of all drugs including orphan drugs.

The NCPE assessment process is about establishing if a product is cost effective at the

submitted price. The HTA system in Ireland uses standardised processes and criteria for

evaluating medicinal products, including orphan drugs, in accordance with guidelines

published by HIQA. Section 19(5) of the 2013 Act requires the HSE to have regard to HIQA

guidelines on HTA.

Should the NCPE not recommend reimbursement, the process doesn’t necessarily finish

there. It may, for instance, provide an opportunity to offer or negotiate a better price.

It should be noted that the current system is always open to new applications and new

information for a particular product. The door is never closed, and a refusal applies to a

specific application only.

Q54. What systems are in place for children with MS in West Cork?

Specifically how many nurses are trained to work with children with MS in West Cork?

In the rare occurrence of a child being diagnosed with Multiple Sclerosis, he/she is referred

by the discharging hospital to the local Primary Care team, which includes the following

services:

Public Health Nursing;

Physiotherapy;

Occupational Therapy

Speech & Language Therapy; and

General Practitioner.

If the child’s presenting needs indicate that an interdisciplinary team input is required, then

that child would be referred to the West Cork Child Development Service (this is a team

service which is based on the progressing disabilities services model). On-going review by

the identified appropriate team would be undertaken to ensure the changing needs of the child

are met and the child’s family are supported to care for their child at home. Referral to

appropriate community and voluntary services may also occur as appropriate.

Public Health Nursing services provide child development assessments at ages 3 months, 9-

12 months, 18-24 months and 3.25-3.5 years for all children. Depending on these

assessments, other more regular assessments may be scheduled. These assessments will

include assessment of the need for equipment, continence wear and other medical/nursing

supplies etc.

All nurses receiving training in dealing with neurological conditions such as Multiple

Sclerosis as part of their general training and some may have a special interest or post

graduate qualification in this area. However, there are no nurses in the West Cork area that

are specifically trained to work with children with Multiple Sclerosis.