Ms Mary Burke:

No. There is already in place legislation on nurse prescribing, which was introduced by former Minister for Health, Mary Harney. It has had a positive impact on patient care in that there is timely access to medication. I am permitted to prescribe pain relief for people in nursing homes who are dying, which is very positive. I am lucky in that a GP in the nursing home in which I work has given me permission to prescribe using his prescription pad. Other nurse prescribers in Ireland do not have that luxury. It is an issue that needs to be addressed.

The Deputy also asked about consultant-led palliative care. During my time in nursing homes I have never witnessed a visit by a palliative care consultant. They do not visit. Such visits would be welcomed. It would assist in terms of greater communication with families. Unfortunately, some GPs visit Monday to Friday and do not get to meet with or have discussions with families regarding end of life. Communication and decision-making is the key to good end-of-life care. Palliative care consultants are the speciality in this regard.

Deputy McLellan asked me to outline the shortfalls in geriatricians. Unfortunately, I do not have the statistics in that regard. I do not know them. Connolly Hospital in Dublin operates an excellent system whereby consulting geriatricians visit all the nursing homes attached to it, which prevents re-admission to the acute hospital. The consultants hold regular team meetings and family meetings. They also liaise with the palliative care teams to ensure multidisciplinary team decisions around care. This service is not available in most other parts of the country. It is a service that should be rolled out. It would definitely prevent re-admission to acute hospitals.

Senator Colm Burke also asked about nurse prescribers. I have already answered that question. On individual nursing homes and our arrangements with GPs, each resident is entitled to be treated by the GP he or she was attending prior to admission to the nursing home. Some nursing homes have GPs attached, to whom they pay an annual fee. In other cases, the GPs own the nursing homes so they get a very good service. The nursing home in which I work is serviced by 14 different GPs. It is difficult to have an equitable service of GPs for residents. Some GPs are excellent and attend every three weeks. Others attend only every three months. The Health Information and Quality Authority, HIQA, recommends that all residents are visited at least every three months. There needs to be more equity in the GP service. The Irish College of General Practitioners is working on this. The chairperson of the committee looking into this is Dr. Tony Lee. He is working on the development of a document which lists the various things which a GP must do during a visit. This should help.

On additional beds and whether the patients concerned could be cared for at home, unfortunately the dependency level of residents now being admitted to nursing homes is much greater than pre-fair deal. Under the fair deal scheme patients must be assessed as requiring long-term care. Therefore, the consultant geriatrician will not sign them off for long-term care if they can be cared for at home. There is definitely a deficit in the beds available. Nursing homes all over the country have waiting lists. As I said earlier, some of the people on these waiting lists are in receipt of palliative care and, often, some die before a bed becomes available. A big issue that has arisen in the context of the establishment of more nursing home beds is what the National Treatment Purchase Fund, NTPF, pays under the fair deal scheme to nursing homes. There is no encouragement for new providers to set up nursing homes because they will not get the rate of pay that is required for the provision of care, in particular at end of life. HIQA standards recommend the provision of additional care at end of life. Where a resident in a nursing home is dying this may require an additional nurse at night to care for that resident, which requires additional funding. This is not catered for in the fair deal amount provided. The shortfall between what the NTPF pays for the cost of care and the standard and quality of care which nursing homes want to provide needs to be looked at. Nursing Home Ireland has a number of times recommended the development of a forum with the key stakeholders, including HIQA, the HSE, Nursing Home Ireland, to work on the key issues. We want to provide an excellent standard of care but are unfortunately prevented from doing so because of financial constraints.

I thank Senator Healy Eames for her questions. On the issue of there being no advanced care directive legislation in Ireland, currently we have the "Let me Decide" and "Thinking Ahead" forms, which allow people when unwell to make decisions in regard to what care they want to receive. Unfortunately, these are not covered by legislation. As such, how legally binding such documents would be at end of life is uncertain. There is a need for legislation in this regard. Another issue that arises in the context of advanced care directives is that what a person wants now in terms of end of life care could differ from what he or she would require in 20 years. This means these documents will need to be updated and reviewed.

A person may enter a nursing home and in six months time his or her health may have deteriorated due to dementia, for example. Therefore, a decision taken six months ago can be very different from what is needed now. Also, advanced care directives requires a huge amount of education and support for staff, GPs and nurses.

Senator O'Donnell mentioned that the Minister for Health, Deputy Reilly, had spoken about dying patients going to accident and emergency units. That does happen, but the situation has improved immensely. We have got much better at talking about end-of-life care and how decisions are made. We can give a diagnosis that a person is dying. There are more communications with families around the issue of dying. We are now confident enough to say to a person's family that if their loved one goes into an acute hospital he or she may pass away on a trolley in an accident and emergency unit. We ask the families if they would prefer to have their loved one die in a nursing home with staff who know them, thus allowing them to die with dignity and respect. Communication with families and residents on end-of-life wishes has improved and we are not transferring as many people to accident and emergency units. I have seen a great reduction in the number of patients to whom this happens.

We must be grateful to HIQA for its standards and new end-of-life thematic inspections. It has recommended that we have end-of-life discussions with every resident. We can compile a document on what a person wants so that things are much clearer. Thankfully, not as many people are ending up in hospital. There may be a difficult family who want everything done for their 99 year old mother and feel that she should be transferred to hospital. Those wishes must be respected.