Dr. Diarmuid O'Shea:

Some of the issues have been covered in responses to other members' questions. Before turning to Deputy Murphy O'Mahony's specific questions, I will comment on primary care and general practitioners. There is now a GP primary care lead physician in the national primary care programme in the HSE. In a very welcome move, the Irish College of General Practitioners is now looking for three GPs to be appointed to the chronic disease programme. That type of engagement is actively happening. That is really important.

Dr. Collins referred to nursing homes. If one looks at international figures, one would expect 33 people per 100 nursing home beds to require hospital care annually. Their lengths of stay range between eight and 14 days. Very good work is being done around the country with clinical nurse specialists, but not yet in the case of advanced nurse practitioners.

I mean clinical nurse specialists working in pilot schemes around the country. They specifically look at nursing home patients who have been admitted to hospital and conduct follow-up, virtually, by contact with the nursing home when those patients are discharged back to the nursing home. There are areas around the country that are considering specific nursing home outreach initiatives. At present there is one in north Dublin and one in south Dublin to name but two. The initiatives have clearly demonstrated reduced hospital admissions and that is when there is interaction between nursing homes, the multidisciplinary geriatrician team or clinical nurse specialist and the GP. It is a little like the question around admission avoidance, which is a term that I am uncomfortable with. One really wants the right person looked after in the right place. There is no doubt that there are nursing home residents and frail older people who require acute hospital care, and when they come in they need care in a quick, appropriate and targeted way. Let us consider the huge improvements that have been made in the care administered to a person who has suffered a hip fracture. In such cases we have focused units that have a dedicated bed in the emergency department, ED. The person is admitted straight away for X-ray scanning and is then sent straight to the orthopaedic ward for an operation, with clear pathways and performance indicators outlined thus resulting in good outcomes for the patient. All of the pockets of work have shown that if one has integrated, co-ordinated and focused specialty care - which is what all of the models have shown in terms of specialist wards and specialist multidisciplinary teams who provide focused care with expert nursing care - then patients will be discharged more quickly and are less likely to go into a nursing home. Clearly, if one came from a nursing home then one will return to the same one. Equally, with such teams and care one is less likely to functionally decline in hospital. We must build on these pockets of excellence that are located around the country.

Deputy Murphy O'Mahony asked specific questions about acquired disability after suffering a stroke. I will begin by reiterating what I said about the value of targeted and co-ordinated models of care on a ward and clear follow-up care in the community. If one needs rehabilitation that either happens in the acute hospital or in an appropriately staffed rehabilitation bed. This is where I think language in everything we do is key. If we mis-designate a bed by calling it a convalescence bed or misuse a bed that is a transitional care bed that gives potential licence to not staff in a correct way the rehabilitation needs required by the patient. Quite separately from the neuro-rehabilitation report that will be launched, rehabilitation for an older person, whether it happens in a hospital, in one's home or in a rehabilitation bed at an off-site or on-site facility, is about the appropriate minutes of exposure one receives if one is able for rehabilitation. Dr. Collins will now comment on the stroke perspective before we continue to reply to questions.