Jerry Buttimer (Cork South Central, Fine Gael)
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I remind members, witnesses and those in the Gallery that mobile phones should be turned off. We have apologies from Senators van Turnhout and Henry and Deputy Regina Doherty. I welcome our guests and witnesses. We are discussing the role of public health nurses. I pay tribute to our public health nurses across the country for the tremendous work they do on behalf of all of us. The care and attention they give often goes unnoticed but it is appreciated and was highlighted by the very successful RTE programme dealing with the great work they do. I thank Ms Mary O'Dowd who has engaged with me on a personal level and as committee Chairman over the past number of months, and I welcome her and Ms Brigid Catterson, Mr. John Hennessy, Dr. Michael Shannon and Ms Martina Queally.

Witnesses are protected by absolute privilege in respect of the evidence they give to the committee. However, if they are directed by the committee to cease giving evidence on a particular matter and they continue to do so they are entitled thereafter only to a qualified privilege in respect of their evidence. Only evidence connected with the subject matter of these proceedings is to be given. Witnesses are asked to respect the parliamentary practice that where possible they should not criticise or make charges against any person or entity by name or in such as way as to make him or her identifiable. Members are reminded of the long-standing parliamentary practice to the effect that members should not criticise, comment on or make charges against any person or persons outside the House or an official by name or in such a way as to make him or her identifiable.

I call Ms Mary O'Dowd, director of the Institute of Community Health Nurses.

Ms Mary O'Dowd:

I introduce Ms Brigid Catterson, the chairperson of the institute's children and family interest group. The title of our presentation is, Best Health for Children in 2013. I thank the committee for this opportunity. We wish to raise some critical issues regarding child health services in the community. The Institute of Community Health Nursing, ICHN, is a professional organisation established in 1985 for public health nurses and community registered general nurses, RGNs. In light of the planned child and family support agency Bill, the ICHN wishes to discuss with the committee the role of the public health nurse, PHN, in child health and well-being and that it is essential in the best interests of children that a dedicated, health-promoting, preventive nursing service for children and families be developed as a matter of urgency. A PHN child health service is not included in phase 1 of the new agency.

Census 2011 identified the number of pre-school children aged 0-4 at 356,000, an overall increase of 17.9% since 2006, and the population of the primary school age group at 504,000, an increase of 12% since 2006. The PHN has an opportunity to assess all these children and families. The dual role of the PHN in clinical care and public-population health and well-being is prioritised towards clinical nursing care as a result of Government policy, the primary care and implementation processes, the moratorium on the recruitment of nursing staff and the absence of a national workforce plan for primary and public health nursing in the future.

The ICHN has been advocating for a number of years to convince policy makers of the gaps and challenges that exist in implementing Best Health for Children, which was first published in 1999 and revisited in 2005. This programme sets out a clear, evidence-based health programme for pre-school and primary school children. The recommended 0-4 years contact by the PHN with the children and family commences with a visit approximately 48 hours after discharge from the maternity hospital and four subsequent pre-school visits. We are the only health professional group who visit the home of every newborn child and mother in Ireland. This places us in a unique position to build relationships with families and their communities.

Performance indicators on early years health screening is limited to quantitative data in the first year. There are no national data performance indicators measuring outputs and outcomes at the 18-24 month screening and the 3.25 to 3.5 year screen. The HSE health staff performance report of 2012 reported a variation of 38% to 100% of children reaching ten months who had received their 7-9 month screening on time, demonstrating an inequity of service delivery to this population group across the country. A recent review by the institute of the school health service demonstrated that the recommendations from Best Health for Children on school health screening are not uniformly implemented. This has resulted in variance in the timing, programme content, equipment and referral criteria and pathways across the country. There are no national key performance indicators on the delivery of school health nursing service.

The ICHN strongly advocates for the provision of designated school health teams for the school health and well being surveillance programme and promotion. The Monageer inquiry 2009, which considered child abuse and protection, recognised that the public health nursing service provided to pre-school children was critical to the identification of children in families in need of early intervention. The institute strongly advocates for improved systems for the further professional development of PHNs to address this need. The child and family needs assessment framework is an assessment tool developed by public health nursing in the midlands. It facilitates early identification of vulnerable children and families, mobilises appropriate early identification and prevents the need for child care and social work services except in cases of serious concern and risk of harm to children. Evidence shows it is possible to prevent abuse and neglect with effective systems and interventions.

The parent-held record is a record held by the parent, which allows it so be shared with other health professionals working with children and their families. The parent-held record is in use in only eight former LHO areas of the country.

The electronic information obtained from this child record has the potential to report the outputs and outcomes relating to child health and well-being. Every child has a right to be afforded a high-quality, equitable community health nursing service. Many children in the community require specialised care and have difficulty accessing services. Despite the variations highlighted in the previous reports, many inequalities remain in the quality of this service. In light of the new child and family agency, the institute believes that the child health service warrants a dedicated focus to improve the systems and delivery of health care to all children in the community. We believe the public health nurse is ideally placed to identify and support families and to counter the obstacles that mean not every child reaches his or her full potential.

The current model of community nursing established in 1966 is not addressing the recommended child health programme. We seek the committee's support in promoting a dedicated child health workforce with proper resources and education that can deliver this service on time to all children with systems that can measure outcomes of child health and well-being. We ask the committee to make a formal proposal to the Minister for Health and the Minister for Children and Youth Affairs.

Jerry Buttimer (Cork South Central, Fine Gael)
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I thank the delegates for their presentation and for the interesting and challenging points raised. I thank the members of the delegation for their excellent work.

Ms Brigid Catterson:

I support Ms O'Dowd's work in all she does. The child health specialist role has been developed in my area of work in the midlands and it is proving very successful.

Jerry Buttimer (Cork South Central, Fine Gael)
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I welcome Mr. John Hennessy, Ms Martina Queally and Dr. Michael Shannon.

Mr. John Hennessy:

I thank the Chairman for the invitation to attend the committee to discuss the issue of public health nursing. I am regional director for HSE West. I am accompanied by Dr. Michael Shannon, director of nursing and midwifery services in the HSE, and Ms Martina Queally, area manager for HSE Dublin South East.

The delivery of community nursing services that effectively meet the health needs of the population within a primary care setting is the primary aim of the public health nursing service. The continued development of primary care teams is also being progressed, focusing on increased emphasis on care in the community and integration of services as outlined in the HSE 2013 national service plan. Multidisciplinary primary care teams provide health and personal social services as well as being the first point of contact for patients and clients in a local setting, which and ensures continuation and co-ordination of services. In the context of care and reform and the current drive toward an integrated health system, treating and delivering care to patients in more appropriate settings is an integral part of the role of the public health nurse and the registered general nurse working in the primary care teams. Public health nursing in Ireland is continuing to evolve in response to the growing demand for health care services in the community, as mentioned by Ms O'Dowd in her presentation.

The public health nursing service provides an extensive range of services within the Irish health service - for example, it provides children’s health services, including post-natal visits and developmental screening up to six years of age. The role of the public health nurse in safeguarding and protecting the health and well-being of children is also provided for in legislation, in the Child Care Act 1991 and the Children First guidelines 2011.

Immunisation programmes are provided as part of the school health service. The school health screening programme, as outlined in Best Health for Children, and immunisation programmes are currently available to schoolchildren in accordance with the national immunisation guidelines of 2008. Public health nurses are involved in the assessment of need and the provision of services to children and adults with disabilities. Health policy also endorses maintaining older adults in their own environment and in their own homes, where possible. Older persons receive assessments and are provided with services including home care packages in accordance with need. The public health nursing service is extensively involved in palliative care and the support of terminally ill patients in community settings. Patients with long-term illnesses are supported in the home setting. Patients with hepatitis C receive services, including the support of the public health nursing service, in accordance with assessed need.

Most important, public health nurses are often a key conduit for the dissemination of information and advice on health to all sectors of the population, often as the first point of contact. In conjunction with its core services the public health nursing service has expanded its remit to include the following: the development and expansion of community intervention teams whose primary aim is the avoidance of unnecessary hospital admission and the facilitation of early discharge from hospitals; the development of the school immunisation programme to include the education of public health nurses to oversee immunisation under medication protocol; and the schools vaccination programme, which is currently being delivered by immunisation teams including area medical officers and public health nurses in many areas of the country. It is anticipated that this programme will be nurse-led in the future. Support is also provided for clinical care programmes which help to facilitate the timely discharge of patients from hospitals. The aim is to allow patients to receive more rehabilitation at home, to remain at home in the long term and to regain independence in daily activities. Support for the nationalnewborn blood spot screening service is another function of public health nurses, who are responsible for ensuring that the test is carried out following notification and that all babies residing in their areas have been offered screening. Public health nurses are involved in the expansion of clinic-based services where appropriate, including assessment and treatment of wound care, continence care, child health, adult health checks, diabetes clinics and parenting programmes. The delivery of more complex care to patients in the community undergoing oncology treatment is also a developing area, and this is currently in place in a number of areas in the west of Ireland, including Donegal and Galway.

There are currently 3,312 public health nurses on the register with An Bord Altranais, of whom 2,402 are on the active file. In March 2013 the total number of nursing staff employed in the public health nursing service was 2,067 whole-time equivalents, broken down as follows: 15 directors of public health nursing; 122 assistant directors of public health nursing; 1,512 public health nurses; 418 registered general nurses; and 43 student public health nurses. Since 2006, in order to streamline the sponsorship of student public health nurse training, the HSE and four participating training colleges, UCC, UCD, NUIG and St. Angela’s College, have undertaken a process of joint entry and recruitment. For the past number of years the four regional directors in the HSE regions were requested to identify their annual sponsorship requirements based on service need. Sponsoring local health office areas provide clinical placements to public health nursing students while they undertake the full-time higher postgraduate diploma in public health nursing. This year, a total of 85 student public health nurse sponsorship places have been allocated, with 14 in the west region, 14 in the south region, 27 in Dublin north east and 30 in the Dublin mid-Leinster region.

In 2013, primary care development funding of €20 million will be invested to support the recruitment of prioritised front-line primary care team posts and to enhance the capacity of the primary care sector. The 2013 national service plan has prioritised the appointment of approximately 250 primary care posts, including public health nurses, registered general nurses, occupational therapists, physiotherapists and speech and language therapists. The recruitment and appointment of people to fill these posts is currently under way.

Analysis has revealed considerable variation across the 17 integrated service areas in the ratios of health care professionals to population and to population numbers in areas of high deprivation.

Based on this analysis, the 70 public health nurses and 37 new registered general nurses in the programme of development for this year will be recruited and deployed to primary care teams under this year's plan. Approximately 42% of the new development posts envisaged in this year's plan will be new nursing posts.

A review of public health nursing services was commissioned by my colleague, Dr. Michael Shannon, director of the office for nursing and midwifery, in 2011, with the assistance of the public health nursing service and the Institute of Community Health Nursing. An expert group was chaired by Dr. Joe Clarke, primary care clinical lead, and the review was completed and published in March 2012. It has helped to inform future policy on the integration of services and the delivery of efficient and safe care to clients in the community.

I will refer briefly to the education programme for public health nurses. The programme educates students to be able to practise as confident, accountable and autonomous public health nurses, with the ability to work in partnership with other members of the primary care team and committee based organisations and with the aim of maximising their contribution to health improvement. Student public health nurses are educated within a national and international context on the principles of professional issues of health promotion and health promotional aspects of public health nursing. The programme has regard to the needs of younger people, families, patients with chronic illnesses, people with disabilities and adults and older people in the community.

In regard to children and families, in particular, I will address some of the points alluded to by Ms O'Dowd. The programme addresses the following modules: theoretical perspectives on child development pathways in early to middle childhood; public health nursing services for families and children aged up to 12 years; determinants of child and family health, including risk and protection factors which influence child health; the concept of prevention, assessment of risk and vulnerability; child health surveillance and screening; child health promotion; assessment planning; implementation and evaluation of nursing care services in consultation with an individual, family, group or community, delivered in conjunction with other primary care team members; best practice in child protection, which includes legislation and policy on child health for young people and families; developing a partnership with children, families and communities; multidisciplinary and inter-agency communication; good practice in child protection; teamwork, networking and collaboration; and interdisciplinary work in the childcare context, including case conferencing.

Public health nurses and community registered general nurses provide a competitive range of nursing and midwifery services as outlined and within the context of unprecedented change and evolving service needs as part of primary care teams. Priorities already identified for the future include developing capacity and systems within the primary care teams and across health and social care networks to deliver a more complex and broader range of care services to communities. This will include responding to the additional requirements arising from implementation of universal healthcare, an increased emphasis on health promotion and well-being for communities, increasing incidence of cancer and chronic diseases in our ageing population, for whom more care will need to be provided at or near the patient's home and requirements for a specialist nursing practice and the provision of nurse-led services for some populations, for example, those with diabetes, chronic heart failure and other chronic conditions.

Together with my colleagues, I will attempt to take the committee's questions.

Jerry Buttimer (Cork South Central, Fine Gael)
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I thank Mr. Hennessy.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I thank the Chairman and join him in welcoming the delegation. I thank Ms O'Dowd and Mr. Hennessy who led the delivery of the presentations and who are very welcome.

Most of us, in one capacity or another, have had experience of the public health nurse service. As a father of five children, I had a very happy experience of it many years ago. A friendship developed from it which remains to this day. I am sure that is replicated in the experience of many all over the country. To the delegation's professional cohort and colleagues I extend sincere thanks.

I have a number of brief questions which were triggered by Ms O'Dowd's presentation but apply to both. The delegates can offer any illumination they are happy to provide.

There are no national key performance indicators for the delivery of the school health nursing service. I ask for clarification on the issue. Does it also take on board oral health through dental care service provision for schools? Is it part of the general range of services encompassed within school health nursing services? I raise this matter because I am very conscious that another group of young people has moved from primary to second level education and there are significant levels of failure in the service to provide for the necessary public dental service checks. In one school cancellations have taken place for the second time for the same class which are now outside the system in second level where the provision longer applies. This is a very serious matter and in a way indicative of other problems, but I am particularly aware of the issue, given the closure of the primary school system last week or this week. Parents are both disappointed and concerned and many of them will not be able to afford private dental checks. I ask the delegates to elaborate on this issue.

What is necessary for the introduction of national key performance indicators? Who will be responsible? How can such a system be brought into being? What would the delegation's recommendations be to us, as elected voices in the committee, on how we can help to bring it about? I accept that it would be hugely beneficial in informing us in the future.

The delegation indicates that the parent held record, PHR, is only in use in eight former local health offices across the country. Would it be able to advise us where they are located? If the information is not included in Ms O'Dowd's notes, I understand, but perhaps she might advise us through the secretariat and Chairman for circulation to us. I am sure the delegation would recommend that we pursue that issue because clearly it is something that would be of great benefit.

I refer to the dual role of the public health nurse in regard to clinical care and public population health and well-being. The delegation is probably aware that in the context of the promised child and family agency, the role of public health nurse has been a point of discussion here. There is some difficulty in recognising how the transition will come occur and whether it will lead to a dislodgement of psychologists in the child and family agency from their peers in terms of theprovision of general psychology services across the community. Will Ms O'Dowd and Mr. Hennessy elaborate on the concerns, if any, they have in that regard? From our deliberations in recent months, I understand public health nurses are designated solely to address issues affecting children, but perhaps that is a city experience.

In my own experience in a more rural constituency, the public health nurse tends to have a variety of target service users. Two sets of experiences appear to be represented here, one from a city perspective and one from a rural perspective. Could the witness elaborate a little on that and give us her perspective on the new child and family agency relative to her professional cohort? I thank the witnesses for appearing before the committee this morning.

John Crown (Independent)
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I welcome the witnesses. What is the number of public health nurses per head of population in Ireland and how does that compare to other countries in Europe?

Colm Burke (Fine Gael)
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I thank the witnesses for the presentation and for the very valuable work they do. Yesterday, the hospice movement gave us an overview of the huge variation in hospice care across the country. The issue that comes to mind regarding children is the recent report on obesity which shows that 25% of children under three years of age are overweight or obese. It is obviously a problem created at a very early age so we must plan to deal with it now. What must be done at national level? The witness spoke about setting up proper structures relating to public health nurses and children. I am asking about dealing with that issue here and now. How has it been allowed to develop so fast in such a short period of time? What are the witness's observations on that issue? It will be a major health problem for all of us over the next ten years because of the way it seems to have developed. Perhaps the witness would discuss that.

Eamonn Maloney (Dublin South West, Labour)
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I thank the contributors. All of us value the role of the public health nurse. While we value it, we must also be honest with ourselves because in many respects I believe it is largely taken for granted. Public health nurses never got public recognition for their role as somebody who monitors not only the health of children but also their welfare. It is an unspoken fact that in some of the cases I am aware of the public health nurse was the first person to go to the authorities about welfare issues for children. That is seldom acknowledged. We know what we are talking about here, given our hidden past and the abuse cases that have been highlighted. That must be said.

I wish to refer to something that was brought up by public health nurses in my locality. There was great hope with the 1999 report, and Ms O'Dowd referred to the report in her contribution. As politicians can say, it was high on aspirations and recommendations but, without putting Ms O'Dowd's future nursing career in jeopardy, there is a very strong feeling among public health nurses that nothing substantial came out of it. It should have. The report was well intentioned, but it did not enhance the role of public health nurses in terms of recognising the work they did. It is disappointing, and we are playing catch-up since. Is that a view she would share about the 1999 report? It referred to preschool children as well as others.

Catherine Byrne (Dublin South Central, Fine Gael)
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I thank the witnesses for their presentations. I recall when I came home with my first baby and the fear and anxiety I felt when the public health nurse first called to my door. It is something most young mothers experienced at the time. When one closed the door after the public health nurse left there was a sigh a relief that one was taking care of one's baby properly and doing all the right things. One felt capable of taking on this new challenge.

I thank the public health nurses. As a public representative I have occasionally had to call upon them for a number of different things in the community. For me, the link is on a daily basis with the people living in the community, not only the children the nurse deals with but all the people in the community and the generational links among families. That is very important. I know people who are having their babies now who still have the same public health nurse their parents had. That is an indication of the commitment of the public health nursing community. A few days ago I spoke to a new mother who had just arrived home from hospital. She spoke about the excellent care she had received within the first three days during the visits from the public health nurse. She was overwhelmed by the fact that somebody took the time to visit her and her new baby.

I was struck by the comment in the presentation that there are no national performance indicator measures. I am not sure what that means but who has the responsibility to do that? How is it done and how is the information collated? That is important. What links do the public health nurses have with women's groups in communities? Are there times when they might visit them or link with them on certain things that happen in communities? That is important as well. Many young mothers who are parents for the first time can be very intimidated by somebody calling to their home, but if there is a link to a community, women's or young parents group they are involved with it could be important.

Ms Mary O'Dowd:

I acknowledge that this committee is a sub-committee in regard to the new child and family agency. For that reason we thought it opportune to meet with the committee to discuss the current programme for Government and the introduction of the new agency. The politicians' constituents are our constituents as well. We serve the same group of people in the local towns and villages. John's presentation clearly demonstrated the length and breadth of the role of the public health nurse. The main point of our presentation is to inform the committee of the breadth of the role of the public health nurse and what we see as an opportunity to have a dedicated child health workforce and the need for it.

To refer to the members' questions, two members raised the matter of key performance indicators, KPIs. Key performance indicators are common within the health services and there are many of them. There are two within the child health service at present. One relates to that critical first visit. We are very proud that it ranges between 87% and 100% in respect of being on the person's doorstep within 48 hours. The second relates to the seven to nine months visit. As I said, that ranges from 38% to 100%, so obviously there no equity there. Both members asked where they emanated from. John can answer this better than me but there is a group within the HSE that examines and determines what should be the key performance indicators. There is none for the four subsequent visits, the preschool visits and the school visits. Again, it requires somebody to focus on that and develop those. However, we have systems for two of them. Hopefully, that answers that question.

With regard to the dental service, that is a separate service and I am not in a position to answer Deputy Ó Caoláin's question. I would not be familiar with it.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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It does not come under the nurse's remit.

Ms Mary O'Dowd:

No. Obviously we refer to it while screening during a home or clinic visit but we are not involved in the dental service in schools.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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That is okay.

Ms Mary O'Dowd:

The Deputy referred to the report by Dr. Sean Denyer and others entitled Best Health for Children published in 1999. It was a very good document which recommended a screening programme and, subsequently, a package was developed. I wish that I could sit here and say to the committee that the report was rolled out in every area in the country since 1999. Sadly, the report and the recommended training has not been fully implemented.

The Deputy asked me to identify the eight areas that have the scheme. Off the top of my head I recall that the programme was originally in Limerick and was subsequently launched in Donegal, Sligo and Kilkenny. I can only guess the remainder but I know that there are eight areas.

Under the scheme a parent holds on to the record and when he or she visits a GP or goes for a hospital appointment the visits by the public health nurse and any developments are recorded. The record is shared, comes in electronic form and provides lots of data. People may argue that the system needs to be updated but it is a good system.

A question was asked about the dual role of a public health nurse. A public health nurse is assigned to a geographical area. Did Deputy Crown ask a question?

John Crown (Independent)
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Do not demote me.

Ms Mary O'Dowd:

My answer covers his question as well. Public health nurses are assigned to geographical areas and the literature states that the recommended ratio is one nurse per 2,500 people. As I speak there are many nurses looking after between 7,000 and 10,000 people due to a colleague being on maternity leave, the moratorium or whatever.

Let me explain the workload of a public health nurse. She will have a clinical caseload but must also deal with child health. Her clinical caseload will be the priority. We argue that child health will be squeezed out of the system unless we focus on the child health part of the public health nurse's role. I hope I have answered the Senator's question.

Models vary and the model used here is not unique. Most other countries have split the service into two groups, child health and adults and older people. I hope that answers the question on health models.

Senator Colm Burke asked a question on hospices.

Colm Burke (Fine Gael)
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I have spoken to Senator Norris about the variation in hospice care and Ms O'Dowd spoke about variation in her presentation.

Ms Mary O'Dowd:

Yes.

Colm Burke (Fine Gael)
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I specifically want to focus on obesity in children under three years of age.

Ms Mary O'Dowd:

Obesity levels in the age group of one to three years are alarming. The Senator asked if there are programmes to address the problem and I can confirm that there are national groups and strategies to address the problem. The public health nurse is the most ideally placed to address the problem. Some areas screen for obesity but there is no national screening programme in schools. There has been a debate about rolling out such a scheme and the most appropriate time to do so. The public health nurse can contribute to the scheme and she is ideally placed to enhance it. Is that okay, Senator?

Jerry Buttimer (Cork South Central, Fine Gael)
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The Senator can comment again in a few seconds.

Ms Mary O'Dowd:

Deputy Maloney mentioned that the public health nurse is key when it comes to the welfare of children. A public health nurse is one of the first to refer a case. Statistics show that over 47% of children referred to the child care system are referred by the public health nurse.

The 1999 document Best Health for Children was not so much a policy document as a blueprint for screening. There was investment in the scheme at the time because it was during the Celtic tiger years. However, the scheme was scattered. The parts that were implemented were really good in some places. There are areas that still have not had the full training recommended in the report and the Deputy was right to point that out. The report recommended a screening programme.

I hope that I answered Deputy Catherine Byrne's question on key performance indicators. She also mentioned women's groups. I can reassure her that most public health nurses are aware of the women's groups. The public health nurse is the central person in any community and links people with all care groups in a local area.

Mr. John Hennessy:

I have been heartened to hear about the positive experiences that Deputies have had with the public health nursing service. It is probably not often that we start on that positive footing in this forum. It has been heartening to hear the comments and good wishes.

Jerry Buttimer (Cork South Central, Fine Gael)
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We try to be fair in this forum all of the time.

Mr. John Hennessy:

I will be delighted to pass on those positive comments to the staff and I am sure that they will appreciate the comments.

With regard to Deputy Ó Caoláin's question on national performance indicators, I shall not repeat what Ms O'Dowd has said. She has covered most of the questions on the issue. The indicators that crop up on the HSE's routine performance monitoring system are the 48-hour visit performance; the immunisation and child development check metrics which involves the percentage uptake achieved in each of the areas around the country; and the performance and delivery of child developmental checks within the prescribed period. The monthly performance metrics reach the management team's table where they are monitored extremely carefully and variances that emerge get escalated to the national management team. I am aware of some particular variances that are of concern.

With regard to future of the service, I do not disagree with the point made by Ms O'Dowd that a task needs to be done. As the incoming primary care director I will engage with the various stakeholders in the system, including the patients and users of the service, in order to discover the appropriate performance measures and metrics for the public health nursing service. The ones that we use are useful and provide a good picture of how the system performs. The performance measures are probably inadequate and not comprehensive enough so we must do more. That will be a priority for me. The consultation process with stakeholders in the system, including the institute, will assist in developing a more robust set of performance indicators for the public health nursing service.

I will briefly mention dental health and answer the question on oral dental health. Dental health does not arise in public health nursing but forms part of the primary care dimension which has performance metrics that are monitored on a very regular basis. The latter entails the delivery of dental checks at primary school takes place at the commencement and end of the primary school term and the follow on treatment, including orthodontics, that ensues from those oral health checks. Children are monitored. If there are delivery problems in local areas due to staff shortages, etc., then they are addressed in the monitoring process. We publish the details in our monthly performance review which can be found on the HSE's website.

I shall ask my colleague, Dr. Shannon, to comment on child health records. A record is very important and the scheme is a great opportunity. There have been pilot schemes in the past five to ten years and I am sure that there will be questions on why it did not progress into a national system. I will be happy to explore that issue as the incoming primary care director and it will be a major priority for me. Dr. Shannon will comment more on the subject at the end of my contribution.

Senator Crown raised the issue of numbers per head of population. Do we have the numbers, Dr. Shannon?

Dr. Michael Shannon: Yes.

Mr. John Hennessy:

Senator Crown raised the issue of the numbers per head of population. I think we have numbers per head of population, which we will publish as well. It is probably worth noting that there are variables in regard to crude numbers in that issues of population age and deprivation indices have a significant factor on the numbers. I think we have the numbers here and we will be able to share them.

Ms Queally will comment on Senator Colm Burke's question on obesity and this major health issue. I see early intervention as an important priority for the future public health nursing service, to which we are moving.

Deputy Maloney acknowledged the value of the service and the fact it is probably taken somewhat for granted, with which I would not disagree. As to whether the role has changed, I would disagree with that point. The role has changed and the public health nursing service has taken a very robust role in the development of community intervention teams over the past five years. It has been hugely proactive in the immunisation programme and in moving towards a leadership role in that process. It is heavily involved in the clinical care programmes, which have been a significant success across the health service and which are achieving results. I agree with the Deputy on being taken for grant but not on the change.

Deputy Byrne acknowledged an issue, which relates to the core issue the institute raised in regard to spectrum of service, namely, pre-natal care through to old age and whether that should be separated out to sub-specialties. That is the key point being raised here, that is, whether we split the service or whether we devise suitable mechanisms within the service to specialise in important areas such as child health.

We have an oversight committee in place, addressing the transitioning of the child and family services from the HSE into the new agency. I would be keen to refer this question for consideration and further attention. We have new directorates commencing very shortly in areas such as primary care and health and wellness and this will be a key issue for those two directorates and an important factor in whether the programme of work for those directorates will be successful. I acknowledge the point and the reasons for it being raised but we need to tease out some of the implications of that and I would be happy to do that with the institute and the other stakeholders in the system.

Dr. Michael Shannon:

I thank the Chairman, Senators, Deputies and colleagues from the Institute of Community Health Nursing. In the context of the record public health nurses keep, I am in this position two years and it has struck me on visits to public health nursing services throughout the country that there is some uniformity in the record system and that there is a variety which has been developed locally to meet local needs. Over the past year, we have commissioned, in partnership with the Institute of Community Health Nursing, a pen drive which is working in Dublin north and which is a universal system to gather data around records and information for public health nursing that will feed into the performance indicators of the HSE but, importantly, for patient care and client outcomes and, specifically, for indicators for the public health nursing service itself. We have just evaluated that very successfully and, in consultation with Mr. John Hennessy in his new role, we will look to roll that out.

Senator Crown asked for figures, etc. The total public health nursing service, which excludes the student public health nurses, is 4.51 per 10,000 of population. He asked how it compares internationally. My colleague, Ms Mary O'Dowd, made the very valuable point that the public health nursing model here - I am very proud of the public health nursing community in this country - is very different to that in other countries, including the UK and Sweden, so it is very difficult to make comparisons because the actual function and role of public health nursing in Ireland is somewhat different from other models internationally.

Ms Martina Queally:

Senator Burke's point is well made. The obesity issue is a very serious one facing the country. The public health nursing role is crucial to that because many of the issues around obesity arise very early on and, indeed, prevention is much better than cure. While there is not a formal screening programme, elements of screening are done by the public health nursing service - in terms of developmental screening - and weight measurement is one of the important parameters of that screening. At each developmental screening from birth, the child's weight will be monitored. Initially, the concerns would be failure to thrive or insufficient weight gain but as time goes on and as the child grows, it is monitored. Issues such as breast-feeding, which public health nurses promote, are crucial to maintaining correct weight. We now know from some of the evidence that babies who are breast-fed are less likely to become obese. Weaning practices are very important in terms of weight management later on, as are early childhood nutrition and family nutrition. All these education issues are within the remit of public health nursing, so they are crucially important. Sometimes it is very easy to identify the things we do not prevent but if we are preventing things well, it is harder to measure. The public health nursing role is critical to that.

There is also the new clinical care programme around obesity. The public health nursing role in that clinical care programme is crucial. Their work as part of the primary care team, as Mr. John Hennessy said earlier, is critical because there are other elements to that. Many of the dietitians in health promotion are moving across to the primary care teams. We have some very successful programmes, such healthy food made easy, of which Deputy Byrne has been very supportive over the years, with health promotion and public health nursing. That is a community-based nutrition and advice education programme, which has been very successful and has shown very good outcomes.

Equally, our interventions with the broader population, such as schools, are very important because children must maintain participation and activity in order to maintain a certain weight. Nutrition is one element but obviously physical activity is another. Issues, such as playground markings or local sports partnerships, which the Government has supported, are crucial to maintaining a healthy active young population which grows into a healthy active adult one. It is critical that public health nurses are part of that broader primary care team and work in that integrated way with community partners and internally with health professionals.

Colm Burke (Fine Gael)
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We have identified the problem of obesity. There is only so much public health nurses can do. Is there something else we, the Department or the HSE can do to give a level of support to public health nurses to deal with this issue, even if it is providing more information? It is a frightening problem given that 25% of children are obese at three years of age. What is the witnesses' view on that?

Sandra McLellan (Cork East, Sinn Fein)
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I welcome the witnesses and thank them for their presentations. Like other members of the committee, I acknowledge the valuable work done by public health nurses. We have all had experience of them and all have been positive experiences.

I hope I will not be repetitive. I had written down a number of questions, many of which have been dealt with, so I will skip over some of them. The ICHN's briefing document indicates something of an issue in regard to accurate data for public health nurses work in terms of child health services.

The briefing documents from the Institute of Community Health Nursing raise the issue of accurate data for public health nurses working in child health services and states there are no key performance indicators for the delivery of the school health nursing service. We also see that parent-held record is only in use in eight former LHOs. There are gaps in the data. Are they significant and how can the data be improved?

I agree that many people need specialised care. Generally in health care it is likely that those who need the services most have greater difficulty in accessing them. Do those who are disadvantaged such as the economically marginalised, minorities and Travellers have difficulties in accessing these services?

A review of public health nursing services was commissioned by my colleague, Dr. Michael Shannon, director of the office for nursing and midwifery, in 2011, with the assistance of the public health nursing service and the Institute of Community Health Nursing. An expert group was chaired by Dr. Joe Clarke, primary care clinical lead, and the review was completed and published in March 2012. It has helped to inform future policy on the integration of services and the delivery of efficient and safe care to clients in the community. Mr. Hennessy referred to a review by his colleague Dr. Michael Shannon and Ms Martina Queally and stated: "It has helped to inform future policy on the integration of services and the delivery of efficient and safe care to clients in the community." Will they outline how the provision of public health nursing will be improved following that review? On the provision of nurse-led services for sub-populations, those with diabetes and chronic heart failure, I presume this will be a considerable task; for example, the number affected by diabetes is considerable and perhaps rising. How will this affect the service? Will more public health nursing work be conducted in the primary health care centres which are being built and is it likely that the workload will increase and in what areas is it envisaged to increase?

I think all of the other issues have been covered.

Regina Doherty (Meath East, Fine Gael)
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I apologise for being late, but I had briefed myself on the subject. I pay particular tribute to public health nurses because of my experience of the public health nurses in the Dunshaughlin health centre who are outstanding. I have had four children and they have been absolutely magnificent to me and I am now dealing with them on the issue of elder care provision. They are second to none and, as Deputy Caoimghín Ó Caoláin said, the relationships built are not lost. I met the lady delegates a number of weeks ago. As a result of that meeting, I was prompted to have a conversation with my mother and her sister on public health nurses. Deputy Catherine Byrne touched on this point. The reputation of public health nurses in the past was very different from my experience. I view the public health nurse as a person with expertise who will respond to a telephone call and will come and visit someone. I looked forward to their visit because I had at least 15 questions for them. My mother and her sister were absolutely petrified to see a public health nurse coming to the door for a number of reasons. They were probably much younger when they had babies than my generation was. They did not know what they were doing. They were probably in fear of criticism and critics, but obviously they now see the service in an entirely different way.

My fear about the establishment of a new child and family agency - I would like this point to be elaborated on - is that if it is established without the complete co-operation and support of the public health nurse system and not in collaboration with PHNs, it could be perceived and may well be perceived by the general public as a child protection agency, as opposed to a family agency. We may find ourselves going back to a stage where people were fearful of the public health nurse. We could find ourselves going back to having women and families fearful of the public health nurse coming to the front door. That would be a significantly retrograde step. What can this committee do to change the establishment process and bring the public health nurse into phase 1 of the establishment of the child and family agency?

Ms Mary O'Dowd:

I thank Deputies Sandra McLellan and Regina Doherty. In relation to the data to which Dr. Shannon has alluded, there are really good systems being developed within the public health nursing service. Dr. Shannon referred to the population health information tool which was developed by a nurse, Ms Ann McDonald, who has progressed it to what we call a "digifit". That certainly addresses the need in relation to data, if it is accepted and rolled out. There are plans afoot to improve the data and really good data could be extracted in the use of this tool.

I refer to children with complex needs. Children with very complex needs are being discharged from paediatric hospitals. They will require specialised nursing care. Again, it favours the argument for a specialised child health nursing service.

We are all aware that the health profile of and life expectancy among marginalised groups is much lower. Again, there are pockets where there are really good programmes for marginalised groups. In so far as they can do so, their needs are addressed locally. However, there are variations. Again, the public health nurse is the key person who is aware of the families concerned and can address some of their health issues.

l was delighted to hear the comments on nurse-led clinics. We are making ground in the community and the benefit for clients is that they do not have to attend hospital but can stay at home

Jerry Buttimer (Cork South Central, Fine Gael)
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How does Ms O'Dowd see the public health nurse service playing out in the evolution of primary care services in the next couple of years?

Ms Mary O'Dowd:

Public health nurses have been central to the primary care teams since the roll-out of the programme in 2001. There are good examples where it is working really well. I know it is a work in progress; some work has been done, but there is a lot more to be done. Mr. Hennessy referred to some examples of nurse-led services, with clients being able to access oncology services at home.

Deputies Catherine Byrne and Regina Doherty referred to the relationship with the public health nurse. That is a piece of magic which one cannot write in policy. It takes investment in the way the relationship evolves. The critical question concerns the new agency. We must be creative. The institute is quite interested in working with the HSE and the agency to see how best we can deliver child health services. We are not included in phase 1. We can argue why we are not a priority because it was recommended by the task force that we be a priority. We are here to familiarise ourselves with the current issues. We must go back to the drawing board and see how best we can deliver child health services. It may be a mix and match that will link people between the agency and primary care services. The debate needs to start on what will happen next. My fear is that because we are not included in phase 1, the debate on child health services will be delayed again.

Jerry Buttimer (Cork South Central, Fine Gael)
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Does Ms O'Dowd think it will be delayed further?

Ms Mary O'Dowd:

We are not included in phase 1.

Jerry Buttimer (Cork South Central, Fine Gael)
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What do we need to do to get to phase 1?

Ms Mary O'Dowd:

As far as I understand it, the gate is closed. My point is that we need to be creative in how we address these child health issues

Mr. John Hennessy:

I do not think the gates are closed. In fact, they are open and opening even further. I will explain the reason. A number of very important points were raised in the contributions, on which I would like to comment. I know Ms Queally and Dr. Shannon wish to comment also.

On the question of performance indicators, particularly on the issue of school health, we have acknowledged that the need for data is a significant issue. I have prioritised it for my agenda on the 2014 service plan, the preparations for which are under way.

Jerry Buttimer (Cork South Central, Fine Gael)
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When is that due to be published?

Mr. John Hennessy:

Around the time of the budget, which is in October this year.

Jerry Buttimer (Cork South Central, Fine Gael)
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Okay.

Mr. John Hennessy:

It will be earlier this year anyway. It will give us an opportunity to take a careful look at what is counted and reported, and at how performance is measured within the system. There is a balance to be struck between asking people to count, report and spend their time compiling data and asking them to treat patients and deal with their priorities. There is a role for technology in this respect. It is clear to me and others that what we have at the moment is not an accurate or comprehensive reflection of the scale and scope of what is carried on in the school health programme. I would like to make it more robust by adding some qualitative metrics to the crude number-crunching and number-counting that is taking place at present. It is easy to say that, but it is more difficult to do it. Somebody has to compile it and prepare the statistics. There is a fine balance between deploying staff to do that and deploying them to deliver front-line care. We have to strike that balance. I acknowledge that we need to demonstrate performance and activity in a much more effective way than we are doing at present. I hope to make inroads in that regard in the 2014 plan. This process will involve engagement with the stakeholders in the system, including the institute and our own staff internally.

I would like to respond to the important points made about the child health record. It is a huge opportunity for parents to own and hold the child health record for their child. It is probably the most appropriate and safest place for that record to be held. I see an opportunity to expand on those pilot areas. I am conscious that if this were easy, it would already be done. Obviously, there are difficulties. A number of technology issues are probably associated with the extension of this. I am happy to explore it further

The critical question of access to services for minority groups and disadvantaged groups arises in particular in the context of the issues of health care outcomes and equity and fairness in the system. I will ask Ms Queally to tackle that issue and make some comments on this critical area. The achievement of outcome equity as well as access equity is an important objective. This means focusing on disadvantaged groups in the design of health care systems. I am aware of a number of pilot projects around the country that aim to address this issue by examining how the design and delivery of the service can suit the needs of particular groups, as opposed to the vast majority. I am well aware that Travellers, for example, can fall through the gaps in the generic delivery system. Ms Queally might comment a little more on that.

One of the future primary care priorities is to ensure primary care becomes a far more productive part of the bigger health system. For practical purposes, that means moving an awful lot of activity that is currently conducted in hospitals out of that environment and into primary care centres. I am particularly focusing on areas of diagnostics, particularly primary diagnostics such as ultrasound and endoscopy. There is also a focus at the other end of the spectrum on chronic illness. Significant amounts of activity in both areas can be conducted safely and appropriately in primary care settings. It is pretty inevitable that this will increase the workload. It is more appropriate. In the future, it could determine whether hospitals and community settings work effectively and productively. The objective of the exercise, as far as I am concerned as the incoming director of primary care, is to reduce the number of routine patients who turn up in acute hospitals every day and every week and transfer that activity to primary care.

I acknowledge the good experience mentioned by Deputy Regina Doherty. It is good to hear that she has availed of our modernised public health nursing service. I appreciate her concern, which is shared widely, that the children and family agency may become a child protection agency only. I acknowledge the concern that the public health nursing service may engender fear in households rather than receiving a supportive reception. It is a hugely important point. I will have to discuss it with my colleagues in the new department and in the HSE. We have to ensure we avoid that risk. I would see it as a retrograde step. I note the Deputy's concern about this critical issue.

Before I ask Ms Queally to speak about equity in the system and Dr. Shannon to take on the questions about obesity, it is worth repeating that the HSE and the institute have shared objectives in respect of a number of issues that have been raised today. It is useful for us to explore the model of public health nursing and service delivery. It is pretty clear to me that we have a shared objective in improving the health of children. Major emerging issues such as obesity have been raised. It is important for us to get good value for money. The public health nursing service is an expensive service but it is also a well-qualified, well-trained and well-focused service. It is important for us to get good value and good productivity from the resource and a good return on the investment. I will not make any excuses in that regard. This will be a priority for me. It is also hugely important for us to get consistency across the country. It is fine to have good pilot projects and models in certain areas, but we need to ensure that is applied consistently across the country. Likewise, we need to achieve fairness in the system in terms of equitable access and equitable outcomes from the input of the entire health service but particularly the public health nursing service.

Dr. Michael Shannon:

I might take the questions asked by Deputies McLellan and Regina Doherty together, if that is okay.

Jerry Buttimer (Cork South Central, Fine Gael)
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I would like to apologise on behalf of Deputies Ó Caoláin, Naughten and Catherine Byrne, who have had to go to other meetings.

Dr. Michael Shannon:

A question was asked about the future policy and vision for public health nursing, which is absolutely critical in the context of what Mr. Hennessy quite rightly said about the consistent and uniform delivery of public health nursing right across the country. Since I qualified as a nurse in 1985, a great deal has changed with regard to the role of nursing, the education of nurses, how nursing fits into health care governance structures and how nursing supports the broader disciplines. When I took up my current position two years ago, we compiled a report on the current public health nursing services - it was in our brief to do so - in partnership with key members of the public health nursing community, including our colleagues at the Institute of Community Health Nursing. The report, which was published in 2012, outlines the current roles and governance structures within the national public health nursing teams. Since then, I have been working closely with all the directors of public health nursing in Ireland. We have been working on the development of a position paper to clarify the roles and functions of those who support primary health care teams and, critically, support patient care in the community. There has been a discussion in that context on the role of a universal health care public health system, a specialised public health nursing system such as the child health care system, or other best practice international models. When the paper is presented to me at the end of the month, we will talk to Mr. Hennessy and our colleagues about models and options for best practice in public health nursing.

I would like to mention that what has evolved over public health nursing services over the years is that we have very competent and well-educated professionals. These are supported now by registered general nurses, a new evolution in this country over the past number of years in the context of skill mix. We must also ensure that we look at a national educational model for registered general nurses and the public health nurses for the future. We will bring proposals on that to Mr. Hennessy and his colleagues in early July in the context of suggestions on best practice for the future role of public health nurses.

Members also mentioned the issue of diabetes. In the context of nursing and the diabetes clinical care programme, we are very fortunate that we have employed quite a number of clinical nurse specialists in diabetes over the past year to support patients, both within the community and acute services. We have a shared care model that is evolutionary and follows the patient from hospital to community or community to hospital. The linchpin or critical point is that we now have a clinical nurse specialist in diabetes working with our public health nurses, acute hospital nurses, practice nurses and with the wider teams, such as GPs, primary health care workers, etc. I am very confident that the shared care practice for nursing and diabetes has developed significantly over the past year.

Ms Martina Queally:

With regard to Travellers and asylum seekers, these are just some of a number of sub-groups within the population the public health nurses serve well. The issue with regard to these sub-groups relates to quality of service and outcomes. Some specialist programmes have been put in place to ensure Travellers, asylum seekers and others can access the services in the same way as does the mainstream population. There is also significant peer-led education to get across the difficulty of any cultural boundaries there might be. This is an important area for development because we do not want to see the statistics improve for the services but for the gap between the mainstream population and these sub-groups to widen. In this regard, Mr. Hennessy referred earlier to looking at resources and how they are deployed and taking some of the social indicators into consideration in terms of deployment.

Senator Byrne asked what the solution was to the question of obesity. I believe we must develop a multiple strategy that is multisectoral. The new Healthy Ireland strategy indicates that the responsibility for some health promotion activities must be shouldered by the health sector, but other sectors must also show a much greater interest in this area. Ireland is probably good in regard to doing this because as a smaller country it is easier to build relationships between sectors. The issue is not just related to one sector. It is about public policy, the choices available in terms of food and the education and health sectors working together. Our farming community and public policy on pricing are also factors.

Regina Doherty (Meath East, Fine Gael)
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I should have wished Mr. Hennessy the best of luck in his new role. I am delighted he said the gates are not closed and that he will talk again to his colleagues. The agency will be set up this year, so, no pressure, but will Mr. Hennessy do that sooner rather than later? Will he come back to us shortly with his thinking on that?

Mr. John Hennessy:

I would be happy to do that.

Jerry Buttimer (Cork South Central, Fine Gael)
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I congratulate Mr. Hennessy on his appointment and wish him well in his new position. I am sure we will see a lot more of him at this committee. I also thank Ms O'Dowd, Ms Catterson, Ms Queally and Dr. Shannon for attending. I thank them all for their tremendous work and hope they found this meeting beneficial and useful.