Oireachtas Joint and Select Committees
Wednesday, 17 October 2018
Joint Oireachtas Committee on Health
New Standard Operating Procedure for Assessment of Need under the Disability Act 2005: Discussion (Resumed)
This morning, we are meeting representatives of the Irish Association of Speech & Language Therapists, IASLT, in respect of the standard operating procedure, SOP, for the assessment of need under the Disability Act 2005, which was recently commenced by the HSE. Members will recall we met occupational therapists, the Psychological Society of Ireland, PSI, the Dedicated Children's Advocacy Warriors, DCA Warriors, and the HSE on 27 June and, therefore, this is a follow-up meeting.
On behalf of the committee I welcome Ms Vickie Kirkpatrick and Ms Deirdre Kenny of the IASLT. I draw their attention to the fact that by virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence 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. Witnesses are directed that only evidence connected with the subject matter of these proceedings is to be given and are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person or entity by name or in such a way as to make him, her or it identifiable. The opening statements submitted to the committee may be published on the committee website after the meeting.
Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official either by name or in such a way as to make him or her identifiable.
I invite Ms Kirkpatrick to make her opening statement.
Ms Vickie Kirkpatrick:
I thank members for inviting us here today. The IASLT welcomes this invitation by the Oireachtas Joint Committee on Health to address concerns about the HSE's standard operating procedures on the assessment of need. Our colleagues from the PSI and the Association of Occupational Therapists Ireland, AOTI, along with the parent group, DCA Warriors, addressed the committee earlier this year on 27 June. I thank the members for meeting us today and giving us the opportunity to meet with them.
The IASLT is the recognised professional association of speech and language therapists, SLTs, in Ireland. It provides up-to-date information for the public to aid in the understanding of speech, language and communication needs, as well as that of feeding, eating, drinking and swallowing disorders. Some of its aims include: establishment and maintenance of professional standards in SLT practice within Ireland; evaluating, accrediting and monitoring of speech and language therapy training courses in Irish universities; representing the profession at national and international level; supporting continuing professional development through education and research; and co-ordinating the gathering and dissemination of relevant information to promote the exchange of professional information.
As the committee heard, my name is Vickie Kirkpatrick and I am the chairperson of IASLT. I am joined by long-standing IASLT full member, Ms Deirdre Kenny. We are delighted to have this opportunity to speak to the committee about the concerns of our members and the risks the assessment of need, AON, SOP poses to the children and families we support. Having recently reviewed the transcript and video of our health and social care professional colleagues' presentations in June, the IASLT wishes to echo many of the concerns presented and expand on those specific to SLTs.
First and foremost is consultation. Concern was raised by our members about the absence of formal consultation. While 8 September 2017 is reported as the date of the HSE consultation on the AON SOP, members have reported that notice of this meeting was poorly communicated. The short notice meant that front-line clinicians who had pre-arranged appointments and front-line obligations could not attend. Furthermore, the IASLT never received formal invitation to this meeting, nor has it received a copy of the AON SOP to date. Information on the AON SOP came to the IASLT's attention via our own members.
The lack of consultation with SLTs is further evidenced by the inadequate definition of communication in the SOP. SLTs hold expertise in speech, language and communication needs, and absence of a proper definition poses risks to the identification of such needs. Further consultation could be considered through partnership with the HSE's own health and social care professional, HSCP, office, which co-ordinates many working groups with representation from various health and social care professionals, including SLTs who represent the IASLT. They work collaboratively with stakeholders to facilitate a unified voice for health and social care professionals. One of the office's key aims is the co-ordination of HSCP input to design, plan and implement strategy within the HSE. Collaboration between the HSE disability operations and the HSCP's offices would ensure appropriate governance, terms of reference and operational recommendations are in place.
The IASLT welcomes the plan for progressing disability services and recognises the need for standardisation of assessment of need. Appropriate consultation and collaboration are vital, however, for appropriate and effective change management to ensure the best outcomes for the children and families we support.
The need for resources - those being human, infrastructure and IT - to support the implementation of Progressing Disability Services for Children and Young People was widely discussed at the committee's previous meeting. We welcomed the acknowledgement by Dr. Morgan that disability services have been under-resourced and are hopeful that the 100 posts announced in the recent budget are part of a multi-year programme of investment. As previously mentioned by our colleagues in the Association of Occupational Therapists of Ireland, AOTI, chapter 9 of A National Model of Care for Paediatric Healthcare Services in Ireland outlines the need for detailed workforce planning for health and social care professionals at primary, secondary and tertiary care level. The operation of this standing operating procedure is challenged by these resource issues across both social and primary care.
One key challenge to speech and language therapist, SLT, staffing is the length of time it currently takes to replace vacancies. It can take six to eight months from one staff member walking out the door to a replacement SLT arriving. Experienced, knowledgeable staff members who avail of promotional opportunities are often replaced with less experienced staff who need more time to upskill in the clinical area and join the new team. The new clinician may not have been trained up in some of the assessments required to determine the presence of a disability. The standard operating procedure as outlined cannot work without a properly trained team with the necessary skill mix.
We know from talking to the families we work with that they want the right care for their child in the right place and at the right time. If children could access the intervention services they need in a timely fashion there would be a reduced number requesting assessments under the Disability Act and the need for this standard operating procedure would be greatly reduced.
Margaret Lennon of DCA Warriors identified the need for Irish data on the numbers of children presenting with disability. If we are to adequately meet the needs of children and families we need to collect information on prevalence and incidence of disability and its subtypes in Ireland.
As to best practice guidelines, Irish Association of Speech and Language Therapists, IASLT, members are bound by the IASLT code of professional conduct and ethics of 2015. As practitioners in the Republic of Ireland, speech and language therapists must hold registration with the Health and Social Care Professionals Council, CORU, under the Health and Social Care Professional Act of 2005. The assessment of need standard operating procedure is in breach of the following sections of the code - to "act within the best interest of the service user"; and "a member shall also appropriately address concerns regarding policies, working conditions, actions or inactions of others which compromise the care of service users or public safety". For speech and language therapists, as with other health and social care professionals, assessment is a dynamic and ongoing process whereby clinicians rely on their training and experience to assist parents in setting goals to meet the child and families’ needs. The preliminary team assessment as outlined in the standard operating procedure is in many ways a breach of this. In many instances a complete diagnostic assessment is required to ensure appropriate differential diagnosis. Differential diagnosis is essential for clinicians to make recommendations regarding appropriate pathways of intervention. Without complete diagnostic assessments, children and families will be unable to access additional services such as home tuition; autism spectrum disorder, ASD, special classes; or, other specialist placements. Such recommendations are not possible without comprehensive diagnostic assessment. The standard operating procedure will result in delays in accessing appropriate interventions as well as accessing the most suitable educational placement, thus placing additional stress on the families.
Finally, the code of professional conduct and ethics further states that "members should take any time necessary to sensitively communicate their decision/s with the service user and family members, in the context of the constraints of confidentiality". The standard operating procedure is intended “to ensure that children and their families access appropriate services as quickly as possible”. However, in its current form, in some areas, it will place additional demands on teams that are already struggling in provision of services. An audit of assessment of need practices across the country would highlight areas where assessment of needs have been of benefit and the reason for the bottlenecks. An audit would ensure all children with suspected disabilities access services in a similar manner, as well as highlight the barriers in other areas where assessments of need are either under or over utilised, and establish why this is so? The absence of an audit results in a ‘one size fits all’ model without considering local differences. Furthermore, the limitations of the preliminary team assessment will breach best practice regarding the HSE’s own policy on informing families.
We have outlined the main issues for speech and language therapists in relation to disability services, but also want to summarise some recommendations, many of which have already been identified by the HSE. These include detailed workforce planning; collection of data on incidence and prevalence of disability in Ireland; developing an implementation plan for progressing disabilities services utilising existing structures including the health and social care professional, HSCP, office; and, consultation in relation to proposed changes using the HSE change model.
In conclusion, IASLT recognises the need for standardisation of procedures for the assessment of need process. However, the increased demand for assessments of need must be evaluated and an appropriate response put in place. IASLT welcomes formalising structures for appropriate consultation with the HSE, the HSE’s disability operations officer, as well as with the Minister for Health to ensure services developed adhere to best practice guidelines for both our clinicians and the children and families they support.
Ms Kenny and I welcome the opportunity now to discuss this further and answer any questions further.
I thank the Chair and both Ms Kirkpatrick and Ms Kenny for coming in here this morning. It was my idea originally to highlight what are obvious difficulties with the new proposed standard operating procedure. The original meeting was my idea. Apologies if our guest speakers were left out on that occasion and I hope that we can all move on together. It was not intentional. As highlighted by Ms Kirkpatrick and Ms Kenny this is not just about speech. People think that speech therapists just deal with speech but as the disabilities spokesperson for Fianna Fáil, I am aware that the witnesses' profession does much work with swallowing, eating and all functions of the throat. Sometimes the general public are not aware of that which is good to highlight.
The assessment of need is a major problem in any event and these new proposals are making a bad situation worse, in my mind. It is like a yellow pack assessment of need, for want of a better word. In the opinion of our guest speakers, do they see conflicting requirements from clinicians in general and do they believe that the preliminary team assessment is contrary to the spirit of the Act, especially concerning the 90 minutes that is so short, and in my opinion, very insulting to have such a limited time for assessment? I am aware that Ms Kirkpatrick and Ms Kenny spoke about meetings on short notice, etc. Was the whole thing drafted without any concrete consultation with their association?
The standard operating procedure proposes that only children who have "complex and significant needs" access an assessment of need. In my opinion, complexity is very subjective. This will lead to problems and I would like to have the association's views on this point. Does the association believe this will lead to misdiagnosis and wrong diagnosis?
Ms Vickie Kirkpatrick:
I thank Deputy Murphy O'Mahony. I will start with the easiest point as to the process. The document was created without any consultation with us. Members have reported that it has been a knee-jerk reaction towards trying to manage the large increase recently in those waiting for further assessment of need.
On the preliminary team assessment suggestion, having not been around the table when this came into being, the Act deals with the determination of disability, and the steps required to do that. It is never straightforward. Often best practice requires a multi-disciplinary approach to do that. One of the solutions would be the implementation of disability network teams under Progressing Disability Services for Children and Young People, if that was implemented.
The objective is for parents to have one point of access. Over time there have been delays in accessing services. Our members are seeing parents going an AON route to ensure they can access services rather than going with the provisions of the Disability Act 2005, per se. It is very likely that without an audit people might wait in an AON queue when it was never designed for that purpose, particularly with regard to the level of complexity of the needs of the people in that queue. It is one aspect of the wait list numbers.
The risk of misdiagnosis is widespread with the current form of standard operating procedure. As I mentioned in my opening address, speech and language therapists, occupational therapists and social workers are currently regulated. Physiotherapists and psychologists will soon be regulated. This is to protect the public and ensure we do not engage in any practices that might put people at risk. It is our duty to highlight the risks that this presents. Even if the time changes, autonomous practice is required to ensure clinicians have the scope to meet the emotional needs of families. We heard that very much from the DCA Warriors. It is correct that speech and language therapy is not just about communication or feeding, eating, drinking and swallowing. A therapeutic relationship is formed with people because of the nature of communication. Working with younger people this takes longer to develop that trust in the family context. We need to gather the information in a timely fashion.
I would be as bold as to suggest that the issue with the wait list in AONs is not how long it takes us on the other side to do an assessment but rather the volume. Clinicians work as teams to ensure best practice and that work is the most important aspect of the process. If we audit and quantify it, this would not be the piece delaying the numbers at the door. Does that make sense?
Ms Deirdre Kenny:
With regard to the preliminary team assessment, my understanding is that the idea came from services being reconfigured under the progressing disability services programme. There is an initial meeting with families and it is something similar to the preliminary team assessment. There is a first meeting and then they go straight into either interventions or pathways. Services are set up to meet needs in intervention and there is an initial meeting with the family to consider the family's goals and what path to set it on.
Ms Deirdre Kenny:
I do not know where the timeframe came from. The initial assessment was fairly time-bound and it led straight to interventions. The difference comes in that most parts of the country have not been reconfigured. These people are waiting on the AON and are not accessing intervention straight away. Between getting assessment of need and the time accessing intervention, there could be a gap of one, two or even three or four years in places. In doing a short summary assessment at the start, one cannot give the family something to go away with for the next four years. If there were reconfigured teams behind this, they could meet the families and set them on an intervention pathway very quickly. It relates to the nature of operations.
I echo the point that has just been made, as it would not be early intervention if people must wait years for it. It falls at the first hurdle under the definition. I thank the witnesses for coming in. When we discussed this previously, one of the matters raised concerned the inconsistencies throughout the country. My question is simple and concerns models of best practice. Do we have individual models of best practice? Where we have models of best practice and where they are working, is that just associated with resources? One often hears the process is working in a certain area and the work in that area should be modelled; this implies that everybody else is not working hard or smartly enough. Generally, when we drill down, we find the areas where a new scheme, idea or policy works generally have an association with resources. I am interested to know if that is the way the witnesses see it. Does this explain the geographical inconsistencies?
Reference was made to the recent budgetary announcement and the possibility of recruiting additional personnel. I assume the same difficulties regarding recruitment and retention exist in speech and language therapy as in other areas. Will the witnesses comment on that briefly, although I acknowledge it is not the specific issue before us? In the context of a multi-annual programme, I share the optimism of the witnesses but it is all it is. What was announced was just a one-off number and there was no hint there would be any multi-annual funding associated with it. Will they comment on that? The introduction of a new or rearranged SOP will not change anything unless there are resources and staff but I am interested in their comments.
Ms Vickie Kirkpatrick:
I will address the matter of numbers and models and Ms Kenny might speak to recruitment. With respect to best practice models, from the numbers given to us by the disability operations office in June that were shared with the committee, it is not hard science. Those with the lower numbers are in places that have reconfigured. One of the barriers for clinicians on the front line, or even most important for families, is the one point of access. We echo Dr. Morgan's point that it is not only about human resources for those posts; it is also about restructuring and models of best practice. We had that model with its publication in 2005 through to 2009. The greatest challenge is that a change of that magnitude requires front-end investment and project management, as well as lead-out. It cannot be done in a vacuum. It is a big restructuring process. My suspicion is the places where there has been change are smaller and it has not been as cumbersome to restructure them. This is all the more reason for proper project management and investment to manage the change required.
We heard figures in the previous session about investing now because of what the cost would be later. It is again about ensuring that a workforce is in place. The workforce in health and social care has increased exponentially over the past 15 years with Irish clinicians training at top universities. The programmes are recognised. The IASLT enjoys mutual recognition with the United States, Canada, United Kingdom, New Zealand and Australia. Our graduates are recognised and, therefore, we have the power to produce highly qualified professionals. It is about the structures in place and not necessarily about a targeted number of posts. It is important that there be a structure to facilitate one point of access for families. The tiered model moves into a social model of care rather than an impairment model. The other struggle is even in terms of legislation. The Disability Act 2005 was a great advance for people with disability in Ireland but as legislation it needs to continue to grow and modernise. It is an impairment-based model in terms of what people can and cannot do, which is difficult when a person is three years old.
Ms Deirdre Kenny:
It was a good question about recruitment and retention. The last time there was workforce planning, it followed the Bacon report of 2001. There have been recommendations from the HSCP to look at workforce planning nationally.
We are working on old information.
The reason clinicians generally leave is because they might be looking for promotional opportunities or they want to move around the country. Their initial placement might be somewhere they do not ultimately want to live. There is anecdotal evidence that the urban centres might be suffering because it is so difficult for people to afford live in Dublin.
The second half is around replacing those who leave posts. There might be a post that becomes available and there is interest in that post, but the length of time recruitment is taking is an issue. There is a national recruitment service, the Health Business Services, HBS. There are panels in place and when one person walks out the door, one must submit the paperwork locally. It has to go through local pay bill. That can take however long, depending on where budgets are at the local area, before it ever goes to national recruitment. When a person walks out the door, one has a whole-time equivalent post but it may take six to eight months for somebody else to arrive in to that post. Not only is nobody being seen in that length of time in that particular setting but when the new person comes in, he or she needs to be inducted. It might take longer to upskill. I refer to all that extra time on top of the length of time the post has been vacant.
The speech and language therapy is in primary care and social care. Where a child at 12 months is not talking, the public health nurse may say that he or she will refer the child to a speech and language therapist in primary care. When the child comes to that speech and language therapist, she may recognise that it is a much more complex disorder - potentially autism spectrum disorder - and then look to refer on to a disability team. Depending on waiting lists, the child may have waited 12 months to see an SLT in primary care and then have to wait another 12 months or longer after he or she is assessed.
In terms of the work practice, as speech and language therapy, nationally, in primary care, we have looked at a review of how we can deliver services better. There is a report sitting in the HSE that has yet to be published which looks at how we can improve the way we work in primary care.
I welcome the witnesses from the Irish Association of Speech and Language Therapists. I have a long association with the disability Bill - one withdrawn, there was a second one and then, finally, it passed through the Houses of the Oireachtas in June 2005. That was a time of great hope and expectation, that has been badly dented in a number of ways. Emotionally and otherwise, that is where I am coming from in this discussion. The focus on starting with the children and moving along was a practical one in the Act and made sense.
I will respond to some of the points the witnesses made. Ms Kirkpatrick referenced Dr. Cathal Morgan stating here in June last that disability services were under-resourced and hoped that the 100 new posts in the budget which we are all delighted with would be part of a multi-annual provision. Ms Kirkpatrick is at least hinting that there is more needed to do this work.
Then there was talk about replacement and churning of staff, with experienced staff moving on and less experienced staff coming in. Ms Kenny mentioned it takes six to eight months from when somebody goes out the door to get his or her replacement. My question is twofold. The first is a difficult one to be scientific about the answer. In terms of the need for professionals and therapists to deal with this issue, is the bottle half full or half empty? I accept there are many other issues as well. It is important to get some sense of what step change the witnesses feel needs to be made. Second, is allowance made for the effect on teams, including various allied health professionals and clinicians, of somebody stating, "I am out of here. I am moving on. I am going somewhere else." or has everyone their fingers crossed every day hoping that their staff will stay there forever?
Reference was made to the risk of misdiagnosis being prevalent. I do not know what is meant by "misdiagnosis". What I mean by that is often it is about getting from symptoms to a cause. Somebody presents with a symptom or symptoms. Ms Kenny talked about someone being referred to her by the public health nurse and Ms Kenny stating there are possibly other things going on here and she cannot deal with it. It is easy to talk about the person having a condition. In many cases, the person might have symptoms on foot of which he or she needs interventions but that is very different from knowing what are the root cause or causes. What is the impact? How is that dealt with? When we talk about early intervention, there is this idea that it is a matter of whether one can get in to see the speech and language therapist, then it takes time to go and be seen again, and the children have gone through two or three pairs of shoes in the meantime. How does the operation of the Act deal with the greater complexity in getting from symptom or symptoms to a diagnosis? I suppose what I am getting at is often one needs to intervene before one has the final diagnosis. Is that an impediment or how do they work around that?
The final little cluster of questions I have relates to what the witnesses stated on a number of occasions about restructuring. I want to use the words "culture", "approach" or "attitude" in the same discussion. Are there different areas in the HSE where maybe the same resource gets worked better? Clearly, I started off with issues about resourcing but I suppose I am suggesting that is not everything. It is about how one harvests and uses the resources. Are there places that are better able to get product from those resources, by which I mean better support the children and their families?
Ms Deirdre Kenny:
I will start with the resources and how that links in to where things are working. The National Disability Authority came up with the figure of 400 therapy posts and that was without detailed workforce planning. I suppose when we talk about the 100 posts versus 400, that is already 25%.
Ms Deirdre Kenny:
Across the board, yes. We talk about the 100 posts and where that will fit. I suppose that is where the workforce planning really needs to be done and the audit around the country of how different services are resourced and how they are operating. We are relying on anecdotal evidence because we do not have an audit of what is working well around the country. It would be useful to conduct such an audit.
In terms of whether one is going into work crossing one's figures hoping nobody will leave today, our managers conduct workforce planning as much as they can within their services. They know they have some clinicians who have been working with them for five years, are looking for promotional opportunities and are waiting on the next appropriate promotion coming. There are staff one might be looking at who one knows will be going when the right opportunity arises. No matter how much one might be supporting them and they might enjoy working in an area, they are obviously looking for that next step. One cannot replace that person until he or she leaves and one has gone through the forms. No matter how much one is prepared for staff leaving, one cannot shorten that time to replace them.
That is at a local level. Is there somebody or some entity in the HSE going back and stating, whether it is occupational therapists, OT, speech and language therapists or whoever, that in the past year X per cent moved, in the previous year Y per cent moved and one can anticipate a figure?
In Ms Kenny's trade, how many people are coming out of college every year in Ireland?
Ms Deirdre Kenny:
Approximately 100. The health business services, which carry out recruitment, have working groups pertaining to the various professions. We try to solve problems at that level and highlight the difficulties. That is the national group in which we look at recruitment. I understand the HSE is reviewing those services at the moment.
I spoke about primary care and the disability team level. In regard to the impact of symptoms, I refer again to the example of the one year old who is not talking, has no words and is not interacting. The speech and language therapist care meets him or her in primary care. Depending on how services are set up, that child may get some intervention at primary care level while he or she is on another waiting list. However, if one has cancer, one wants to be seen in a specialist cancer centre. It is not desirable to have a GP manage those symptoms. We can manage those symptoms to a certain level and give the child's family some ideas and strategies. However the long-term management of the needs of that child and family needs to be done in a specialist centre where a team works together, as opposed to one clinician offering the family some supports. While they might get some support and manage some of those symptoms, to give that child the service he or she needs, the family needs the benefit of a team.
Ms Deirdre Kenny:
The issue is the waiting time. We have the specialist disability services-----
Ms Vickie Kirkpatrick:
On the point of not having enough services, sometimes there is not a clear transition from primary care to the disability service because the progressing disability services for children and young people programme has not happened. There is an administrative issue as well.
That comes back to Ms Kenny's point about the specialist teams. As clinicians we play a continuous role. It is a dynamic process, working with people around their communication and language development, especially around their social and communication skills. For example, a lot of discussion during the earlier session concerned ASD. A cohort of experts analogous to a cancer expert, as Ms Kenny put it, does exist, but the wait times for their services are long.
The Disability Act 2005 created a mechanism to capture the need that was not there previously, the legal right to an AON. However, my understanding is that it was designed for complex disability, with the non-complex cases to be managed within primary care. Our models for intervention have evolved, developing a social strength-based aspect. We are always working towards people's strengths and their ability to achieve, not their impairments or their disability. Finding those strengths is so much a part of what we do to help children and families to meet their goals.
Ms Vickie Kirkpatrick:
Without a clear audit of who the AON applications are made by, it is difficult to say. Perhaps the HSE has drilled down into the type of people on those AON wait lists, the scope and the access to service they are seeking.
There is also suspicion that people access the waiting list as a way to access service rather than accessing their disability rights. Does that make sense?
I welcome our guests and thank them for attending. I have a couple of questions. The witnesses made reference to collating data but collecting data is equally important. To what extent have they been in a position to collect as much data as possible, as quickly as possible? The collation comes after that, but the collection is obviously the first part of it.
Has the IASLT had competition from overseas for the skills set within the sector? Most other sectors have had challenges from overseas and difficulty in retaining staff. I would like the witnesses to comment on that.
Waiting times seem to be a problem everywhere. Is this entirely due to a shortage of staff? Are there other issues? Is it a shortage of staff plus appropriate skills, or a combination of all of those?
I had occasion in the past to visit other countries where different treatments are available. In the old days, oddly enough, Hungary developed a particular set of skills and treatments that seemed to be better or had more effect than what was available in this country. In some cases they had a dramatic effect. I would like a comment on that.
I have recently been dealing with the case of a child with ASD who has been receiving home tuition, having previously been in a special class. When moved to home tuition, the child improved dramatically. The child's condition worsened in the special class, apparently because of having to compete with the surroundings. There had not been the same level of individual attention one would expect from home tuition. I would like the witnesses to comment on that.
Reference has been made to a report that is on the shelves of the HSE. How long has it been there? When is it likely to be published? There is not much sense in issuing reports. The world is great at issuing reports. All Departments are good at reports, but after that nothing happens. The first thing that has to happen is that a report must be published.
Ms Vickie Kirkpatrick:
I will start with the first two queries and return to structure and workforce planning. In regard to collating data and drilling down into it, IASLT is not privy to its own specific data. The recommendation is to form a clear understanding of where the health and social care professionals are currently situated in the HSE and in the sections 38 and 39 organisations. It is desirable to map that to ensure disability teams are set up on the basis of best model practices. As we mentioned, the national model of care for paediatric healthcare services in Ireland recommends a ratio of 1.5 speech therapists per 100 children with disabilities.
As I said in reply to Deputy O'Reilly earlier, the need for project management to implement that change must be examined. It is important to set up systems that can measure our effectiveness and link with Irish universities to deliver training and programmes that are evidence-based and play to people's strengths. That is what we need to allow people to live life to the full based on their ability in the spirit of the UNCRPD.
In terms of challenges for overseas, during the crash a number of Irish clinicians emigrated, particularly to the UK, Australia and New Zealand. We were privy to that as they wrote to us seeking letters proving their membership of their professional body. While I do not have figures with me, I believe the numbers emigrating have decreased considerably in the past two or three years and Irish graduates are finding employment within Ireland.
In terms of the personal example the Deputy gave of a little boy with autism moving from a special class in a school to home tuition, there could be many reasons for that. Again, without assessment or making choices or a long-term plan for what that child needs both at home and in school, it is difficult to say why the family felt that was particularly successful. Certainly, in my clinical experience, I have found that setting up structures is extremely important. This means setting up a team, drawing up an education plan and a home plan to ensure the steps are in place to support the child at home, at school, in the community, at the swimming pool and at the airport. Again, I am giving an answer in the broader sense and I apologise for being unable to answer the question specifically.
On ways of working and the shortage of staff, I ask Ms Kenny to address our current numbers in workforce planning.
Ms Deirdre Kenny:
On the question of staff shortages versus skills shortages, it is probably a little bit of both. In addition to the time needed to recruit, we also have a number of staff on maternity leave, parental leave and sick leave. In many cases, these staff are not covered or may only be covered for a short period. When covered is provided, it is done by agency staff who would not be familiar with the area, the team or the children. While this cover is of some benefit, these staff need significant upskilling. When the team gets new permanent staff we upskill them as quickly as possible. Most areas have induction and supervision processes in place to provide this for new staff. In some areas the ratio of senior staff to staff grade employees across the health and social care professional, HSCP, structure is such the number of senior staff available to support these processes is limited. Senior staff generally have more experience and clinical skills whereas someone at staff grade could be a new graduate therapist. We have a supervision structure between senior staff and staff grade therapists across most of the HSCP structure.
The report I was referencing is a primary care speech and language therapy review. I understand it was completed in June 2017. Again, the IASLT was not involved in it. The HSE requested speech and language therapists in its organisation to examine this so we do not know what is in the report either. We know that the people who were involved in writing the report also want it to be published in order that we can look at it as a profession and see how we can make changes. That is at the level of primary care, which will obviously influence children who are accessing disability services. It is specific to primary care.
Aside from the issues they have already raised, will the witnesses identify the two most important issues affecting the manner in which they deal with their workload and the extent to which a child needs specific attention?
Ms Vickie Kirkpatrick:
One would be easy access for parents. Families and children need to be put first and their voice needs to be heard in terms of what makes sense for them. We heard repeatedly from people that they do not know where to go when something is going wrong with their child. In terms of the public health nurse and having that first point of contact, that should be the easiest, simplest and most direct way of proceeding. By the time I have met parents in my day job, they have navigated a daunting labyrinth. As a clinician, I then have to peel away all those walls to work with them because they are so hardened by the journey to get that far. It should not be that hard.
The second most important issue is the focus the Disability Act places on developing people's strengths and playing to their ability. As clinicians, there is a culture there - somebody used the word "culture" earlier - but it needs to be celebrated and watered, so to speak. It needs support and structure to facilitate the bringing on of people's strengths. That requires a multidisciplinary approach based on evidence and centred on the family and the children. It is hard to mention only two key issues. I could mention more.
The witnesses are very welcome and I thank them both for their time. I want to get their views on the delay in access. Ms Kirkpatrick said parents were negotiating a labyrinth to try to even get access to speech and language therapists for their children. How long is it taking to get an assessment? Once parents decide there may be an issue with their little boy or girl that needs to be looked at, how long does it take to get an assessment for the child? Following the assessment, if it is deemed that speech and language therapy is required, how long does it take to get the therapy?
Ms Deirdre Kenny:
If we are looking purely at a speech and language therapy difficulty as opposed to a complex disability, if a child has a primary speech and language difficulty, or if that is what is picked up first, and the public health nurse refers or the parents pick up the phone, ring the speech and language therapy team and put their child on the referral list, as they usually can, it then depends on geography. In some areas a child will be seen for assessment within four months. In the majority of areas, the aim is to see children within 52 weeks. It takes longer than that in a small percentage of areas. In one area, people will wait three or four months, while in another area people will wait for a year. After that assessment, if a child requires therapy it again depends on geography. In one area, the intervention may take place within six weeks of the assessment, while the waiting time may differ in another area. The health statistics show that more than 90% of children are seen for their first therapy session within 52 weeks but approximately 10% of referrals are waiting longer than that, including some who are waiting for up to two years. Again, that intervention depends on where one lives.
The way speech and language therapists often work with families on these types of difficulties means that it is not a matter of a one-off intervention. It is not the case that a child comes once, we give the answer, and we never have to see the child again. Some of these children are coming for long periods of time. The way the system and the waiting list operate means that, in those areas where resources are stretched, a child might wait 12 months for assessment, a further 12 months for therapy and then he or she might only get six or eight sessions. The child then goes back on the waiting list for another year. It is very much based on geography. In some areas, a child will be seen very quickly, whereas a child living elsewhere may wait much longer.
Ms Deirdre Kenny:
I do not have the figures with me but I know that CHO area 6 is one that is doing well. CHO areas 7 and possibly 4 are among the outliers in which people are waiting longer. The health statistics are available on the HSE's website but the most up-to-date figures were not available when I last checked.
These are significant variations, with children waiting between six months and three years depending on where they live. Will the witnesses give us a sense of the missed opportunity caused by this variation of two and half years between those waiting for six months and those waiting for up to three years? Will they describe the missed opportunity for the children who must wait an additional two and a half years?
Ms Vickie Kirkpatrick:
We might look at child development and the developmental process, whether in terms of speech and language therapy or other health and social care professions.
In the context of child development and speech and language, one must remember that all social interaction is based around communication. If communication is not happening and parents are not learning strategies to facilitate it, there are considerable risks for additional learning, beginning school, literacy levels and so on. It is important to be aware not just of developmental language disorders but also other physical milestones being missed. We must look at the whole child. Child development can be assessed through play, motor skills and language. While we do not have a crystal ball in terms of what will happen as children with speech and language difficulties grow up, there is strong evidence to suggest that there will be serious repercussions in terms of achieving in school and so on.
Ms Vickie Kirkpatrick:
This goes back to the issues of data and workforce planning. We do not know where the gaps are in terms of service delivery and lack of data means that we cannot make reliable projections. I referred earlier to the Bacon report from 2001 but there has been nothing as extensive done since then. That report made projections out to 2015. Many good things came out of the Bacon report, including the development of three more programmes for speech and language therapists which increased overall capacity in Ireland to enable us to meet the increased need for services at both paediatric and geriatric levels.
Some of the variation is related to workforce planning, retention difficulties as well as the time it takes to replace staff and to build up a team again. In some areas, staffing arrangements are in continuous flux. I also suspect that it is more difficult to recruit in some places than in others.
There is a relatively simple view that if children have to wait for two and half or three years in Kerry and Cork for speech and language therapy, we must hire ten therapists now and when they are hired, we must be nice to them so that they do not leave. If they need to go on maternity leave, their absence should be covered. For the love of Jesus, if we know that children are waiting for three years, why is the HSE not hiring the therapists needed to bring those waiting lists down?
Ms Vickie Kirkpatrick:
Deputy Donnelly will have to ask the HSE that question.
Ms Kirkpatrick represents the therapists. I have asked the HSE and it has given me very convoluted answers, amounting to no more than the fact that life is terribly complicated. Sometimes, however, it is not terribly complicated in that we just need to hire people and be nice to them. I am asking Ms Kirkpatrick, as the representative of therapists, why it is proving so hard to hire therapists in these areas.
Ms Deirdre Kenny:
I will respond to that question, if I may. It is not that it is difficult to hire staff. Posts can be filled when they become vacant but part of the problem is the length of time that takes. Another issue is staff taking different types of leave and that leave not being covered. In areas where there are very established staff who are not going anywhere, one tends to have more maternity leave, parental leave and sick leave. As the Deputy said, in order to retain experienced staff one must be nice to them so requests for leave are granted. The issue then is that the HSE does not cover that leave which results in gaps in service.
In terms of what works well, a review of primary care speech and language therapy services was conducted to see if we could make improvements to the way we work. We know that the more clinicians one recruits, the more children will come to the door. The easier it is to access services, the more people will start recognising that they are having difficulties. There is a proposed model in this report to change the way we work to meet the needs of more children. A recent schools project initiative created some extra posts for speech and language therapists and occupational therapists to determine if working in schools is more effective. In some of the very disadvantaged areas of Dublin, for example, greater numbers of children are presenting with communication difficulties compared with their peers in other areas because they have not had the same opportunities. The project is looking at whether therapists working in schools and training up teachers and parents will improve outcomes and is also looking at how that will fit with primary care services. We recognise that we could do more at a universal and targeted level and this project is looking at whether changing the way we work will be beneficial. As speech and language therapists, we acknowledge that we can improve the way we work but the report is sitting in the HSE.
If I may, I will go back over this again. There is an urgent need to hire speech and language therapists everywhere, but particularly in certain parts of the country like Cork and Kerry. Is it that the HSE is not trying to hire therapists or that it is not willing to pay them enough? Is it that the HSE in certain areas has a bad reputation as an employer and word has got out among therapists that they should not go to work for the Cork and Kerry community healthcare organisation? Is it that the HSE is not trying to fill the posts or that it is trying to do so but it has a bad reputation in certain areas, or is it that the HSE is not willing to spend enough money? Are these jobs located in a part of the country in which speech and language therapists do not want to work? Why are not enough people being hired to serve these children?
Ms Vickie Kirkpatrick:
I will attempt to answer that. I am here today representing the Irish Association of Speech and Language Therapists but I am also a clinician in the field. Historically, many promises were made regarding the implementation of the HSE's progressing disability services plan. My experience tells me that these issues will be resolved when we progress. In terms of disability services waiting lists, there are 1,700 people waiting for assessments of need in Cork and Kerry but there was a reluctance to hire people because the proposed restructuring of the health service meant that the HSE did not know where they would be located. As a result, nothing happened and we are at a standstill.
While the progressing disability services plan is not perfect, it is at least a step into the 21st century for Ireland but it will require funding. It is not just a question of funding posts but also of developing strategies to implement enormous change for staff in section 38 and section 39 organisations as well as the HSE in order that they can work collaboratively. We need funding to build teams and to make sure they are properly co-located. In some ways, the project almost seems too big. The process of resolving these problems is at an impasse.
That is frustrating because, on the face of it, it is such an easy problem to solve. We have 1,700 children who need help so we need to hire the people who can help them. We seem to be able to manage it in other parts of the country.
I thank the witnesses for their responses. I have one last question on latent private sector capacity. Fianna Fáil wants a public healthcare system that can deal with this. However, as with inpatient and outpatient services, the waiting list numbers are going up and up. One of the short-term measures that is working is the NTPF. Anecdotally, I am hearing that a fair number of our nurses working in the public system are moving over to the private system because the working conditions are better. Staff are treated well and staffing ratios are much better. They may not be getting more money but the working environment is much better and does not have the highly objectionable stresses and strains that are a feature of the public system.
Is it the case that we have enough speech and language therapists in the country to serve the population and that we are seeing a migration of them everywhere or in some places from public health posts to operating in private practice? If this additional private sector capacity exists, would an extension of the National Treatment Purchase Fund as a short-term sticking plaster be something that could be used to reduce these waiting lists and get these children, who have been waiting three years, the help they need?
Ms Vickie Kirkpatrick:
I do not have numbers but Ms Kenny does. This has been looked at in terms of procurement but the Deputy would have to ask the HSE. I am not sure about areas with regard to managing the assessment of need numbers. From a practical point of view, without real planning we will just create a bubble elsewhere in the system. Telling people they have a disability without the dynamic assessment we spoke about earlier and without planning for intervention means they will just sit somewhere else, so to speak, and then we will run the risk of privatisation of interventions. The way it might differ from the medical model is that someone going for hip or heart surgery will get better but people with a disability may have a lifelong condition and they might need to dip in and out. A system that, from the get-go, can give people strategies because the structure contains a one-point access would be simpler.
A Band-Aid solution would be very short-sighted in terms of supporting families for an assessment. We are more than our assessments in terms of what we offer families.
Ms Deirdre Kenny:
On specific numbers, we can look at how many members we have in private practice. We have some records. Anecdotally it is a small number. Many therapists who work in private practice do both. They might work in the public sector and also do some private work. Traditionally it has been a very low base although it has improved. We can get the figures for the Deputy afterwards.
How do speech and language difficulties feed into the educational system? Obviously they lead to educational deficits. If there is a delay in assessment and treatment, how does it feed into the primary school structure? What levels of support are needed in the primary school structure to look after these children? How do we compare internationally with other countries in our approach to the assessment of need and the delivery of services? As has been outlined, the waiting times are unacceptable. How do we compare with other jurisdictions with regard to staffing numbers, training, recruitment and retention?
Ms Deirdre Kenny:
I will refer to the educational element. There is a very strong link between communication ability and literacy skills. Children who start school with very poor communication and pre-literacy skills struggle in the educational setting. I understand schools have reorganised and try to identify children very quickly when they start school. They have also reorganised how they support these children in school and are looking at their programmes in this regard. If children start school with poor communication and speech and language skills, they have significant difficulties accessing the curriculum.
Ms Vickie Kirkpatrick:
I do not have particular statistics on how people access services, but with regard to speech and language therapy, it depends on the governance and the various systems in place. Waiting times in social healthcare are problems in many places. It is about how to create a solution that fits the local level. In my home place of Ontario in Canada, there could be various waiting times along the pathway, which is why in the Irish context the pathway should be as straightforward as possible with a one-point access for families. This is the purpose of the national access criteria. There is a HSE document on ensuring that, from public health nurses to assessment of need officers, there is a transparent pathway for parents to navigate with regard to wait times.
With regard to rationing services or denying children services at an early stage, they do not go away and their problems multiply. If they are not dealt with in the preschool environment, we end up dealing with them in the school environment, which means the child does not have the same opportunities and the expense transfers to the primary school system where we have special needs assistants and various other supports for children who should have had these supports before they ever went to school in the first place. Surely there is a false economy in not providing the service at the first and earliest opportunity.
Ms Vickie Kirkpatrick:
I believe there is a report in the UK that £1 spent saves £4 later. I can get the report with regard to this knock-on effect in the system and why early assessment of people's strengths and needs means structures can be put in place to support them and, where further assessments are required, onward referrals can be made.
It shows the disconnect between our health service and our educational service. There is a huge link there and Professor Dolan often speaks about the social determinants of health. The health service not supplying the service means the educational service must supply additional services. It does not make any sense not to have joined-up thinking.
I thank the witnesses for their presentations. I apologise for missing some of the meeting. I was in the Seanad dealing with the availability of therapeutic services for children with autism in a school. The Minister for Health had come to the House to deal with the queries I had on the matter. One of the responses he gave me was that a review is being carried out that is supposed to be delivered in the second quarter of 2019. Is the IASLT involved in looking at each area? They witnesses may have dealt with this question, and if so, that is fine. I will go back over the transcript. I imagine that in each HSE area the ratio of speech and language therapists per head of population is the same. Has the southern region been looked at in this regard? Are the numbers far lower in real terms compared with other areas? The Minister has announced that more than 100 speech and language therapists are to be employed. We need to prioritise where they should go. Has the IASLT been involved in any discussions on this issue?
A major concern I have with the HSE is that it has taken on an additional 12,000 people since December 2014, which is greater than the entire workforce of the Irish Army. I wonder about value for money. For argument's sake, we may have an area with a higher ratio of speech and language therapists than other areas but a longer waiting list. Has any examination of this been done with regard to whether there is a particular way the service is being organised that leads to the delays being caused? I came across an issue in dermatology where one particular area had many more specialists than other areas but the number of cases they were dealing with was less than 50% of what was being dealt with in another area that had fewer specialists.
That is one issue that needs to be examined. If we employ additional speech and language therapists, what level of backup facility and ancillary staff supports would need to be put in place? It is like appointing a medical consultant to a hospital but not providing additional beds, nurses or accommodation to carry out a clinic to ensure he or she can do his or her job. Has this been examined when dealing with the HSE or the Department? One can have a therapist appointed but there might not be facilities to carry out the work and or the support staff to arrange simple things like appointments. Has that been examined?
Ms Deirdre Kenny:
As far as we were aware, the 100 posts recently announced were across all therapies. We would be grateful to take them all for speech and language therapy, however.
Looking at disability waiting lists, it is not enough to have speech and language therapists because we work in teams. To make a diagnosis, one needs psychologists, physiotherapists and occupational therapists. In terms of disability teams, more speech and language therapists alone will not solve many of those issues.
The Senator referred to a review in 2019. That is the first we have heard of that.
This is in the southern region. It was contained in reply to a Commencement matter I received this morning. It stated:
HSE disability services is currently engaged in a major reconfiguration of its existing therapy resources for children with disabilities into multidisciplinary, geographically based teams as part of its national programme on progressing disability services for children and young people ... The HSE is working towards having the progressing disability services model in place in Cork by the second quarter of 2019. It is expected that this will facilitate access to therapies for all children with disabilities.
Ms Deirdre Kenny:
In terms of the infrastructure, if one employs speech and language therapists, accommodation is a significant issue in some parts of the country. There is nowhere to put therapists or there is not enough office space. While many new primary care centres are being built, they do not always match up to where the staff need space or where the clients might be based.
The Senator referred to support staff for appointments and administrative work. I do not know if anybody has mapped what the ratio should be of therapists to support staff. It is a valid point that could be examined.
Ms Vickie Kirkpatrick:
It is interesting the Minister of State confirmed the implementation of the progressing disability services model. One issue around the implementation is adequate project management. The Senator spoke about resources. In some places, physical resources have been a significant issue such as co-location of sites, desks, computers, assessment materials and toys. These are all the pieces for a clinician to do his or her job collectively in terms of offering training to parents. It is interesting to hear this is moving forward. It is to be hoped resources will be put in place to facilitate that. It will make some of it a little bit easier and, one hopes, it will contribute to knowing what types of posts these 100 need to be and where they need to go. It is not necessarily around having additional people but having the resources and structures in place in order that the clinicians and front-line staff can meet the needs of the families and children.
Has better delivery with the existing resources been examined, as well as blips in the system? Overall, the HSE has taken on an additional 12,000 people in three years, a significant number of people. However, we are still finding waiting lists like this. In my dealings with the HSE, I have found there is meeting after meeting but, 18 months later, there is no real progress. Why does that happen? Is it the case of meeting for the sake of it or meeting with a genuine commitment to improve the service?
Ms Vickie Kirkpatrick:
In retrospect, when documents have been produced, we have.
In terms of the role of the professional body to support its members on the front line and ensuring they are working within best practice guidelines to support families, our advice has been sought through the National Health and Social Care Professions Office. That structure has worked well in hospital settings for clinical care programmes where clinicians who represent a professional body contribute to documents which are then implemented. Our recommendation would be for a similar sort of relationship for governance and reference. It is important to ensure that changes called for by clinicians on the ground can happen.
On the document in question, as a professional body we are not consulted about it. Speech and language therapists in the HSE contributed to that document but it has yet to be circulated. We suspect that, again, it is about changing our practice. We know that there are always ways to move forward to improve services, reduce waiting lists and work more efficiently. Working efficiently also means effective representation and being invited to contribute in a meaningful way.
Ms Deirdre Kenny:
Ms Kirkpatrick referred to the speech and language therapy primary care services review report. Speech and language therapists working in the HSE have put together this document which the HSE has. We are waiting for it to be published. That is a recognition that we need to change and look to improve how we deliver services at primary care level.
The progressing disability report has outlined how we can improve delivering disability services. It will be implemented in the second quarter of 2019. That will go some way to providing solutions to some of the current issues.
The visions are there for how we can improve how we are working. We have that information from those pockets where they already have progressed and reconfigured.
Were other therapists, such as physiotherapists, psychologists and occupational therapists, consulted on improving the services? Is it that speech and language therapists were unusual or that other groups were not consulted as well?
Ms Vickie Kirkpatrick:
My suspicion is that consulting the health and social care professionals, outside of the doctors and nurses within a medical model, is often an afterthought. In terms of disability, we are often the first point of contact. Contributing at a higher level and ensuring the structures are there for us to contribute are paramount. I do not think speech and language therapists were consulted.
Not engaging with front-line staff would lead to significant deficits.
Such staff have huge input into how services are delivered and into identifying what are appropriate services. On behalf of the committee, I thank Ms Kirkpatrick and Ms Kenny for giving of their time to be here this morning. Following on from the committee's meetings in June and this morning, we will be producing a report, which, hopefully, will be available in the next month or so.