Oireachtas Joint and Select Committees
Thursday, 17 November 2022
Joint Oireachtas Committee on Disability Matters
Disability, Mental Health and Ageing: Engagement with Minister of State at the Department of Health
We have received apologies from Senators O'Loughlin and Clonan. The purpose of today's meeting is to discuss disability, mental health and ageing. On behalf of the committee I welcome the Minister of State at the Department of Health, Deputy Butler; Ms Siobhán McArdle, assistant secretary and head of social care, mental health and drugs policy, and Dr. Philip Dodd, mental health policy and clinical specialist in the mental health unit, of the Department of Health; and Mr. Niall Brunell, principal officer, disability policy unit of the Department of Children, Equality, Disability Integration and Youth. The Minister may call on officials to speak briefly for clarification during the meeting where a specific or technical point arises. The officials can clarify issues for the committee. Any follow-up questions should be put to the Minister because she is the person accountable to the committee. I am aware there is a wide range of issues to be discussed today. If necessary, further and more detailed information on certain issues raised can be sent to the clerk to the committee for circulation to members. Before we begin, members are reminded of the long-standing parliamentary practice that they should not comment on, criticise or make charges against a person or entity by name in such a way as to make him, her or it identifiable or otherwise engage in speech that may be regarded as damaging to the good name of the persons or entity. Therefore, if a statement is potentially defamatory in nature to a person or entity, the member will be directed to discontinue their remarks. It is imperative that such direction is complied with. I call on the Minister of State at the Department of Health, Deputy Butler, to make her opening statement.
I thank the Cathaoirleach and members for the invitation to this meeting of the Joint Committee on Disability Matters. I am joined today by Ms Siobhán McArdle, assistant secretary, of the social care, mental health and drugs policy division and Dr. Philip Dodd, mental health policy and clinical specialist, in the Department of Health; and by Mr. Niall Brunell, principal officer, disability policy unit of the Department of Children, Equality, Disability, Integration and Youth.
The Government is committed to providing universal access, under Sláintecare, to integrated, person-centred health and social care. We are also strongly committed to enabling people with care needs, at all ages, to live independently in their homes and communities for as long as possible and to reorienting the model of care towards primary and community care to support this. These objectives underpin policymaking and service delivery across the intersecting domains of ageing, mental health and disability, which are the focus of our discussion today.
Improving access to home support is a priority for the Government and home support hours in communities are increasing in line with enhanced investment. Next year, the overall home care budget will be more than €700 million and approximately 24 million hours of home care will be delivered. The dementia-specific proportion of new home support hours will increase from 5% in 2021 to 15% in 2023, valued at €5.2 million.
Delivering this enhanced capacity requires substantial recruitment. In March 2022, I established a cross-departmental strategic workforce advisory group to examine the challenges in front-line carer roles in the home support and long-term residential care sectors. The advisory group’s report was published on 15 October and makes 16 recommendations spanning across recruitment, pay and conditions of employment, training and professional development and sectoral reform. Implementation has commenced.
The development of a statutory scheme for the financing and regulation of home support services is advancing at pace with the development of primary legislation for the licensing of home support providers and of regulations to underpin the new licensing regime. HIQA is also developing national standards that will underpin the ongoing quality enhancement of home support services.
There will continue to be a requirement for long-term residential care for service users with very complex care needs and a range of reforms are in train to address this. These include community support teams to assist with infection prevention and control, as well as the recent launch of the national nursing home experience survey.
Many disabilities are acquired as we age. Article 25(b) of the United Nations Convention on the Rights of Persons with Disabilities, UNCRPD, indicates that states are required to provide relevant health services to people with disabilities and specifically highlights older persons in this regard. The Government is working to ensure that people with disabilities are enabled to live an independent life of their own choosing. There has been a consistent increase in the number of hours of personal assistant, PA, services delivered to people with a disability under recent HSE national service plans.
In day services, we have moved to person-centred support based on individual needs. This is a vital service for many people with disabilities and dementia and an important source of respite for family carers. The sum of €2.1 million has been provided in budget 2023 to ensure that dementia-specific day care centres can return to full capacity. This is in addition to €1.7 million for the continued provision of dementia-specific day care at home, which suits some people. Increased investment in dementia supports is already making a difference in the lives of the 64,000 people living with dementia and their families in Ireland today. The national intellectual disability memory service is in operation and we now have memory technology resource rooms and dementia advisers nationally.
Early next year, the HSE will launch a model of care for dementia, which will outline clear care pathways for people living with dementia, from identification of symptoms through to assessment, diagnosis, disclosure, care planning and post-diagnostic support. The UNCRPD makes no distinction between a physical or mental impairment and the convention applies also to persons experiencing mental health or psychosocial difficulties.
The Government and I are committed to the reform of mental health services in Ireland to ensure that everyone has access to the highest quality and most appropriate services to meet their needs. Since I took office in 2020, my focus has been to implement the five mental health clinical programmes on adults with attention deficit hyperactivity disorder, ADHD, self-harm and suicide ideation, eating disorders, early intervention in psychosis and dual diagnosis. I am also progressing the mental health intellectual disability model of care and the specialist model of care for mental health services for older people to provide more consistent and linked-in services across the country. I was particularly pleased to launch a new ADHD app for adults recently, developed by the HSE, ADHD Ireland and the UCD school of psychology.
The opening last week of the modernised National Forensic Mental Health Service in Portrane and the relocation of the Central Mental Hospital from Dundrum is also a very welcome development. Drafting of the new mental health Bill continues. This Bill will overhaul our mental health legislation, making it more person-centred and human rights-focused, taking into account our UNCRPD commitments and principles of the Assisted Decision-Making (Capacity) Act 2015.
Our national mental health policy, Sharing the Vision, sets out our reform-agenda for the period from 2020 to 2030. Its overarching objective is to enhance all aspects of mental health services, from promotion, prevention and early intervention to acute and specialist service delivery.
I thank the committee for its attention this morning.
I thank the Minister of State and her staff for attending today. It is long overdue. Commencement of the Assisted Decision-Making (Capacity) Act 2015 has been further delayed. Can the Minister of State discuss the impact of this delay on mental health and the home care strategies? Many people, especially older people, are very fearful of Covid-19. It is isolating them. What additional efforts are being made to tackle this problem? I was also curious about how home care is unregulated in Ireland. Is there a plan to address that across the board, to bring that in line and to deal with the private and public aspects of this? Dual diagnosis is a major problem. We have no specific group dealing with dual diagnosis.
There are many issues, which I have encountered many times. People have gone to hospitals and were turned away because they had mental health issues but they had also been taking drugs or alcohol. Will the Minister of State explain what plans are in place to deal with that? Under Housing for All, the new housing plan, there is a review of the adaptation grants for older people and people with disabilities. Those limits have to be changed and the income thresholds must be addressed. Will the Minister of State tell us when the review is going to take place? Inflation and other issues have had a massive impact. Regarding community healthcare organisation, CHO, 9, it has been brought to my attention that there have been no peer support workers there. The Minister of State does not have to respond, but I would be pleased if she would comment. It would be unacceptable if no peer support workers were employed in the whole of CHO 9.
I thank the Deputy for his question. I will work in reverse. With regard to CHO 9 and the lack of peer support workers, the whole premise of Sharing the Vision, our new mental health policy, is key supports in the community with peer support and people with lived experience of recovery, hospitals and all the community supports needed. I am surprised to hear that and I will look into it. I will write back to the Deputy. I cannot give him a specific answer. Earlier this week, I met with the department in the HSE on recovery and education. There is funding for 21 posts that are currently being recruited. I will write back to the Deputy with a substantive answer.
Home care is one of the most important services we can provide. I am in a unique position; my budget for home care this year was approximately €660 million. It will be €700 million in budget 2023. Some 56,000 people will receive home care today, but there are unfortunately 6,200 on a waiting list because, although their home care provision has been funded, we do not have the workforce to deliver the home care. When people are on a waiting list, we have to prioritise the most complex and vulnerable cases and those that are at end of life. It is disappointing that we have to do that. Working with the Department, we put in place a strategic workforce advisory group earlier this year. A huge amount of work was done with the private, public and voluntary providers and across all Departments. Some 16 recommendations were made. I have taken on board each one and we are putting them in train. I will speak to three of the recommendations that are important. The first is that the new tender from the HSE will include the living wage, currently €12.90, to be paid to anyone providing home care. The HSE rates, as the Deputy will be aware, are higher than that, but some of the private contractors do not pay that. Second, mileage will have to be included and paid to anyone travelling. The third is that we will move quickly to extend the permits outside the EU to bring in workers. For example, 1,700 people are working in the nursing home sector who came in on those types of permits. I hope we will be able to move quickly on that.
On dementia-specific home care supports, when I came into the post initially I ring-fenced 5% of all home care hours for dementia-specific care. In next year's budget it will be 15% because we found out quickly that we were exceeding our targets. Some people with dementia do not like going to a day care centre or to a specific day care centre. We are providing home care in the home for those people at a cost of €1.7 million. I originally put that in place during Covid-19 and it has been retained. I will pass over to my colleague, Mr. Brunell, to speak about the Assisted Decision Making (Capacity) Act 2015.
Mr. Niall Brunell:
I thank the Minister of State and I thank the Deputy for his question. On the delay around assisted decision-making, it is worth noting that the Department and the Minister are still committed to enactment and commencement in the earliest possible course. The Minister recently met some members of the committee and other Senators on issues coming out of the Seanad Committee Stage debate. I reassure members that work is continuing in a concentrated effort to move as quickly as possible on that.
On the impact on home care and the questions the Deputy raised, assisted decision-making represents a significant reform that has an impact on a number of issues, but it is not necessarily determinative of progress on the other issues. I am not aware of a delay to other areas of work arising out of assisted decision-making's progress. It is an important element but it is not a barrier to progress in those areas.
Dr. Philip Dodd:
I thank the Deputy for the question. The area of service improvement for dual diagnosis is about providing appropriate supports to people with mental health difficulties and addictions, which is a key part of Sharing the Vision, our mental health policy. The HSE has established a national clinical programme to develop services for dual diagnosis in collaboration with the College of Psychiatrists of Ireland and the national working group with key stakeholder representation. The model of care for that service improvement is at a late stage of drafting and should be launched and approved within the next two quarters. In advance of that, funding has been provided for the establishment of a number of pilot sites, including in the Limerick area. The clinical lead for that programme, Dr. Niazi, is providing key clinical leadership within the HSE to develop clear pathways for people who often find it difficult to negotiate appropriate care pathways when they present, for example, at emergency departments. It is a key focus of service improvement, as it is in Sharing the Vision, and has been the focus of investment.
I have seen people being turned away from hospitals many times and people dying by suicide. It is appalling the number of times it has happened. We need to have some means to deal with it in the hospitals as opposed to people being turned away. The psychiatrist is supposed to see them, but they have to make a clear judgement that this person, even though there is perhaps alcohol or drugs involved, cannot be turned away.
The new policy we work off does. Everybody welcomed that. The Deputy is correct; people can present with mental health illness but that might be masked by addiction to drugs or alcohol. Previously, that was perhaps a reason that mental health issues could not be addressed. That is no longer the way. We are building on that but it takes time. We started, as Dr. Dodd said, with some pilot schemes. It is an area that is hugely important because we are seeing massive addiction issues across all of society.
That comes under the remit the Minister for Housing, Local Government and Heritage and not mine. I take the Deputy's point, especially regarding older people. In my constituency in County Waterford, the social housing stock is where the challenge is. The budget is always tighter, whereas people who own their homes can avail of the budget more quickly in my experience in Waterford at least. I have spoken to the Minister, Deputy O'Brien, about it. What most people need is probably to take the bath out, a level-access shower or a wet room so they can access the bathroom, especially if they are wheelchair users. It is important; I have raised it with the Minister and will continue to do so.
I thank the Minister of State for her address yesterday in the context of the briefing in the audiovisual room on the National Gender Service. Representatives of transgender people and individuals affected were grateful for her position on that. It has nothing to do with this meeting but I thank her for that.
I also commend her on the incredible work that has been carried out by her Department, for the budget, for the commitment she shows in her work to people who are suffering in the areas of mental health, to reforms and to home care. The Government has provided tremendous support in this area, led by the Minister of State, Deputy Butler.
My questions cover two areas. The first relates to recruitment. It is one of the big impediments to the roll-out of home care and keeping people in familiar surroundings in their home and close to everything they have lived with. For people facing dementia and other disabilities at an advanced age, being supported and surrounded by things that are familiar is important. However, one of the impediments to the delivery of home care is recruitment. The Minister of State has spoken about - and it also crosses into the Minister of State, Deputy Damien English's, Department and he has also worked on this - extending permits to outside the EU in this area. It is essential that be advanced.
One thing I will raise for her information is that I know of many people who have the qualifications within their own countries but when they apply to Ireland, they may need to complete one module of a Quality and Qualifications Ireland, QQI, course to qualify at level 5 or level 6. People cannot get a personal public service number, PPSN, unless they are living in Ireland and they cannot do the course to get the qualification unless they have a PPSN. They cannot do QQI courses online without one. Perhaps that could be looked at. For example, we could give people a grandparenting oversight or something like that when they arrive. It is essential we extend our workforce in this area.
The second area I will raise with the Minister of State is assisted decision-making. I note Mr. Brunell is accompanying her. There have been meetings and I am receiving daily emails from people who are anxious about the fact that the Assisted Decision Making (Capacity) (Amendment) Bill is not on the Seanad schedule. I ask Mr. Brunell to repeat the confirmation and commitment that it will return to the Seanad soon, that any matters that need to be sorted out are being addressed and that we can expect the legislation to be put on the schedule as soon as possible. I value the meeting I was allowed to attend and the discussion during it. Hearing directly from Mr. Brunell and others present at the meeting about how this would work was incredibly helpful.
One area of the Assisted Decision Making (Capacity) (Amendment) Bill relates to advance healthcare directives and people with mental health issues. There are circumstances when their right to an advance healthcare directive is suspended and set aside. Part of the implementation of that is dependent on the Mental Health Act being reformed. Those two things need to happen in tandem and they must happen quickly. I ask the Minister of State whether she has any comments on that, for example whether she has an idea of timelines and whether she is contributing to the process. It is important that we have reform. A report of the Mental Health Commission a number of weeks ago contained frightening statistics about restricted practices and approved centres. There is a need for overhaul. It is important.
I thank the Senator for her questions.
On the recruitment piece and the strategic workforce advisory group, SWAG, one of the most important issues in the delivery of home care is that there must be agreed standards. Deputy Ellis raised this as well. Legislation is coming in the new year on standards for home care across public, private and voluntary providers. That is important. Recommendation 10 from the SWAG report was that Solas review access to QQI modules. A person must have a level 5 QQI qualification so it is currently looking at that. We will certainly take the Senator's comments on board.
I am working closely with the Minister of State, Deputy English, at the moment. We have held several meetings and will make an announcement in the next few weeks. The work is ongoing with our departmental officials on the permits. As I said, one of the recommendations was that we should go outside the EU to try to recruit more staff. The recommendation is that 1,000 should be provided. If we recruited 500 or 600 people - most home care workers see six people a day - that would almost deal with the waiting list.
As a result of Covid-19, we are seeing more people being referred for home care and the cases are much more complex. Many of the people who need, receive and deserve home care, need two carers at a time if they have to be hoisted or lifted or for whatever medical needs they have. The most important thing is that we can provide home care because people want to get the care they need in their homes.
On the Assisted Decision Making (Capacity) (Amendment) Bill, it is important legislation that represents significant legal reform. To touch on my piece which is the Mental Health Act 2001, it has been confirmed it will be priority legislation after Christmas. There are approximately 130 heads in that Bill. It is a massive Bill and involves a huge amount of work. We are currently working through it and about 40 of the heads have been completed, but work is ongoing. One person has been working on this Bill for two years. We have received great support from the Attorney General's office and across the whole Department. I spoke to the Chief Whip about this so it will be prioritised after Christmas.
I will hand over to Mr. Brunell to respond to the other question.
Mr. Niall Brunell:
I thank the Minister of State and the Senator for the question.
I can absolutely reiterate the commitment to moving ahead with the Assisted Decision Making (Capacity) (Amendment) Bill as soon as possible. It is our intention to see enactment completed before the end of the year. I hope we will be in a position to publish a schedule shortly. We are working to close out a few issues that came out of the Committee Stage debate in the Seanad, but we are working intensively to close those out as soon as possible and the commitment of the Department and the Minister, Deputy O'Gorman, is to see enactment happen before the end of this year.
On the interaction with the Assisted Decision Making (Capacity) Act and the Mental Health Act, it is worth going back to when we started to work on the general scheme of the Assisted Decision Making (Capacity) (Amendment) Bill. Our starting position in this area - and we were well supported by the Minister of State, Deputy Butler's, Department in this - was to simply delete the sections in the Assisted Decision Making (Capacity) Act 2015 that disapplied sections to people whose treatment was regulated under Part 4 of the Mental Health Act. In simpler terms we wanted to remove the disapplication of decision supports for people who were receiving involuntary treatment under the Mental Health Act. It became clear as we worked through it and as we received legal advice on the issue, that it was much more complex than a simple deletion and that what is required as a first principle issue is the reform of the 2001 Act. Part of the reason for that is the architecture of that Act, the way it is drafted and that some sections in the Mental Health Act 2001 have to be unpicked to do what we want to do in assisted decision making.
Intensive work was done during the passage of the Assisted Decision Making (Capacity) (Amendment) Bill through the Houses and, before that, in preparation of the general scheme. On Committee Stage in the Seanad, the Minister, Deputy O'Gorman, moved amendments that allowed assisted decision-making supports to be extended to what we believe is the majority of people who receive involuntary care or whose treatment is regulated by Part 4. Where we cannot go further is on the definition in section 3(1)(a) of a mental disorder. That is not my language. It is the language of the Mental Health Act. The reason is that a careful balance of constitutional rights comes into play, difficult legal issues need to be unpacked and the redrafting of section 3(1)(a) in the 2001 Act is required in order for us to go further.
We have been working closely with others and have been well supported. The relationship is very good and collaborative as we have been working with officials not only in the Department of Health, but also the Decision Support Service, DSS, and the Mental Health Commission and we are moving as far as we can in this issue. I understand from conversations with the Mental Health Commission that extending decision supports to persons who meet the section 3(1)(b) definition in the Mental Health Act 2001 will extend decision support services to the majority of people who receive involuntary treatment under Part 4 of the Mental Health Act. Importantly, it extends decision supports to persons who fall under what is probably one of the more paternalistic sections of the 2001 Act. The section 3(1)(a) category that we cannot extend provision to, in the absence of reform of the 2001 Act, relates to people who are likely to cause serious and immediate harm to themselves or others.
We are talking about people whose need is very acute. I accept it is not an ideal situation and both Ministers and both Departments in this area have been very clear that the move needs to be towards full parity. As I have said we are constrained in doing that with the architecture of the Mental Health Act 2001 as it stands. We have extended provisions in the section 3(b) definition, which is a bit wordy but in essence relates to people who are treated where the treating clinician thinks treatment is in their best interests. It is one of the more best interest-heavy models within the Statute Book and we have been very happy to extend assisted decision-making provisions in that area.
I wish to highlight again that the commitment is that the Assisted Decision-Making (Capacity) Act 2015 will be complete and in law ready for signature by the end of this year, which is only a couple of weeks away so that will come as a great relief. Second, the Mental Health Act 2001 is on the priority list of legislation for after the break in the new year which is fantastic news as well. I also wish to say to Mr. Brunell that I hear him and really appreciate that there are obviously disputes over the use of "immediate and serious harm" to self or others and that on occasion there are individuals who would say that is abused and used or weaponised against them to get their co-operation in situations where they would otherwise prefer not to. I appreciate that is also in the mix for discussion, to enhance the protections for people and their right to have their voice heard. I thank Mr. Brunell for the clarifications.
I welcome Minister of State at the Department of Health with responsibility for mental health and older people, Deputy Mary Butler, and her staff. The first point I want to make as spokesperson on older people, and it is also a point that is made to me regularly, is that disability does not disappear when one turns 66. For example, one man told me his wife was disabled due to a stroke and she was receiving supports and services in the community. When she turned 66 she was told she had to move to a different service that was for older people but it did not offer the same supports. They did argue the point and the supports were maintained for her but disabled people often say to me that it is like their disability has suddenly disappeared.
Even when we talk about the cost of disability, the Indecon report that was published a year ago said the cost of disability was anywhere between €8,700 and €12,500 on average, depending on the nature of the disability. Older people who have a disability have asked me why they were not given the €500 this week because they still have the additional costs and they were not given it. They do recognise they were given double payments etc. and they appreciate that but they were still not given the recognition that there is a cost to disability regardless of what age they are.
Second, I welcome the increased spending on home care supports but we have an ageing population so we have increased need. As the Minister alluded to there are many people who have been approved for home care hours and nobody is providing them. That has led to delayed release from hospital and to people having to consider going into a nursing home and that is the last thing they want. The sooner the pay and conditions can be dealt with, the better so we can get more people working in this area.
The Minister mentioned that the most vulnerable are prioritised but that is not my experience in every case. In the case of one man the community nurse told his wife that he and one other person in the community were the most vulnerable and in need yet his care providers are not available and he has not been prioritised for care. This is the matter of the person who was offered the home care cash grant that I brought up with the Minister before and neither he nor his wife is in a position to be able to negotiate that. It might be a grant that suits people who have children who could look for and hire the person but that is not available to this couple.
Another matter that is brought up with me on a regular basis, and that I raised with the Minister before, was the boarding-out option. Not everybody needs nursing home care yet they may not be able to live in their own home. There is a boarding-out option which is much more economically viable than nursing home care yet it has not been reviewed in 12 or 13 years. Some boarding-out places are closing because the money they receive has not risen in tandem with the cost of living and inflation.
My colleague, Deputy Ellis, raised the issue of dual diagnosis which related to addiction and mental health issues but it also has to do with mental health issues and disability. Mental Health Reform attended this committee a few weeks ago and we discussed how people constantly fall between two stools because disability services say that mental health services should be dealing with someone, and the mental health services say that disability services should be dealing with them. The child and adolescent mental health services, CAMHS, is an example of this where they will not accept people with a diagnosis of autism for mental health treatment. I make the point that a lot of people have mental health issues because they are not getting the supports required when they have a diagnosis of autism but, regardless of why, there needs to be cross-departmental work between the different groups to address the issues.
The UN Convention on the Rights of Persons with Disabilities, UNCRPD, is about supporting people to live independently. I have an example of a 21-year-old man in my constituency who has muscular dystrophy. His mother was his main carer but is not able to help him to get in and out of bed now due to an accident. The home care support comes in, sometimes as late as 11.15 a.m., so he is not up until 12.30 p.m. What is worse than that is that they have him back in bed at 6.30 p.m. that evening. That is not a life or independent living. This is a young man of 21 and some days he is only up for six or six and a half hours. I know other people had complained about the timing of the care and that it is down to constraints on the number of carers that are there but it needs to be looked at. The person's needs have to be taken into account as well and especially when they are a younger person but it applies to many across the spectrum that they have to get up at a certain time and have to go to bed at a certain time to suit the carer, rather than the carer suiting them.
I thank Deputy Tully for her continued interest. At the outset I want to say that she did raise the issue previously about personalised hours for home care in the Dáil and I checked it out afterwards; I apologise as I did not realise they were available in community healthcare organisation, CHO, 1 although it is not available across the other CHOs. This used to be available previously and they are an area that I think should be in the tender going forward. I have put that on the record and I believe they work for some people but not everyone. The day Deputy Tully raised it I thought she was actually speaking about disability hours and I want to clarify that she was completely right and that they are available in her area but not in the other eight CHOs. It probably deals with people who find it very difficult to get support at the weekend so a budget was provided for them.
Deputy Tully said that disability does not disappear at 65 and it certainly does not but there is not a cut-off at 65 for people with disabilities. There are people over 65 in receipt of day services and home support through disability services but I understand the point she is making and they are based on individual need. At the moment we are developing the interRAI which is the standardised assessment to ensure transparency in decision-making. We want to move to a situation where people can be cared for completely at home and we want to put a scheme in place where people do not have to go into a nursing home even though they might require nursing home care. In order to do this we have to roll out the interRAI standardised assessment. We currently have four pilot sites in operation throughout the country and we are currently recruiting 128 interRAI assessors. Recruitment is starting and Ms McArdle will speak further on that.
Ms Siobh?n McArdle:
I thank the Minister and the Deputy. The interRAI assessment will address some of the issues she spoke to which is, at times, a lack of transparency perhaps in how home support may be prioritised. It is really important we are all working to the same level playing field and that we all understand the decision-making for service users and for staff. That will definitely complement the work that is ongoing in terms of increasing the workforce. InterRAI is a care assessment tool that is being rolled out in CHOs, in many hospital settings and in pilot sites to do with home support.
It is a care assessment for all the people who work with an individual, that is, the nursing staff, physiotherapists and occupational therapists. Our integrated care programme and specialist team for older people are beginning to adopt the standardised assessment. Throughout the country, we will be able to have an assurance that when people are identified as having care needs, their allocation will be based on that assessed need. That will be important in making sure the right people are getting the care they need.
I agree with the Deputy's point about timing. It is important that when people are identified as having particular care needs, the timing matches their lives and is not based on what the system can tell them they can have. It has to be more about putting the person at the centre rather than the workforce issue. We accept we need to get to that place.
I agree with the Deputy in that one does not want a situation in which somebody might only be up for six hours per day. However, we face challenges because many people who deliver home care work split shifts and wish to go home in the evening. I often hear from families that they do not wish for their mother or father to be put to bed at 6 p.m., but in fairness, the home care worker has probably already worked in the morning and the evening. We are looking at work-life balance.
The integrated care programmes for older people, ICPOP, teams have made a considerable impact. We have 22 of them up and running and we have to get to 30. They are fantastic. It is like a one-stop shop for older people. When an older person presents to the ICPOP team, they will look at everything. They will look at the person's frailty and check whether he or she is at risk of falls or stroke. I was delighted to provide the funding to the psychiatry of later life team earlier this year. It is not included in the ICPOP teams. I secured the funding to put three pilots in place because an older person being able to present at one particular facility and have all their care needs met and analysed, as against having to go across the road to a psychiatric facility to get a piece of what they need, will help to take the stigma out of psychiatry of later life.
Dr. Philip Dodd:
I will deal with the issue of mental health and intellectual disability diagnosis, or dual diagnosis. It is a particular focus of Sharing the Vision. Two models of care for adults with intellectual disability and mental health issues and for children were recently published, that is, the CAMHS intellectual disability, ID, model of care and the adult mental health of intellectual disability, MHID, model of care. Since 2015, approximately 150 staff have been recruited into supporting the provision of the service throughout the country. It has been difficult to recruit in the CAMHS ID area in particular. It is a particular focus of recruitment endeavours, especially in the area of training more psychiatrists to take on the role of consultant child and adolescent psychiatrist with a special interest in intellectual disability.
With regard to the access for people with autism and mental health difficulties, the published CAMHS clinical operating guideline from the HSE published in 2018 clearly sets out the appropriate pathway for people with autism. If a child with autism is presenting with significant mental health problems of a moderate or severe level, it is appropriate that they be referred and seen by CAMHS teams. It can become difficult, clinically, to decipher whether the behavioural presentation of the individual is primarily a mental health issue or related to difficulties the child has with autism and various environmental triggers and difficulties.
Best practice suggests good engagement between the CAMHS ID team, the CAMHS team and the network area disability team to work out the primary needs of the child and then to work out what service is most appropriate. There is a particular recommendation in Sharing the Vision that looks to that as an area of service improvement. The HSE is looking at that example of an integrated care challenge across children's services.
We have community care homes in the south east in counties Waterford, Wexford and Carlow. I visited a couple of them in Carlow with Deputy Murnane O'Connor. They are community care homes that provide low level supports for people. It is a step between a nursing home and leaving one's own home but a nurse is always on duty. It is a fantastic model because it is a home from home. The person is living in his or her own community and is not on fair deal but pays a percentage of his or her pension. It also means local people are working there whom the person may have known all his or her life in the community. We have ten of these homes in the south east. The model is fantastic. It is like the boarding-out model but we will certainly take a look at it to see whether there is anything we can do with regard to the costs. I am not sure how many people take part in boarding out. It is unique to specific areas in the country but it works very well for some people.
There were two issues with it. The HSE pays a certain amount but each CHO area pays different amounts. When there is a boarding-out facility on the border of two CHO areas, as there is in my area between counties Cavan with Longford, the HSE pays different amounts as do the individuals. As the person said to me, there would be war if they found out they were being charged different amounts. Standardisation and an increase in the amount paid would be welcome. I welcome everything the Minister of State has said. The ICPOP teams sound brilliant but are they like the children's disability network teams? On paper, that is a brilliant model of care but the recruitment of staff to these teams to make sure they are complete-----
These multidisciplinary teams are working well. I recently visited the community nursing unit, CMU, in Ennis, County Clare. It is a fantastic facility but I was struck by the ICPOP team being located within the hospital. They are the way forward. We have 22 teams in place and we will get to 30. There are nutritionists and dieticians, physiotherapists and clinical nurse specialists working on those teams. The whole purpose is for people not to have to present to the emergency department. The fall they may have might be pre-empted. Some people, through no fault of their own, may not be having a sufficiently nutritious diet. It is like a one-stop shop. People will have a raft of tests done and the best plan will be put in place for them, working with their GP, public health nurse and the team.
Ms Siobh?n McArdle:
Further information will be available on the HSE website with information on the services provided in each CHO for the public. If the Deputy has any particular questions from her area, we would be happy to redirect them to her CHO. Considerable information is available on pathways. They are in development and we hope to get feedback from families and service users about how well they have worked or if there are areas in which we need to invest more. There are strong links with home support and our community and voluntary sector. We know those teams work with meals on wheels or other parts of the community to ensure the community around the individual supports him or her to live well at home.
I thank the Minister of State for attending. Many of my questions have been asked, especially about the Health (Amendment) (Professional Home Care) Bill 2020. It was very important to us. Last week, we launched a report on independent living. What supports will be provided to people to make decisions on home care and living arrangements and will impact on the drive to independent living? I come across that issue often in my clinics. How will marginalised, vulnerable, hard-to-reach and minority groups of older people be supported in respect of home care?
We spoke about the mental health Bill. I was glad to hear that is being worked on and hopefully it will be done as soon as possible. It is very important.
Will the Minister of State elaborate on any cross-departmental initiatives to support people as they age to maintain, improve or manage their physical mental health and well-being?
I have been raising the Assisted Decision-Making (Capacity) (Amendment) Bill. I am delighted to hear that legislation should be passed by the end of the year.
I have always been concerned about staff recruitment and the Minister of State always raises the issue. I know the funding is available, and that is really welcome, but the position is similar in the area of home care packages. I deal with families daily where someone has been sent home from hospital with no home care package put in place. Especially with the cost of living now, people are working to survive and they are finding it very hard to mind a parent or person with a disability. It is creating major challenges.
Some families I have been working with get home care for half an hour three times a day, in the morning, at dinner time and in the evening. At the weekend, they get half an hour in the morning and again in the evening. As the Minister of State mentioned, two carers are often needed. Many people tell me that half an hour is not enough and they need more support or help. How will the recruitment problem be sorted out? The funding is in place. The only people suffering are the most vulnerable. I know the Minister of State is committed to addressing this. She stated: "The Government and I are committed to the reform of mental health services in Ireland". That is the most positive commitment.
I know there are challenges within mental health services. I face them every day when I talk to people. I am in CHO 5, as the Minister of State knows from her visits to Carlow, for which I thank her. The challenges in mental health are to provide more supports and services and to recruit more staff. Recruitment also seems to be the issue with regard to home care packages.
I am thinking about the different CHOs. I was working on a case yesterday involving a lady who had a really bad stroke. She lives on the border of Carlow and Laois. She is half an hour from Portlaoise but two minutes from Carlow. I informed CHO 5 that this lady lives in County Carlow and gets the bus into Carlow town to do all her shopping. It takes her half an hour to get to Portlaoise. CHO 5 told me it cannot interfere. Common sense has to prevail here. There is no point in CHO 5 telling me it will not take this case. Families are going through enough. The cost of living is a huge issue for people. If someone has to travel to Portlaoise every day, twice a day, what is the cost? I know the Minister of State has made a commitment to this but all the CHOs need to show common sense, which is not the case.
Many of my questions were answered. I know how hard the Minister of State works on this. I see the challenges. Whatever we can do to try to help families and people with disabilities is important.
The Deputy raised many valid points. Home care is one facet of supporting people to live at home. Some people receive seven hours a week and others 14 hours per week. The various CHOs are probably challenged in trying to spread the hours as much as they possibly can so that as many people as possible get the supports. We also have almost 300 day-care centres in Ireland. These are another support for older people to re-engage. Many people found it hard to re-engage after Covid and found it difficult to get back into their communities. We also have the provision of meals on wheels. Today, for example, 400,000 people in Ireland will receive a delivery from meals on wheels. It is so much more than just a nutritious meal. It means that someone is coming to the door, handing in the meal and there is contact. It is like the postman, in rural areas especially.
One area I am a bit concerned about in relation to older people is that not everyone has reconnected since Covid. Some people are still nervous about Covid and finding it hard to reconnect. There is great collaboration with Healthy Ireland. We also provide funding for Age Friendly Ireland. We are trying to support people with independent living. We have a pilot under way in Waterford. It is the first of its kind. St. Joseph's nursing home, a beautiful listed building, had been vacant for many years. By the end of the first quarter of 2023, we will have 71 independent living apartments and own front door units for older people from the inner city in Waterford. These people will have the opportunity to right-size. They may be living in a house with three bedrooms upstairs and they may not be able to manage the stairs.
The point I want to make is that the voice and choice of the older person will always be heard. Nobody will be forced to do this. What we want to do is put in place wrap-around social supports so that, for example, people will know where they can get their meals on wheels, support if they need forms filled in and different social care supports that we all do in our constituency offices every day of the week. We want to support older people like that. It is very important that we can reach those people. We have been engaging with marginalised groups via targeted and public stakeholder engagement. We received 210 responses to recent public consultation and we have regular meetings. For example, yesterday I met Age Friendly Ireland and I met Sage Advocacy the day before yesterday. I have regular meetings with all these organisations to make sure I am hearing what they are hearing. There is no better place to know what is happening than in one's constituency office.
Returning to recruitment, that falls under the strategic workforce advisory group. There are 16 recommendations and we are putting them all in train. I will touch briefly on one of the challenges. We spoke about paying the living wage to staff in private organisations. For those who provide home care in the HSE, the rate is approximately €16 per hour and they also receive mileage but we are still struggling to recruit, even in the HSE. Many people moved away from providing home care during Covid. They may have children with underlying needs or vulnerable parents, for instance, and they decided to change the way they earned a living. We are trying to encourage people to return to providing home care and to make it a viable career opportunity. We want people to be able to transition so that they come in with a level 5 qualification but can scale up. I know one person who started as a home care worker and is now a nurse in University Hospital Waterford. She transitioned right through. That is what we are trying to achieve.
On the Deputy's point about a lady living on the county border, a common sense approach should be applied. The whole premise of Sláintecare is to provide the right care at the right time as close to home as possible. There should be a little bit of flexibility at times.
I will ask Mr. Brunell to clarify the timeline for the assisted decision-making legislation. I know a question was asked and we did not get to it.
Mr. Niall Brunell:
The Department is getting similar correspondence to committee members on the timeline for this so I want to take the opportunity to clarify exactly what that looks like. We are working towards enactment by the end of the year. We are at the mercy of the Houses as to the schedule for the Bill but that is what we are working towards in the Department and we see that as achievable. There will be a period between enactment and operationalisation of the new system because the Act will need to be commenced. In particular, there are a number of regulations for largely procedural operational matters around fee schedules and so forth, which need to be placed on a statutory footing. We need the amendment Bill to do that and we can do that quickly. We are talking about a matter of weeks but there will be a process for making those necessary regulations and, for example, putting the fee schedules and approved forms in order, and then commence the amended 2015 Act in full.
To be clear and avoid an erroneous message being sent, we will not see operationalisation of the full system by the end of this year. It will be early next year, but we are working towards enactment for the end of this year.
I thank Mr. Brunell. The delay was the main issue. We could have the Bill passed by Christmas, but enacting it will take time. There may be amendments. We have a duty to try to get it through as quickly as possible, which is the main aim. Once people know that, they will be happy, but there is a lack of communication. Mr. Brunell's comments were important. Having the legislation enacted by early next year would be important.
There is always a lead-in time. I will give an example. The committee will be aware that one of the items of legislation that I passed was the fair deal for farmers, which addressed an anomaly. Even though the legislation was signed in August, there was a provision whereby it could only be enacted after 90 days, so a lead-in time is always to be expected. It is important that we state what the lead-in time is. If matters are left open-ended, legislation can drift.
I thank the Minister of State for the update, particularly on the ADHD app for adults, which is a good development. I commend her on last week's opening of the National Forensic Mental Health Service in Portrane and the relocation of the Central Mental Hospital from Dundrum, which was a major achievement.
The Minister of State has an important brief. It takes care of some of the most vulnerable in society. It is a challenging brief because, despite the funding being put in place to resource the HSE adequately to deal with waiting lists and to provide beds, step-down facilities and support, be that through social workers or home care workers, we have a service-level challenge. This is down to recruitment and other staffing issues. We need to see them resolved because our older people, people with disabilities and patients must be at the centre of our healthcare services. There are incredible people working hard in this sector and in the Department. I see that every day in my constituency, where we have social workers and healthcare workers, including therapists, working round the clock to provide vital services. I also see it in the services provided by Peamount Healthcare, which the Minister of State visited recently, and Stewarts Care, which I hope she will visit. The problem is that not all people are being reached through these services.
My second point is on ageing. I have a particular concern about older individuals who are caring for people with disabilities, including intellectual disabilities, or severe mental health challenges. Those people are living with their ageing parents and are themselves older adults now. Their parents are very worried about what will happen to their children when they are gone and who will care for them after they have been cared for in their homes their entire lives. This is one of the main challenges, given the untold stress it puts on the ageing parents and the uncertainty and upheaval it creates in the lives of the people with the disabilities or mental health issues. When I encounter these cases, I find them heart-breaking because finding a solution is difficult.
We need to invest better in planning in order to support people in this situation. We need better interventions and adequate disability accommodation across the country. Waiting lists are probably the main hurdle for people. They are the issue that I hear about most frequently. I welcome some of what the Minster of State has said in this regard, but a further update would be great.
Everyone will have heard that we have a fantastic new forensic mental health hospital in Portrane in north County Dublin. It involved a €200 million investment and it is the best forensic mental health hospital in all of Europe. I have visited it a couple of times. It is a job well done. It took a while to get it opened, but all of the patients from the Central Mental Hospital were transferred safely, securely and without issue last Sunday. They were relocated with the minimum amount of fuss and the best supports that could be provided for them. The new hospital is good news.
I thank the Deputy for raising the issue of ADHD. It is an area on which I have focused. I launched the ADHD in adults national clinical programme on 14 January, 2021. I was struck to learn that many adults with ADHD did not receive diagnoses as children. I am referring to people who are now in their 50s or 60s and who have always felt that there was something about them and that they had fallen between the cracks. When the programme is fully implemented, 11 adult ADHD clinics will be established to provide assessments and multimodal treatments in the various CHOs. I visited the team in Sandyford, which is one of the three ADHD clinic sites that have already been set up. Next, there will be four more in the CHO 7 area of Dublin, the CHO 4 area of Cork, the CHO 4 area of Kerry and west Cork, and the CHO 8 area of Longford, Westmeath, Offaly, Laois, west Kildare and Wicklow. The remainder will follow. Since becoming Minister of State, I have recognised that the clinics have to be built incrementally. We established three last year, we are establishing four this year and we will establish the others next year. Even if we had all the funding in the world to do this, we would not have the staff, so the clinics have to be built incrementally.
Last week, I was delighted to launch the ADHD app. Anyone can download it on his or her phone free of charge. It gives support not only to people with ADHD, but also to their family members, in understanding some of the side effects or symptoms. I was surprised to learn that there were 117 ADHD apps available, but this one has medical support. It is a collaboration between ADHD Ireland, the HSE and University College Dublin. It is a good app. I was interested to hear that it did not cost the sun, moon and stars. It is a valuable tool for any adult living with ADHD and is great to see.
Mine is a challenging brief, but all of those working in mental health services, older people and others who provide care give so much. I am proud of the fact that, during the Covid pandemic, 85% to 90% of all mental health supports and services were retained. This was not easy. Many of our NGO partners acted quickly to move their supports and services online. Some did so within four days. Yesterday, I launched the Samaritans' report. In 2021, 1,300 people per day were contacting the Samaritans for support. I was struck to hear that, in 2021, the Samaritans received 19,000 calls from prisons. They were in prison and probably extremely lonely. The Prison Service did well in keeping Covid at bay, but it meant that people were isolated and they had to stay in their own premises.
A great deal of good work is being done. I was delighted to be able to visit Peamount Healthcare. To touch on another matter, Huntington's disease is a serious illness. I compliment Bloomfield Health Services on all the work it does in this regard. It sought funding of €1.5 million from my budget, which I supplied. Bloomfield Health Services provide the most experienced and dedicated supports for people with Huntington's disease and others with acquired brain injuries. They have a real understanding of how difficult some neurological disabilities can be.
The Deputy was right about dual carers. There are people who care for older adults - their parents - while also caring for children with intellectual disabilities. This situation can be difficult for what I call dual carers.
Another area on which I have placed great deal of focus, especially in the context of dementia, is that of those living with Down's syndrome, who are susceptible to accelerated ageing and are at a higher risk of developing dementia. I often meet ageing parents who have adult children with Down's syndrome who are developing symptoms of dementia at, for example, 40 years of age. The main concern for the parents is what will happen after they die.
That is an area that has been given focus. The disability memory service provides specialist supports; I think it is in the Mater hospital. The worry for parents is that until their adult child gets a full-time placement, they cannot relax. There is a focus on this issue.
On waiting lists, we do well in psychiatry of later life. There is no waiting list, which is great. For adult mental health services, the waiting list is 12 weeks. We do not keep waiting lists; people are seen within 12 weeks. There is a challenge regarding child and adolescent mental health services, CAMHS. The waiting list is currently about 4,000. The waiting list in CHO 4 Cork and Kerry doubled in the past 12 months because of challenges in relation to the Maskey report on south Kerry. I am working with my team to see if we can put in place a dedicated waiting list initiative to reduce that waiting list. Early intervention is key, as the committee knows. Only 2% of children will need the support of CAMHS, but when a child receives support from a multidisciplinary team, it can be life-changing. We are running a waiting list initiative on primary care psychology targeted at those waiting more than 12 months. We have reduced it by 25%, but as quickly as we are reducing the waiting list on one side, more referrals are coming in. Cases are more complex and need more supports. Whether that is a fallout from Covid-19 or we are seeing more children being referred, we are acutely aware of the situation, with children being added to waiting lists on a weekly basis. I am a parent. The last thing any parent wants to see is their child being told they will not be seen for six, nine or 12 months. We do not want that to happen. On the Maskey report, the Mental Health Commission is doing a review and the HSE is doing an independent audit, which will provide a lot of information early next year regarding the 73 teams we have in place. It will give us invaluable data we did not have before. I thank the Deputy. I hope I answered all of the questions.
The overlap between disability, mental health and old age is complicated. It is important for the committee to take time to discuss this theme. I thank the Minister of State for attending today. Mental health falls under the Convention on the Rights of Persons with Disabilities, CRPD, which gives people with mental health conditions additional protections and rights. As people age, they can develop disabilities which present different challenges. The CRPD gives people the right to live independently in their communities, while the programme for Government commits to introducing a statutory scheme to support people to live in their homes. The reality is very different, with more than 6,000 people on waiting lists for home care this year alone. There have been more than 1,000 delayed discharges from hospitals directly linked to home care shortages. Part of the staff shortage problem is that massive responsibility is placed on home support workers, who are often the lowest-paid workers. As part of plans to improve the provision of home care, and the Minister of State mentioned the funding allocated, what is being done specifically to support the support workers in that allocation? There is a creeping privatisation of the sector. What is the Minister of State doing to stem that? An issue of concern is the continuing lack of regulatory framework or independent regulator for this sector. The Minister of State mentioned the development of regulation for home support services. Will she give the committee an idea of what that will look like? Will it involve an independent regulator's office or something to that effect?
The committee recently heard how interaction between community healthcare organisations, CHOs, and mental health services can negatively impact the quality of life and increase rights restrictions placed on disabled people in the community, such as, for example, individuals having to stay in mental health acute units, sometimes over long periods of time, because appropriate supports are not in place. Core to this issue is the structure of the HSE, with the disability services and mental health services operating off different budgets and systems with a lack of co-operation. Teams are then arguing about who should take responsibility for an individual. The committee has received examples of these cases. The Minister of State must also be aware of them. Will she share her response?
Currently, under the Assisted Decision-Making (Capacity) (Amendment) Bill 2022, treatment decisions are being removed from enduring power of attorneys. This means that people will now be forced to go through two processes at a potentially difficult time. For example, members of the Irish dementia working group have pointed out that shortly after receiving a diagnosis of dementia, individuals will have to draft two separate instruments with different requirements for supporting evidence and witnessing etc. This is especially burdensome if the relevant person wishes to authorise the same person who holds the enduring power of attorney as their designated healthcare representative. Given her responsibility for older people, what are the Minister of State's thoughts on that issue?
The next question is for Department of Health officials on the national policy on access to services. Will they provide details on how integrated it is? For example, in west Cork there is a situation where young people are at risk of not being able to access day services because there is no suitable public transport. It is all well and good to have the models of care, but how well integrated are they? The ADHD app has been mentioned a lot. What is it called? People watching may want more information about it.
I will try to get through as many of the Deputy's questions as possible. If I forget any, she should come back to me. On her first question, it is a complicated area but there is huge overlap as well. I was struck by what was said earlier, that just because a person is an older person, that does not mean that his or her disability fades away. What we are doing for home support workers? I refer back to the strategic workforce advisory group and the 16 key recommendations. We took all of them on board. We engaged with the public, private and voluntary sector and cross-departmentally. These recommendations must be enforced across all of the Departments.
The first was that when the HSE is outsourcing hours to the private sector, the living wage should be the minimum wage paid. The current living wage is €12.90 an hour; it is going up next year. That was one of the key recommendations, which everyone bought into. On the second recommendation, there are some people who work for private providers who do not always get mileage passed on to them. They have told me this themselves. The second recommendation was that mileage would have to be paid and passed on to the worker. Another recommendation was that the provision of home care should return to a 50-50 split between public and private. It had always been a 50-50 split, but because of the extra €150 million secured over the past two budgets and the fact we delivered more than two million extra hours last year alone, up to 20.9 million, we had to depend more on private companies.
One of the recommendations from the strategic workforce advisory group was that we move quickly back to a 50-50 split. That is what I want to see. We are also asking all nine CHOs to have a recurrent recruitment campaign. The point I made earlier was that the terms and conditions for home care workers working in the HSE are better than some of the private providers, yet we are still challenged trying to recruit through the HSE. There are challenges there. We want to increase the direct provision of home support provided by the HSE. Nursing home care is an 80-20 split, with 80% private and 20% public. That is what we are doing to try to support workers.
One of the other recommendations was that home care be seen as a viable career pathway. Someone coming in with a level 5 Quality and Qualifications Ireland, QQI, qualification could progress the whole way through if he or she decided to do more in caring for people. That person could take on additional courses and skills and be encouraged and supported to do that. It is important that we do that.
On reform of the regulatory framework, in recognition of the need for reform, in January this year we determined a two-phase approach to examine primary and secondary legislation.
We have put in place a national nursing home experience survey, which is under way at the moment. We felt that there is a link between nursing home care and home care because health care workers and nursing staff provide these. I have also put in place a patient advocacy service. We now have a situation where PAS staff, for example, are going into nursing homes and meeting with the residents and hearing their concerns. These concerns can relate to any type of abuse, be it emotional, physical or financial. We are trying to make sure that those supports are there. That is something that we are rolling out.
In October, the Government approved the drafting of the regulated professions (health and social care) (amendment) Bill 2022 to provide for the initial enhancements across the two schemes. I hope to move that legislation. In simple terms, it will provide for standards and best operating procedures for home care across public, private and voluntary. We do not have that in place yet and it is part of making sure that we have a standardised approach for everyone receiving home care, regardless of where they are in the country.
That has been welcomed across all the sectors that they receive a minimum of the living wage and that they also receive mileage when they are delivering home support. In north county Dublin, for example, I met staff in an organisation in CHO 9 a few months ago. They provided 900,000 home care hours last year. There was no waiting list and they are part of a voluntary organisation. With a lot of their care, they do not have to travel far between clients. In rural areas, a lot of travel is involved but in the case of this organisation much of their care is provided by walkers, as they are called. They even provide a shoe allowance every quarter for their home care providers. We can learn an awful lot from them. They pay different rates for Saturdays, Sundays and bank holidays. CHO 9 is one of the best performing areas and the care is provided by a voluntary organisation.
No, through both. At the end of the day, a person who needs home care does not care who is providing that once the home carer comes in the door. Previously, it was a 50:50 split. There was 50% of home care provided by the HSE and 50% by private companies and voluntary groups such as the organisation I mentioned. I received additional funding of €150 million in my first budget to deliver extra home care hours. The HSE is recruiting but the problem we have in this regard is that many of the HSE carers are older. Despite bringing in more people, we also lost people naturally through retirement. As a result, we had to reach out to the private providers and, in fairness to them, they stepped up and they provided more hours. At the moment we have a 60:40 split but one of the recommendations is ----
It is 60% private. It went from 50:50 to 60:40 but one of the recommendations in the strategic workforce advisory group is that we would move back again, as best we can, to a 50:50 split. We have asked all nine CHOs to put in place a recurring recruitment campaign for health care workers. The point I will come back to as well is that some people who were health care workers no longer want to work in that space. We are doing everything we can to try to support workers in that space and to try to make it a viable career pathway for them.
We do not have a timeline but we will work out the timelines on all the recommendations shortly. Many of the CHOs are recruiting at the moment and they are finding it difficult to recruit staff, even on €16 per hour plus mileage. We are seeing that across the board.
Mr. Niall Brunell:
The question was about the removal of treatment decisions from enduring powers of attorney in the Assisted Decision-Making (Capacity) (Amendment) Bill. It does not depart from the policy positions in the 2015 Act. It is chiefly about procedural improvements and there are two strands to those improvements,in the main. One is procedural improvements and efficiencies, removing red tape. For example, throughout the Act we are removing a number of mandatory referrals to the courts system where that is just not appropriate or necessary or would incur undue cost or burden. The other strand is improved safeguards. There is a couple of junctures in the Act where it is necessary to balance the removal of red tape and improved efficiency and safeguards. During the preparation of the Bill, we received feedback from clinicians in the HSE regarding EPAs that there are superior provisions in Part 8 of the Act around the making of advanced healthcare directives than in Part 7, relating to EPAs. In some instances, some of those decisions will quite literally be, on-the-spot, life or death decision around a person's care. The advice that we received from clinical experts was that there could not be too many cooks in that scenario. What was needed was one person who had authority. If there were multiple people with authority, it would introduce a lack of clarity. That could have adverse consequences for the person at the end of the day. We were also advised that the processes set out in Part 8 are much more extensive around where there is an ambiguity as to what a person's will and preference regarding treatment might be and that Part 8 offers better safeguards in those scenarios for a person's safety and for respect for a person's will and preference. That was the basis of the decision to remove treatment decisions from the EPA process.
Mr. Niall Brunell:
Yes, but the Decision Support Service has some operational levers to make that easier. It has fee waiving powers for example. There are levers when the Act is in operation that can reduce the burden on having to make two applications. They could be made at the same time. The DSS will be able to assist in that process. There are superior safeguards under Part 8. That has been the primary reason we have done this.
Dementia was one of the areas that I prioritised when I took up the position as Minister of State. We had eight dementia advisers and we now have 28. We also have 31 memory clinics throughout the country. As I said earlier, 15% of all home care hours are dementia-specific. We also have dementia home care packages. We have made a lot of progress in what we have done for dementia. Prior to 2020 there was no ring-fenced money for dementia. We were always dependent on dormant accounts and philanthropy. I have embedded dementia in the base of all health budgets going forward. We have built on it over the past three years. There are quite a lot of complications in capacity when it comes to dementia. I believe that the clarity in the Assisted Decision-Making (Capacity) (Amendment) Bill 2022 will be helpful. Dr. Philip Dodd will reply to the question on delayed discharges.
Dr. Philip Dodd:
I thank Deputy Cairns for asking that question about a vulnerable part of our population. The national psychiatric database that the Health Research Board has in place monitors psychiatric inpatient admissions and discharges. Based on the report in 2021, the numbers of people with intellectual disability admitted to psychiatric hospitals is very low. However, the time that they spend in hospital is very long. That speaks to some of the care planning issues that the Deputy highlighted.
Sharing the Vision is aware of this as a challenge and two particular recommendations seek to ameliorate this problem. Recommendation 45 looks at gathering much more detail on delayed discharges from approved centres. Recommendation 48 specifically looks at a greater level of integrated care planning for these types of individuals. With that in mind the HSE has established the national placement oversight group, which is an integrated group from mental health and disabilities that seeks to come up with the most person-centred and timely placement for people who often present with quite complex needs. The effort is to provide the most individualised service as close to the individual's home and community as possible.
Ms Siobh?n McArdle:
The national access policy for children is about ensuring that children, regardless of need, have one door to enter in terms of pathways of service. That means within CHOs the policy speaks to the expectation that the primary care teams providing children's services liaise very closely with the children's disability network teams, and that the two teams working together ensure that for families and for the child, the services provided focus on that child. For some children it may be a period with primary care, for instance a speech and language therapist but if the child has more complex needs, he or she may need two or more complex interventions. In that case such children get those services in the children's disability network team. What we are seeing in terms of disability services is the development of the children's disability network teams and I know this has come up in the committee before. We see different levels of completion of those teams across the country. The focus for the HSE, and it is very much a HSE policy, is to ensure integrated and cohesive delivery. It is certainly important that we see and are able to get that update from the HSE around how that integration is working, and having metrics that speak to getting that assurance from the HSE that it is happening for families. The Deputy has given an example from Cork, which is possibly more to do with adult services and around transport.
No, these are for children trying to get from the Beara peninsula into Bantry for education purposes. I had a Topical Issue matter on it yesterday that was taken by the Minister of State, Deputy Rabbitte. The HSE gave a response stating that there was a bus service, and the Minister herself said that all she had to do was google it to realise there was not. The local Society of St. Vincent de Paul chapter and family resource centre had to put up the money to provide a temporary service. However, after Christmas there will be no service and it feels like while the model of care is there, the integration of that is not happening. We know that children's disability network teams, CDNTs, in general, are a failure at present. There is not one fully staffed team. As we have spoken at length about those issues at this committee, I will not go into them now. Does Ms McArdle feel these models are being integrated into the communities?
Ms Siobh?n McArdle:
They absolutely need to be and the policy speaks to that. However, we might come back to the Deputy separately on the transport piece. That is around how to do them together, because transport would not necessarily fall to the health service, be it primary care or the children's disability network team. It sounds as though there is a local issue there that we could perhaps come back to.
I thank Deputy Hourigan for allowing me to take her slot, as I need to leave for another meeting. I thank the Minister of State and all the officials for their time. This is a really important issue. We speak quite often about mental health at this committee. It is at the intersection of every topic we come across. I thank the Minister of State at the Department of Health for her work since she has taken on responsibility for mental health and older people. I think we all agree that she has been reforming, and has been knee-deep in a lot of crises, from the pandemic to residential care. She has had her fair share of trials in this Department and she has taken on those challenges. We see this in the home care Bill and in her reforms where, as she said in her last contribution, she has ring-fenced that dementia budget for the first time. It is really important as that looks back to her previous career as chair of the cross-party dementia group. I want to congratulate her on that. It is also great to hear about her work with Minister of State, Deputy English, around visas. Staff are critical to everything we want rolled out in that integrated model of care. To see the Minister of State looking beyond the normal inter-relation is crucial, as it is both critical and absolutely urgent that we fill those spaces, particularly around home care. We know the challenges around getting that home care package. The money is there for that family or individual to get the care, but they are sitting lingering and waiting for that person. This committee will do everything it can to support that. I want to ask about the specialist ADHD clinics and how they can be accessed, as they are really important. I want to ask about progress on the mental health care model, as it is one of the main strands the Department is working on. I also want to take up the issue of mental health services in the Prison Service. There is a huge level of cross and dual diagnoses in the Prison Service. How is the Department working with the HSE and the Prison Service to improve the level of care and the outcomes for prisoners who have a mental health issue?
I thank the Senator and the committee for their continued interest. This is one of the stand-out new committees. It is a really important one we did not have previously. I welcome the opportunity to put a lot of what we are trying to achieve, and the work we are doing into the public domain. It is very helpful. Going back to ADHD, the current situation is that this was launched in 2021. The Adapt team in Sandyford is one of three current ADHD clinics set up by the national clinical programme. The others cover Sligo, Leitrim and Donegal, and CHO 3, which covers Limerick, Clare and north Tipperary. As I said, I have provided funding for four further teams this year, for which staff are currently being recruited. Those are CHO 7, Dublin, and CHO 4, Cork. The latter covers north and south Lee and north Cork. There is CHO 4, Kerry and west Cork, and then CHO 8, which covers the midland counties of Longford, Westmeath, Offaly, Laois, Kildare west and Wicklow. We have not seen anyone coming to my own area in CHO 5 yet, in case anyone thinks there is ministerial preference. The reason we picked the current areas is because we already had part teams in place, so felt we would be able to recruit into those areas more quickly. When these next four clinics are in place, it will mean that 50% of the adult population have access to specialist ADHD services. However, I will be the first to admit there is still a postcode lottery depending on which area you are in. It is hard if you are living in Waterford and want to be referred to a clinic in Cork. That does not happen easily. Once the 11 ADHD teams for adults are in place, everybody in the country will have that coverage.
When I visited Sandyford and met the multidisciplinary team I happened to meet one or two of the service users. I am still struck by the words of a 61-year-old man who said that getting a diagnosis had changed his life and that he had always felt there was something not quite right but he did not know what it was, and now he knows. One can live very well with ADHD when it is diagnosed. ADHD supports are provided for young children and those who receive the support of CAMHS. Some 40% of all referrals to CAMHS are for ADHD. Just because someone turns 18, it should not mean that supports stops. This is one of the five clinical programmes on which we have worked very hard and I give credit to Dr. Amir Niazi for all of his work on the clinical programmes.
Regarding mental health and prison services, I said yesterday that there were 19,000 calls to the Samaritans in 2021 from the prison sector. We did not have those data previously. The Samaritans noted that this occurred the during Covid-19 pandemic when there was a lot of isolation. I recently met a nurse who works for mental health services in the prison sector. This work can be very challenging. She was out of work for six months due to an incident in which she was hurt. It can be very difficult but there are services in place. Dr. Dodd will speak to those.
Dr. Philip Dodd:
I thank the Deputy for asking this question. At a policy level the improvement of forensic mental health services is well-placed within Sharing the Vision. There are four recommendations specifically in that area. Since the publication of Sharing the Vision in 2020, the Departments of Justice and Health established a high-level task force to look specifically into the area of improvement. The task force was chaired by former Minister of State with responsibility for mental health, Ms Kathleen Lynch, and its report was published approximately four weeks ago.
The high-level task force report built on Sharing the Vision's policy focus and looked at three particular areas of improvement. The first was the whole area of diversion of vulnerable people with mental health problems as they potentially come into contact with the criminal justice system. The second area was enhancing treatment for those individuals who are in the prison system and presenting with mental health difficulties. The third work area was having a pre-release focus to try to ensure the pathway is enhanced as much as possible for individuals with mental health difficulties who are about to be released through the Probation Service or community services.
With regard to monitoring the implementation of the high-level task force recommendations, the Departments of Health and Justice are agreeing an implementation monitoring structure in collaboration with the national implementation monitoring committee, which is the independently chaired committee established by the Minister of State, Deputy Mary Butler, to oversee the implementation of Sharing the Vision.
Specifically with regard to existing mental health supports in prisons, we have a National Forensic Mental Health Service that was primarily based in Dundrum and has moved now to the new site at Portrane. That is associated with a number of prison outreach specialist mental health teams which see prisoners who present with mental health difficulties and provide treatment. There were significant capacity issues with the Dundrum site, where capacity was approximately 98 beds. I am happy to say that the opening of the new service at Portrane will increase capacity to approximately 170 beds.
Another important part of our current supports in prisons is the psychology service in prisons. The National Office for Suicide Prevention specifically monitors the levels of self-harm taking place in prisons and has provided significant support to the enhancement of the clinical expertise of psychologists working within the Prison Service.
I welcome the Minister of State. I have two questions, both of which are about integration. I want to go back to ICPOP, which is a very worthwhile undertaking and a very good programme. I want to do a deep dive on it if that is okay. I have been reading research papers around the development of ICPOP but I do not expect the witnesses to have read them before coming to today's meeting. One issue that came up in some of that work is the challenges being encountered in ICPOP. I will speak about the funding of ICPOP. One of the challenges raised was fragmented funding structures. One issue that we tend to talk about, whether in this committee, the Joint Committee on Health or the Committee on Budgetary Oversight, is multi-annual funding and the possibility of moving towards a multi-annual funding model. The context is that I know the Department of Finance does not like multi-annual funding. Is there a challenge around fragmented funding structures when dealing with a number of disciplines, from occupational therapy and psychiatry to everything else, in terms of making sure pathways towards an integrated programme are provided? Are high-level discussions taking place on the possibility of having multi-annual funding, even if it is not a full multi-annual commitment but perhaps a framework, rule or version of it that is set out for programmes, almost like indexation? We talk about that a great deal as well, and we are not quite there yet with social welfare either. What would be the rule if we were to keep this programme going for many years into the future? That is one area I want to talk about. I would also like to understand what the staffing shortfall on those programmes is at the moment given that we have been discussing recruitment quite a lot at this morning.
The second area also relates to integration. We have talked a lot about access to home care. I wonder about the integration across other Departments. We talk about teams deciding what an individual's care needs might be but I have come across constituents who have an offer of housing or a place, for example, but cannot get home care in place in time. What mechanisms do those care teams use to reach out to local government, the approved housing bodies, AHBs, and the Department of Housing, Local Government and Heritage to ensure that decision-making model is in place?
We have been talking about carers and what we can do to support them and I note that carer's mileage was mentioned, which is welcome. Although everybody should walk and cycle, the reality is that people need to drive around to get to their care appointments. A big issue in Dublin and one I have been following up is that we really need a carer's pass for people's cars. Many older people have family who take their passes. People can get a pass for the road they live on and a member of the family, such as a daughter, may want the pass. However, the carer may need a pass to visit five different houses per day. I have been in contact with Dublin City Council many times on this. It would be very practical and would help carers if they could have a general pass that would allow them to park while visiting people. I ask for answers to my two questions.
I thank Deputy Hourigan for her questions. The ICPOP team is part of the enhanced community care, ECC, programme so they technically come under the Minister for Health's funding stream. We have 22 of the 30 teams and dedicated funding in place. The challenge is not funding but, again, workforce planning. Some 60% of posts have been recruited.
I will give an example. One of the first pilots started in Waterford in 2017. We call it Waterford integrated care for older people, WICOP, and we are very proud of the programme. It has a huge interaction with the community nursing unit in Waterford. A multidisciplinary team is put in place and sometimes there are vacancies on that team. While we have 60% of people in place, some teams can be more adequately filled than others.
Ms Siobh?n McArdle:
A team comprises a range of disciplines, including consultant geriatricians, specialist nursing staff, occupational therapists, social workers and physiotherapists. Once a person is recruited to the team, they immediately begin working to support the individuals in their area. It would not be that they sit and wait until the team is at 100%. They work to maximise what they can do within the staffing arrangement. They work with public health nursing colleagues who work in the primary care teams and the community health network. They also work with colleagues who involved in residential care for older people.
Funding has been committed, and work is ongoing in terms of recruitment. There are some particular specialties in respect of which it is are harder to recruit. All services, whether it is disability services, or older persons services or mental health or primary care, are looking for the same type of trained people. These include dietitians, social workers, speech and language therapists and occupational therapists. Sometimes those disciplines can be harder to recruit for because there are smaller pools of people available. For advanced nurse practitioners, there has been quite a commitment in terms of funding and training to ensure that we have a pipeline of people to come through and fill positions. The HSE assures us that as people are recruited, they begin their work. It is about maximising the staff they have; not waiting until they get to the magic 100%. That is really important. Then there is the target of continuing the funding in order that we get a widespread geographical distribution of these specialist teams across the country.
Specialist community teams also have a really important role in the context of working very closely with local acute hospitals to ensure that they can support diverting of people away from emergency departments. On the other hand, when people are being discharged, they work to support safe discharge, whether that is to home or into residential care. Sometimes, in the context of transitional care beds, they work to give people the interventions that support them to regain and optimise their functions. It is a very new model, and the Deputy referred to some of the research that is emerging. We will be continuing, both in the Department and with our colleagues in the HSE, to evaluate how best to deliver this model over time.
Ms Siobh?n McArdle:
We have been advised that it is envisaged that the full complement of the 30 teams will be in place in 2023. However, it depends on getting the staff into those teams. The funding has been committed for that. The Department and the HSE will be monitoring the uptake in respect of those posts and will be getting those teams up and running throughout 2023.
One can get a simple referral from a GP to an ICPOP team. ICPOP teams work very closely with local community older persons services. They also help develop end-of-life care pathways. I have only heard good things about these teams. I have spoken to many people who avail of their services. It simplifies that people do not have to go to six different clinics in six different weeks. Everything is dealt with in one particular area. The teams are located quite close to acute hospitals or community nursing units or in primary care centres. They work hand in glove, especially in relation to discharge, with these facilities. This is important when discharging older people who no longer need acute medical care or the care of a consultant but who are not well enough to come home yet. There is a lot of intervention there in the context of step-down facilities and transitional care beds. The teams also get the correct home care packages in place as quickly as possible.
For somebody living at home who is ageing and starting to develop different health issues, the first port of call in the context of receiving home is the public health nurse. If the person involved is not in hospital, the public health nurse will carry out an assessment. They will then make an application in respect of what they believe are the relevant care needs of that person. That is the first step on the road. People often tell me about cases of family members who are getting home care, for example, for half and hour in the morning and half an hour in the evening, that the health of the person involved has declined. In such cases, people can ask public health nurses to carry out reassessments. That has happened. Especially for people living with dementia whose symptoms worsen, reassessments can be sought and more home care hours can be secured. That is how it works in the community. If someone is being discharged from hospital, there is always a planned meeting put in place with the next of kin, the family, the public health nurse, the GP and the team that has been looking after the person in order to determine the correct pathway. That is where the ICPOP team can be involved as well.
What about somebody who is not being discharged from hospital but who needs to move for whatever reason? It might be that they are renting and they have to move, or they are a younger person who is moving out of a family situation because they want to live alone. How do these people interact with the ICPOP teams and how do they secure housing?
The whole purpose of the ICPOP teams is to try to prevent people having to go to hospital. Their work is pre-emptive. When a person attends, they are given a raft of tests. A team will look at frailty, falls, dementia and nutrition. It will then try to support people with a social worker, a physiotherapist or whatever is required.
In demographic terms, we know that we are going to have a huge population of renters who are going to get older and who may have to move on. Is it the social worker who has the contact with those responsible for the social housing list? Is it Clúid? I am trying to work out at what point the care team makes contact with the housing team.
Ms Siobh?n McArdle:
When a home care assessment takes place, if the person doing the assessment identifies that there are deficits in the living environment that are a risk from the point of safety, for example, the bathroom, they would make a referral to the local authority. One of the positive things we are doing is the investment in age-friendly homes. Over the past two years or so we have had nine pilot projects around the country involving one point of contact in a particular local authority area that brings together an assessment of the person's home and co-ordinates that with their care needs. Those involved work with the local authority and the HSE to ensure that people's homes are age-ready. They also ensure that people who have experienced frailty or a particular medical event are able to access the service. This begins to open the doors for them, whether it is about energy grants, making adaptations to their homes or identifying the need to access things like meals on wheels. So we have funded----
The meals on wheels services in my constituency is great. On the ICPOP teams, who is the advocate for the person? Is it the public health nurse? Who is making the call? I do not mean making the decision; I refer, literally, to the person who picks up the phone?
Ms Siobh?n McArdle:
We would have to find that out, because there may not be just one discipline. The team operates a key worker model. That means that every person who is a patient of a particular team has a dedicated key worker. For some it could be a physical therapist, for others it could be a social worker. We would have to get the HSE to speak a little bit more about how that works. I would not say in all instances that it is one particular professional. In different teams, in different parts of the country or in the context of the individual's needs, it may be deemed appropriate that a particular discipline applies.
In the context of age-friendly homes, I was asked to provide further funding next year. As a result, €5.2 million was provided in the budget in order to roll this out across the 31 local authorities.
If you are an older person living at home without family support or an immediate next of kin, there is a dedicated person within the local authority. If you want to rightsize, because you have decided your home is too big for you or you cannot heat it any more - apparently "downsize" is no longer the right word, it does not have to be a local authority house and can be a private house, but this dedicated person is there to give you support, for example, in relation to hiring an auctioneer, an estate agent or something like that. As this has worked really well in the nine pilots, we are now extending it to support older people with that. We will get the exact details regarding the question asked because it is a very valid point. There are a lot of people, who are renters and who may be in hospital and they might not have that home to go into. It is the HSE's responsibility for anyone with complex care needs, that a place might be found for them. That could be in a nursing home and it might not be the person's express wishes. There definitely always has to be communication and it is very helpful when there is family involved too.
It is a really good point. I am dealing with people for whom heating at the moment particularly is an issue. Rightsizing might be a solution if they are in bigger houses they literally cannot heat. I want to ask one quick question. I know the ICPOP teams have been involved in training members of the Garda and things like that. Is that correct, that they are training gardaí in how to deal with dementia?
My question was going to be if the same was being done with local authorities. I am just trying to imagine, when someone reaches out to the local authority, do they know what they are looking at when they get the call?
There has been a huge amount of outreach around dementia, so we have dementia-friendly communities. A huge amount of work has been done with libraries so the signs of dementia are recognised. It is one area where there has been a reach out to first responders in respect of dementia. I can remember a case I was aware of, where a person in a shop was really disorientated and she started to knock some items off the shelves. She had dementia, she was very confused and did not know where she was. It is really important that this is recognised. The dementia strategy has done a huge amount of work reaching out to the libraries for example. That is one scheme I am very aware of. We are also starting to see dementia-friendly communities happening in the way we see autism communities. It is an area we really need to ramp up as well, and build as much as possible.
The dementia advisers are very much to the fore and I met some of them recently who had taken part in LGBT+ training so they could also recognise the symptoms. Well, I do not mean the symptoms. The point I am trying to make is that I met a gay woman one day and her only fear was that if she developed dementia, nobody would know she was gay because she could not remember. The dementia advisers have taken on the role of dementia champions and I was delighted to see that happening. All 28 dementia advisers we have on the ground are really active in the communities. When a person receives a diagnosis of dementia for the very first time, it is a shock. There is also a lot of stigma around it, which thankfully we have moved away from. However, to have a dementia adviser in your own community that you can reach out to is important because some people can get early-onset dementia. One of the things I want to touch on is that we talk a lot about the fair deal scheme in relation to nursing homes but one of the areas I am exploring at the moment is that dementia-specific category within fair deal. Everybody here will be familiar with Carebright, Bruff, County Limerick, and St. Josephs, Shankill, which are dementia-specific-only for your pathway through dementia. At present, 64,000 people in the country have been diagnosed with dementia. We have 11 diagnoses per day. We are an ageing population and we are going to see that grow. There is probably a raft of people with dementia who are not diagnosed. One of my focuses is that it is really important that we put in place the right supports. Some 70% of people currently in nursing homes either have a diagnosis of dementia or have dementia symptoms. It is an area that needs a lot of focus.
I thank members, the Minister and the team. There are two issues. Years ago, there was not enough money in the allocation for home care. Now there is money but no staff. I know efforts have been put in to try to do that. That is crucial. It is showing up the challenges that are there, in both urban and rural Ireland. This will not be of any surprise, but in my region young people and kids who have fallen between different cracks find it hugely difficult to try and get a CAMHS consultation. It is becoming a major strain on families. I know everyone here is working on it but I ask them to make sure it is a priority. Across all sectors, members have mentioned adults with additional needs and disabilities whose families are worried about what is going to happen to them. That is something where a very serious policy needs to be looked at in terms of how that is and what services are available. A lot of the time, the layperson, for want of a better expression, does not know where to go looking for advice and stuff. There needs to be a clear pathway because that is becoming more and more pressing every day. They refer to their public representatives and others to try to guide them through the process, which can be hugely problematic. They are the couple of issues I would like to be taken from this morning's meeting.
I thank the Chair, who I know has been a strong advocate for home care for many years. We see the challenges especially at weekends in rural areas, like Saturday and Sunday. Home care works really well from Monday to Friday in a lot of areas but if you are in a particularly isolated area and you need two carers three times a day on a Saturday and Sunday, it can prove problematic. Obviously, carers do a great job but need time off as well. They have to have their own work-life balance. They are areas where we have been trying to think outside the box. All the various Departments were included in the strategic workforce advisory group. We were working closely with the Department of Social Protection too, because we are exploring areas where some people might come back and do ten, 12 or 15 hours a week but their entitlement to a medical card might be affected. For example, some people might come back and do three hours a day but cannot sign on for those days. We are trying to look at all those different angles to see if we can get people who might no longer be working but who might be in a position to come back and do between ten and 15 hours a week, which could take a lot of pressure off. I understand completely about the waiting list in CHO 4, covering Cork and Kerry, around CAMHS. We have seen it almost doubled. A lot of difficulties remain in terms of staff but we are acutely aware of it and I am in constant talks to see what we can do with Michael Fitzgerald, who is the chief officer down there, and Kevin Morrison, who is the lead on mental health services. There are some areas performing much better than others. There are reasons for this but at the end of the day, there is a child waiting for support and that is something we are putting a complete focus on.
I thank the Minister, the officials and our members this morning for their dedication to the job at hand and to their interest in our work. I also thank our team that does so much work behind the scenes and continues to do so.