Oireachtas Joint and Select Committees
Wednesday, 18 June 2025
Committee on Disability Matters
Progressing the Delivery of Disability Policy and Services: Discussion (Resumed)
2:00 am
Maurice Quinlivan (Limerick City, Sinn Fein)
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Apologies have been received by Deputy Seamus Healy and Senators Nikki Bradley and Maria Byrne. The purpose of today's meeting is the discussion on progressing the delivery of disability services. On behalf of the committee, I extend a warm welcome to Mr. Bernard Gloster, chief executive officer of the HSE; Ms Martina Queally, regional executive officer of the HSE, Dublin south west; Dr. Aoife O’Donohue, assistant national director, HSE disability services, transformation and programme co-ordination; Ms Mary Doran, assistant national director of HR, disabilities workforce and resourcing lead; and Ms Sinéad Stone, assistant chief financial officer, disability finance, national finance department.
Before we begin, I wish to read a note on privilege and some housekeeping matters. All witnesses are reminded of the long-standing parliamentary practice that they should not criticise or make charges against any person or entity by name or in such a way as to make him, her or it identifiable, or otherwise engage in speech that might be regarded as damaging to the good name of the person or entity. Therefore, if their statements are potentially defamatory in respect of an identifiable person or entity, they will be directed to discontinue their remarks. It is imperative that they comply with any such direction that I may make.
I also remind members of the constitutional requirement that, in order to participate in public meetings, members must be physically present within the confines of the Leinster House complex. Therefore, as members of the committee are aware, if they are attending this meeting remotely via MS Teams, they must do so from within the precincts of the Leinster House complex.
I now call Mr. Bernard Gloster to make his opening statement.
Mr. Bernard Gloster:
Good morning. I thank the committee for the invitation to attend this meeting to discuss a range of aspects regarding the HSE provision of services to people with disabilities. I am joined by my colleagues, as the Chair has outlined, and I am supported by Ms Sara Maxwell, general manager in my office.
I will start by focusing on the resource profile of the HSE disability services. Funding of disability services within and through the HSE has increased in recent years. The 2025 allocation for disabilities is €3.2 billion, which is an increase of €330 million on the 2024 allocation. The increased funding is made up of €131 million, or 40%, to meet both the pay costs from the public sector agreement and the WRC agreement in respect of section 39 workers in the disability sector. A total of €199 million is to fund the incremental cost of 2024 activity, of which €111 million mainly relates to residential placements and day services. There are also additions for demographic pressures and some new developments.
Regarding the staffing of disability services, in December 2019, 18,244 whole-time equivalents were employed in these services, that is, services of the HSE and section 38, not section 39, agencies. In April 2025, this number had grown to 21,761. We are currently engaged with the Minister, the Ministers of State and the Department with the aim of bringing full clarity to the resource position going forward. This will allow for better planning and appropriate control of expenditure.
We hope to conclude a necessary pay and numbers strategy for this sector in 2025. I consider this a significant priority. I welcome the commitment in the programme for Government to the possibility of multi-annual funding approaches, as this would bring certainty to both the pay and non-pay aspects.
Outside of pay, the significant costs in disability services are the provision of residential care placements and grants to section 38 and section 39 agencies. Given the increased volume and complexity of demand in respect of disability services, it is essential the HSE be able to plan beyond a single year.
In the context of our services, we will provide residential care to almost 8,700 people and intensive support packages to a further 600 in 2025. Day services of various types will be provided to 23,000 people. Some 6,300 people will avail of respite supports, while 10,000 people will avail of either personal assistance or home support hours, totalling 5.5 million hours.
Despite these record levels of resourcing and services, many challenges remain for people, both for children and adults and their families who care for them. From a HSE perspective, these challenges can be prioritised and are quite similar to other challenges in health service provision, such as: access to services; recruitment and retention of specialist staff; and models of care being relevant to the individual need or experience of people. The HSE is working with the Department of Children, Disability and Equality and across the Government through the dedicated Cabinet committee on disability to respond to these challenges. A HSE response alone is not an effective solution to any of these challenges. Our most significant challenge is not the absence of plans, but the pace at which we can implement them and bring about necessary change.
I particularly wish to reference children’s specialist disability services. I am acutely aware of the serious challenges in that part of our work. While members will be familiar with the issues associated with assessment of need, I wish to emphasise that exclusive focus on that would be somewhat misplaced. Assessment is important and has its place. It requires reform. In my experience, however, what people want most is access to services and supports. I have recently met several groups of parents in different regions and separately with staff working in disability services to hear both their experiences and practical solutions as to how we approach change. I hope in the coming months to add to our approach by taking some practical steps, which are informed and will yield improvement. These steps include: a single point of entry for referral of children to community healthcare services, inclusive of primary care, disability and CAMHS; a dedicated key work co-ordinator post in each area; a reduction in therapists' time in non-therapy administrative work; and a more flexible approach to how we implement the progressing disability services programme.
I will conclude with two remarks. First, I thank the many staff we have across the country who work in our disability services, be they in section 38 or 39 organisations.
They come to work every day to support people to live a life to their full potential. They do that with professionalism and care in equal measure.
Second, I want to recognise that despite a significant amount of services delivered, increased Government investment and a renewed focus on building our capacity, I am conscious that for many people today, we simply have come up short. It is important for me as CEO of the HSE to recognise this, apologise to those families and explain our attempts to do something about it.
In conclusion, my statement was submitted prior to the airing of last evening's report on the "Prime Time" programme in respect of people under the age of 65 living in nursing homes. I want to acknowledge the significance and seriousness of that issue. I am certainly very happy in the course of the morning to address any questions members have on that.
Maurice Quinlivan (Limerick City, Sinn Fein)
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I thank Mr. Gloster very much. I now invite members of the committee to put their questions. When I call members to speak, they should adhere to the agenda item scheduled for discussion and to their time. The first speaker is Sinn Féin's Deputy Ó Murchú.
Ruairí Ó Murchú (Louth, Sinn Fein)
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The witnesses are all very welcome. I will jump straight into children's specialist disability services. I accept what Mr. Gloster said in the sense that what people want to see and want to have are therapies and supports for their children. There is a particular issue. We had Cara and Mark Darmody here, and their fear is that we have not sweated the private sector sufficiently. They would say it has been a failure by Government with regard to making sure we know what capacity there is. I have no issue with having conversations with the likes of speech and language therapists, SLTs, occupational therapists, OTs, and psychologists. All the organisations have stated at times that what is lacking is the conversation with them on the best means of providing therapies and the assessments. Parents are still being forced to get assessments for schools or whatever. No matter who says they do not need them, the fact is that they are told they do. I know the numbers have slightly increased with regard to the children's disability network teams, CDNTs, but my fear is that even if we fill that entire number of unfilled positions, we will still not be able to provide the capacity.
Mr. Bernard Gloster:
I do not dispute any of that whatsoever. I have met Mark and Cara, and I will meet them again in the coming weeks.
With regard to the use of private sector capacity for assessments of need, I have no principled objection to using it. I would rather it was not the case, but I do not have any objection to using it. One of the concerns I have is that we do not use inappropriate private sector capacity. Simply put, that is people saying they are qualified to offer a family something when they are not. I have a fundamental issue with that. It is very unfair to families. However, we can speak to the detail of the amount of private capacity that we are using. Dr. O'Donohue might comment on that.
Dr. Aoife O'Donohue:
Yes, and how we have improved it. To date, our level of new referrals who came into the system in quarter 1 is 3,131. The number of assessments of need, AONs, we actually closed out in quarter 1 was 1,412. That is an increase in our actual overall capacity of 65% based on quarter 1 last year-----
Ruairí Ó Murchú (Louth, Sinn Fein)
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That is a fair bit actually.
Ruairí Ó Murchú (Louth, Sinn Fein)
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The big question I have is about the conversation the witnesses are having and this Cabinet sub-committee is having with regard to the best means of delivering assessments and then delivering therapies. I have always been a big believer in school therapies, but the witnesses are here answering to a degree with regard to what the CDNTs in particular are meant to offer.
Mr. Bernard Gloster:
I will mention a couple of things and we can again speak to the numbers; it is no difficulty. I could list off a couple of items regarding the principal focus at the Cabinet committee, the first of which concerns the Department of further and higher education and the conversation about increasing the supply of allied help professionals. The simple reality is that every part of the health sector and, indeed, beyond the health sector, is now trying to recruit therapists for different reasons and there is a limited supply. The second thing is that the Department of education is building and designing its own special school service and special class service of providing therapy in the classes. I expect it will be advertising those positions in the coming months.
With regard to the HSE itself, the Taoiseach specifically asked me to see whether there is anything additional we can do in the short term in the private capacity to alleviate the pressure on the assessment waiting lists. That is the first thing-----
Ruairí Ó Murchú (Louth, Sinn Fein)
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So, that is being done at the minute.
Mr. Bernard Gloster:
Yes, absolutely. As I said, the only line I draw is the quality. The second thing I would say to the Deputy is that apart from increasing the supply, I believe assessment of need requires legislative reform. I do not believe the legislation has kept pace with the modern day development of skill and practice.
Ruairí Ó Murchú (Louth, Sinn Fein)
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Would that change the nature of what the assessment of need is?
Mr. Bernard Gloster:
What I am saying is that it is absolutely not changing the nature of what an assessment of need is, but changing the basis on which people would access it and how it would be done. In fact, it is reforming the legislation to actually improve people's chances of having their rights in law vindicated rather than the current one. There are two ways to do that. One is to slightly reform the legislation in terms of the purpose of the assessment. The second, and the Deputy quite rightly mentioned it, is that I have no doubt that despite the fact there might be a policy position that people do not need an assessment of need for certain things, they are being told they do or they are being led to believe they will get it faster if they do. I believe approximately one third of referrals to assessment of need are actually quite inappropriate. At the moment, we see that there is no sign or indication of a disability in approximately one third of concluded assessments. That suggests people are being pushed into accessing assessments for accessing other things for which they should not need an assessment of need. I do not believe people should need an assessment of need for things like basic equipment in education, special needs assistance support or, indeed, social welfare entitlements. I do not control that. I am around long enough to remember when the Disability Act was written. The Disability Act and the assessment of need were written for a very different purpose than for what people are trying or being forced to access it today or feel they are forced to access it. That is the reform I am talking about - not changing the purpose or removing the right.
Ruairí Ó Murchú (Louth, Sinn Fein)
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On the pay and numbers strategy, I just want to ensure we are filling all positions and that there are no suppressed positions. I will throw these other things out as well. Obviously, talking about adult services, the HSE relies on the likes of St. John of God. There seems to be an issue at the minute with regard to the capital assistance scheme, CAS, funding with which it would have been able to buy properties. It is an issue that needs to be addressed. It looks like there will be an issue with regard to disability housing and how it was accessed previously.
Ms Mary Doran:
That recruitment is proceeding within the pay and numbers strategy for the disability posts. There has been quite a substantial increase, particularly with the CDNTs, in the workforce to date. There have been 415 since 2023 in the children's disability network teams. With regard to St. John-----
Mr. Bernard Gloster:
We are rapidly getting close to filling more jobs successfully. The next challenge for us is retaining people. It is very challenging and difficult work, and people do have choices.
With regard to the CAS funding, I have seen nothing but a very strong commitment from the Department of housing to exploring every modern way in which CAS could support a whole range of people with disabilities.
Ruairí Ó Murchú (Louth, Sinn Fein)
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I think there has been a change in the last couple of days. I agree with that.
Maurice Quinlivan (Limerick City, Sinn Fein)
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The Deputy's time is up; I am sorry.
Ruairí Ó Murchú (Louth, Sinn Fein)
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The CAMHS, intellectual disability, ID, multidisciplinary team is-----
Maurice Quinlivan (Limerick City, Sinn Fein)
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The Deputy can come back in again. The next speaker is Deputy Quaide.
Liam Quaide (Cork East, Social Democrats)
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I thank the witnesses very much for being here today. In recent years, the problems in children's disability network teams and, indeed, child and adolescent mental health services have been well acknowledged and documented, and there have been efforts to address those. However much of a distance we have to go with that, the first stage is acknowledging the scale of the difficulties. However, what has flown almost entirely under the radar has been the equally serious or, in some parts of the country, much more intractable crisis in primary care services.
For people tuning in who may not know, primary care services support young people with mild to moderate mental health difficulties and also mild to moderate disabilities or developmental issues. CDNTs are for young people with more complex disabilities who require long-term support. As we know, primary care tends to offer a very short-term intervention; it could be three or four sessions of OT, six to ten sessions of psychology and then the young person is typically discharged. One of the main purposes of primary care is to intervene early, before difficulties become entrenched and the young person might need either CAMHS or a CDNT. What anyone in my former discipline of psychology will tell you is that primary care has been neglected for years.
Most parts of the country are now in deep crisis, with waiting lists that are out of control. Staff morale is on the floor. It is getting more difficult for psychology managers to fill the paltry number of posts they are allowed to advertise. Often, candidates would be taking up a role in a service that has been hollowed out. In many cases, the love of working with young people and their families is overtaken by the grim tasks of doing file reviews and informing families that they will not be seen for years or that they need to be redirected to another service.
For example, the primary care psychology service waiting lists in Cork-Kerry in May of last year were in excess of 5,000 people. At that stage, 109 children had been waiting four to five years for maybe seven sessions before they would be discharged again. A year on from that, with recruitment largely frozen for much of the intervening period by the pay and numbers strategy, the list is now up to more than 6,500 people. This is for Cork-Kerry alone. Long before the pay and numbers strategy and long before the official recruitment embargo, there was also the issue that when the progressing disability strategy was being rolled out, a very large volume of the more non-complex disability referrals were redirected from CDNTs to primary care. However, there was not a commensurate recruitment drive in primary care services at that stage. We have definitely had retention issues in CDNTs, but over many years we have not seen the HSE pursuing recruitment in primary care. Basically, this has been a disaster of clinicians which has grown in plain sight over a number of years. It has not really received much political attention. What is the HSE's recruitment commitment for primary care services, as distinct from CDNTs, to address this crisis?
Mr. Bernard Gloster:
I thank the Deputy. I think his extensive professional background informs his views. The day before yesterday, I met 600 staff from CAMHS, disability services and primary care services on a webinar. Some of the primary care staff who participated left me in no doubt about their views. The truth is probably in the middle. The Deputy is right when he says that primary care was always seen as a generic service. For good or bad, the determination was made, based on evidence, to specialise. As a result, we now have CDNTs, CAMHS and enhanced community care, which deals with chronic disease and integrated care for older people. The more we specialise and the more we advertise jobs for specialists, as the Deputy will know, the more we attract the people who were in the generic service to consider those specialisations, and they do. That leaves some level of natural depletion. Primary care faced challenges long before the pay and numbers strategy was implemented. I will say two things about what I intend to try to do about it. First, this year, we will have a more properly shared distribution among all those services. We are creating a single referral point into community services for children. Representatives of CAMHS, primary care services and disability services will assess them and route them appropriately. It is hoped that they will help each other in that spirit of integration. Second, we are planning, with the Department of Health, to do a short-term initiative to clear a number of primary care waiting lists. Then we will try to build up the number of staff in primary care to make the clearing of the waiting lists more sustainable. I would not for one minute say we will have 100% success in that. Part of our problem with primary care is that there is an absence of data and information. I have met the Deputy's colleagues, the heads of psychology services for the country. I was very encouraged by their responsiveness. This year, we are trying to make sure that doctoral psychology students are not counted as whole-time employees and therefore, not counted in the staff number. These are things I can do to help to increase the supply. Primary care has a huge role to play, but it faces challenges. The simple reality is that every single part of the health service, from a surgical department to a medical department, to an emergency department, to an older persons' service, to a children's service, are looking for multidisciplinary teams. However, the supply is not there to service all of that.
Liam Quaide (Cork East, Social Democrats)
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I want to take up the point about the psychology trainee posts. An additional 45 psychology trainee placements were announced, which was very welcome. Initially, the psychology managers had been told that, through the pay and numbers strategy, this would not affect recruitment outside of that. I know that in some parts of the country, areas are being asked to forfeit posts in order to make way for the new trainee posts. Will Mr. Gloster give some assurance on this?
Mr. Bernard Gloster:
I am not asking any area to forfeit posts for that. I met the heads of psychology. I have yet to work that through with the regional executive officers. I was involved in starting the University of Limerick programme many years ago. I remember they became counted in the staff count because of a Labour Court judgment. We should not have our core workforce suffer because of students and these doctoral researchers are students. I am going to separate those and there will not be a forfeit for that.
Liam Quaide (Cork East, Social Democrats)
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That is very reassuring. I thank Mr. Gloster.
Keira Keogh (Mayo, Fine Gael)
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I want to go back to the issue of assessment of need. I agree with Mr. Gloster that many people are seeking assessments of need to get the piece of paper in their hands because they feel they will be able to access services quicker. There is such a demand on services in terms of CDNT teams. There is a big push towards assessments of need so that people can access SNA and SET hours, the domiciliary care allowance and the CDNT teams. If we are looking for legislation change or policy change, would Mr. Gloster agree that we should be prioritising the people who are on the assessment of need list who will suffer the longer they do not get the assessment? I am thinking about autistic people who need the diagnosis to access home tuition, an autism class or a special class. What are Mr. Gloster's views on this? Is there any way that before a legislation change we could prioritise those people with expected diagnoses who are on the list?
Dr. Aoife O'Donohue:
A person does not need to have an assessment of need in order to access primary care services, CAMHS or CDNTs. That is why the single point of access will be really clear for anyone referring in, be that the GP, the school or the parent. If they identify a need for a child, there will be one single point of access to those referral pathways. If a child in a CDNT could benefit from the input of CAMHS, this will now be done internally. It will be a much smoother process and a more timely intervention. The other thing within the CDNTs is that with the workforce being recruited inwards, our delivery of service has increased significantly. Although the assessment of need has a key role regarding the required assessment, what is key to many families we speak to is the intervention they require.
Keira Keogh (Mayo, Fine Gael)
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I completely agree, but is there a way to prioritise the people on the assessment of need list who need a diagnosis? A person does need a diagnosis to access an autism class or home tuition, but a person does not need one if they have a sensory processing disorder and they want to access an occupational therapist or a CDNT.
Mr. Bernard Gloster:
I have to be honest and say that is a very difficult thing to do. Clinicians make decisions based on their best judgment of what is in front of them. In different parts of the country that might have some level of subjectivity to it. When assessment of need was first introduced in the Disability Act 2005, it was intended to be associated predominantly with the healthcare needs of a particular age cohort. There was separate legislation on the Statute Book for special education that was never activated. This led to an inward demand onto the assessment of need list. When we add demographic growth to this, as well as the fact that it is the one right people have in law, it is clear that it is a very precious thing for people. I would not expect them to give that up. Unfortunately, as a result of the Superior Court's interpretation - which is not the fault of the court; it can only interpret what is presented - and the demand for different services, including things like social welfare, there is every chance that the children who actually clinically need the assessment are in danger of being lost in the list. That is what the legislative reform is for.
Keira Keogh (Mayo, Fine Gael)
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I hope that Mr. Gloster understands the balance. Parents want that piece of paper; they have that right. Regarding the regional hubs and recruitment, have we looked at overseas recruitment at all? Will Ms Doran give me an update on the six regional hubs?
Ms Mary Doran:
Yes, we look at international recruitment but the truth is that there is a significant global shortage, particularly in the health and social care professions. While we have a small amount of international recruitment, the majority - by far - of recruitment into these specialist roles takes place domestically. As Mr. Gloster mentioned earlier, we are looking to grow the domestic market for the pipeline. We have had good success in the health and social care professions. In the past 18 months, 300 extra whole-time employees have gone into CDNTs.
We have had some success in the domestic market.
Keira Keogh (Mayo, Fine Gael)
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Is there any update regarding the six regional hubs?
Keira Keogh (Mayo, Fine Gael)
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We were told six regional hubs were being opened that would hopefully help alleviate issues and streamline the AON process.
Dr. Aoife O'Donohue:
Through our engagement with the staff teams, we have looked at a number of initiatives regarding the development of the six hubs. The hubs will actually oversee it. A lot of the time, these children have many assessments and interventions. We are looking at the assistance the teams can offer to primary care, CDNTs and CAMHS. The people who require an AON are not just children who are on a CDNT list and being supported by CDNTs. We have looked at the enhancement of the assessment of the resources that has already been done in respect of the child and the in-reach of that. We have had a lot of success in some local teams. Further work needs to be done and there are plans on how we will do that.
Mr. Bernard Gloster:
In fairness to the then Minister of State, Senator Anne Rabbitte, she wanted to separate the assessment from the CDNT in order that the CDNT could get on with the work with the children on the list and that there would be a process for the assessment because of the volume. It proved extremely difficult to recruit to it, retain people and set it up in a way that it did what it was intended to do. There are variations on a theme. At the moment, if we were to staff those six hubs tomorrow to do what they were intended to do, we would still be under serious pressure. That is why I have said the assessment of need requires reform at multiple levels.
Keira Keogh (Mayo, Fine Gael)
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I only have 15 seconds left, so I will start a question and may be able to follow up on it later. Regarding CDNTs, there was a move away from direct blocks of therapy to more parent education. Therapists were talking about burnout and not being able to provide the therapy. We may come back to it later because my time is up.
Dr. Aoife O'Donohue:
The model supports family-centred practice. We work with each family to establish goals. We then have a three-tiered approach to the support we provide those families based on the needs of the child. The universal target and the specific needs of the child are considered. A part of the ISP is about supporting the child, not only in the direct family home, but also in the supports around that, such as in society, in school and in areas with which they engage, and enhancing that experience for that child.
Mr. Bernard Gloster:
It is fair to acknowledge that there are polarised views about direct therapy versus supporting the primary carer and the family. I meet parents every day who say they just want direct therapy for their child, but I also meet professionals every day who say that that is not a productive way to support the child. There are professional views and differences about it. At the moment, the model is family-centred. One of the things I have asked all people working in CDNTs to do is to be appropriately flexible and not rigid in how we apply that.
Laura Harmon (Labour)
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I thank the witnesses for attending. I look forward to engaging with them. It is good to have this discussion. I am sure the committee will be engaging with the HSE throughout the course of its work over a number of years. I thank Mr. Gloster for his opening statement.
I wish to focus on assessments of need. I am from Cork. Recent figures show that there are more than 1,200 individuals who are currently overdue an assessment of need, 77% of whom are overdue by three months. Legally under the Disability Act, people are entitled to an assessment of need within six months. The first three months are taken to process the application and then the application is completed in the following period. As of quarter 1 of 2025, it is concerning that just 7% of assessments of need were completed within the timeframes of the Disability Act. By the HSE's own figures, more than 15,000 were overdue by the end of quarter 1 of 2025. This is projected to rise to more than 25,000 by the end of the year. I note that there is also an 8% increase in those who are overdue this year compared with quarter 1 of 2024. I just wanted to outline that initially.
Early intervention is key for people in terms of getting assessments so that they can move forward with the care they need. The representatives of the HSE have talked about the reforms to the assessment of need. Will they elaborate? What is their view on the legislative reforms that may be proposed by the Government in terms of changing the timeframes in the context of the six-month legal requirement? Are they opposed to changing that?
Mr. Bernard Gloster:
I do not want to speak for the Government. They will make their own decisions. My contribution to that conversation has been more about ensuring that the legislation defines the purpose of the assessment and enables access to it, rather than it being a catch-all for everything in the State. That is my requirement of the reform. I have not heard any reference to wanting to amend or change the timeline so far. There is an acceptance, certainly on my part, that we have to accept and be honest with people. The way the issue has evolved over the years, the way demand has changed and the way other things have and have not happened, we do not have a hope of being compliant with the law the way it currently stands. That is not to say we should take away anyone's right. Rather, it is about the purpose of the assessment and that that should define access to it. We could then make a very credible inroad into it. I genuinely believe that and have said it to the Government. It is not about changing the time to simply suit the waiting list. That would not be appropriate, fair or proper.
Laura Harmon (Labour)
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We heard from campaigner Cara Darmody and her dad last week regarding this. They were concerned about potential changes to the legislation. That is why I wanted to get Mr. Gloster's view on it.
Moving on to the issue around waiting lists in terms of therapies, the figures nationally are concerning. Locally, the waiting lists in Cork for psychology, speech and language therapy and audiology are concerning. There are 30-month waiting lists for primary care assessments for autism in Cork city. Children with complex disability needs are waiting an average of just under 12 months - 11.75 months - to access these services in Cork. What are the key barriers to the recruitment and retention of CDNT staff and what needs to be done to address them?
Mr. Bernard Gloster:
I might ask Ms Doran to talk about recruitment. Before I do, however, Ms Queally is a regional chief and is very experienced at running these things. There is a paradox in therapy waiting lists where the more therapists that are provided, the more demand can be increased. It is a good thing and people benefit from it, but it distorts the picture. I have a particular concern about Cork. I have raised my concerns with the regional team there. In fairness, I have asked for a very specific focus, not just in disability services but in CAMHS and children's services generally. The waiting lists in Cork are quite distorted. Ms Queally might pick up the question from there.
Ms Martina Queally:
I will refer to some of what Dr. O'Donohue said. The way in which we organise the teams and how we do our business is important in terms of the child's needs being met at the most appropriate level. In response to Deputy Quaide, we discussed a stepped model of care in Sláintecare, which is about the child coming in and being seen at the most appropriate level. The real thrust of our efforts in establishing the regions is aligning our children's disability network teams, our CAMHS teams and our primary care teams to ensure that the child's needs are met as early as possible. In up to 26% of referrals, and higher in some CDNTs, the child was not appropriate for the specialist team when the assessments of need were looked at. This means that those children still have needs that have to be met in a timely manner. I would like to see a lot more collective working between primary care, disability and the mental health teams in order that they look to the populations they are serving in an integrated way.
There are 96 primary care teams in the country and 93 children's disability network teams. There is a requirement to align those teams in order that they have a focus on the populations they are serving. Equally, the CAMHS teams are geographically based. The main thing is that the child gets access on time and he or she is seen as quickly as possible by the right therapist. The CEO spoke of the integrated approach to referral and having a centralised referral system. That is critical in order to ensure that we completely understand our demand and our own activity so that we are optimising the staff effort and not going from one to the other.
Maurice Quinlivan (Limerick City, Sinn Fein)
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Please, be very brief.
Ms Mary Doran:
On recruitment for CDNTs, we have improved since October 2021. There were 1,500 members of staff in CDNTs then and more than 2,000 members of staff now. Within Cork, 275 posts have been filled and there is a 10% vacancy rate on top of that. Those are the unfilled posts.
The barriers mainly relate to the pipeline coming in and the perception of working in the disability sector. A number of our initiatives in the past year have borne fruit with regard to increasing the workforce.
Paul McAuliffe (Dublin North-West, Fianna Fail)
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I welcome Mr. Gloster, Ms Queally and all the team. It is good to have Mr. Gloster before us in an environment other than a meeting of the Committee of Public Accounts. I am usually asking difficult questions about numbers.
Paul McAuliffe (Dublin North-West, Fianna Fail)
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I am going to ask difficult questions about numbers here, too. As we drill down into the whole area of assessments of need and CDNTs, one thing that struck me was the idea that one third of children could go through the process and not reach the bar for an assessment of need.
Paul McAuliffe (Dublin North-West, Fianna Fail)
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One third of children are coming in to seek a diagnosis of autism where there is no other alternative publicly. One third of the time taken by CDNTs relates to assessments of need rather than the delivery of therapy. I am focused on therapy. To me, that must be the priority. It is where interventions happen. Assessments of need are important and required by law, but my worry is about how we will reach the point where we are delivering treatments and therapies.
On the pathway for those who suspect they are on the autism spectrum, the real worry is that, unless they get an assessment, there appears to be no pathway within the public healthcare system whereby they can get a professional assessment. The Minister said that for, school and many other services, one does not need an assessment of need. However, one also cannot access a public professional assessment. Am I wrong in that?
Dr. Aoife O'Donohue:
We are just in the final stages of developing the autism protocol, for which there has been co-development and co-design. The protocol states clearly that if somebody believes he or she requires an autism assessment, there is a tiered approach. For some people who require the assessment, the clinical pathway is quite clear. For some people who present with symptoms of autism, an ongoing assessment is required. The protocol sets out a three-tiered approach. What is fundamental is the need for timely intervention. For people who require that level of support, we must ensure we are intervening and supporting them to reach their potential.
Paul McAuliffe (Dublin North-West, Fianna Fail)
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What will the autism protocol look like? At the moment, people are referred to a CDNT, which takes a long time. Their schools are anxiously awaiting some sort of professional assessment and the children are waiting for treatment.
Dr. Aoife O'Donohue:
One thing the protocol is going to do is to provide a consistent approach. If we consider a child's perspective, the primary care CDNTs and CAMHS teams will all have the same pathway and approach towards the autism protocol. It is not that it prescribes that a CDNT take a particular approach. It is about a consistent approach and keeping the child front and centre.
Paul McAuliffe (Dublin North-West, Fianna Fail)
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Perhaps it is unfair of me to ask before the protocol is published, but the bit I am not clear about is how I, as a parent, can get my hands on a professional assessment so that I can approach a school and tell its representatives that my child essentially has a diagnosis.
Mr. Bernard Gloster:
Just before the Deputy came in, I explained to his colleagues that I would make changes in October this year. I have met many professionals and parents in recent days and weeks. I attended an Irish Medical Organisation conference a few weeks ago and was struck by the number of general practitioners who told me how much time they spent referring children to HSE specialist services only to be told they had opened the wrong door, at which point they had to start again. We are changing the system so that there is only one front door and there is no wrong door. Whether it is a GP, a teacher or a family member, a child will be referred. The combined efforts of CAMHS, disability services and primary care will decide which offers the best chance for the quickest pathway for that child to receive an appropriate response. That will include the autism protocol.
Paul McAuliffe (Dublin North-West, Fianna Fail)
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The challenge then is determining the difference between an assessment of need and a professional assessment. We then fall into the same space we were in when the court case was taken, that is, a lower version or poorer interpretation of-----
Paul McAuliffe (Dublin North-West, Fianna Fail)
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When I looked at the judgment, there was not a clear pathway forward as to how the system should respond. That was one of the things I noticed. We must retain the right to assessment of need.
Paul McAuliffe (Dublin North-West, Fianna Fail)
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I do not think there is any-----
Paul McAuliffe (Dublin North-West, Fianna Fail)
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We must also get to the point whereby we are freeing up hours and recruiting more staff. I want to talk more about recruitment and so on. I know the Minister for Further and Higher Education, Research, Innovation and Science, Deputy Lawless, has put in place a number of posts, which is welcome. The Minister of State with responsibility for disabilities is a Deputy in my consistency. Mr. Gloster might be aware of An Saol, which is a neurological treatment service. It was the subject of a "Prime Time" programme last night and I raised the issue with the Minister of State at the same time. As part of its master plan, it has identified a site in Ballymun with Dublin City Council. There is money in the capital plan for the site and a feasibility study. The gentleman who runs the organisation, Mr. Reinhard Schäler, is a fantastic guy. He is from Germany and cannot understand the cultural addiction we have to bureaucracy. He just wants it to happen for our patients. Is there a commitment that the project will be in the capital plan?
Dr. Aoife O'Donohue:
There absolutely is. Our team in the locality have been actively engaging. The HSE estates team is engaging on the procurement and development of that land and what that service looks like.
Mr. Bernard Gloster:
One of the frustrations that organisations, and particularly new-initiative organisations, feel is that frustration with bureaucracy. I find it myself quite often, despite what people might think. Equally, there are reasons for certain aspects of bureaucracy, as I think the Deputy knows, when we invest public money. There is a strong commitment to supporting that initiative. I would be happy to meet and hear directly from those involved because I was impressed by what I saw last night.
Paul McAuliffe (Dublin North-West, Fianna Fail)
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Dublin City Council has put forward the site but it also wants to be sure it is a realistic project and the council will not be left holding onto the site for a long time for a project that will not happen. The HSE has demonstrated its good faith, but demonstrating it to Dublin City Council and An Saol is important.
Mr. Bernard Gloster:
There are three stages. One is assessing the actual cost. Sometimes, organisations tell us that something will cost €800,000 only for it to actually cost €2.4 million. The first step is the assessment. The second is the planning process and the third is the allocation of the money for construction. There are delays in our processes but I think we have tightened them and I want to tighten them further. Dublin City Council is right that it cannot hold that site vacant forever. More importantly, the people who need that service cannot wait forever.
Paul McAuliffe (Dublin North-West, Fianna Fail)
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I will definitely take Mr. Gloster up on his offer to meet the organisation.
Gillian Toole (Meath East, Independent)
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I wish a good morning to the witnesses and thank them for meeting us. I will not go back over questions that have already been asked by my colleagues. The exchanges to date have been informative.
I have a series of questions to run through. In his opening statement, the chief executive said the HSE had "come up short". Why is that the case?
On the Department of Health's short-term initiative to clear waiting lists, Mr. Gloster cited an absence of data. Why is there an absence of data? I note in the figures that €39 million is quoted for new developments and €49 million is available for demographic growth. Is that with a view to getting data together?
Moving to recruitment and barriers, I will say as feedback that a possible barrier to recruitment that was cited by a student who has moved abroad was the CORU fee of €500. That has been cited to me on more than one occasion. Do the witnesses understand that there will be competition with the new National Council for Special Education initiative to recruit therapists?
I represent the constituency of Meath East. I am seeking information, perhaps not now but in follow-up correspondence, if possible, on whole-time equivalent staff numbers, excluding CAMHS, for primary care and CDNTs in Meath. I believe there is a 50.1% staffing level currently, but I would like a breakdown of that information.
Excellent pilot schemes have been run previously in the area of speech and language therapy. Those included Tiny Talk and Talking Buddies. Several groups of parents have in recent years, using friends who are occupational therapists, speech and language therapists, primary school teachers, etc., run ad hoc meetings. The feedback from parents as of last Thursday night was that they would like to train, some in speech and language therapy and others in occupational therapy.
Is there the opportunity to partner with the University of Limerick for initiatives like that? For example, it has the partnering in occupational therapy telehealth services, POTTS, programme. Do these initiatives come under the €39 million in new development figures? It is excellent to hear about the single referral point and single doorway, whether it is general practice, the teacher or the family. When will that actually come in? Do we have a date for that?
Can the National Treatment Purchase Fund be used for families, who are extremely anxious and recognise that their child has complex needs? Can it be used for those who are financially distressed to purchase a private assessment? How are private assessments procured and from whom? The witnesses will be glad to hear that is it. I appreciate that I have raised specific Meath-related issues. I note the disability services manager has recently retired. A follow-up on that after today would be acceptable.
Mr. Bernard Gloster:
We come up short for two reasons. The first is the sheer demand, volume and pressure against the number of people we are able to recruit to service that. We also have to own that there are always shortcomings in public service organisations, and they need to reflect on how they do their business, their work and how flexible and responsive they are to people. We ultimately only exist to serve them. That is the reason; it is nothing other than that. I could have the same conversation about 75-year-old people on trolleys this morning.
I turn to data and why there is a paucity of the development of ICT systems. Since the time of health boards, which I remember having been in health boards, there has been a paucity of data and ICT systems. The ultimate answer to that is the electronic health record system. There is currently a business case with the Department of Health that hopefully will make its way through to approval to bring that about. We are taking a stepped approach to it in the meantime. However, we are still a way off having the accuracy of data we should have.
On the recruitment obstacle of CORU, I have heard many references to CORU and the time it takes to get registration for those coming from a training college abroad or training in another jurisdiction. I did not hear that the €500 was an obstacle, so I am not familiar with that. I will certainly take it up and see what is behind it.
The Deputy asked if the National Council for Special Education pathway of developing a therapy service in schools cause competition for therapists. Yes, no more than CDNTs caused it for primary care, enhanced community care caused it for primary care and assisted decision-making caused it for acute hospitals. That is just a feature of career choices and professionalism. My colleagues can come back to the Deputy with regard to Meath.
I have no principled objection to the idea of parents training. I am not sure. I would like to see more detail of what is behind that.
I have mandated that the single front door starts in October. I have been around a long time and know it will not be easy. I think I will meet professional objection to it in parts, because people will feel the system is not ready for it. However, if we do not press on with it, we will be talking about it forever.
The NTPF would be an option if private capacity were available to buy and if money was short. The one thing I can say is that despite any deficit I have on the HSE books, I have not been left short of money to purchase assessment of need in the private sector. Mark and Cara Darmody raised this with me previously. The difficulty is that, while I have no principled objection to giving individual families the money to purchase their own, I have a view and strong fear about the quality of what families might purchase. They might be exploited and left open to harm. That is a fear I have. Whether or not it is well placed, it is for others to take that.
At the moment we procure private sector services through a framework. We have a procurement process. A company, a firm or an individual can come on our framework. If they are on our framework, a local area like Ms Queally's or anyone else's can use that to buy assessments. I am informed we have bought up what private capacity is there. I will say this because I will be saying it in a health context in the next few weeks. I have a slight concern. I am happy to do it to clear a list but, no more than with aspects of health, I have a slight concern about what we call insourcing, which is buying our own staff outside of their public time. Unfortunately, when we do that, we run the risk of perverse incentive. That is not to say individuals are malevolent in any way. People will do what they are asked to do. We have opted to use private capacity to clear assessment of need where we can. I believe we have maxed it out. If there are any private providers with credibility who believe we are not using them, I am happy to hear from them. We will assess their credibility and if they are credible, they will go on the framework and we will use them.
Margaret Murphy O'Mahony (Fianna Fail)
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I thank Mr. Gloster, Ms Queally, Dr. O'Donohue, Ms Doran, Ms Stone and Ms Maxwell for coming in. I know they are busy people, so I appreciate that and look forward to working with them. I acknowledge Mr. Gloster's comprehensive opening statement in which the HSE's plans, priorities and challenges are acknowledged. I thank him for that. I also acknowledge that Mr. Gloster met families, parents and staff. That is the only way to find out what is really going on.
Margaret Murphy O'Mahony (Fianna Fail)
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Well done to him for that. I hope he continues to do so. I acknowledge the front-line staff who are keeping all of our centres, etc., going every day. They are the powerhouse of the whole system. I would also like all of us to remember that behind every statistic and plan is a person with a disability and his or her family. They are navigating a life they had not planned on and did not seek. We all need to remember that.
On the workforce front, staffing numbers are up, which is great. However, we still hear about retention challenges and burnout in the sector. What is being done, not only to fill the posts but to build career pathways and retain skilled professionals, especially therapists and key workers?
Ms Mary Doran:
I thank the Senator. There has been a quite substantial increase in staffing and that contributes considerably to retaining our staff. Within overall disabilities the retention rate is still maintained, which demonstrates the commitment of staff to working in those areas. There is a turnover rate of approximately 8.2% within overall disabilities. That is rather in line with the rest of health and points to the commitment of those staff working in disabilities.
On retention, I have commenced work to look at retention strategies. We know from international research the main things that retain people are career progression, team support and work-life balance. They are the main elements, rather than the financial incentives. We are working on particular recruitment strategies on that and retention.
Mr. Bernard Gloster:
I will just say that Ms Doran, Ms Stone and Dr. O'Donohue are now exclusively full time in their jobs. When I started as CEO disability recruitment was part of the overall big family of health. We now have a dedicated full-time expert in it, and expert she is. It is the same for finance and reform. We are starting to see, even within a few months, the fruits of that focus and I intend to continue building that focus. We have a long way to go yet but we are pointed in the right direction.
Margaret Murphy O'Mahony (Fianna Fail)
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There is obviously a plan in place, so well done. The pay and numbers strategy was flagged as a priority. When can we expect to see this strategy completed and how will it support the multi-annual planning that reflects the real-life service demands, particularly in the high pressure regions?
Mr. Bernard Gloster:
There are more than 21,000 people in our disabilities space and 126,000 in our health space. I am sure those in the health space would tell their colleagues in disabilities to stay far away from a pay and numbers strategy because it is a much maligned process. The pay and numbers strategy for disability will be solid because it will do two things. First, it will tell us exactly what our funded workforce is and, second, it will allow us to plan for more than a single year.
To give the Senator an example, we have about 21,000-odd in the disability workforce at the moment. If we secure the pay and numbers strategy, which I hope members of this committee will help with when that comes through to the Estimate process, I believe that progressively, over the next three to four years, we could realistically have a disability workforce in the order of about 25,000. That is for both adults and children. That is significant and necessary because of the demographic that we know is in front of us.
Margaret Murphy O'Mahony (Fianna Fail)
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I thank Mr. Gloster. As regards the administrative burdens, there is a reference to reducing non-therapy admin tasks for therapists, subject to the public service agreement. We all agree that an awful lot of time is taken up in admin work and, obviously, that time would be better allocated elsewhere. Can I get clarity on how this will be actioned and whether support staff or maybe digital systems are in the pipeline to free up the therapists to do what they should be doing?
Mr. Bernard Gloster:
The Senator has probably answered the question in the question. I am told repeatedly that therapists and professionals who are engaged with children are constantly consumed in terms of time with compliance work and paperwork and that an increased administrative assistance would give them greater face time with the people they are supporting. I subscribe to that view. I have seen initiatives in the past where that has not worked but I have given a commitment this year to try that. That is why I need a pay and numbers strategy to see exactly how many admin staff I have to deploy. That is the first thing. Second, as we introduce digital to other parts of the wider HSE system, that may free up admin staff to be redeployed to support front-line practitioners. We probably will initially need a small increase in numbers on the disability side to do it. Separate to admin, I am a huge believer in expanding the numbers and hope we can do so. There is some hope that we can do so this year as regards what we call the grade of therapy assistants, who work with children and families but work in a very structured way under a qualified therapist.
Margaret Murphy O'Mahony (Fianna Fail)
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Good idea. I thank Mr. Gloster.
Maurice Quinlivan (Limerick City, Sinn Fein)
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The next person is Fianna Fáil's Martin Daly.
Martin Daly (Roscommon-Galway, Fianna Fail)
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Along with my colleagues, I thank the witnesses for coming in. We know they are extremely busy. I will not go through all their names - Margaret has done that - but I thank them. A lot of the questions I had proposed to ask have been asked. The witnesses have explained some of the issues. In a practical sense, as regards the one-door policy of getting someone in, I have had situations where people have moved with companies abroad and have had assessments of children in another jurisdiction, namely, the United States. In one case the child had ADHD, was put on medication, had settled very well with therapy and medication and came back to this country. We had no pathway to refer. We referred to CAMHS and got a very perfunctory letter back from our CAMHS service in Roscommon, which outlined that it could not believe in the diagnosis and would have to go through the process of verifying the diagnosis and that the child would have to come off medication in order to go through the process again. That is extremely frustrating if you have written two or three letters. It has improved recently - that was about 18 months ago - but that gives the witnesses an idea. Of course, there was no suggestion as to how we would obtain a service for this 12-year-old, who was still in primary education. That is just a practical example of the frustration on the ground.
I would like the witnesses' thoughts on the movement away from disability being seen as just a health issue and into the education sphere. How do they feel about that? It will not be an either-or. I imagine and hope that, even though it will create some tension in recruitment and retention in the health services, there will be a crossover between the education piece and the health service.
Mr. Gloster has explained the pay and numbers policy very well but it is an issue. We have a lot of representation from allied health professionals who have gone through interview processes and have been told there is a post for them but are ending up working as agency workers. That may not be right but that was in the midlands. I do not want to identify the people, obviously. I have had repeated representations on behalf of them. They have come back from the UK. Recruitment and retention are so important, and that is a practical example of what we hear back.
Mr. Gloster has answered about CORU. If there are qualified people who want to work in our services, there must be a way of recognising their qualifications but expediting that because there is a need here.
They are the main issues around this. The competition between different services for what is a definable resource will be the challenge. Would the witnesses be able to deal with some of those points?
Mr. Bernard Gloster:
Again, the answer is perhaps in the question. I will be honest: I had some concern about two years ago about the concept of recruiting separately into the education sector. I have come full circle on it. The reason I have is what I said in my opening statement. We are trying, we are making progress and I do not think we are doing a bad job, but the simple reality is that we are coming up short for too many children. Rather than seeing us as the HSE or the Department of the Minister, Deputy McEntee, as education, at the end of the day we are all public services, and if recruiting into education causes me a bit of hassle but actually does something for children, who am I to argue with it? We have not tried it so we should try it. That is my view. I do think it will be challenged because of the models of modern-day practice. I think there is still a high expectation of direct therapy versus family-centred therapy. I think there could be some challenges there, but my view now is that we should get on with it and let us see how it works.
On CORU, my colleague Robert Watt, the Secretary General of the Department of Health, took that up as a wider health issue and I think we might get to expedite that.
I am saddened to hear if there are people recruited on panels and they are working for us as agency staff because what most people do not know is that right through the recruitment pause or moratorium, a dreadful pay and numbers strategy and all those things I did, we never stopped recruiting in disability. That is why our numbers are as high as they are. In fact, I would say disability benefited because we were not recruiting in other places. However, I would be disappointed to hear if we have people in the pipeline and they are with us as agency staff. We should take that at face value, look at it and bottom it out. Overall, as regards the Deputy's point and his observation about children who have come from other jurisdictions or had a formal, professional intervention in their lives, whatever about us wanting to validate that, it should not take us too long. If a child has been in a treatment plan in another jurisdiction with qualified professionals of high standing, I do not see why we should say, "Go back to zero and, in the meantime, stop your whole plan." I would find that quite destructive. I am not a fan of and I am highly critical of our organisation because of the perfunctory letters. I think we add insult to injury, quite frankly, by writing back to people saying, "Sorry, we do not do that here." That is no way for a modern social care system to operate. The Deputy is quite right: disability being viewed through the lens of health is not helpful. A social care construct is required around it. It does not matter whether it is the Department of Social Protection, the school, the HSE or the local GAA club; there is an entire social construct around helping people to live lives to their full potential and of their own determination. Like I said, if that causes me a few headaches, is that not a good thing?
Martin Daly (Roscommon-Galway, Fianna Fail)
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I just want to correct the record about the allied health professional. It was for the acute service-----
Martin Daly (Roscommon-Galway, Fianna Fail)
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-----for the disability. I do not intend to be misleading.
Maurice Quinlivan (Limerick City, Sinn Fein)
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The next person is Deputy Micheál Carrigy from Fine Gael.
Micheál Carrigy (Longford-Westmeath, Fine Gael)
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The witnesses are very welcome, and I apologise for being in late. I chaired the Joint Committee on Autism in the previous Dáil-Seanad term.
We produced a report with 109 recommendations across all areas, including education and health. I know we have made significant progress with the implementation of the autism innovation strategy, which was launched last August. There are recommendations in that strategy but it is an 18-month strategy. We need to get to a point where we legislate for it to ensure the supports referred to in the strategy are there permanently for every child and every person. Ultimately, we need to give every child the same chance in life to reach their potential, but we are not doing so. When we walk in the front door of Leinster House, we can see the 1916 Proclamation and the reference to treating all the children of the nation equally. Some 109 years later, we are not doing it. It is sad this is the situation after the significant economic boom we have had and the good position we are in.
I would like to hear Mr. Gloster's view on the assessment of need situation as is and what he thinks it should be in future. Do we have enough third level places now existing to allow people to become qualified to be employed in the education system with the NCSE, which, to be honest, I agree with, or in our CDNTs and primary care sectors? I believe around 600 positions are currently unfilled across the approximately 90 CDNTs. Is this the case? What is the situation now - I am hearing about this on the ground - concerning children moving from the CDNTs to primary care? Does the primary care sector have the staff to support the additional children who will now be going under its remit? From being on the ground in my county of Longford, I know it does not have the staff. I ask Mr. Gloster to respond on those questions first.
Mr. Bernard Gloster:
I will let colleagues deal with the autism protocol and the current numbers of vacancies on the CDNT side of things.
I discussed the subject of assessment of need with the Deputy's colleagues earlier. Assessment of need requires reform. This is not code for taking away people's right to it or for changing the timeline. It has become something it was never intended to be. Every single need across public services and across Ireland Inc. is now being tied to an assessment of need, either because people are led to believe they need it or they form a belief they will get something faster. This is leading to children who really need an assessment of need being delayed and children who do not actually need it being put through it. I have concerns about both those aspects. I have proposed to the Government and the Department that there should be appropriate reform to define what an assessment of need is for and what it actually means and is about. I think that will help. We can also help in the way we do our work and the way we approach assessment.
The second question that I was anxious to answer related to whether I believe that enough people are in the training pipeline. No, I do not, to put it in very simple terms. I am not sure anyone does. To be fair, the Ministers for Further and Higher Education, Research, Innovation and Science in the current Dáil and the previous one have both brought forward additional places and these numbers will grow. Quite frankly, however, with the way modern healthcare and social care have changed, with multidisciplinary teams for everything, we simply cannot serve the amount of need with the supply we have. We are not, therefore, just going to have to increase supply but change the way we provide services and work in that regard.
Dr. O'Donohue might respond on the autism protocol and outline to the Deputy what we are doing about it. We will then turn to the numbers.
Dr. Aoife O'Donohue:
The autism protocol has been in development in a co-design, co-development style. We have engaged with adults and children who have gone through the pathways to see areas of improvement. What we have also done through this protocol, which is in the final stages, is to have a consistent approach from our CAMHS, primary care and disability teams regarding what that assessment looks like. Significant emphasis, however, has also been placed on the need for timely intervention.
The assessment pathway is quite clear for some children who present, but for other children the assessment could be a prolonged or ongoing process across several different environments. We will, though, have a consistent approach depending on the child being supported. There will be a similar pathway in the CDNTs, CAMHS and primary care. Equally, in line with this protocol, there will be a single point of access. If a child has a requirement or referral need, it will go through one single point of referral so there is consistency across it. In line with this are the new governance structures concerning the six regions and the IHA areas. It is based on population health but it is not only about the assessment of these interventions. It is about looking at population health and overall supports that can be provided in line with the autism strategy we are developing, and engaging our partnerships in the community.
Micheál Carrigy (Longford-Westmeath, Fine Gael)
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It is important to have one point of access.
Micheál Carrigy (Longford-Westmeath, Fine Gael)
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Okay. What is the situation then in primary care?
Mr. Bernard Gloster:
The primary care numbers have grown every year, including during the moratorium. To be fair to workers in primary care, and Deputy Quaide raised this issue earlier, we also count enhanced community care in the primary care area, which is a specialised service for people with chronic disease and older people. This has depleted the numbers we would traditionally have had in the local health centre, which we call primary care. This has depleted the numbers, so, to be clear, they are under pressure.
Micheál Carrigy (Longford-Westmeath, Fine Gael)
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I know I am going over my time but I have one more quick question. Iit was mentioned that psychologists were not coming under CORU registration. Is that due to happen? Is it going to happen?
Mr. Bernard Gloster:
I do not know exactly where it is in the programme. Perhaps Deputy Quaide as a psychologist can help with that question. In fairness, I do not think it is the resistance of the profession or CORU. There is a scheduling aspect and another aspect around the criteria, but I do not know where that is at.
Micheál Carrigy (Longford-Westmeath, Fine Gael)
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The reality is that it needs to happen, to be quite honest, because-----
Mr. Bernard Gloster:
I agree with the Deputy 100%. I could not agree with him more. We have seen a very small number of dreadful examples in the past ten to 15 years of people who put a plate outside the door and called themselves psychologists when they have been anything but. It is a hugely skilled and very honourable profession and I think it is at risk when it is not registered. I just do not know what the exact timeline is, but I will certainly come back to the Deputy.
Micheál Carrigy (Longford-Westmeath, Fine Gael)
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I have one more half-question.
Maurice Quinlivan (Limerick City, Sinn Fein)
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I am sorry, Deputy, but the time is up. We will finish our first round and then the members will be able to come in again. I wish to ask two brief questions. When do we expect the autism protocol to be published? What is its purpose? This question is for people listening to us this morning. Mr. Gloster might also expand on the single front door policy and what we hope to get out of it.
Mr. Bernard Gloster:
On the single front door policy, we have examples of it already. We have one in the top end of the midlands, which is a very good example of it. We presented that to 600 professionals the other day. We have to do some modification of the policy, which I think will happen over the summer. There will be many workshops with the professionals who are involved in the process. Despite the fact that I am sure I will meet challenges in the industrial relations space, as I said, I have said I believe we can make it happen in October 2025. That is my view. It would be helped if we had an electronic referrals system. We do not have that yet, unfortunately, but if we have paper in one place, there is nothing wrong with having it in another place, so I do believe we can do that.
On the autism protocol-----
Maurice Quinlivan (Limerick City, Sinn Fein)
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I am sorry but on the single front door policy, who can make the referrals?
Maurice Quinlivan (Limerick City, Sinn Fein)
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It can be anybody.
Maurice Quinlivan (Limerick City, Sinn Fein)
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It could be schools, professionals-----
Maurice Quinlivan (Limerick City, Sinn Fein)
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I thank Mr. Gloster.
Dr. Aoife O'Donohue:
Over the next few weeks, the autism protocol will be signed off by our oversight clinical team in the HSE. We will then move into the implementation phase. It is about a consistent approach across all areas and its implementation. That will happen in September or October.
Maurice Quinlivan (Limerick City, Sinn Fein)
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That is perfect. I thank Mr. Gloster and Dr. O'Donohue. That concludes round one. We start on round two now and return to the rota. I call Deputy Ó Murchú.
Ruairí Ó Murchú (Louth, Sinn Fein)
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Go raibh maith agat. We have all been talking for a long time about ensuring there is no wrong door and a single point of access, so the sooner we get it, the better. We have also always been talking about CAMHS in Scotland and that sort of idea. It is a bit frightening when someone said we still need an electronic referral system. I understand that IT systems in the State set-up have not had a great history in the last while, but this should be able to be bought off the shelf.
Whatever alterations are needed, such a system should be relatively easy to put into operation. What is the timeline to have it in place?
Mr. Bernard Gloster:
In general in community services, the time to get to a fully robust system that we might say functions at every level to give us the data and information is probably about three years. In terms of an electronic health record that primary care and community services could feed into, that would be a little bit longer. We are starting with a shared care record, which we hope to have in place in about 18 months. These are all steps to progressing towards the full electronic health record. There are GP referral systems and electronic systems today, but they are not fully integrated in the sense that all professionals working in the community can access them.
Ruairí Ó Murchú (Louth, Sinn Fein)
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Which is obviously what we need. That makes complete sense. On some level, Mr. Gloster has dealt with a fair amount regarding therapies and assessments of need. It is about how we obtain the best bang for our buck. We all welcome the fact that those workforce planning pieces are being put in place, although they are not sufficient, it is not happening quickly enough and all the rest of it. That includes the granting of bursaries on the condition that somebody works within a CDNT. All of that is necessary. What is the timeline? The Minister said yesterday that 414.5 positions remain unfilled in the context of AONs. Will it still take four or five years or will it happen sooner?
Ms Mary Doran:
There are currently 445 unfilled posts. We have had expedited recruitment in the past 18 months. There has been growth of 415 in that time. We have benefited from the slowdown in recruitment in health, but the strategies and actions that we have put in place are bearing fruit with regard to interest in working in disabilities. To progress that, I would see us keeping the momentum. If we have recruited 415 in the past 18 months on top of our baseline, I would see us continuing with that for CDNTs alone.
Ruairí Ó Murchú (Louth, Sinn Fein)
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I accept that everyone is coming from the one pool.
Ruairí Ó Murchú (Louth, Sinn Fein)
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Faster, quicker, better is what we are looking for, given that we are starting from a bad place. The big issue is what conversations there have been about the best means of offering the service on the basis that we are not going to have all of these positions filled for a period. There is the issue of the use of assistive technologies. School-based therapies also have to be a huge part of it.
Ms Mary Doran:
Regarding assistive technologies, we are collaborating with the WHO. A significant programme of work is going to be done in collaboration with UCD and Maynooth College, where we are doing a literature review regarding best practice both here and internationally. We have to learn from some of those practices. That is looking at how we do assessments, interventions and support. To give a very simple example, a parent said she went to an intervention that was recorded on video and when she went home, she was able to model that intervention with her child. There was an immediate learning as opposed to us providing that intervention in a documented way. There is that element. There is also the use of assistive technology across all spectrums, such as CDNTs but also respite and residential, in terms of how that can support and enhance the lived experience, building and growing on the strengths-based approach to assistive technology.
Ruairí Ó Murchú (Louth, Sinn Fein)
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That is brilliant. I know from the case of our Toirleach that when my wife and I went, we would have got something on a piece of paper and so on. We might have had great plans as to how we were going to build it, but two weeks later, where was that piece of paper? I know some of that is on us, but if there was something app-based or on video, to a degree it would be that reminder piece that everyone can use, whether teachers or anyone else. We just need to do all of this faster, quicker, better. There is very little else I can say.
I will turn to my own constituency. We all know the issue that existed around CAMHS and the reason for the autism protocol. In County Louth, some of my constituents now have access to a consultant for CAMHS-ID but the multidisciplinary team is not in place. This needs to be expedited as soon as possible. I would say the same in regard to the outcomes of the neurorehabilitation team, particularly in my area, where there is no service.
Mr. Bernard Gloster:
We are challenged in respect of both for the same reasons. When I started working in the health service, I remember that there was one CAMHS consultant with no staff for the entire mid-west region. There are now five or six teams led by consultants and we are moving into some specialising with CAMHS-ID. Servicing the demand for the multitude of multidisciplinary teams is next to impossible. That is where the problem is. The pace of progress is passing us out and we have to find other methods of supporting that. We can come back to the issue of the community neurorehabilitative teams later, and Ms Queally will speak to that. They are so badly needed yet populating them is so difficult.
Liam Quaide (Cork East, Social Democrats)
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I want to raise a frustration that I am experiencing regarding the answering of parliamentary questions. I would be grateful if the HSE could address that locally. On 8 April, I submitted parliamentary questions to all regional health areas separately on primary care psychology waiting lists. I asked for the years and months spent waiting, as well as the longest wait time. What the HSE will initially send back is a category of “+52 weeks” waiting in addition to the shorter waits. The period of +52 weeks is largely meaningless because it could be 53 weeks or, in the case of Cork-Kerry and other regional health areas, could mean up to 300 weeks, and that is no exaggeration. I have yet to receive any response from the Dublin and north-east regional health area and the Dublin and midlands regional health area, although I have followed up on those twice in the past ten weeks. I am aware anecdotally that the waiting lists in question could be well in excess of five years.
Separately, I asked the HSE for a composite response on those waiting lists. Instead of asking each specific regional health area, I just asked one question. With several of those attempts, the primary care access and integration office in the HSE has declined to offer a more refined breakdown than +52 weeks, even though I know it can just refer that on to local managers who will provide that information. It is very frustrating. It is almost like being put into an Orwellian loop with regard to trying to access reasonable information.
I want to come back to Mr. Gloster on the recruitment needs of primary care services. I am pleased to hear about recruitment to CDNTs being expedited but when we talk about staffing levels in disability services, we have to also include primary care within that. As I outlined at the start, primary care services are deep in crisis and this is not well recognised. Will Mr. Gloster tell me if there is a particular commitment in terms of staffing numbers? Are we going to see a comprehensive recruitment drive to primary care specifically? Is it, as some of my former colleagues fear, going to be a case of robbing Peter to pay Paul when it comes to the redeployment of clinicians from CAMHS into primary care or from CDNTs into primary care?
Mr. Bernard Gloster:
First, my apologies about the parliamentary questions. It is one I find frustrating at times. We will certainly try to get behind that. There are staff here from the parliamentary affairs office and we will see if we can get behind that for the Deputy.
On the 52-week issue, as the Deputy knows, it is a service plan KPI. I am not sure how much data is there. If the data is there, my view is that we should compile it and give it to Deputies. I repeatedly make the point that Members of the Houses of the Oireachtas are representatives of the people. They are entitled to ask reasonable questions and have them answered.
Mr. Bernard Gloster:
If it is there, I would say that the Deputy should have it. Ms Queally will certainly take that back to her colleagues. We will follow that up.
With regard to primary care, although I am still going through the Estimates process, my intention and hope is that within the health allocation for next year, we will be able to address some of the deficit that has arisen in primary care because of many other reasons. My problem with it is that, to be fair to the Minister, Deputy Carroll MacNeill, if she says, “Here is X for primary care”, with the recruitment pipelines and supply lines that we know we have, the likelihood is that will impinge or impact on something else because people will move and mobilise. However, I would rather have the chance of people mobilising to where they feel they will be most productive and where they want to be professionally.
We get a better return from professionals in that circumstance. If I advertise 500 jobs in primary care tomorrow, they have to come from somewhere. There are very few professionals who could work in primary care who are unemployed. There is only a small portion that will come from abroad. It is a double-edged sword.
Liam Quaide (Cork East, Social Democrats)
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I emailed Mr. Gloster about another point. I do not know if he had a chance to look at it. Due to my role in mental health I have a strong focus on people with severe and enduring mental health difficulties. They fall under the ambit of this committee, particularly given the focus we have on the UN Convention on the Rights of People with Disabilities. This is a cohort of people who suffered hugely throughout their lives. They often require ongoing intensive multidisciplinary support and, sometimes, residential placement to attain stability and a decent quality of life. I met Mr. Gloster in June 2023 with former Deputy, Neasa Hourigan. We both raised concerns with him about a proposal by the HSE to invest €64 million in a 50-bed residential mental health service on the grounds of St. Stephen's Hospital in Glanmire. St. Stephen's Hospital in Glanmire is the site of a new elective hospital, which is very appropriate. It is also an appropriate location, in my view, for acute mental health admissions. It is not a place where people should be living out significant periods of their lives, as is the case with any community mental health residence. St. Stephen's Hospital is 1.7 km walk from the nearest shop of any description, which is a service station. It is a 3 km walk to Riverstown, where the local SuperValu and a few other shops are. There is not even a footpath from St. Stephen's Hospital to those places. It is not remotely integrated into any community setting. This is going to centralise a huge amount of the funding. A figure of €64 million is projected for that capital investment into a service that will be very far removed from the communities of origin of many of the residents there. It is going to draw in people from far-flung places in County Cork. It is completely at odds with every mental health policy that we have had since the 1980s. It is at odds with the UN Convention on the Rights of People with Disabilities. I have had huge frustration trying to remonstrate with the HSE locally on that. I implore Mr. Gloster to look at this. He knows from his time at Tusla that there was a residential unit for young people which was not suitable for them. It is not suitable for adults to be living on the site of a hospital. People with-----
Maurice Quinlivan (Limerick City, Sinn Fein)
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The Deputy is well over his time.
Mr. Bernard Gloster:
To be fair to the Deputy he did raise this with me along with the Owenacurra Centre. I hope we have made progress with the Owenacurra Centre. I know it is slow, but it is gone to planning. I did say we would build on the site to keep it in the town. We have four residents in a house and we have four more moving into a house before the end of this year. It is a lot slower than I wanted. There was flood impact on the site. There is planning submitted, with money behind it, for a new 15-bed community residence there and I am looking forward to it. My staff, professionals, the estate people, and everybody tell me the site in Glanmire can be de-institutionalised in the way it is proposed to be configured. There are wider council plans around bus routes and access. I am told the style of the design can be completely de-institutionalised from what people might perceive it is going to be. It is five-by-ten units. I hear the Deputy's concern. I have asked, and will continue to ask, but I have a lot of people telling me the opposite.
Liam Quaide (Cork East, Social Democrats)
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I met Dr. Andy Philips as well and he said there was going to be a community of neighbourhoods around-----
Maurice Quinlivan (Limerick City, Sinn Fein)
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Sorry Deputy, we are moving on.
Liam Quaide (Cork East, Social Democrats)
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The zoning does not add up to that.
Maurice Quinlivan (Limerick City, Sinn Fein)
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I call Deputy Keogh.
Keira Keogh (Mayo, Fine Gael)
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I have five more questions and six minutes. I might ask them and witnesses can answer them in varying degrees. Some might require a short answer and some will have us here all day.
On recruitment of speech and language therapists and occupational therapists, I was speaking with one speech and language therapist who is on the west coast, in Mayo. She would love to work for the HSE but she talked about infrequent opportunities to interview for the panel. She is in private practice at the moment and so she was given one day where she could interview. She would have had to cancel therapies, try to get a babysitter etc. She was not given an online option. She missed that panel interview, and another one will not come up for a while. That is her present experience. I ask the witnesses to speak to that.
We have not talked about respite services and waiting lists. Maybe we could get an overview of that.
A lot of day services for adults with disabilities are carried out by section 39 workers. My background is in behavioural consultancies, so I have been in a variety of these centres. I see massive differences as to whether there is a curriculum or a schedule. I wonder what kind of input do we give with regards to that.
Mr. Gloster said he would love to talk more about moving people from nursing homes when it is an inappropriate setting for people with disabilities. I would love to hear about that.
Augmentative and alternative communication, AAC, devices have been transformative for many of my clients in the last five years. My experience before I was elected was that some clients' AAC devices, which they got two or three years ago, are now cracking or the batteries are dying. There are kids who are fully reliant on these AAC devices as their fluent voice. They cannot wait two days for a replacement. When the batteries get weak they need mobile chargers. Is there now a follow-up plan for people who have AAC devices for two or three years, which, naturally, are going to fall out?
Keira Keogh (Mayo, Fine Gael)
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I suppose it was going back a few months. It was the general process-----
Mr. Bernard Gloster:
We are short of staff and pressured to recruit therapists in all parts of the health service. If that SLT wants to write to me she will have a interview, and if she passes the interview, she will have a job. The Deputy need not worry about that. I will go and interview her myself if I have to.
Regarding respite, I will come back to that with Ms Queally in a minute.
On the nursing home and the under-65s, I would like to add some additional balance to one part of last night's programme. The money and the resources to do this are important, but if I had a blank cheque today the actual availability of capacity to respond with appropriate care and services for people outside of nursing homes is limited. We might not even be able to use the money we get all of the time. I wanted to slightly correct that balance. As opposed to under-65s, I am sure there are many people who are aged 66 years in nursing homes who would feel they should not be there either. When a person who is dependent on care, whether it is disability, mental health or acute hospital care, feels they are in a place they fundamentally do not want to be in, or are unhappy in, that beholds all of us to try to do differently and do better. I am a firm believer in supporting people to stay at home as much as we can. The day you leave your own front door is the day you incur an unintended disadvantage. There is no question about that.
I will come back to the subject of devices if time allows. I am anxious for Ms Queally to talk on respite.
Ms Martina Queally:
To reference a previous point made by the CEO, our ambition is to be as flexible as possible. Respite is a huge pillar of support for families in term of their caring requirements. We look at centre-based, in-home, home-to-home family support, Saturday clubs, summer camps and after-school clubs. Through talking to families in my own region I know that is what they want. They like that flexibility. That is what supports them most. In 2024, the HSE exceeded the national service plan target on both day and overnight respite services. That said, we need more. We have funding for in-house respite and we are developing respite houses in all six regions. While we were waiting for those developments we offered very flexible models around after-school family support etc. That has proved really successful. I would like to see my own team, in my own region, continue that flexibility with families based on the child and family needs. Unfortunately, the demand, particularly for residential placement, sometimes means some of our respite beds get blocked. Sometimes that is in order to try and deal with an emerging situation.
I am glad to say that our teams are very much getting ahead of the curve in terms of understanding and predicting demand in order that we have fewer emergency places. That is where we want to get to, that we have much more planned placements. Respite is a huge pillar of support for families. The feedback we receive on that is very positive.
Mr. Bernard Gloster:
It is important to note whether they are health-provided devices, as opposed to education. I made a decision last year that from the time it is prescribed, no child will be waiting for more than three weeks for a decision to approve and fund an appliance of any type, be it wheelchairs, walking aids or other devices. It might take longer for the supplier to make them if they are special, but we approve them within three weeks. That applies for every child. I am now expanding that to include any technology that we provide, including the type that has been talked about. That has to include replacement.
Maurice Quinlivan (Limerick City, Sinn Fein)
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The next speaker is Deputy Gillian Toole. She has six minutes.
Gillian Toole (Meath East, Independent)
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I have some follow-up questions. It is fantastic to hear about the single front door. Could the witnesses elaborate on how that will be accessed and advertised? I appreciate it is a couple of months away, but it is important that we are prepared.
I raise alternative respite. The benefits of respite are fantastic. I have received feedback from parents in Meath regarding access to what they would consider alternative respite. I have seen the benefits. It includes equine therapy, drama and art therapy. They are low-time interventions and are relatively low-cost compared with overnight care, but are hugely beneficial. How can families access them? How can we be involved in the process in terms of channelling people and being signposts?
My next question relates to personalised budgets. I note the word "pilot" has been used. As far as I am aware from some families with whom I have worked in my other role as a pharmacist and linking people up, the pilot may have been in existence for five to six years. When will it be mainstreamed? The approaches and supports are different for people with different needs and that is where the personalised budgets would be hugely beneficial.
I mentioned the pilot schemes, namely, tiny talk, talking buddies, etc. These interventions could be digitised through the likes of Maynooth and UCD.
I referenced the University of Limerick's POTTS programme for those with dyspraxia earlier. Might they be considered or are they in the pipeline? I also asked about the why of it. Demand is increasing. What research is the HSE involved in? Does it link with other researchers to determine, leaving aside genetic based reasons, the why of it? Is anything happening in that space?
On recruitment and cross-linking with therapy systems, an informal meeting is taking place between an education and training board, ETB, and a CDNT in my area to look at opportunities for work experience in respect of Dunboyne College of Further Education, which provides post-leaving certificate courses in OT and SLT of the gateway variety. Is that something the HSE is looking at or would consider? It would get students who are committed or who come from particular family backgrounds, which would mean that the vocational piece would be there.
I go back to the queries I had about Meath for follow-up. Would it be possible, at Mr. Gloster's convenience, to get the figures for 2019 and 2024-25 in relation to whole-time equivalent, WTE, posts for OT, SLT and psychology.
By way of feedback, a parent contacted me this morning whose child's AON has been completed. The third one is being submitted to primary care in Meath. The first two were lost. That may be a system failure, but I mention it to raise a flag.
Mr. Bernard Gloster:
I will ask Ms Queally to speak about how a single front door works as she is familiar with the concept, not only in disability, and how simple the aspiration is but how difficult it is to achieve.
Ms Martina Queally:
The idea is to have a front door where there is a multidisciplinary team and a triage, for want of a better word, where children's applications are assessed. The needs of the children are understood and they are directed to the correct service. This is so they go to the right services the first time. It is so people do not, as has been described, go from one to another. That is the idea. It means that the multidisciplinary team is needed, so the expertise is around the table to understand the demand. Good pathways of care that are agreed with the disciplines are also needed in order that the transition is seamless for the child. That is the theory. However, to get that, the pathways of care have to be established. In addition, good administrative systems are needed in order that what the Deputy described will not happen. We do not want people lost to follow-up or administrative error where we lose referrals. The clinical pathways and administrative pathways needs to be working correctly in order that the administration system works when patients come in.
Ms Mary Doran:
The current filled workforce for CDNTs in Meath is 89 WTE posts. There are 23 vacancies. That is to the funded level.
On therapy assistants, it is absolutely in our programme of work to work with the ETBs to ensure there is a pipeline of people coming into those therapy assistant roles. Last year, the HSE established the role of therapy assistant and made the qualifications and eligibility criteria as broad as possible in order to have the broadest pipeline coming in.
Mr. Bernard Gloster:
On personalised budgets, it has been a lot longer than six years. I remember doing one about 15 years ago. It is a brilliant concept, but it is difficult for us to achieve. Apart from the administrative complexity, we are, by our nature as public services, still coming from a very paternalistic approach in terms of how to care for people. That is not always the best approach, but we do it from the best place. If personalised budgets go wrong, they can equally leave people in a great deal of peril. An evaluation is due by the end of the year. That will inform further choices. I fully agree with the Deputy, but I do not see the pace of it being near what is expected. I will ask Dr. O'Donohue to briefly comment on the alternative respite equine pilots and research.
Dr. Aoife O'Donohue:
Regarding alternative respite, we are looking at all capacity across respite. We work closely with section 38 and 39 organisations and private providers. We are expanding the development of the home-sharing care model, which is a model of a home-from-home experience for adults and children. We are also working in partnership and giving opportunities to children and adults on the basis of their will and preference. If they want to be engaged with sport, dance or other mainstream opportunities, they will have access to them. We are also looking at the community amenities required to support those alternative options. Parents are looking for a myriad of options, as Ms Queally alluded to earlier, so we are looking at expanding across all models.
We look at research in all areas, such as what is best practice in home-sharing, for example. We looked at international best practice and clinical guidance. We always look at what is done, what we are doing and how we can improve our practice.
Gillian Toole (Meath East, Independent)
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With the Chair's indulgence, can I ask one more question?
Maurice Quinlivan (Limerick City, Sinn Fein)
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Very, very briefly.
Gillian Toole (Meath East, Independent)
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On the actual access to the door, if the teams and administrative systems are not in place by October, does that mean open door access will not happen?
Mr. Bernard Gloster:
They will be put in place by October but, equally, I have to be careful that the system does not consume itself by making this more complex than it needs to be. In every county, there is some version of a primary care team, a CDNT and a CAMHS team. The point is that each of those teams will have to supply professional input to processing what comes in at the point of referral. That might be one professional from each team. They can more than competently do that. There will be one standardised referral form. It will not be up to parents, schools or teachers to say what the need is. People should not be expected to be qualified to say that. They should simply need to say what the issue or challenge is, why the child is being referred. Then the three teams need to decide which is the best pathway or shared pathway to respond to that child. There might still be a waiting list, but at least if children are on the right list for the right pathway, they will have half a chance. That is really what the shared front door is about. I am insistent on making it simple, and I will meet a lot of people between now and October who will make it very complex.
Maurice Quinlivan (Limerick City, Sinn Fein)
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Thank you very much.
Margaret Murphy O'Mahony (Fianna Fail)
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I will touch again on the single referral point and key work co-ordinators. Will the HSE be able to ensure a postcode lottery does not occur in this and that it will be consistently spread out across the country?
Mr. Bernard Gloster:
Consistency is one of the biggest challenges in public services. There are pockets of excellence and pockets of not so excellent. Sometimes it is about resources and sometimes it is not. We are all in favour in changing things as long as they are changed our way. I am not negotiating with myself. There is a history to our services. I believe people will work with this to achieve consistency.
The matter of key workers is slightly different. Parents I met in the past few weeks repeatedly talked about how excellent their experience of CDNTs was and how dreadful it was. There was a range of reasons for that. One thing they said was that when they had one person to talk to, no matter what their need or issue was, things worked a lot better, and that is the reasoning behind the key worker. In fairness to the Minister, Deputy Foley, and Minister of State, Deputy Naughten, they are supportive of my push to try to make sure that everyone who accesses a specialist service has an identifiable key go-to person.
Margaret Murphy O'Mahony (Fianna Fail)
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We are talking a lot about outputs this morning, but outcomes are the most important thing. Does the HSE have any plan for a reporting mechanism once a year or so to tell us and the public what is working and what is not?
Dr. Aoife O'Donohue:
We endeavour at all points to engage directly with the children and their families. We are always asking them for feedback. Also, if any adults or children remain in designated centres, we have a direct mechanism to engage with them regarding the support and quality of the service and to learn to say we can improve and enhance this. We can only do that with direct engagement. As a result of our engagement with children's services, we have taken immediate actions that we are going to improve. This is what we want to do and what we would like to see happen. There is a clear need for enhancement of how we do that and especially how we hear the voices of young people using our services.
That is something we will also action in the coming months.
Margaret Murphy O'Mahony (Fianna Fail)
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I thank the witnesses again.
Micheál Carrigy (Longford-Westmeath, Fine Gael)
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Apologies for having to leave earlier; Midlands 103 called me for an interview on something. I am the father of a young autistic son so I have been in and out through the system, etc., but we are lucky. There are families in worse positions. With regard to the summer programme, which I know is under the Department of education, the local CDNT in my area will not provide any service or supports in July because the Department of education will be providing the summer programme. However, as the special school in our town is not providing a summer programme, the kids with the highest needs will not get that support from anybody. I ask for that to be looked at.
Mr. Bernard Gloster:
With no disrespect to our staff or educational staff, and perhaps people will tell me there are nuances I am not aware of, but I find that shocking. I find it absolutely outrageous that one service expects another service to do something in July but the other service is not doing it, so, therefore, nobody is doing any service at all. I will certainly look into that. It would be wrong of me as the CEO of a public sector body to come in here and try to defend that. That is indefensible. I apologise for the blunt response but I find that abhorrent.
Micheál Carrigy (Longford-Westmeath, Fine Gael)
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Mr. Gloster might come back to me on it.
Micheál Carrigy (Longford-Westmeath, Fine Gael)
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Deputy Toole touched on the following issue. There were a number of courses in five ETBs with speech and language assistant positions. Do the witnesses see that being rolled out further? I know this is crossing into education but there would be a huge benefit if we could have speech and language assistants in schools. I know the school inclusion model is the aspiration, with the NCSE employing therapists who would come into the schools, but there are roles that could be very beneficial to kids within schools. Some of the issues kids have are sensory issues that could be dealt with in the classroom on a daily basis rather than waiting for that one appointment you might get in six or nine months time or might never get it. It would be preferable to have people trained to a certain level who could do it on a daily basis.
I totally concur with the point made in respect of alternative therapies. My son does equine therapy with a fantastic lady and her husband in Longford. It is one of the best things that has ever happened to him. It is fantastic. He opens up completely. It is all about opening up, relaxing and being able to verbalise. We use music therapy, listening fitness training, LiFT, therapy through a psychologist and a speech and language therapist in Galway. It is brilliant and anyone who has done it knows it works. There are other supports out there. I know there was reference to pilot programmes and it was said pilots have to be done. We do not need pilots. These therapies work and everybody knows they work for everybody. Are we funding equine therapy in some parts of the country but not in others? There is a place in Liskennet and another in Charleville, County Cork. Are we going to regionalise that?
Along with three of my colleagues on the committee I went to Scotland in October 2023. We met the Scottish health Minister, Scottish Autism and departmental officials. We came back to the then Minister of State, Senator Rabbitte, and highlighted a lot of activity under way in Scotland, such as one-stop shops and the way they work it. AsIAm has now rolled out two one-stop shops which are due to open. When will we regionalise those one-stop shops throughout the country? As Mr. Gloster said, people want to talk to somebody and get answers. A lot of the problem is that when people get a diagnosis or a referral, they look things up online or whatever. We need people to be able to go into a one stop shop, speak to a person and get that wrap-around support and proper, factual information about what they can do and where you can go. That needs to happens sooner rather than later. We need to put those in place.
Dr. Aoife O'Donohue:
To respond to that, the HSE is responsive to all options and all therapeutic input and anything the child wishes to have or, be that an adult, regarding respite. Regarding equine therapy, we are engaging with a number of different programmes across the country. Sometimes it is not just about going to the equine, it is about the transport of the child, the collection of the child and having that enhanced support. We are looking at that. It needs to be enhanced and grown but we are actively engaging in respect of a number of different therapies.
Regarding the ETBs and the expansion of knowledge, any opportunity we have to expand knowledge with anyone regarding how to respond to children and adults with a disability and additional needs is something we are committed to. We have engaged with the GAA for the Cúl Camps over the summer. How can we partner with it and use the knowledge we have and the model it has? It is about the experience of the child with additional needs in those camps but it is also the knowledge that those coaches will grow, develop and hopefully be the staff of the future if they get an opportunity to do that.
Micheál Carrigy (Longford-Westmeath, Fine Gael)
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Dr. O'Donohue mentioned the GAA. It has rolled out the All Star inclusive clubs programme. I have linked in with Athlone GAA-----
Mr. Bernard Gloster:
To go back to the point about personalised budgets, for things like music therapy, equine therapy and other supports, that may be a good place we could start with families having access to their own budget or space to do that, rather than it just being kind of professionally fitted by us and everyone having to fit into that. There is space for that to happen. To be fair to the then Minister of State, Senator Rabbitte, she pushed very hard to increase the visibility of those other supports for families. We have a bit of work still do on it but we are putting a couple of million euro into it. I would like to see if we could do it in a more personalised way.
Micheál Carrigy (Longford-Westmeath, Fine Gael)
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Coming from a GAA background myself, I have seen a number of things. I know Athlone GAA was one of the first in the midlands in this regard. Another club in my home county has started to roll out one-to-one supports and training for kids with additional needs. That is fantastic and the way we need to go. It is about society changing and understanding. We worked on a project here in Leinster House. As a committee, one of the first things we did was to challenge the Houses of the Oireachtas on an understanding programme and turning Leinster House into an autism-friendly Parliament, which we did very successfully. The EDI team did a fantastic job here along with the other services. We have the highest autism-friendly parliament standards in the world for families and for schools that come in to visit. We also did an awareness project for all staff members and political staff. More than 1,000 people did autism awareness training and we are looking at expanding that again.
Ultimately, when people understand things, it is easier to get things changed or done. It is important that every organisation, be it the HSE or Government Departments, does that. We need to do it in all those organisations.
Maurice Quinlivan (Limerick City, Sinn Fein)
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I have a few quick comments and questions. Mr. Gloster spoke about the a front door policy which will hopefully open in October. He made the point that he wants it to be a simple process but getting there might be complex. I ask him to expand on what will be the complex issues before the HSE gets there. Could any of those delay it further?
Mr. Bernard Gloster:
The first thing is that I suspect there will be some challenge on the staff side. To be fair to our staff, that is not because people are resistant to wanting to do good, but sometimes we still trade in perfection being the enemy of the good. People will want the IT system, the single referral system and everything else in place before we do anything. I think we should do it the opposite way around. We are currently doing it with bits of paper and IT, so there is no reason we cannot press ahead. There will be a little bit of pushback there, in my view, and there will be a view in individual parts of the service that if they participate in that, it may bring more pressure onto their waiting lists without them having the resources to respond to it. They are natural responses but I am not indifferent to how challenging that might be.
The second challenge will be finalising the pathway for parents, teachers, doctors and others to ensure everybody knows how to make that referral on the system and where the points in each county are to do that.
There is a significant communication exercise as well.
The one thing I am anxious not to do with it is to do a pilot because we tend to spend an awful long time looking at pilots. We do not get beyond that to consistency. I would rather try for consistency with the old 80:20 rule. If I got 80% of it working, I would probably be happy that it is doable. There are some challenges but I am pretty determined. When I met parents I promised them I would try to do something now as opposed to just next. In fairness to the Cabinet committee, there is a lot being done on the "next". I have a responsibility to do something now. There are children today who will not be children in a few years' time. I have a couple of months left in my public service career so I am pretty committed to getting this one piece in.
When I started working in the health service there was a single point of referral. That was in Ballynanty Health Centre over 30 years ago.
Maurice Quinlivan (Limerick City, Sinn Fein)
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In my local area.
Maurice Quinlivan (Limerick City, Sinn Fein)
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The second question is following on from what Deputy Carrigy said about people looking for answers. It is really important. In my own constituency of Limerick, we have a school, Le Chéile National School. There has been an ongoing problem there with services. The HSE says it is not its issue and that it is the Department of education but, bizarrely, there have been emails between the organisations with one telling the other to contact the other, even though in the email it says there will not be a response but, "Off you go and contact them". Could Mr. Gloster intervene for that school and give it the services it is looking for? I know the Minister of State, Deputy Moynihan, has been looking at that school and I hope something positive will come from that.
Mr. Bernard Gloster:
The Chair has called out the interminable challenge. When services are under pressure, they look to see what other services they can refer people to or that might help. The reality is that what we show the public is that we are simply saying, "It is not for us, it is for them, but we know when you go to them you will not get anything." That is really just a lack of integration. I am hoping that as the National Council for Special Education builds a therapy service in schools we will be able to bridge a much closer alliance between its services and ours.
Maurice Quinlivan (Limerick City, Sinn Fein)
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I thank Mr. Gloster. Does anybody else want to come in with brief comments? Deputy Ó Murchú wants to come in.
Ruairí Ó Murchú (Louth, Sinn Fein)
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My comments will be brief. It was really positive what Mr. Gloster said. Whether we are talking about the All Stars inclusive clubs programme or the High Five boxing academy or, as I have seen myself, Louth Disability Cycling Club, where kids were given an ability to cycle when they could not have previously done it, these initiatives are really good.
As a follow-on, sometimes it is very useful for parents. I know that parents have made the point that in some cases they get fed up and they are offered parenting programmes but some of them would say that sometimes they are looking for something more comprehensive where they can have that shared experience or whatever else. What we are talking about are strategies to de-escalate circumstances - I used to call them "moments" and my wife used to give about it. She would kill me if I did not mention it. Members of Archways are across the road in Buswells Hotel at the minute. She works on the Changing Lives Initiative. I know from my own constituency work that a huge amount of people have utilised that and found it beneficial. That is for kids who present with ADHD but, in an awful lot of cases, you would also have kids with autism and comorbidities. They found it really useful. I am asking about that piece around family supports but something comprehensive.
The wider issue, which hits those with mobility issues in particular, is transport. It seems to be an issue with hospitals and appointments. There was funding available at one point but I think it needs to be looked at across the entire health service.
Mr. Bernard Gloster:
I could not agree with the Deputy more. There is a role for the Department of Transport, transport providers, Local Link and others, but there is a special additional requirement for people who are in what one might call particularly sheltered or supervised day services and have very high levels of dependency. I have heard so many times that it is pretty useless giving someone a place if they cannot get to it. My view is that we should provide that transport. I do not think it is doable within the normal transport networks. We have some allocations for it but it always one that is very challenged.
Ruairí Ó Murchú (Louth, Sinn Fein)
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I ask the witnesses to comment on the family piece.
Dr. Aoife O'Donohue:
One model we are looking at, even as families join our teams, is the understanding of the model and everything. We are looking at the Connect Family Network. We are looking at myriad options but for families who have utilised this and are aware in their local areas of what supports are there, we will connect those parents. That has been done in Tipperary, Galway and Cork and the evaluation of it has been really successful. We are looking at expanding that but also responding and listening to families through their IFSP and those goals to see what has and has not worked, and to respond appropriately.
Liam Quaide (Cork East, Social Democrats)
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I want to come back to the St. Stephen's Hospital proposal for continuing care, rehabilitation and recovery, and a 50-bed service. Mr. Gloster mentioned the progress that has happened with the Owenacurra Centre. Two houses have been acquired in Midleton, which is brilliant. That rebuild is stalled but it is going through the planning process. My experience of that campaign, and that of some of my colleagues and families who were involved is that it was basically a sustained battering ram of negative publicity against HSE management that got us to this point. That is not how these things should be sorted out.
We had very compelling arguments from an ethical point of view and a service provision point of view in respect of mental health policy as to why removing all of those services from east Cork was wrong. There are objectively established reasons why the proposal in St. Stephen's is going to be not only very ethically questionable, and wrong in my view, but a massive misdirection of public money. There are places like Clonakilty and Cobh that do not have community residences for people with severe and enduring mental illness and because that money is now getting centralised into St. Stephen's Hospital, they will not have it into the future. There will be 50 residents there and while they might be living in nice bungalows on site, it is not in any way integrated into the community. All of the land around St. Stephen's is zoned for agricultural use. Across the road, it is zoned for light industry, which is actually an online warehouse. As I said, there is not even a footpath to the nearest service station, which is 1.7 km away. It goes against everything we have been doing in mental health services since at least the nineties, if not the eighties.
When I joined north Cork mental health services in 2013, many of my colleagues had been working for years, helping long-stay patients of St. Stephen's Hospital to move out into Kanturk, Newmarket and Mallow. This is actually a reversal of that trend.
Maurice Quinlivan (Limerick City, Sinn Fein)
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Before Mr. Gloster responds, it is up to himself. I do not expect him to have an answer on every individual project.
Mr. Bernard Gloster:
I thank the Chair. I appreciate that. To be fair to Deputy Quaide, he has raised it with me in his time in elected politics and also as a professional.
What I would say to the Deputy is that there are so many varying views about these things, it is often hard to know. You make the best decisions you can. I would like to think that beyond the battering ram of the Owenacurra story, at least when I came to it, the Deputy experienced something different with respect to the disposition of the organisation. When I came to it, there was no possibility of replacing Owenacurra. It is now going to be replaced on the site and integrated into the community.
Equally, with regard to the scale of the investment planned on the St. Stephen's site, what I will do is this. Rather than the battering ram, I am happy to put the plan up there and for different groups and interests - the public, the Mental Health Commission, professional groups and community groups - to make submissions on what they think is right or wrong with that. Let us see what kind of consensus we can arrive at for the future.
It is a very big-scale plan, so it is not one I am simply going to put in the bin and walk away from. I hear what the Deputy is saying and I am not indifferent to what he is saying. I am told the configuration of Glanmire will fundamentally change. I am only telling the Deputy what I have been told. I would be very happy for the local authority, the HSE, the Mental Health Commission and all of the interests to objectively have a good cut off the plan and then see where it takes us.
Liam Quaide (Cork East, Social Democrats)
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St. Stephen's is in the hinterland of Glanmire.
Liam Quaide (Cork East, Social Democrats)
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I would much prefer to engage with HSE in a productive collegiate way, rather than this kind of war of attrition which is where we often end up with campaigns.
Mr. Bernard Gloster:
I certainly do not want to see that war of attrition or campaign. I want to respect campaign, but equally I hope we can find a process where we except that a process has to come to a conclusion and outcome. I am not going to prescribe what that is, but I am happy for that process to happen.
Gillian Toole (Meath East, Independent)
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I thank the witnesses for their feedback. It has been an informative session. I do want to be cheeky or anything, but Mr. Gloster said he has a few months left. As organisations change, my fear is that projects, visions, ambitions and plans might change down the line. Can the good things that we have heard be documented and continued in Mr. Gloster's absence? That is just by way of cheeky comment.
Is access to alternative respite made in the standard way through a disability services manager? Does the HSE liaise with the NTA on transport? Historically, a community fund could be used for niche transport. When I raised this in the context of Meath, we have been steered towards giving new routes to Local Link flexibus. Something like this for people with additional needs must be more bespoke. That is where the restoration of the community fund would be helpful.
Mr. Bernard Gloster:
Through the Department and directly in bilateral opportunities, we take every opportunity to explore the transport. We were hoping during the cutbacks, particularly during austerity, that someone else would pick up the transport bill and it would be less of a bill for us. That is a reality. We have to accept that there are certain things that we do need to provide transport for.
On the matter around the plans, many of them are already happening or have happened. They are not all of my creation. They are documented. The organisation has signed up to them and will sign up to them in the next round of the service plan and corporate plan. The Department of disability back nearly almost everything that we want to do. There is very little it would not. It is certainly not about me. It will well live beyond me. The members can see with the people on my left and right that there is great possibility for leadership of the future.
Micheál Carrigy (Longford-Westmeath, Fine Gael)
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I wish Mr. Gloster the best of luck with his retirement.
Are census figures used to forward plan? If we examine the figures and percentages, we know the number of the kids with disabilities. That was not done years ago but it would have been critical. We did not forward plan enough. I acknowledge we cannot plan for everything, but particularly with third level education places, we need to ensure enough people qualify.
I do not expect the witnesses to know the answers about St. Joseph's campus in Longford where we have St. Joseph's Care Centre and primary care unit. I am working with local HSE officials because we had a recent issue that they were considering removing the physiotherapy department from Longford and bringing it to Westmeath. The people of Longford would have to travel to Westmeath. As of today, I am hopeful that we have had a solution in the past 24 hours to keep it there. This followed a HIQA report on the care centre that recommended the removal of physiotherapy services from the care centre, yet the physio was giving a service to the patients there. Day patients coming into the primary care are entitled to this. HIQA officials need to concentrate on issues not being handled correctly, rather than removing a service where a great service is being provided. I wish to put that on the record for the staff in St. Joseph's. I ask the witnesses to come to back to me on the provision of primary care centres in the regional towns in the county of Longford. They are all at a certain point and they seemed to have stopped. We need them. I wish to see them progress. I acknowledge Mr. Gloster cannot provide an answer today.
Mr. Bernard Gloster:
No, that is fine. On the primary care centres, which is on the health side, we did hit a wall. We have developed many of them. There were three opportunities. This included public-private partnerships, which was a small number; the lease model, which was the preferred option and provided the biggest number; and a small number of direct builds. They proved to be successful where they have been built. We could use them better. The difficulty, quite frankly, is that we reached a point with construction inflation, the construction recruitment challenge and market saturation that developers who had been awarded the development opportunity for primary care centres no longer saw it is as financially viable to pursue it based on the original lease cost that we had agreed. We have gone back to the market to see if there is any movement in that. If we cannot yield quick enough, we are going to have to look at direct build if the market does not take.
On the matter of St. Joseph's, I do not know the answer but I will check that out. I do not know about the physiotherapy service but I will make sure that colleagues do. We will come back to the Deputy on it.
Maurice Quinlivan (Limerick City, Sinn Fein)
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I thank the members for their contributions. I thank the HSE officials. Everyone will agree that it was a constructive meeting and engagement was good. I thank the HSE witnesses for the answers they gave. They answered all the questions that members asked. This unfortunately does not always happen in committees. With the members' agreement, we will go into private session to discuss housekeeping matters.