Pádraig Mac Lochlainn (Donegal North East, Sinn Fein)
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The Minister is very familiar with this issue, having attended a meeting with the parents involved and with management from Letterkenny General Hospital. The difficulty which arises is that despite the protestations of the management at the hospital and those of the management of the West Northwest Hospitals Group, the parents to whom I refer are of the view that they have lost access to a critically important service provided by the paediatric clinical nurse specialist. Approximately 145 children in Donegal under the age of 18 have type 1 diabetes. The Minister is well aware of what this means for families and of the challenges faced by their children. At a recent public meeting in Donegal, the families involved told their stories and outlined the type of pressure and anxiety with which they are obliged to live. They also indicated how desperately important this resource - which is provided at the hospital - is to them. Under the national diabetes plan, there was to have been one paediatric clinical nurse specialist for every 100 children. One could argue that the number should be 1.5 specialists in place for the children to whom I refer in Donegal.

It is clear that there is confusion in respect of this matter. The management of the hospital has written to public representatives in Donegal since the meeting to which I refer took place. Management has not agreed to a further meeting with parents and public representatives in order that matters might be clarified. Is the Minister in a position to intervene in respect of this matter? I am aware that he has agreed to attend a meeting organised by the parents on Tuesday next. I welcome this development but I ask him to resolve the matters to which I refer before that meeting takes place. I request that he make clear to management at the hospital that what is not needed is someone who deals with children on a part-time basis and that what is actually required is a dedicated paediatric clinical nurse specialist who will deal solely with the children in question and their families.

Pearse Doherty (Donegal South West, Sinn Fein)
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I echo what Deputy Mac Lochlainn stated with regard to the Minister's acceptance of an invitation to meet the families next week. Oireachtas Members from the county will be also at that meeting and I hope it will be possible to bring about some finality in respect of this matter. It is unique that the four Opposition Deputies from Donegal have raised this matter. I accept, however, that the Government Members from the county support us in respect of it.

When he met the families in April 2013, the Minister informed them that they were reasonable people with a reasonable request. The request they were making at that time related to the diabetic clinical nurse specialist. As Deputy Mac Lochlainn indicated, we have received reports from the hospital to the effect that this is an enhanced service and we have been asked why we are complaining because what is on offer is actually better than the service which previously obtained. On paper and otherwise, it does appear to be enhanced. This is because there is an integrated clinical nurse specialist on site. As a result, there is not a shadow of a doubt that there is an enhanced service available for those with diabetes. However, we are focusing on the area of paediatrics and the nurse who previously provided the service in this regard has been replaced. The upshot is that there will now be a clinical nurse in place to deal with both adult and paediatric patients. The nurse who previously worked in this area was a specialist and she provided expert care to children. What is required here is a dedicated clinical nurse specialist.

The parents are concerned with regard to the amount of time the new nurse will be in a position to allocate in respect of paediatrics. The relevant expert group recommended that there should be one clinical nurse specialist for every 100 children. As Deputy Mac Lochlainn indicated, in Donegal at present there are 145 children under the age of 18 who have type 1 diabetes. Six of those children were diagnosed with the disease in the first 12 weeks of this year. This indicates that one case is being diagnosed very second week and that the rate is increasing quite significantly. I understand that the Minister has called on the management at the hospital to resolve this matter and stated that a clinical nurse specialist should be appointed to the area of paediatrics. I hope he will confirm that the latter is, in fact, the case and that we will be united on this issue.

Charlie McConalogue (Donegal North East, Fianna Fail)
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I acknowledge the Minister's support in respect of Letterkenny General Hospital since it was flooded and thank him for it. I also thank him for providing - in conjunction with West Northwest Hospitals Group - the funding necessary for repairing the hospital and for coming to Donegal to reopen it. When he came to Letterkenny, the Minister met representatives from the parents support group who were protesting outside the hospital. As welcome as the new facilities are, the level of staffing and the qualify of service provision are crucially important in the context of how hospitals operate. There is an inadequacy at the hospital at present in the context of the service which is supposed to be provided by a paediatric clinical nurse specialist. The relevant unit is under-resourced, particularly in the context of the number of children who visit the hospital. Some 145 children in Donegal have been diagnosed with type 1 diabetes. The most recent policy advice available from the Department indicates that there should be one paediatric diabetic clinical nurse specialist for every 100 children. On that basis, one and a half specialists would be required to cover all of the children in Donegal with type 1 diabetes. I accept that an additional person has been appointed to deal with the adults in Donegal - approximately 5,000 - who have diabetes. The service is stretched but I welcome the appointment to which I refer. There is a need for a commitment from the Minister that a full-time paediatric clinical nurse specialist will be appointed to Letterkenny General Hospital.

The other point I wish to raise - in respect of which I ask the Minister to communicate further with us - is that which relates to centres of excellence for paediatric diabetes. There are currently five such centres throughout the country, all of which are located south of the Dublin-Galway line. There are three centres in Dublin, one in Limerick and one in Cork. The nearest centre for those in the north west is located in Dublin. When one looks at a map, the position is this regard is made obvious in very stark terms. There is a significant imbalance in this regard. That is not appropriate. I ask the Minister to provide a commitment to the effect that a centre of excellence will be developed in the north west in order that children there who suffer with diabetes might have easier access to services. When those children travel to the existing centres of excellence, they have access to dieticians, consultants, clinical nurse specialists and psychologists. It is important that the services of such individuals be made available in the north-west region.

Thomas Pringle (Donegal South West, Independent)
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I thank the Ceann Comhairle for selecting this very important issue for discussion. Its importance is emphasised by the fact that it has been raised by the four Opposition Deputies who represent the county. As Deputy Pearse Doherty stated, the Government Deputies from the county support the request we are making. I take this opportunity to acknowledge the Donegal Diabetes Parents Support Group and the Donegal branch of Diabetes Ireland for the work they have done to highlight this issue on a continuous basis. I hope the Minister will be in a position to indicate that a clinical nurse specialist for paediatrics will be appointed to Letterkenny General Hospital because this is the only acceptable solution.

The claim made by the management at the hospital has indicated that an enhanced service is available is not really acceptable, particularly as parents do not know what way the nurse specialist on site will divide his or her time in the context of dealing with adult and paediatric cases. Children from Donegal will be still obliged to travel to Dublin to avail of services.

Mr. Paul Gillespie of the Donegal branch of Diabetes Ireland put it well when he referred to the effects that travel has on children with diabetes. He remarked that one of the problems of travelling with a child with diabetes related to if their blood sugars became a little high since they would be more prone to getting car sick and that they would be four hours from their destination. Also, once they got to Dublin they found the Dublin clinics were jammed out the door and he adverted to the associated difficulties.

The HSE standards indicate that there should be a nurse specialist for every 100 children. We argue that there should be 1.5 posts in Donegal but the Donegal branch is looking for one post to provide a service close to home for the children that need and deserve it.

The diabetes expert advisory group has outlined nine standards for diabetes care. Standard No. 4 states that the provision of diabetes services for children and adolescents should be equitable and fair throughout the country. Equitable and fair treatment is all we are looking for in Donegal and this is something the Minister should be able to deliver.

James Reilly (Dublin North, Fine Gael)
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I thank the Deputies for raising this issue, which is clearly of considerable importance and concern to parents in Donegal. I also thank Deputies Mac Lochlainn, Doherty, Pringle and McConalogue for affording me the opportunity to reassure parents of children with diabetes and adults with diabetes that the restructuring of nursing resources for diabetes in Letterkenny will not result in a reduction of current service levels and will enhance patient care by strengthening the links between diabetes care in primary, community and acute settings. I realise this issue, as others have pointed out, is of great concern to Deputy Joe McHugh, who asked me to meet the families concerned, and to the Minister of State, Deputy Dinny McGinley.

As the Deputies are aware, I had the honour of presiding over the official reopening of the emergency department at Letterkenny General Hospital last month and seeing at first hand what can be and has been achieved through the commitment and hard work of management and the entire community around Letterkenny. Despite the pressures and challenges facing our health system there is a determination to move forward to improve what we are doing and to deliver the best outcomes for patients. I had the chance to meet representatives of the parents of children attending diabetes services and I understand the concerns.

As parents we want dedicated resources for our children and, as a parent, I accept this. When dealing with a complex chronic illness such as diabetes we want consistent support. As a doctor, I appreciate the reassurance that such supports can bring. I believe these supports are in place as a result of the restructuring of the diabetes nursing resource in Letterkenny.

I am working from memory but, as I understood it, there was the equivalent of 0.8 time given by the nurse. She is now becoming whole-time but across adult and paediatric care. She is involved with paediatrics at the level of approximately 0.6. However, she will have the additional resource of another clinical nurse on half-time, which means the service is going from 0.8 to 1.1. I realise on paper, as the Deputy has said, this is an improvement and I believe this will be the case, but I recognise that the parents want a full-time dedicated nurse. One of the parents put it to me that they need to be reassured such that at night when something happens a hypo they can pick up the telephone to talk to someone who knows what they are talking about. It would be wonderful if that person knows the child but that is not always possible because people cannot be on-call 24 hours, seven days per week. That is not reasonable and it is no life.

I have been thinking about what is happening in Sligo and the nursing expertise there and I cannot understand why we have been unable to put together a 24 hour, seven day on-call service whereby people can lift the telephone to talk to an experienced paediatric nurse who can advise them what to do when a child's blood sugar is going off, whether high or low. We will certainly examine that. I have heard clearly what people have said about a centre of excellence north of the Dublin to Galway line and it is something I will certainly look into.

When I was in Letterkenny to officially open the emergency department in early March I spoke of my gratification at seeing the way Letterkenny General Hospital works in partnership with local general practitioners and primary care services to address local population health needs in order that those who need acute hospital care are directed to that care. This approach supports the aims of the national clinical programme for diabetes, including the development of an integrated care programme to improve diabetes control, the development of a chronic disease management programme for diabetes and the reduction in overall bed days for acute hospital diabetic care by 40,000.

I wish to make a particular comment about Donegal. It has always been the case that primary care there has been well supported because of the huge geographic area that it covers. There was a realisation many years ago that a hospital-centred delivery system simply could not deliver for such a wide geographic space. That is why primary care in Donegal is probably more developed than in many places in our country.

I am keen to ensure that our health service provides safe, quality and timely care and this is a priority concern of the Government. I acknowledge sincerely the commitment of the staff of the Letterkenny General Hospital diabetes service to the patients and I believe that commitment is reflected by the interaction I have had with the families, who have nothing but the height of regard and respect for the paediatric nurses. I assure the many families for whom the service is so vital that the addition of an integrated clinical nurse specialist will enhance the quality and timeliness of their children's care.

I will not leave it at that. I have taken on board what the Deputies and families have said and I look forward to meeting them next week. I will be seeking to address the issue as outlined by them as well as meeting the needs and improving the service from their point of view. Yesterday, I launched a new awareness site for Adam Harris, who has set up a site for people with autism. During the event I remarked that the service needs to listen to what people want from it and not only take the view that it knows best about what to deliver for them.

Pádraig Mac Lochlainn (Donegal North East, Sinn Fein)
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I concur with the last remarks the Minister made to the effect that the system should not consider that it knows best. This is the concern we have. We received another response yesterday from the management of Letterkenny General Hospital in co-operation with the management of the west northwest hospitals group. It reads to a lay person as if it is addressing the concerns of the parents but I am somewhat unsure. I am trying to be practical and constructive about this. Could the Department obtain a copy of that letter from the manager of Letterkenny General Hospital, Sean Murphy? The Minister knows what the parents are looking for and he has met them. Could the Minister and his Department, in their expert opinion, establish whether the changes are now addressing the concerns of the parents ahead of the meeting next Tuesday? That would be helpful. There seems to be some breakdown or misunderstanding of what is happening. It was clear to us, as public representatives, at a packed public meeting in recent weeks in Donegal that parents who desperately need help expressed the view that they were not getting it and that they were not satisfied with what is on the table. We are asking the Minister to referee and sort it out. I thank the Minister for the work he has done thus far on the issue.

Pearse Doherty (Donegal South West, Sinn Fein)
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I am going to read positivity into the Minister's comments because he did not deliver the standard HSE response, which is largely a defence of the existing position. I read into the Minister's comments that there is a need to address this and I hope it can be addressed. As we have said, the call is for a diabetes clinical nurse specialist. The half staff nursing position that will accommodate the clinical nurse, which is a 0.67 position, is a trained adult position not a paediatric post. Again, it looks fine on paper but in reality it does not. I hope we can bridge this gap.

I agree completely and concur with the Minister's last statement about listening to service users. My nephew and Godson is among this number. I have listened to what he goes through, what his mother goes through and the fears, anxieties and concerns about someone going hypo or hyper. After the public meeting I had the opportunity to talk to teenagers who use the service. They had nothing but the height of respect and regard for the person they are losing. Much this comes down to that emotional attachment but this is an opportunity for them and for all of us to live up to best practice as per the 2008 expert group recommendation, that is to say, there should be a clinical nurse specialist for paediatrics. I hope we can finalise this next Tuesday.

Charlie McConalogue (Donegal North East, Fianna Fail)
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I thank the Minister for his response. The parents have been indicating for a long time that they believe the resources for diabetes paediatric care in Letterkenny General Hospital are inadequate for the number of children that are attending there.

Although the appointment of an additional clinical nurse specialist in the community who will focus on adults is welcome and will improve the overall level of service provided to diabetes patients in Donegal, it does not enhance the level of staffing that parents believe is necessary to meet demand at the hospital. Some 145 or 150 children are involved. According to the Department's own policy, this number is sufficient for 1.5 dedicated diabetes nurses.

We are seeking a commitment from the Minister to allocate a dedicated paediatric nursing post to the hospital at a minimum, as there is none currently. This is what the parents want. I welcome the Minister's statement that he will re-examine the current setup of the centres of excellence, given the fact that there are five south of the Galway-Dublin line and none above. Will the Minister indicate a timeline for a response on what can be delivered in that respect?

Thomas Pringle (Donegal South West, Independent)
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Like other Deputies, I thank the Minister for his response. He stated that the HSE needed to listen to parents and those who use the service and deliver a service that responds to their needs instead of just telling them what they will get. This is important. I hope that the Minister will be able to reassure parents at next Tuesday's meeting that he will go down this road. What will make a difference for families across Donegal is a commitment that whole-time paediatric diabetes nurse specialists will be recruited for Letterkenny. As the Minister stated, this would have a major effect by preventing future complications for people and costs for the health service. He should grasp this matter, reassure parents at next Tuesday's meeting and ensure it gets done.

James Reilly (Dublin North, Fine Gael)
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I thank the Deputies for their contributions and the tone in which this debate has been held. We are all trying to improve services for our people. There is no more emotive issue than services for our children. I will endeavour to get a copy of the letter that Mr. Murphy wrote, review it and have my Department review it before next Tuesday's meeting.

I also listened to Deputy Pearse Doherty. I wish his nephew well and a bright future. Perhaps he will follow his uncle into the Chamber some day, although not necessarily under the same banner. I jest.

I want to determine how we can address the issue raised by Deputies McConalogue and Pringle. It is not just a question of economics, as it makes perfect economic sense, but also a question of children's quality of life. No one wants to hear of children having to travel four hours by car when the alternative could be just one hour regardless of in which part of Donegal they are. I will examine the matter and try to get the best outcome that I can for parents and their children.