Michael Mullins (Fine Gael)
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I welcome the Minister of State, Deputy Shortall, to the House.

Fidelma Healy Eames (Fine Gael)
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I am pleased the Minister of State is present to listen and respond to this Adjournment matter. This is my first time speaking with her in her ministerial capacity. I congratulate and wish her the best of luck.

My request is for the HSE to enable registered nurse prescribers, RNPs, from the private and voluntary nursing home sector to prescribe general medical services, GMS, products for medical cardholders who are nursing home residents. Nurse prescribing was introduced by the then Minister for Health and Children, Ms Mary Harney, and was initially only open to the public sector. The criteria have been changed to allow all nurses to apply, including those from the private and voluntary sectors. Strict criteria, mainly concerning governance and supervision, were put in place.

It has become apparent that there is an issue with RNPs who have completed the course and are registered with An Bord Altranais prescribing for patients with medical cards. This makes no sense, as there is no issue with prescribing to private patients under the same roof. RNPs can prescribe to these patients once they fulfil the terms of an approved collaborative practice agreement but they cannot prescribe using GMS pads in private practice. What is the rationale?

RNPs working in elderly care services in the private sector cannot prescribe for 95% of residents. The number of long-term places for older people in the public sector are limited. Since the introduction of the fair deal, older people can choose where they are placed. Technically, this means that people in private nursing homes are at a disadvantage, as they cannot be treated by RNPs even if their GPs have agreed to that treatment. Circular SO222-NCO-09, of May 2009, alignment of community drug schemes to incorporate nurse and midwife prescriptions, did not reference restrictions to RNPs in the private and voluntary sectors, although it alluded to further circulars to be issued to clarify the policy decision on the GMS scheme. This circular reiterates that the legislation allows registered nurses and midwives who have completed an approved education programme, appropriate clinical experience, registered with An Bord Altranais as RNPs and authority from the health service provider employing them to prescribe a range of medications within their scope of practice. Nowhere within this clarification of the legislation does it refer to restrictions on RNPs in the private or voluntary sector. If so, why can they not prescribe in practice?

In July 2011, circular 01/311, community registered nurse prescriber primary care prescription pads, outlined specific criteria to apply to community RNPs in the HSE's voluntary and statutory services. RNPs from the private and voluntary nursing home sectors fulfil four of the six, yet the circular states that RNPs in private nursing homes will not be issued with primary care prescription pads. It does not provide a rationale for this decision.

The majority of residents in private and voluntary nursing homes hold medical cards and receive medical services from GPs who are under contract with the HSE. Furthermore, a number of these residents are in beds that have been contracted by the HSE under the contract bed or delayed discharge initiative. When responding to a parliamentary question from Deputy Stanley on 12 April 2011, the Minister for Health, Deputy Reilly, stated:

It is important to note that a person's eligibility for the medical card and drugs payment schemes is unaffected by the nursing homes support scheme. In other words, a person can continue to receive goods and services in accordance with the terms of these other schemes regardless of whether they are in a nursing home or elsewhere.

Given the stress under which the HSE is operating, this issue needs a common sense approach. RNPs offer a vital and cost effective service to older people. Without them, doctors need to be called for emergencies and transfers need to be arranged to accident and emergency departments. The RNP could examine, diagnose and treat people in the interim. The current situation does not make much financial sense.

The HSE should enable RNPs in the private and voluntary nursing home sector to prescribe GMS products for residents who hold medical cards. While the preference would be for RNPs to have primary care prescription pads with their own GMS numbers, it would be acceptable, albeit more difficult in the interim, were the Primary Care Reimbursement Service to issue a circular to GPs concerning GMS prescription pads for RNPs who provide services for the former's patients in private and voluntary nursing homes, as per the practice outlined for practice nurses in the circular to which I referred. I look forward to the Minister of State's reply.

Róisín Shortall (Dublin North West, Labour)
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I thank the Senator for raising this issue and for her good wishes.

The introduction of nurse and midwife prescribing is a significant change in nursing and midwifery practice. There is strong international experience that supports such prescribing as being effective and safe and as improving services to patients. Regulations specifying the legislative requirements and conditions for prescribing of medicinal products by nurses and midwives were signed into law in May 2007. The legislation allows registered nurses or midwives to prescribe a range of medications within their scope of practice provided that they have completed an approved education programme, appropriate clinical experience, been registered with An Bord Altranais as a registered nurse prescriber and authority from the health service provider employing them.

I welcome the initiative shown by the nurses and midwives who have undertaken training as part of the nurse prescribing education programmes. Since the legislation came into effect in May 2007, 662 nurses and midwives have been funded by the HSE to undertake these programmes. Some 322 RNPs are in practice and prescribing in 106 health service providers. The remainder are in training or are preparing to register as nurse and midwife prescribers with An Bord Altranais.

The implementation of nurse prescribing in the community is progressing. Of the 322 RNPs, 211 are from acute hospitals, 97 are from primary and continuing care and 14 are from private organisations.

The HSE issued a circular in July 2011 outlining that GMS prescription pads will be made available to nurse prescribers employed by the HSE who are approved at local level and work in collaboration with GPs who are contracted under the GMS. The HSE considers it appropriate to restrict access to GMS prescription pads to this group of nurses at this time. In this regard, it should be noted that there are other restrictions on access to GMS prescription pads. For example, medical practitioners who do not hold GMS contracts with the HSE do not have access to GMS prescription pads, nor do hospital prescribers.

Turning to the position of patients in private nursing homes, general practitioners are contracted by the HSE under the GMS scheme to provide services to medical card and GP-visit cardholders. Such a patient is registered with his or her chosen GP, who acts as a gatekeeper for prescribing choices for his or her panel of patients. Medical cardholders are entitled to retain their medical cards when they move into private nursing homes. They also have the right to retain the GPs of their choice in the same way as if they were living in the community.

GPs receive a significantly enhanced capitation rate for medical card patients in private nursing homes in view of the additional medical care required by such patients. This includes the prescribing of drugs and medicines for such patients. It is clear, therefore, that the restriction on access to GMS pads does not serve to prevent patients in private nursing homes having appropriate access to drugs and medicines.

Any proposal to provide GMS prescription pads to private nursing home employees would require a very significant policy evaluation, involving a full assessment of clinical, patient safety, contractual and financial implications. I regret to inform the Senator there are no plans to make those changes.

Fidelma Healy Eames (Fine Gael)
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Is the reason, therefore, that the GPs are already receiving a significantly enhanced capitation rate, as stated? Is it a matter of cost rather than making best use of the resources? The GP has, apparently, approved the nurse prescriber to do the work. Can it not be arranged between them?

Róisín Shortall (Dublin North West, Labour)
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I envisage a very strong role for nurses in the roll-out of health reforms. They will be critical to the development of primary care. As regards chronic disease management in the community, bearing in mind that we want to see a considerable shift in activity from the hospitals to the community, nurses will be the key professionals involved in delivery. I want far more nurses involved in prescribing. They have a critical role to play in primary care.

With regard to people in nursing homes, there is a real difficulty. As matters stand, the GP is the gatekeeper to GMS services, doctor services, practice nurse services and drugs covered under the GMS. It would be extremely complex to bring about an arrangement whereby a GP responsible for the medical care of a patient in a private nursing home would also have some other professional with prescribing rights working for that patient.

Fidelma Healy Eames (Fine Gael)
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It is a private issue.

Róisín Shortall (Dublin North West, Labour)
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It is. As I stated, GPs are very well recompensed for providing the additional enhanced care for people in nursing homes. When an issue arises and where the patient needs medication, it is the GP that is paid to provide what is required.

Fidelma Healy Eames (Fine Gael)
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I thank the Minister of State for the clarification.