Tuesday, 22 April 2008
Joint Committee on Health and Children DebatePage of 3
Chairman: I welcome the members. We welcome representatives of the Health Information and Quality Authority, HIQA, to make their presentation. I also welcome the people in the Visitors Gallery, particularly Ms Jean Spain and Ms Siobhán Kane of Inclusion Ireland, representing people with intellectual disabilities, fresh from their recent AGM in Tullamore. I invited them to today’s session because it is clear they have an interest, but we will return to that issue later. I propose to enter into the business straight away. I welcome Dr. Tracey Cooper, CEO, Dr. Marion Witton and Mr. Marty Whelan of HIQA.
Deputy Alan Shatter: Before we proceed, Deputy James Reilly is at a conference and I am substituting for him. I understood there were some matters on the private session agenda to be dealt with and he has discussed this matter with me.
Chairman: I prefer to bring in the witnesses rather than leave them sitting outside for half an hour. We will take the presentation, which I understand will take approximately 15 to 20 minutes. Then we will allow members to put their questions. We will deal with the private issues on the agenda immediately after the meeting. I invite Dr. Cooper to speak first.
Dr. Tracey Cooper: Thank you. On behalf of the Health Information and Quality Authority, I thank the Oireachtas Joint Committee on Health and Children for giving me the opportunity to discuss the overall work of the authority and specifically the national quality standards for residential care settings for older people. I am joined by Dr. Marion Witton, our chief inspector of the social services inspectorate and Mr. Marty Whelan, our head of communications and stakeholder engagement. We very much welcome the opportunity to appear before the committee members. We appreciate they have a wide range of concerns and a very full agenda. Therefore this opportunity to engage with them on the agenda, particularly at this stage of our evolution, is especially welcome and valued.
As a newly established authority coming up to one year old, we are very conscious of our responsibilities and we look forward to hearing the views of the joint committee and the Government and working with them today and for many meetings in the future. As chief executive it is my strong wish, and the clear determination of the board of the authority, that we engage with all concerned with our work, including the Oireachtas and this committee, in an open and constructive manner. It is to the credit of the Oireachtas that, uniquely in the world, Ireland has established an independent authority with the powers to set, monitor and investigate health and social care standards and services. Our role is also to evaluate the effectiveness of the medications and treatment being used and to advise on the collection and sharing of information across health and social care services. We believe the key drivers of quality are all contained within the functions of the authority which are set out in the Health Act 2007.
The authority has been in existence for just under a year and is already making an impact on Ireland’s health and social care services. I will describe the functions, values and organisation of the authority, outline a number of the key achievements to date and then focus more specifically on the national quality standards for residential care settings for older people.
I will begin with the functions and values of the authority. The authority was established on 15 May 2007, as part of the Government’s health reform programme. Independent in reporting to the Minister for Health and Children, the role of the authority is to promote safety and quality in the provision of health and personal social services for the benefit of the health and welfare of the public. This means the authority has responsibility for setting quality and safety standards for our health and social care services with the exception of mental health services which come within the remit of the Mental Health Commission for monitoring and, as appropriate, enforcing these standards, for supporting providers and staff in bringing about improvements in service quality, for undertaking investigations where there is a serious risk to a person or people using services in Ireland, for evaluating new health technology, more generally for promoting the better use of resources in our health and social care services, for publicly reporting on our work and providing information on health and social care for the public, the users of our services, health and social care policy makers and the Government.
The social services inspectorate, the interim health information and quality authority and the former Irish Health Services Accreditation Board were integrated into the authority on its establishment in May of last year. The former social services inspectorate, responsible for the inspection of Health Service Executive children’s residential care centres, has now expanded functions and powers in the establishment of the office of the chief inspector for social services within the authority. The former Irish Health Services Accreditation Board continues its accreditation work as part of the health care quality function within the authority. I will describe that more fully later in the presentation.
Since the commencement of the authority a considerable and extensive focus has been on the start-up nature of the organisation. This included recruiting the senior management team and commencing a significant recruitment programme, to ensure that with the commencement of our functions we had the right people with the right skills at the right time. This is essential. It also included establishing effective governance arrangements, an effective operating framework and the necessary systems and processes to be effective, efficient and supportive of our staff; maintaining the ongoing work on its establishment; and planning for and commencing the new functions to ensure that the authority was evidence based, effective and robust in discharging its functions, while responding to a number of key public safety issues that have occurred over the past 11 months.
In carrying out our work it is fundamental that we are clear on what our mission is and on the core values that drive our behaviour and the way we do business with the system. The mission of the authority is to drive high quality and safe care for people using our health and social services. This is the compass for all our activities. Our core values express what we believe is fundamental to how we deliver on our mission, how we do business and how we strive to work with stakeholders, including this committee and Members of the Oireachtas. These values drive the culture of the organisation. Our core value is putting people first. We will put the needs and voices of service users and those providing services at the centre of all our work. We will be fair and objective in our dealings with people and organisations and undertake our work without fear or favour. We will be open and accountable. We will share information on the nature and outcomes of our work and accept full responsibility for our actions to encourage excellence and innovation. We will strive for excellence in our work and seek continuous improvements through self-evaluation and innovation and through working together. We will engage with people providing and using the services in developing all aspects of our work.
The organisation has its headquarters in Cork. We currently have offices in Cork and Dublin and will establish offices in the west and midlands. It is imperative for us to ensure that we develop local relationships at a regional level with the people with whom we will work. We have organised the authority to reflect our main functions. Consequently, we have six directorates that are corporately led and managed by an executive management team. The director of health technology assessment is Dr. Máirín Ryan. The purpose of health technology assessment is to ensure that resources in our health services are used in a way that ensures the best outcome for the patient or service user, specifically through the assessment of the clinical and cost effectiveness of health technology in Ireland. The director of health information is Professor Jane Grimson who is chair of the Centre for Health Informatics at Trinity College Dublin. Her function is to identify and advise on health information deficiencies, establish an information governance framework, set standards for information systems and evaluate and provide information on the provision of health and social services. We will hear more about the social services inspectorate from Dr. Marion Witton. Its functions are as follows: to inspect and register social care services, including residential services for older people, for children and for people with disabilities; to monitor children’s detention centres, special care units and foster care services; to undertake inspections into suspected service failures in social care as deemed necessary; to monitor the Health Service Executive’s inspection of preschools and crèches; and to set standards for and monitor the independent assessment of need for people with disabilities.
The functions of directorate of health care quality, the director of which is Mr. Jon Billings, are to develop person-centred standards for health and social care; to design and implement a quality assurance programme to promote improvements in quality and safety standards in health; to identify gaps and monitor to ensure that the standards are being met; and to undertake investigations into suspected serious service failures in health care as deemed necessary.
Our head of corporate services is Mr. Sean Angland. Support services within the organisation are essential, particularly in a start-up. The function of the corporate services divison are to ensure that the authority is fit for its intended purpose through the following: effective governance arrangements; an active recruitment programme in the start-up period; a well supported workforce; robust performance management; effective value for money in its use of resources; usable and meaningful management information; occupation of suitable premises; and a number of other key support services.
Mr. Marty Whelan is our head of communications and stakeholder engagement. In this area our functions are: to ensure that the authority’s communication systems are effective and robust; to manage the authority’s communications with internal and external stakeholders; and to ensure that we maintain and establish collaborative relationships across the health and social care systems.
Some of the key achievements we have managed successfully to deliver since May last year include the undertaking of a national inspection into the placement of children aged 12 and under in residential care in Ireland. The report was launched at the latter end of last year. We have also developed, published and submitted to the Minister for Health and Children the national quality standards for residential care settings for older people, which we will cover later in the presentation.
We are in the process of developing draft national quality standards for residential care settings for people with a disability. We have undertaken and published, at the latter end of last year, a national hygiene quality review across all of the 51 Health Service Executive hospitals. We have initiated two major investigations into the misdiagnosis of patients with symptomatic breast disease in Ireland. The first investigation into the care received by Ms Rebecca O’Malley was completed and the report published earlier this month. We have commenced a national quality review of symptomatic breast disease services against the symptomatic breast disease standards mandated by the authority and subsequently approved by the Minister for Health and Children in May 2007.
We have also completed and submitted a health technology assessment into the human papilloma virus vaccine to reduce the risk of cervical cancer. That has been submitted to the Minister, to the National Immunisation Advisory Committee and to the National Cancer Screening Service Board. We are also commencing a health technology assessment into a colorectal cancer screening programme for Ireland. We have hosted a large international patient safety conference in collaboration with the World Alliance for Patient Safety, part of the World Health Organisation. I hope I have given the committee a flavour of the organisation and some of the key achievements and functions of the authority.
I will proceed with some of the more specific developments around standards for residential care settings for older people. We believe that one of the most important tasks we have undertaken as an organisation is the development and publication of the national quality standards for residential care settings for older people. These crucially important and significant standards, and supporting criteria, were developed in order to ensure that the most vulnerable of older people are protected and supported to live a quality life in a safe, caring and respectful environment. For the first time in Ireland, these standards clearly set down what is expected of a provider of services and what a resident, his or her family, carer or the public can expect to receive in residential care settings.
One of the great tests we face as a society is how we care for the increasing numbers of our older people. This would be challenging in any context. However, we face this challenge in a rapidly changing context of smaller families, changing social connectedness, and the changing nature of life, work and family. Our collective challenge, therefore, is not just to care for people for longer; it is to do it much better. It is also to care for them in a context in which the traditionally assumed architecture of extended family is certainly much changed and perhaps, for some, is simply not there at all. More and more people, as they get older, move into residential care settings such as nursing homes. It is very important that in the care they receive their rights are protected and that they are allowed to lead their lives as much as possible in a caring and respectful environment.
The Health Information and Quality Authority was asked, as a priority and at the request of the Minister for Health and Children, to review and develop further draft standards that had originally been developed by the Department of Health and Children. Subsequently, the national quality standards for residential care settings for older people were developed and published by the authority. In order to ensure the standards were meaningful and appropriate, we set up a working group to advise us on and share in their development. The group included representatives of nursing home owners, older people’s advocacy groups, those involved in the care and treatment of older people, the Department of Health and Children and the Health Service Executive.
When the working group completed a set of draft standards, we published them to allow residents in residential care settings, their relatives and carers, and members of the public to share their views on the proposed standards before they were finalised. We believed everybody had a right to make a contribution to what the standards would look like. We also held meetings with residents in residential care settings and their relatives and carers to hear their views on the key issues relating to safety and quality in residential care settings and to consider the extent to which those issues were addressed within the draft standards. The working group considered the responses and the final standards were approved by the board of the authority on 25 February. They were formally submitted to the Minister and are awaiting the development of underpinning regulations and a regulatory impact assessment.
The standards cover what is important to residents and what they can expect from providers. There are 32 standards in total, each of which is supported by a number of criteria. The criteria set out in detail ways in which the standards can be met by service providers. The standards make it clear that everything about the service should contribute to the enjoyment of a good quality of life and an experience of care that is positive, person centred, safe and respectful.
The social services inspectorate within the authority will use the standards to inspect, register and report on the quality of service provided. All services, whether run by the Health Service Executive, private providers or voluntary organisations, will be inspected and those that meet the standards will be registered. Only registered services will be allowed to provide residential care services for older people. The standards are grouped into seven sections which cover the rights of residents, the protection of residents, their health and social care needs, their quality of life, staffing requirements, their environment and the management and governance of facilities. There are also extra criteria that apply to residential care settings that specialise in the care of people with dementia. I will deal with these later.
From the perspective of the resident, the standards mean that all those living in a residential care setting for older people can expect to have their rights respected. Rights for residents mean they will have accessible information, they will be encouraged to express their views and will be consulted about the organisation of their care setting. Their consent to treatment and care will be sought. Their privacy and dignity will be respected. The inspectorate will listen to and act upon any complaint that they, their family, friends or representatives may have. Protection of residents means that they will be protected from bullying, neglect and any other forms of abuse. Their interests will be protected by policies and practices that safeguard their finances and which can be demonstrated through inspection. For health and social care needs, residents will receive assessments of their care needs prior to and during their stay as their circumstances change. They will be able to participate in the decisions made about their care.
Standards for quality of life mean residents can exercise choice and control over their lives and will be enabled to maximise their independence in accordance with this. They will benefit from policies that promote their health, rehabilitation and well being. They will be consulted on their health needs which will be reviewed and met on an ongoing basis. Their family, friends and others will be able to visit and they will be encouraged to maintain contact with them.
Staffing standards mean that suitable staff will be qualified and checked to ensure they are safe to work in a residential care setting. There will be enough staff on duty, both day and night, to ensure the needs of all residents are met. There will be ongoing professional development for staff to ensure their skills and qualifications are up to date. The care environmentmeans that the physical environment enhances quality of life and the care setting is a pleasant place in which to live. It means that it meets residents' needs in a comfortable and homely way and that the premises are kept clean, hygienic and that there are systems in place to control the spread of infection
Governance and managementmeans that the person in charge is a nurse who has the professional training, expertise and experience to manage the residential care setting. It means that the quality of care and experience of the residents is monitored and reviewed so that the service residents receive is continually developed and improved upon.
All the standards already outlined were considered to ensure they met the needs of people with cognitive impairment such as dementia. It became apparent during the work of the working group that we also needed to develop a specific standard where special care facilities in a residential care centre are providing services specifically for people with dementia. There is an additional standard specifically for special care centres that provide services for people with dementia. These are specifically for residential care units that are exclusively for people with dementia. All the standards outlined equally apply to such centres but they must also meet additional criteria in regard to the specific needs of the people who live there and to allow them to live the fullest lives possible. These additional criteria cover the diagnosis of dementia; promoting the understanding of residents and family members of the nature of dementia, care planning and assessment for people with dementia; provision of person-centred care, use of appropriate therapies and techniques; facilitation of appropriate communication, staffing arrangements, practice development; staff training, and the physical design, layout and configuration of dementia specific units.
The Health Information and Quality Authority has now been in existence for under a year. We have begun our work and have a significant remit and mandate on which to deliver. The members of the authority are committed to discharging the responsibilities bestowed on us in a person-centred, robust, professional, objective and independent manner. In doing this our focus is, and always will be, on driving high quality and safe care for people using our health and social services.
We are conscious that the well being of some of the most vulnerable people in our community will depend on our capacity to set high standards, to follow through on their delivery, to work in effective partnership with all involved in the delivery of care and to be a resource of knowledge and experience for the future.
On behalf of the authority, I thank the committee for this opportunity and look forward to working closely with it in achieving our objectives objectives that we all have a vested interest in successfully achieving.
Chairman: I will open the meeting to all members who have indicated an interest in speaking. I welcome the fact that the authority is up and running and look forward to its success. Bearing in mind the orders under which the authority was set up, for the first time we were creating a body whose purpose is to set quality standards and monitor enforceable standards in an open and transparent way. The report the Health Information and Quality Authority published following the misdiagnosis of Rebecca O’Malley made 15 recommendations. In that context, I wonder about the report into Rebecca O’Malley and, in particular, the commitment given that everything would be done to develop and ensure patient safety. The report was initially due to be published in December 2007 and then it was deferred. What is the response of HIQA to that? In view of the commitment in the mission statement we hope that HIQA will monitor all recommendations that go to the Health Service Executive. In light of the fact that nothing has happened in regard to those recommendations, how will recommendations be acted upon in future investigations or reports?
I am conscious that the AGM of NAMHI took place last Saturday week in Tullamore. There are huge concerns in the area of people with disabilities. Where is the protection and the standards for those people? In recent years they have been given to believe that their issues would be given priority. They are people who are vulnerable. There are approximately 30,000 people in residential homes throughout the State. I do not see a commitment coming from HIQA to deliver a somewhat similar safety check. In light of what has happened at Bank of Ireland with the issue of laptops containing sensitive information, has HIQA the authority to ensure that patients’ files, particularly computer files, are protected by a security system that it can check and validate?
Dr. Tracey Cooper: I will summarise the questions to ensure I have not missed anything: first, on the delays in the publication of the report; second, on the implementation of the recommendations of the report; and third, on the standards for people with disabilities. I may seek a little more clarification when I get to the final question on security.
Dr. Tracey Cooper: They were very relevant questions. On the delay in the publication, as the Chairman correctly stated, we had anticipated publishing the report in the middle of December. If the Chairman has had an opportunity to read the report he will notice that there is a Ms X who was named in it. The information on Ms X came into our possession very late in the day and the decision of the board or the authority was that it was important we investigated the care received by Ms X as part of the investigation and it would have been an injustice for us not to have done that. That was a very difficult decision and the discussions around risk, as the Chairman correctly stated, were taken into account. It was important that we delayed the publication to continue to progress the investigation of Ms X’s care. What happened during January and February was that further interviews took place with Ms X and with various members of staff within the respective hospital to ascertain her story and make appropriate recommendations. That was the reason for the delay.
On the recommendations, I agree with the Chairman that it is imperative in undertaking our work that we do not publish a report which then sits on a shelf. Those members of the committee who have had an opportunity to read the report will note that the fifteenth recommendation requests the Health Service Executive to identify a national director accountable for taking over the implementation of the recommendations and we have begun that process of follow through to meet with that national director and to sign off the action plan against the recommendations. As written in the report, we will agree a process of returning to the respective hospitals to ensure that the recommendations have been implemented.
Dr. Marion Witton: As members will be aware, the services for people with disabilities have not been regulated previously and to commence, we needed to look at setting standards for services for people with disabilities. We set up a working party in the middle of last year with representatives of organisations representing people with disabilities and we included some service users. Rather than have a traditional consultation exercise, we have set up monthly working party meetings that have enabled the service users to be able to participate and to contribute to the development of those standards. We believe that they reflect the priorities for service users.
We have heard some very moving accounts from some of the service users about what is important to them. One of the service users, a person with intellectual disabilities, described how it was important for her to be able to go to her general practitioner by herself, that she did not always want to be accompanied by somebody else. It was put to her by one of the carers that she would not understand what the general practitioner was saying and she rather acutely stated that it is up to the general practitioner to make sure or she would write it down, bring it back and ask somebody. That has been extremely helpful for the development of the standards.
We have two more meetings of that working party and then we will have focus groups and a public consultation. Once the standards are developed they will be launched, following agreement by the Minister.
Dr. Marion Witton: Given that their services have never been regulated previously, we owe it to all the service users, whether they have physical or intellectual disabilities, and their representatives such as parents, families, carers and service providers, to ensure we have a thorough consultation exercise to ensure we have not missed anything and that the standards are appropriate. We want to make sure we do not rush into anything, so we would like to have a proper and meaningful consultation. This will lead us to the end of this year, and we hope to publish something at the beginning of next year.
There is obviously an anomaly with regard to inspecting private hospitals. Is there anything on the horizon in this regard? When and how will that anomaly be addressed? Is HIQA geared up and staffed to inspect nursing homes so that they can register for eligibility under the fair deal system when it is introduced? When will homes be inspected according to the new regulations? Are there sufficient staff available to do this? If staff are available, they are awaiting decisions before they can start working. What is the position on this? What is the role of HIQA in the current situation, in which health professionals around the country are expressing deep concern about the real dangers to patient safety caused by under-staffing and over-working?
Dr. Cooper stated: “The mission of the authority is to drive high quality and safe care for people using our health and social services”. However, this excludes psychiatric patients and services. Dr. Cooper will say these are not covered under the Act but by the Mental Health Commission. However, the Mental Health Commission does not have the same resources or approach, while the HSE has the facilities and the authority required. Is this discriminatory? In one area of mental health namely, dementia the HSE has authority. Does this cause duplication? Obviously it does, but the same standards are not applied to psychiatric patients. Does Dr. Cooper accept that this is discriminatory?
Senator Frances Fitzgerald: I welcome the delegation. I am sure this is the beginning of dialogue with the organisation. It appears that quality and standards are such an enormous issue in the health service that it is almost overwhelming. We must consider reports from maternity hospitals, rates of MRSA, individual experiences in accident and emergency departments the list goes on and on. HIQA is a potential beacon of light in terms of setting standards and everyone in the committee welcomes the work it is trying to do.
I have some concerns which have already been raised by the Chairman, including the issue of implementation, for example, and the ability of HIQA to monitor implementation of its recommendations. I ask the representatives to comment further on this as it is a key aspect of the work of the organisation. Is HIQA in a position to follow through on the recommendations it has already made in various areas? Does it have the staff and resources to do so? With regard to the high rates of MRSA in hospitals, for example, can HIQA carry out unannounced inspections of hospitals to ensure its recommendations are being met? Has it done that since the report?
I refer to HIQA’s review of symptomatic breast disease services. We know that standards were set in 2000. How many services have been reviewed at this point? When is it intended to publish the report? Will it be published piece by piece or will HIQA wait until the whole review is completed? In that context, how will HIQA’s work dovetail with the review being carried out by Professor Keane and the Health Service Executive? It appears parallel investigations or assessments are being carried out by the HSE and an independent body, namely, HIQA. How will this work? Given that the forthcoming report on failings in this area will be the seventh such report, the timeframe for publication and liaison between HIQA and the HSE will be critical.
On progress in the monitoring and inspection of private hospitals, as the Deputy may be aware, the Minister for Health and Children established the Commission for Patient Safety and Quality Assurance, of which I am a member, one year ago last January. One of the key aspects of the commission’s work is to consider a licensing framework. Subject to its recommendations, licensing may mean bringing together public and private hospitals in one standards and inspection framework. This function will be similar to that performed by the Social Services Inspectorate which is responsible for registration and inspection. The commission is due to report in June or July this year. Subject to its recommendations and decisions being made thereon, its findings will clarify whether private hospitals will be inspected and the timing of such inspection. Our remit in the area of social services covers the public, private and voluntary sectors, while in health care it extends to the Health Service Executive and those providings services on its behalf. The key next step will be the commission’s recommendation on licensing.
Dr. Marion Witton: As members will be aware, the launch of the first standards for nursing homes for older people has been broadly welcomed. Everybody will know what they can expect if they or a relative need residential nursing home care. As a result of the launch, a regulatory impact assessment must be carried out. We will await its outcome, at which point the standards will have to be given legal effect.
Nursing homes are currently inspected by the HSE, including those in the private and voluntary sector. A significant amount of work has been done in transferring some eligible HSE staff to HIQA. Negotiations are under way with the trade unions and we are seeking to ensure all those eligible for transfer are fully informed of the implications. They are being given information on the outcome of the decisions made and the right of appeal. Once that process has been completed, we will know exactly how many staff will transfer from the HSE to our inspectorate. Thereafter we will pursue open recruitment for inspectors. At that point, we will want to ensure all inspectors are trained because people from different professional backgrounds will join the inspectorate. We want to ensure we have effective, proportionate inspection with the necessary safeguards. All of these processes are taking place.
The owners of nursing homes have welcomed the publication of standards in advance of these processes because it gives them an opportunity to examine and review their services and consider how the standards can be implemented, if they have not already done so, although many of the standards are being applied in many care homes. Similarly, those who are considering establishing care homes will have the standards and know what will be expected of them. That is the current position on the nursing home sector.
On the question of the fair deal, as members know, we will regulate the private, voluntary and public sectors. The standards will apply to all homes, irrespective of who funds the placement residents can be privately or publicly funded. Our job as the regulator is to ensure the standards are applied and that all residents, irrespective of where they come from or where they are, receive the care appropriate to their individual needs.
The third question was on the staffing required for the inspectorate. The staffing levels were set out. I have explained the recruitment processes. We are looking to have a complement of 48 inspectors for the older persons services. That will mean a case load of about 20 homes, which is a reasonable average that matches other inspectorates.
Dr. Tracey Cooper: I have to respond to two more questions and I have another point that may be helpful on the question of private hospitals. I talked about the Commission on Patient Safety and Quality Assurance and our remit on private health care. When we mandated the symptomatic breast disease standards and as part of our approach to ensure equity of standards throughout the system, I wrote to the chief executives or managing director equivalents of the private hospitals across Ireland to invite them voluntarily to participate in a symptomatic breast disease review. Some 14 private hospitals are participating in that review. We approached public and private hospitals in the same way and they volunteered to be involved, which is important in advance of the commission reporting.
Deputy Neville’s final two questions were on health professionals, understaffing and overworking and mental health. We consider the appropriate level and calibre of health professionals through several means. First, in the standards that we set on, for example, symptomatic breast disease services, we are clear about the numbers of professionals that we expect to see in a high performing centre. Similarly, in residential care standards, we detail the minimum number of staff qualified to undertake the work. Setting standards gets us only so far. It is also a question of meeting and reviewing organisations to see how staff relate to each other and behave as a team on the shop floor. When there are serious safety issues, which may or may not relate to the number of staff, they are referred to in our recommendations.
In some respects, Deputy Neville answered his final question on mental health. As he rightly pointed out, mental health is not part of the Health Act 2007 or our functions. The Mental Health Commission was established well in advance of HIQA, but we work closely with it, particularly considering social care. We are mindful that, when we set standards for and inspect services in residential care centres for older people, they may be special care centres for people with dementia. We are similarly mindful about disability services and the overlap when dealing with children and adolescents who have mental health challenges and are in a residential care centre for children. We are having discussions with the Mental Health Commission to ensure we can come together on one approach to inspection when such overlaps occur in order that we do not increase the burden of inspection on providers. That is particularly important.
Dr. Tracey Cooper: Sorry, Senator Fitzgerald also asked a question. I will be quicker in my answers. She asked about monitoring the implementation of our recommendations. That is fundamental. It is key for us in ensuring our recommendations are implemented. To that end, we have different powers from those on social services. As members know, we have enforcement powers on meeting standards from the registration inspection regime. On health care, we can undertake a review of any service or national service as we feel appropriate. For example, the Rebecca O’Malley investigation has been followed up specifically to ensure the standards set out in the recommendations are met. One of our functions concerns the ability to review an aspect of services across health care as we feel appropriate. If that is tied in to monitoring standards and recommendations, it is key.
The Deputy mentioned the hygiene review. We will be conducting a subsequent review against the hygiene services at the end of this year and will expect the recommendations made last year to have been implemented. Subject to how that develops, the ongoing review of those services will be key. As a result of the hygiene review last year, we identified the need to set infection prevention and control standards for the country. A working group is well under way. We hope to engage in public consultation in the next four to six weeks on those standards. That is as a result of another level of need. In the future we will review whether those standards have been implemented. There must be cause and effect and a follow-on.
The Deputy mentioned symptomatic breast disease standards. A set of standards was published by Professor Niall O’Higgins and his team in 2000. Subsequently a working group, again chaired by Professor O’Higgins, established standards that we mandated in 2007. It is those standards we are reviewing. We have commenced the symptomatic breast disease review. It is a two-stage review. The first is in regard to a self-assessment undertaken by providers. The second is an on-site review to validate where services believe themselves to be at. That self-assessment has begun. We hope the self-assessment stage will conclude during May and we will be in a position to communicate with the respective organisations as to when we will visit them. We also have private hospitals which are part of that process.
In regard to publication, self-assessment represents the views of a provider and it is important that we validate whether those views are accurate. It is most suitable and appropriate for us to publish the findings, which we will do at the end of the complete review of providers, which is a self-assessment followed by a site visit.
The Deputy asked also about the director of the interim national cancer control programme, Professor Tom Keane. That programme is fundamental for us. We see the reconfiguration around symptomatic breast disease services as a large change management process which is important to ensure the quality of safety of patients. We are having discussions with Professor Keane and his team to ensure we are adding value to drive the changes needed and ensure they are made in a safe way.
Chairman: I must move on and be fair to everybody. I will take speakers in the order in which they have indicated. The next speaker is Deputy O’Sullivan, followed by Senator Prendergast, Deputies O’Hanlon, Conlon, Connaughton and Caoimhghín Ó Caoláin. Deputy Shatter has not indicated but I presume he wants to speak.
Deputy Jan O’Sullivan: I welcome Dr. Cooper and her colleagues and compliment them on the work they have done so far which is very impressive. I am particularly impressed with the Rebecca O’Malley report. I attended the launch recently. It is very comprehensive and I understand why it was delayed. It was important to evaluate the information on a further case that had emerged. Dr. Cooper referred to implementing the report. It is important that we tease that out a little further, particularly in terms of Senator Fitzgerald’s question about how the roles of the different bodies, including Professor Keane, HIQA and the HSE, dovetail and how they will work to ensure we will never again have the inadequacies evident in the Rebecca O’Malley report. Dr. Cooper said she was to have a meeting with the person who had been given the job by the HSE of implementing recommendation 15, the umbrella recommendation. Is it intended to set a timeframe for implementing all of the recommendations, some of which clearly depend on the provision of resources?
I think of the recommendations regarding, for example, triple assessment and the need for a pathologist, radiologist and surgeon in a multidisciplinary team in the various centres. There are serious resource implications in this recommendation and also with regard to equipment. The report was critical of equipment and of aspects of care and diagnosis.
To what extent can HIQA insist that resources are put in place in the various centres? There is concern, for example, at what is going on in the south east. There is concern in my area that resources will not be put in place in the centres to ensure that they can deliver a safe service in accordance with the recommendations of the report on the O’Malley case.
My second question also relates to Rebecca O’Malley. She has become an advocate of patients’ rights. One of her recommendations is that there should be a central register or sharing of information when mistakes are made and that we should learn from errors. That recommendation was particularly highlighted this week when two significant mistakes came to light. One led to the death of a woman in childbirth and the other occurred in Our Lady’s Hospital for Sick Children in Crumlin, Dublin. Does HIQA have a role in ensuring that there is sharing of information about errors that have been made and that we learn from them? We all know that clinical errors can occur. We need a system to ensure that there are people whose job it is to see that an error has been made and that action is taken to deal with it.
I believe HIQA has made a further report on misdiagnoses of cancers. I know there have been two reports on this matter, one into misdiagnoses by Dr. Geagea in Cork and one into misdiagnoses in Galway. Which of these reports was done by HIQA and when will it be published?
My colleague, Senator Prendergast, will ask questions about standards of care for older people. However, I have just one question on this area. I understand the National Treatment Purchase Fund will have a role in assigning older people to particular hospitals. Will HIQA have a role in ensuring that money will not be the determining factor in these decisions but that standards will also be important?
With regard to the hygiene report, does HIQA have a role in ensuring the issues relating to resources are addressed? I think particularly about overcrowding in Ennis hospital which contributed to the outbreak of clostridium difficile there.
Disability spokespeople are anxious to see standards established as soon as possible. I understand the need for extensive consultation. Are there clear channels of communication so that organisations such as the National Association for Mental Handicap in Ireland can take part in this consultation?
What were the measuring standards for residential care settings for older people? Was there a discrepancy between HIQA’s aspiration and the situation on the ground? What procedures are or will be followed when standards are not attained? What effect has the recruitment embargo had on the delivery of services? In cases where HIQA was not happy with its findings, what action was or will be taken?
Dr. Tracey Cooper: I thank Deputy O’Sullivan and Senator Prendergast. I hope they will remind me and my colleague if we miss questions. Deputy O’Sullivan spoke about the implementation of the recommendations of the report into the O’Malley case and the relative roles of the HSE and HIQA. This provides a good opportunity to tease those issues out. The Health Service Executive is responsible for providing and commissioning services, so its executive responsibility to ensure that the services it provides on a daily basis are safe should be inherent within its governance arrangements. Our role is to set standards and assure that what it is doing is to the level that it should be. We are a kind of external verifier. We provide external scrutiny, periodically reviewing progress made against a reference point, which in this case comes from the recommendations.
Professor Tom Keane is the interim national cancer director. Much work has been going on within that directorate to figure out the resources needed to meet the symptomatic breast disease standards. One of the reasons we brought forward the review of symptomatic breast disease, which subsequently led to the HSE’s announcement of the eight designated centres, was to review those centres against the totality of meeting the standards. We can then revisit them next year to ensure progress has been made when they are national centres and no longer designated centres. Our role in external verification is to make sure everything is in place, while the role of the HSE is to undertake to deliver and provide those services.
The HSE needs to be given the time to put together an action plan on the recommendations. We will have discussions to agree to sign off that action plan in the near future. We will then agree a process to meet on a regular basis to hear progress against those meeting the action plan. If needed, we will revisit the hospitals concerned at a point in the future to ensure that the information we receive is happening in reality.
Dr. Tracey Cooper: Absolutely. We brought the symptomatic breast disease review forward because of the number of investigations into symptomatic breast disease in the country. The very hospitals concerned will be part of the review of the hospitals as designated centres, so the same standard will apply to ensure they are fit for purpose as they become national centres next year. Many of the standards overlap with the recommendations to that end, as the Deputy rightly pointed out.
The Deputy also spoke about sharing information on errors. The most important level of the system in which lessons are learned is the facility concerned. The report on Rebecca O’Malley shows that key for us are the issues of clinical governance, management and risk management. A hospital, a group of general practitioners or a mental health unit should learn about adverse events within their own confines, because they should govern those services. That is the first fail-safe mechanism and the culture within that is absolutely key.
We then must aggregate these adverse events and near misses and form an opinion on the state of the nation. There is a reporting system in place as part of the State Claims Agency, which is the clinical indemnity scheme. Hospitals are required to report an adverse event to the clinical indemnity scheme. We are having discussions with representatives of the clinical indemnity scheme, the Department and the HSE about how we can learn together from the system when adverse events and near misses occur. There is activity at several levels, but the most important thing is that it is governed at a local level so the same problem does not recur, which we hope will resonate in all the recommendations of our work.
Dr. Tracey Cooper: We are in the process of concluding the Galway investigation and we hope to go through the necessary requirements of circulating that report to the individuals involved in the next few weeks. We hope to receive comments on the draft report and for the board to receive the report by the end of May. We hope to be in a position to publish it as soon as possible after that.
Dr. Marion Witton: It is a very interesting point. On a strictly legal basis we can only register and inspect what applies to applicants. Therefore, so far as the placement of residents is concerned, whether they are privately-funded and can choose, or whether there is an assessment, strictly speaking, is not within the regulator’s role. What we can do is apply conditions to care homes nursing homes to ensure those homes can only look after people where the layout of the building or the staffing qualifications reflect their statement of purpose. Each care home must be able to demonstrate that it can meet the needs of people placed there. That is a very important point.
Having mentioned the strict legal view, we have an ageing population. We hope that through the standards requirement, there will be a change from the kind of institutional care that some people experience currently. Future applicants for registration as nursing homes will be looking at a more diverse range of care so than when we get older, or when our relatives are considering residential care, there are different models of care. It is a very exciting time for people to be able to ask whether residential care is what we want in the future or whether something better or different could be provided. We have a role in helping people and in influencing the sort of care that will be provided in the future. There is the current position and there is the future position.
The Deputy also asked about the disability standards and the channels of communication. We have been fortunate in the standards working group that most of the major organisations have been represented. They have taken their work on the working party very seriously. They do not just turn up at meetings but draw up standards. We put the assessment of standards before the working party meeting and they take them back to their organisations. We have tried to ensure that the views of as many people as possible are taken into account. With public consultation, we will endeavour to reach other people. One of the difficulties of not having services regulated heretofore is being able to identify where they all are. Because there are different models of care within disability services, the question is whether they would fit into the description of a designated centre. That is a big challenge for us.
Senator Prendergast asked whether we are measuring standards in regard to what happens with discrepancies. Obviously there are sanctions within the Health Act that we can apply if somebody refuses to provide a service which protects residents. Given that people live in the homes, that is very much a last resort. We want to work with the providers to help them to improve.
In addition to the standards, we are producing what we call a fit person assessment pack, which is a distance learning pack, so there is training for each of the standards. The providers can take it back to their staff and ask what it means for them. If there is a choice of meals and there are 100 residents, what does that mean in practice? At the end of the training period, there will be an assessment which will be part of the fit person assessment. This will enable us to make a decision regarding registration.
There are a number of measures we can take but we would rather work on the influence. In the future we want a robust system whereby if people do not meet the standards and put people at risk, or they are being treated in a way that is not satisfactory, we would not hesitate to take the appropriate action.
Deputy Rory O’Hanlon: I thank the representatives of HIQA for their presentation. I welcome the establishment of the authority which has the potential to make a major contribution to improving the standards of care for all. There are seven criteria for the care of the elderly in a residential setting. I wonder whether these include the distance from the elderly person’s home to the residential care setting in which he or she is placed. Many are placed 50 or 60 miles away, which is not necessary if there is a range of facilities available closer to home.
My other question relates to the elderly and children. Does HIQA have a remit, in co-ordination with other State agencies, in the case of children in looking for the early intervention of psychology services with the Department of Education and Science and in the case of the elderly in having an input with the local authorities where planning permission is refused to children who want to live near their elderly parents and who would provide a better level of care than anything that can be provided away from home, or in expediting payment of the disabled person’s reconstruction grant which in the case of an elderly disabled person who only needs a toilet downstairs can take six or seven months to issue approval?
No country has the resources to provide for the level of service that we would like to see to improve quality of life for everybody. Against that background, how does HIQA determine priorities? Does it undertake comparative analyses between agencies and units of the health and social care services? We always must look for best practice to ensure high standards and productivity.
There is the related question of international standards. I understand HIQA held an international conference here. With all the work it must do, how does it manage to keep abreast of developments in respect of best practice internationally? What is its work programme for the next six to 12 months?
My questions relate directly to residential care for older people. There is considerable concern about the elderly acquiring MRSA and other infections. I was told recently by individuals working in public residential homes and who are operating under stringent budgetary controls that they were being asked to cut back on envelopes and detergents and operate to a strict budgetary level, and that if there was an inspection in the morning, they would not be able to put in place the processes necessary to get through it. It is a real fear for them. In another context I mentioned to somebody that in days gone by when matrons operated on a shoestring in hospitals, MRSA was unheard of. Now when so much money is being provided, there are all of these infections. It is a source of grave concern.
On the elderly, HIQA has correctly highlighted the importance of ensuring those who are most vulnerable are protected. We have all heard the horror stories about patients who were subjected to dreadful treatment in certain establishments. Nobody could condone that. Is it part of HIQA’s remit to insist that residential care facilities have certain policies in place? I am thinking, for example, of anti-bullying policies or a requirement to treat the people in their care with dignity. There should be a clear process in place in order that if a relative or other person witnesses something about which he or she is unhappy, he or she can make a complaint and have it dealt with in a legitimate manner. I agree that for many residential care is a last resort, but because we do not have sufficient community care places, many who would much prefer to be in their own homes must go into residential care.
My next question is related to the one asked by Deputy O’Hanlon. In the next 12 months how many residential facilities will HIQA hope to inspect? Will it be making the reports public? In the case of education, a whole-school inspection is carried out and the report is published for everybody to see.
Dr. Cooper mentioned that sufficient numbers of suitably qualified staff were required. This is very important. Facilities are under pressure because of the embargo. They do not have enough staff. For example, as highlighted last week, at Our Lady of Lourdes Hospital, Drogheda, there were not enough midwives in place and it was suggested they were short by six. Does HIQA have power to force the HSE to rectify such problems which could have fatal consequences for patients? I agree there is no point in having a body such as HIQA which makes recommendations if they are not going to be implemented. The most important part of HIQA’s remit is to ensure that where recommendations are made, they are followed to the last letter.
Deputy Paul Connaughton: I certainly like what I hear today and will explain why. I regard HIQA as being a great protector for many people who cannot protect themselves. Most of the questions I wanted to ask have been asked and I will not go back over them. However, I wish to comment on what Dr. Witton said about one-size-fits-all residential care for the elderly. So many people of that age are committed if that is the correct word to homes. They come from many diverse environments that are completely foreign to where they are going, such that if we take, for example, an institution with 30 or 40 residents, they will come from many backgrounds and have varying views on life and standards and so on. I sincerely hope we will arrive at a situation in which everything will be done to ensure the personalities of the people concerned are protected to the last day. I appreciate it is a lot to ask, but if HIQA is not able to do this, there is no other organisation in the country which can.
Those of us who have been Members of the Oireachtas for a long time know that, particularly in matters of health, there is no shortage of vested interests. They are everywhere. Does HIQA have the punching power, to put it bluntly, to overcome this? Is it able to override all the groupings which believe they have a God-given right to continue doing whatever they have been doing for the last 20 years? Does HIQA have that type of punching power? This is of enormous importance for older people.
I assume HIQA will have a direct input in both private and public residential care for the elderly and no distinction will be drawn between these sectors. Unannounced inspections flying visits at weekends, during the night or at any other time must be part of the new regime. While I am not aware of a private or public nursing home that is not doing its job properly, structures must be in place to give everyone to understand that a heavy hand can be laid on them at any moment, even at the most unusual times or when they are at their most vulnerable. Without such a structure, work practices will develop which are not beneficial to those about whom we are most concerned. I ask our guests to put my anxieties at rest.
Deputy Niall Blaney: I apologise for being late. I welcome our three guests and the establishment of HIQA. As with other speakers, I have concerns in many areas. One issue raised in a different context was the role of the National Treatment Purchase Fund, NTPF. I am contacted every week by people who have been placed on waiting lists for long periods without realising they are eligible for treatment under the fund. I am also aware of patients failing to secure a good response from staff in certain hospitals who have responsibility for dealing with the NTPF. They receive a much better response when they call the freephone number. There is a major deficit in the information available on the NTPF and concerns have arisen about the way in which some hospitals inform patients on waiting lists about the fund. Many more patients could be removed from waiting lists if more regard was paid to the NTPF.
Deputy Alan Shatter: Before raising a number of issues, I apologise in advance if I leave the meeting at speed to attend the Order of Business. If I am not present to listen to the witnesses’ replies, I will read them. I join other speakers in welcoming the establishment of HIQA, a very important organisation. I have concerns about the substantial job the organisation has been given because it may be a number of years before it will be able to deal with areas that are crying out to be addressed.
How is it envisaged that HIQA staff numbers will develop? I apologise if the following issue has been raised in my absence. What will be HIQA’s priority areas in the next two years? While the reports the organisation has published thus far are excellent and important, other areas also need to be considered. What level of co-operation is HIQA receiving from the HSE? Members of the Oireachtas find it extraordinarily difficult to obtain from the HSE coherent or full information that clearly, honestly and comprehensively sets out the position on various positions within anything approaching a reasonable timeframe. As an independent body, has HIQA experienced difficulties securing information from the HSE?
I will not repeat questions posed by other members on issues in which I have a great interest. On child care, however, I have major concerns about the current capacity of the HSE to deliver on its statutory obligations to provide a child welfare and protection service.It is a scandalous outrage that it published its 2005 report on the state of children’s and family services only a few weeks ago. We do not have its 2006 or 2007 report, although we are in the middle of 2008. Apparently, neither the HSE nor the Minister for Health and Children knows how the services are functioning. They are both incapable of responding in a coherent way to queries raised about them.
To what extent is the authority in a position to investigate deficiencies in child welfare services? Is it an area that it intends to prioritise? One of the specific functions that the representatives set out in their opening statements and one particular area in how the organisation is structured deals with health information and efficiencies. Does that extend to deficiencies in child care services? Has the authority examined the HSE’s capacity to communicate the extent to which services are functional? There is a huge problem. If, for example, a child is seriously abused at the weekend, no one knows who to go to, other than the Garda. No functioning office or service seems to be available. We largely have a weekday nine-to-five service. It is a big problem. I would be interested in hearing what functions the authority sees itself as exercising. I know that, as an inspectorate, it has functions on residential care. However, what are its functions, if any, in the context of other services and how soon will it be able to operate them?
Several important points were made about disability services. I have a major concern about the physical and sexual abuse of disabled children in institutional care. In the general areas of abuse that have received so much publicity, I do not believe the specific and particular difficulties of the disabled being sexually abused have been adequately addressed. A report was published on abuse in the old Western Health Board area in the Brothers of Charity services in Galway, but it took from 1999 until November 2007 for a grossly inadequate report on those services even to be published. I have no assurances in my mind that the problems that occurred in the Brothers of Charity institution are not being replicated. I have no peace of mind in a belief that all the required protections are in place. Is it an area that the authority intends to consider and to what extent can that work be prioritised?
My final questions relate to the authority’s remit on general services and the giving of information. There are various difficulties in the health service which are being exacerbated not simply by a lack of resources but by major misuse of resources. Resources that should go to front-line services are used in a bureaucratic and administrative structure of Machiavellian proportions, which is usually wasteful and duplicatory. In the provision of services and dealing with the customers of the health service, the authority has a particular role to play in setting standards and ensuring services meet reasonable expectations we all occasionally have unreasonable expectations. It is scandalous that as we sit here, letters are being delivered to people’s homes in various parts of the country telling them that, unexpectedly, respite care they had booked for elderly, dependent, unwell relations or spouses who are being cared for at home, is being cancelled. I have an example adjacent to my constituency. Leopardstown Park Hospital, which has provided respite care for many years, has this week sent letters to people announcing the 21 beds in its respite ward are being withdrawn from 1 May. People who have booked places for those for whom they care for 51 weeks of the year so they can have a week’s respite in May, June and July have been told the bookings have been cancelled. People who have booked holidays so they can have one week’s rest now have nowhere to place their elderly, dependent relatives of whom they are taking care. It is a scandal.
No well run health service seeking cutbacks should withdraw such services two or three weeks before somebody who is dependent on them believes they can rely on them. Leopardstown Park Hospital has withdrawn its respite care services indefinitely because of cutbacks and the same is happening to respite care in other parts of the country.
Does HIQA have a function in informing people of quality control issues? Is it reasonable that this type of service be withdrawn with that type of notice? Can HIQA investigate this issue in circumstances where people are dependent on such services and, to their detriment, have incurred substantial costs? For example, if they have booked a holiday in the belief that the service would be provided but now find themselves left high and dry. I apologise to the Chairman but I felt it was important to raise some specific issues and I would be very interested in the response.
Dr. Tracey Cooper: We began with Deputy O’Hanlon, who asked a number of questions, and we will run through them. The Deputy’s first question was on distance from home and the placement of older people in residential care, subject to the distance from their social environment. I invite Dr. Witton to comment on that.
Dr. Marion Witton: As I said, one of the primary functions when we register people who run care homes is to ask them to explain to us how they ensure everybody’s needs are met. That is their job. We register them as fit people. There is not necessarily an appropriate care home near everybody, so we examine the arrangements in place for people who do not live near their relatives. While some people might not choose to live near their relatives, others would like to live very close to them. Are there arrangements which enable people to have visitors, for people who might have an elderly spouse who cannot travel to the care home to visit? How do they ensure such a person’s wishes are taken into account, taking account of the fact that there are other people in the home?
If it is a question of whether somebody is in a place where he or she can be properly looked after or be somewhere local which may not have the staff, those issues must be examined. Where is the most appropriate place? What is the priority? If there are deficiencies, what can be put in place to help that person?
Most of the latter questions we were asked were on quality of life issues and we can examine them as a group. How can the providers demonstrate they meet the standards and ensure individual needs are met? The focus of our inspection will be on what it is like to be a person living in this home. Not everybody will be looking for the same kind of facility. It was a very traditional practice where people got up early in the morning and sat around for the rest of the day. We hear a lot about difficulties with staffing and other problems, but the majority of homes that provide good quality care have found solutions to those problems. They have found ways to make life interesting for people and have found mechanisms through which the staff can work with residents rather than getting everybody up and then rushing off to do other tasks. An example from international best practice would include making alterations to an old building so that it comes alive, so that everybody has something to get up for in the morning, rather than sitting around waiting for something to be done.
We have spoken before about making sure people have enough to drink and do not get their last meal at 4 p.m. so they are forced to wait until the following morning for their next meal. Deputy Connaughton asked whether we would be carrying out night inspections. We will be carrying out proportionate, targeted inspections during the day and night. In the past I have carried out night inspections. The providers welcome the night inspections because they feel it keeps the staff on their toes. Residents are also happier to talk to inspectors at night when other people are not around. There is much value to that. It is important for us to carry out spot checks which need not be lengthy. We have had examples of people making facilities available because the inspector was coming, only to be told by the residents that they thought the President was coming because the place had a lick of paint and everything was put in place.
Apart from unannounced visits, there is also a place for telling people we are coming. Regulations are not there to catch people out. Regulations are there to make sure people are being looked after properly. We are publishing a booklet asking the providers whether they are ready for inspection and telling them what we will be looking for. If they cannot get it right when they know we are coming, they will not have the excuse that something was wrong on the day of the spot check. There is a place for both announced and unannounced inspections.
We know that staff will be off sick during the course of the year. Some of them will need to take care of their own relatives, they will be out sick, on holiday or at the dentist. It is certain that homes will be short of staff, so we do not want to be told that it is bad luck that the provider is short of staff on a particular day. We will be asking providers about the systems in place so that when a staff crisis occurs, replacement staff such as agency workers are suitable for the job.
We will be publishing reports which we hope people will enjoy reading. We hope they are meaningful and not lengthy tomes full of jargon. We want to tell the public what is good about a certain facility and what needs to be improved. We will also ask an individual provider to respond to a report so that the public can see what the provider has done about things that needed to be improved. Therefore, the report is balanced because it is about our findings and about what the provider claims to be doing.
Dr. Tracey Cooper: Deputy O’Hanlon asked about the remit of State agencies and he also spoke about the Department of Education and Science. The relationship with the Department needs to evolve regarding the independent assessment of need for people with physical and intellectual disabilities. As the Deputy may be aware different elements of the Disability Act are being implemented at different stages.
There are a number of other State agencies which we link into. Similarly the regulatory bodies across health and social care areas have established a forum where we meet to talk about best practice with a view to reducing duplication.
Deputy O’Hanlon asked how we prioritise issues. That is a very important point. We do it in a number of ways. We recently engaged in public consultations on our corporate plan for the next three years. All of the feedback from the public and stakeholders informed the output of that corporate plan. It is being submitted to the Minister for Health and Children and we hope to be in a position to publish it in the near future. We have to start somewhere with priorities. A number of the priorities have been addressed while accepting that we will also respond to serious issues of public safety as and when they arise.
The main areas for us are around cancer services, health care associated infections, establishing the inspectorate for residential care settings for older people and, next year, inspection for residential care centres for people with disabilities. We have made a decision in regard to undertaking certain health technology assessments that also prioritise improving cancer services because we have cancer challenges in this country, as have many other jurisdictions.
While we have not had much time to touch on the health information function, it would be good to do so at, perhaps, another meeting. As the health information systems across the country evolve, it is important that technical standards are defined so that when an organisation purchases new systems, the systems that evolve around them are able to communicate. That is a real priority.
We are also in discussion on some other aspects of setting performance indicators for the system. Performance indicators mean a defined metric that may be about patient experience, access or finance to ensure people are aware of the performance of the system. That will be a priority for the organisation next year.
There are work programmes to which we are committed such as the symptomatic breast disease review to which we have referred, the hygiene review at the end of this year and the publication of the infection prevention control standards which is key. We are also looking at the new standards for hospitals. What I mean by that is outlining what constitutes a fit for purpose, highly reliable hospital. That will be piloted into next year so that we have a new framework for hospitals for next year.
Deputy Conlon asked about older people contracting infections. We have touched on that issue. She also asked about the mandate and the quality of procedures. The registration inspection process is mandated in its own right. There are sufficient complaints procedures and infection control procedures, etc., in place. The Deputy also mentioned MRSA and the need for resources. MRSA has a number of different factors, including behaviours and management, to sustain a reduction in health care associated infections. It includes the power of the public to safeguard themselves. If somebody approaches them they can ask the necessary questions and feel comfortable to challenge that health care professional. That is a very important power of the patient.
Education is a real issue. People know that wherever they receive or provide services, there are standards around infection, prevention and control that should be in place and that there is inspection and monitoring to check that is the case. In addition to resources, there are many other things that can be done to minimise health care associated infections.
Deputy Connaughton commented on the care we would all want if we were in residential care settings. I think Dr. Marion Witton responded to a number of his questions. The Deputy also asked whether we had the necessary punching power to make an impact. There are a number of aspects to this. Obviously it includes what is in the legislation. We are governed by how the organisation has been set up so far as the legislation is concerned and there are some strong powers in that legislation. It is about how we interface as an organisation and how we interrelate with and influence people. That must be through an objective way, through an honest broker. I consider the authority is the honest broker of patients, residents and staff. We have a central trajectory that we must ensure is in the correct line to drive through around safety and quality.
Our independence is important to us and the objectivity and the evidence base with which we report and make recommendations must be paramount. We must earn the punching power. The Oireachtas has given us the wherewithal to do that and I am sure the relationship will evolve over time.
Deputy Blaney asked about the National Treatment Purchase Fund. Obviously, our role is separate from it. I am not familiar with the provision of information and the interaction between the NTPF and the respective hospitals.
Deputy Blaney spoke of waiting lists. I mentioned performance indicators for the future. One of the areas we are keen to explore with the Health Service Executive and with the Department of Health and Children is how waiting lists become part of those performance indicators for the future. Obviously, how that interrelates with the National Treatment Purchase Fund will be key but we have no specific authority to impact on that relationship between the NTPF and the various hospitals.
Deputy Shatter asked about staff development. Our corporate business plan for this year ensures that we have identified all of our objectives and that our staffing reflects the establishment of the functions to deliver on those objectives for example, setting up the social services inspectorate, setting up health care quality for the review of hospitals, investigations, etc. I hope I have touched on the priority areas for the next couple of years.
Deputy Shatter also asked us about co-operation with the Health Service Executive. We work with the Health Service Executive in everything we do, as we do with private providers, voluntary providers, the Oireachtas and the Department of Health and Children. Our liaison with the Health Service Executive ranges from porters, doctors, nurses and managers through to the HSE corporate entity. From personal experience in other jurisdictions, I would say that sometimes we receive a rapid response and sometimes it takes longer. My findings are that this is the same in the case of many large institutions. What is of key importance for us is that we develop the relationship where we get the information as speedily as we need it. Sometimes that comes from holding direct meetings with members of the Health Service Executive to move matters along and sometimes we receive a prompt response. It varies.
Dr. Marion Witton: We need to be clear that our job is not as the child protection agency. Our job is to register and inspect services and to monitor whether the services are provided, not just for persons who, unfortunately, experienced abuse but to ensure the future protection of all the service users or that persons who are need of services have the relevant protection. Therefore, we would want to ensure that the procedures are in place and that investigations are carried out. We will monitor whether the investigations carried out by the organisations are effective and if they are not effective, then we will take measures against those organisations.
Deputy Beverley Flynn: I appreciate the Chairman’s tolerance and apologise for being late. How does HIQA integrate with the national cancer strategy, in particular, in the case of hospitals that are destined to lose services currently under that strategy? Dr. Cooper will probably be aware, for example, of the interim situation in Mayo and SIigo, where HIQA has made the news in recent times because of the nature of its investigations in the hospital. It has been stated that HIQA is only looking at whether the service is up to the mark during the interim period until such a time as it is transferred to the centre of excellence. How does that affect the inquiry? If HIQA goes in to carry out an investigation in a hospital to check whether a standard has been met, does that investigation change just because it is an interim situation? I would imagine the investigation is exactly the same. If the standard has been achieved, it is the end of the story irrespective of whether services are transferred.
Who determines whether a centre of excellence can absorb the additional capacity from feeder hospitals? Will it be HIQA that clarifies this? The national cancer strategy is being pushed ahead with certain deadlines, but does HIQA have the power to say “Stop” if a standard has not been achieved and the service is not as good as that currently provided in some of the feeder hospitals?
Dr. Tracey Cooper: We have touched on some of these questions, but I will consolidate the answers. The symptomatic breast disease standards, if people have had the opportunity to read them, are comprehensive. With regard to the review, we reconvened the advisory group that set the standards in the first place. They have been providing helpful advice to us over recent months. Subsequent to the announcement of the review of symptomatic breast disease services, the HSE made the decision on which centres were to be designated to become national centres in 2009. They are on a journey, as it were. Obviously this has resulted in quite a great deal of change in recent months. As members know, the patient flow has already changed and there are now considerably fewer hospitals providing breast disease services because of the changes taking place.
In the review, we have taken two different approaches to achieving the same thing, which is to provide assurance that the services provided are as safe as they can be. With regard to the changing terrain, designated centres are currently carrying out self-assessment across the full range of technical standards. There is a large section on the governance and management of change, which means we expect them to liaise with non-designated centres, to have a managed project plan for communicating with patients and with primary care, and to carry out the steps required to take over the responsibility in a safe and managed way. We then follow up with the designated centres to validate the positions they are at, and we will make recommendations about where they need to be to become national centres.
Next year we will return to the designated centres and review them again in view of the plans with regard to where they are as designated centres and where they should be as national centres. Based on this process we will be able to identify exactly where they are at with regard to meeting standards and management and governance of change. Obviously the national cancer directorate is responsible for the executive management of the change and ensuring it is managed in a way that meets standards and communicates to patients the patient flow of primary care. That covers designated centres.
With regard to non-designated centres, we have considered and identified the core standards that need to be in place in the interim period. For example, people have heard much about triple assessment in recent months. This involves a radiologist, a surgeon and a pathologist coming together in one room at the same time to assess the clinical findings of a patient. We expect this to be in place across centres providing services. With regard to the question asked, the self-assessment tool supports the standards that have been identified to maintain core safety. Similarly, there is a large section around governance and management. The onus is also on the non-designated centres to ensure they are engaging with the designated centres for the safe transition of patients. The self-assessment tool clearly demarcates the questions that providers must answer in this time of change.
It is important to stress that this is not just about technical standards. It is also about the management of the process, which is absolutely fundamental. Our liaisons with the national cancer directorate are just as much about the management of the process as they are about ensuring that the core technical standards are in place.
Deputy Beverley Flynn: Are the designated centres on target? It has been indicated that most of the services available in hospitals will have transferred to the centres of excellence by the autumn, although services in Mayo and Sligo will remain in place until the end of the year.
Dr. Cooper referred to core standards in the context of non-designated centres. Does this imply that HIQA will not examine other standards in such centres or that it is prepared to overlook certain areas? Will Dr. Cooper elaborate?
Before the transfer of services proceeds, will HIQA satisfy itself that the required standard has been met? If such a standard is not met, can HIQA call a halt and insist that implementation of the strategy be delayed?
Dr. Tracey Cooper: In response to the Deputy’s first question on whether the process is on track, the Health Service Executive is managing the transition of patients into the designated centres and driving the timing of the process under which non-designated centres will cease to provide acute services, although they will continue to provide follow-up services for patients. I am not in a position to comment on the timing of the process because it is a matter for the HSE. Many women in certain areas are understandably choosing to go to different centres, thus ensuring that management catches up with the changes taking place.
Dr. Tracey Cooper: Yes, a patient flow has started. On the question of what will be the exact position of each centre by the end of the year, I am sure Professor Tom Keane would be the best person to answer from a Health Service Executive perspective.
Deputy Beverley Flynn: Surely it is the job of HIQA to indicate whether the standard has been reached. Professor Keane will pursue his plan and will not be able to indicate whether the required standard has been met. He must be told by HIQA whether it has been met.
Dr. Tracey Cooper: It will be a combination. The change that has already taken place in the system is a reality that must be managed safely by the Health Service Executive. As the Deputy indicated, HIQA’s role is to review the position from the perspective of standards and management. Our self-assessment process has started and is part of a two-stage approach. The Deputy is correct that a self-assessment begins and ends with what is written or sent in electronically. The key issue for HIQA following the self-assessment is to identify services for which we will need to validate whether the details in the self-assessment are in fact the case. All eight designated centres will be part of this process.
Members of the public are becoming mobile to the extent that patients in certain non-designated centres have started to move to the designated centres. HIQA is in regular contact with the HSE to ensure the timing of the follow-up in the non-designated and designated centres fulfils the pace at which the centres must proceed to be on track. It is a combination of ensuring the centres are managing the process safely and assuring ourselves they are meeting the safety standards and requirements of the management process.
On the Deputy’s question on self-assessment, whether HIQA will be able to call a halt or whether the centres are fit for purpose, as part of that we will issue recommendations on foot of our review of each service or centre. These will be fed into the system for the Health Service Executive corporately and the various hospitals. We will agree what is required for the review phase and revisit. At this point, we need to allow the process to work its way through. We will be in constant dialogue with the HSE on the findings and how or whether they need to inform the pace of the process.
I thank the delegation from HIQA, which has given serious commitments during this meeting. I wish the organisation well. To return to an earlier question, in view of an incident involving Bank of Ireland in recent days, does HIQA have the authority to intervene to ensure computerised patient records are protected?
Dr. Marion Witton: For care homes, one requirement on the registered person would be to ensure any records that he or she kept were not only kept safely but available to the appropriate persons on a need to know basis. One will need enough information to ensure one meets people’s needs, but not all residents will want everyone to know everything about them. That is one aspect that we will certainly examine during the inspection process.
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