4. Resources to Implement the Policy and Strategy

4.1 Investment Programme

While it is acknowledged that there is a need to further enhance capacity in health funded services, it is also important to acknowledge the very significant existing level of expenditure on health services for people with disabilities. Investment in services for people with disabilities has been prioritised in recent years by the Government. Overall approximately €2.4 billion is spent annually by the health services on disability programmes (residential, day care, respite, assessment and rehabilitation services), mental health programmes, Domiciliary Care and Respite Care grants and other allowances.

The Multi-Annual Investment Programme 2006 -2009 was announced as part of the Budget Day package in December 2004. It outlined the Government's commitment to a programme of revenue and capital expenditure, amounting in total to around €900m, on specific disability support services over that period. The bulk of this funding, around €720m, is being spent in the health services.

The specific additional health services being provided as part of this programme are as follows:

  • Services for Persons with Intellectual Disability and those with Autism:
    • 255 new residential places annually, giving a total of 1,020 new places over the period of the programme;
    • 85 new respite places annually, giving a total of 340 new places over the period of the programme;
    • 535 new day places annually, giving a total of 2,140 new places over the period of the programme;
    • An extra €2m each year to continue the implementation of the transfer of persons with intellectual disability/autism from psychiatric hospitals and other inappropriate placements.
  • Services for Persons with Physical or Sensory Disabilities:
    • 80 new residential places for persons with significant disabilities who are currently placed in inappropriate settings, giving a total of 320 new places over the period of the programme;
    • 250,000 extra hours of home support and personal assistance, giving a total of 1,000,000 additional hours over the period of the programme.
  • Mental Health Services:
    • 100 new places annually in community based mental health facilities, including mental health day centres, day hospitals and community residential facilities, giving a total of 400 new places over the period of the programme.

In addition to the specific services outlined above, the further enhancement of other support services such as multi-disciplinary or specialist support services for people with disabilities continue to be discussed as part of the annual Estimates and Budget discussions.

In 2006, additional funding amounting to €155m was made available for services for people with disabilities as follows;

  • €59m to meet costs in 2006 associated with the specific Programme commitments outlined above;
  • €41m, which is being used mainly to enhance the level of multi-disciplinary support services available to people with disabilities;
  • €55m capital to provide the infrastructure to support the above developments.

4.1.1 Monitoring the Implementation of the Programme

The Department of Health and Children, in partnership with the HSE, has put in place very clear measures to report on and monitor the implementation of the Multi-Annual Investment Programme, together with the additional funding allocated in 2005. These include;

  • Agreed protocols governing the implementation of and reporting on the Multi-annual Programme;
  • Regular reports to the Cabinet Committee on Health and Children on progress by the HSE in achieving the targets set.

The additional revenue (€70m) and capital (€60m) provided in 2005 was used to put in place the following services:

Physical and Sensory Disability

SERVICE

TARGET

ACTUAL @31/12/05

Increased capacity - residential services

56 places

55 places

Home Supports

100,000 hours

118,985 hours

Rehabilitation and Sheltered Places

90

75

Aids and Appliances

€3m

€2.86m

Intellectual Disability/Autism

SERVICE

TARGET - NEW PLACES

TARGET - ENHANCED SERVICE

ACTUAL @31/12/05 - NEW PLACES

ACTUAL @31/12/05 - ENHANCED SERVICE

Residential

204

96

206

104

Respite

71

58

95

15

Day

409

-

426

28

Transfers from Inappropriate Placements    

45 persons provided with more appropriate care settings

 

Mental Health Services

The €15m allocated in 2005 for the development of mental health services provided for:

  • An enhancement of facilities at the Central Mental Hospital;
  • 12.5 additional consultant-led mental health teams in child and adolescent, rehabilitation and general adult psychiatry;
  • An additional 44 staffed community residential places;
  • 2 new mental health day hospitals (2x10 places);
  • 4 extra home-care treatment teams;
  • A specialist consultant-led mental health team for members of the deaf community;
  • Support for early intervention programme (DETECT);
  • An additional consultant-led multi-disciplinary team for the psychiatry of Intellectual Disability;
  • Additional advocacy support provided for voluntary agencies (Irish Advocacy Network, Mental Health Ireland, Schizophrenia Ireland and STEER);
  • The development of additional specialist self-harm/suicide prevention services in A & E Departments ;
  • Further enhancement of bereavement support services.

The Multi-Annual Investment Programme also provided for additional revenue expenditure of €82m by the Department of Education and Science in relation to

  • education services for adults with disabilities;
  • the expansion of the role of the National Council for Special Education under the Disability Act 2005;
  • increased availability of pre-school provision; and
  • the introduction of the new appeals processes as envisaged in the Education for Persons with Special Educational Needs Act 2004.

Additional revenue funding amounting to €100m has been provided in 2006. This includes €58.8m to provide the specific service elements contained in the Multi-annual Investment Programme and a further €41.2m to address core funding deficits and fund further service enhancements.

Services for Persons with Physical and Sensory Disabilities: €11.8m

SERVICE

TARGET

Increased capacity - residential services

80 places

Home Supports

250,000 hours

Funding is also being provided for the employment of up to three Resource Officers to assist persons with sensory disabilities and for the provision of assistive/adaptive technology for people with sensory disabilities (€0.5m)

Services for Persons with Intellectual Disability and Those with Autism: €39.5m

SERVICE

TARGET - NEW PLACES

Residential

255

Respite

85

Day

535

Transfers from Inappropriate Placements


€2.2m

Mental Health Services: €7.5m

This will fund the provision of additional community based mental health facilities, including mental health day centres, day hospitals and community residential facilities. Details are included in the table below.

Additional Services:

€41.2m

Intellectual, Physical and Sensory Disability/Autism: Multi-Disciplinary Supports: €12.5 m

The priority for the HSE in 2006 is to increase service provision in the area of multi-disciplinary supports to meet obligations to children with developmental delay, in the home, in the community and in other appropriate settings. The investment package will facilitate the recruitment of up to 200 extra Therapists, particularly Speech & Language, Occupational Therapy and Physiotherapy. It is acknowledged that in the short term the recruitment of these scarce grades must be sourced from overseas. The HSE has put in place a project plan to effect same.

Core Under-Funding of Voluntary Agencies: €10 m

A process is currently being put in place by the HSE to quantify and validate the extent of the core under-funding of voluntary agencies. A methodology for allocating this funding will then be developed.

Mental Health Services: €18.7m

This additional funding will be used to enhance the level and range of multi-disciplinary support services available to adults and children with mental illness and to support the implementation of Reach Out - National Strategy for Action on Suicide Prevention 2005 - 2014. Details are included in the table below

Summary of Mental Health Service Developments (€7.5m +€18.7m)

The service developments planned for 2006 are outlined below;

Item

WTE's

18 Multidisplinary Teams

9 m

108

14 Team Enhancements

2.8m

56

36 Mental Health Act Resource Persons

1.8 m

36

Establish of Mental Health Directorate & Service User

.15m

1

The Service Levels in Child Psychiatry

3.25 m

40

Service Development for person with Learning difficulties

2.25m

30

Additional Services for Psychiatry of Old Age

2 m

30

Additional Services for National Forensic Psychiatric Services

1 m

15

Investment in training for Clinical Psychology

1 m

50

Supports for Voluntary Partners in Mental Health

.8m

0

Initiatives for promoting Mental Health

.2 m

0

Specialist Services for Homeless Mentally Ill

.75m

15

National Office for Suicide Prevention

1.2m

7

Total

26.2m

 

Capital Funding

€45m is being allocated to support additional places in services for person with a physical, sensory or intellectual disability or autism. A further €10m is being allocated to support the additional places to be provided in the community based mental health services. This funding is over and above that previously allocated to these services from the Capital Investment Programme 2005 to 2009.

Consistent service development requires increased investment in a systemic way over a number of years. It also requires the identification of priorities, the setting of clear targets and having in place effective systems to monitor service improvement outcomes. The structures which are currently in place together with the additional elements of the legislative framework, and in particular the information requirements in the Disability Act 2005, deliver on these requirements. Through the commitment to the Multi-Annual Investment Programme which the Government has put in place, it has given a very visible assurance of its intention to progressively address identified needs.

Specialised services for people with a disability will continue to be developed over the coming years while Part 2 of the Disability Act 2005 is being implemented. Further details are provided in Chapter 5.

4.2 Social Partnership Agreement "Towards 2016"

The new Social Partnership Agreement "Towards 2016", states that future policy in relation to people with disabilities will be progressed through the National Disability Strategy with particular expression being provided through Sectoral Plans and other relevant mechanisms. Key issues to be addressed in relation to the health services:

  1. Assessment for, and access to, appropriate health and education services including residential care, community based care, and mental health services within the framework of the Disability Act, 2005 and the Education for Persons with Special Education Needs Act, 2004. Developments will include:
    • Implementation of Part 2 of the Disability Act 2005 and implementation of the Education for Persons with Special Educational Needs Act 2004;
    • Person-centred supports will continue to be developed for long stay residents in psychiatric hospitals, with a view to their movement back into community living;
    • Central to the successful implementation of the National Disability Strategy will be a process of financial accountability. Clear guidelines will be developed to ensure that the investment in the Strategy delivers value for money and real tangible benefits to people with disabilities;
    • Person centred supports will continue to be provided to 'adults with significant disabilities', having regard to the range of support needs which they require, e.g. nursing, personal assistance, respite, rehabilitation, day activities, etc;
    • In its consideration of the core funding requirements of agencies providing services for people with disabilities, the Health Service Executive will be asked to take into account the appropriateness of core funding essential health and personal social services;
    • Establishing on a statutory basis the Social Services Inspectorate (SSI) (which currently inspects children's residential and foster care services on an administrative basis) through the legislation for the establishment of the Health Information and Quality Authority (HIQA) which is expected to be published during the 2006 Autumn Session;
    • Developing a strategic integrated approach to rehabilitation services within the context of the Multi-Annual Investment Programme with a view to supporting people back into employment, as appropriate, through early intervention and enhanced service provision.
  2. National Standards will be introduced in respect of specialist health services for people with disabilities, taking into account the draft standards already prepared by the National Disability Authority, together with the report of the Working Group on the development of a Code of Practice for Sheltered Workshops.

Other measures included in the Social Partnership Agreement include initiatives dealing with employment, housing and income which will be addressed through Cross-Departmental initiatives in which the Department of Health and Children will participate.

4.3 Health Information and Quality Authority

One of the key policy aims of the Health Strategy is the delivery of high quality services which are based on evidence-supported best practice. The establishment of the Health Information and Quality Authority (HIQA) on a statutory basis, which was first proposed in the Health Strategy, was one of the recommendations of the Health Service Reform Programme announced by the Government in June 2004.

In March 2005, the interim Health Information & Quality Authority (interim Authority) was established to make the organisational plans and preparations for the Health Information and Quality Authority (HIQA). The Minister for Health and Children recently published HIQA's draft enabling legislation for public consultation. HIQA will be an independent body reporting directly to the Minister for Health and Children.

HIQA will:

  • set standards for services provided by or on behalf of the Health Service Executive (HSE) except those within the remit of the Mental Health Commission and the Inspector of Mental Health Services;
  • monitor service delivery against level of compliance to those standards;
  • review services and make recommendations aimed at achieving best outcomes from the resources available;
  • investigate the safety, quality and standards of any service (except mental health services) provided by or on behalf of the HSE and make any recommendations it deems necessary;
  • accredit services and provide an accreditation service for the private sector;
  • evaluate and provide advice to the Minister on the clinical and cost effectiveness of health technologies, including drugs;
  • set standards (including governance arrangements) in relation to information and data in respect of the health and personal social services and the health and welfare of the population for the HSE and service providers and advise the Minister and the HSE on the level of compliance with these standards.

The Office of the Chief Inspector of Social Services will be established as an Office within HIQA. It will continue the Social Service Insectorate's work in respect of child welfare and protection services. It will also be assigned responsibility for the inspection of residential services for persons with a disability and for residential services for older people, including private nursing homes. It will be the registration authority for these residential services and will inspect them against regulations and against the standards set by HIQA.

4.4 Strategic Review of Disability Services

In accordance with a commitment in "Sustaining Progress", the Social Partnership Agreement 2003-2005, the Department of Health and Children has carried out a strategic review of existing specialist health service provision for people with disabilities, in consultation with relevant interests. A document setting out the key findings of the review will be finalised without delay. The document is being prepared against a backdrop of significant consultation.

This has included the following:

  • Analysis of the advice of fourteen specialist study groups based on contributions from 360 people who are involved in the disability sector;
  • Detailed discussions with the chairs of the specialist study groups;
  • Consultation meetings with parents/carers, service providers and service users;
  • A consultation seminar on the Values and Principles underpinning the document;
  • A series of visits to services (both statutory and non-statutory) in 16 counties;
  • Analysis of around 50 submissions received from a variety of interested parties in response to a public advertisement.

4.5 National Policy Framework for Mental Health

"A Vision for Change" - a new National Policy Framework for the mental health services was published on 24th January 2006. The Report, which was developed by the Expert Group on Mental Health Policy, provides a set of values and principles that will guide both Government and service providers in developing a modern, high quality mental health service over the next 7 - 10 years.

The recommendations in the Report, which have been accepted by Government, propose a holistic view of mental illness and recommend an integrated multidisciplinary approach to addressing the biological, psychological and social factors that contribute to mental health problems. The report recommends a person centred treatment approach which addresses each of these elements through an integrated care plan, reflecting best practice, evolved and agreed with both service users and their carers. Interventions should be aimed at maximising recovery from mental illness, and build on the resources within service users and within their immediate social networks to allow them to achieve meaningful integration and participation in community life. The recommendations in the report aim to enhance the inclusion and functioning of all people experiencing mental health problems.

The report envisages a mental health system that addresses the mental health needs of the individual - a system which is accessible, inclusive, non-discriminatory and equitable. In order to do this the system must meet the needs of all people with disabilities requiring mental health services. The mental health needs of children, adolescents and adults come within the scope of the Disability Act. The type of multidisciplinary assessment, treatment and care envisaged in the mental health policy framework is in keeping with the requirements of the Disability Act. The report also addresses the specific mental health needs of people with intellectual disabilities and makes a number of recommendations about the provision of services to this user group. Early intervention and assessment services for children with autism are also addressed by the report.

The Health Service Executive is in the process of establishing an Implementation Group to ensure that the recommendations of A Vision for Change are realised in a timely and coordinated manner. In addition, an independent Monitoring Group to oversee the implementation of the recommendations has been established. The Monitoring Group will report to the Minister annually on progress made toward implementing the recommendations of the Report and will publish its report.

The programme of investment required to implement A Vision for Change has already begun with an additional €25m allocated to the HSE in the estimates for 2006 for mental health services. Significant capital investment will also be required to implement the report for the provision of new and replacement facilities for the mental health services. This has been estimated by the Expert Group on Mental Health Services to be of the order of €800m and much of it could be realised from the value of existing hospitals and lands.

The Mental Health Commission in exercising its function regarding the promotion of the interests of all persons availing of mental health services will have a role to play in ensuring the accessibility of mental health services for people with disabilities.

4.6 Report of Comptroller and Auditor General

The Comptroller and Auditor General's report (Provision of Disability Services by Non Profit Organisations) raises important issues for the Department of Health and Children and the HSE. The report examines how disability services are provided, the service framework within which non-profit organisations deliver services and how these services are monitored and evaluated. It stresses the importance of good governance and accountability systems.

Among other steps, the report recommends a formal specification of service agreements with non-profit organisations and the establishment of financial reporting norms and key requirements regarding disclosure of information. The Comptroller and Auditor General points to the need for clarity regarding access to services, and to the need for clear standards of care for persons with disabilities.

The Department of Health and Children and the HSE will work closely together to ensure that the important challenges raised by the report are fully addressed. The HSE will engage with the non-profit organisations concerned.

4.7 Health Service Manpower Issues

Numbers employed in the health and social care professions have increased substantially in recent years (see table below). Many of these are employed in the disability and mental health services.

% Changes in Numbers Employed from the Health Service Personnel Census for Certain Health and Social Care Professionals

Grade

% Change 2005/1997

% Change 2005/2001

Physiotherapists

+112

+40

Occupational Therapists

+188

+59

Speech and Language Therapists

+107

+46

Dietitians

+207

+39

Chiropodists

+35

+3

Orthoptists

+60

+14

Diagnostic Radiographers

+35

+6

Radiation Therapists*    
Medical Scientists

+68

+20

Clinical Psychologists

+91

+30

Social Workers

+77

+22

* Grade established in 2000

Implementation of the Disability Act, the Education of Persons with Special Educational Needs Act and the commitment to the further development of disability and mental health services, will require substantial additional health service employees. These employees will include speech and language therapists, occupational therapists, physiotherapists, psychologists, nurses, care workers, care attendants, clerical staff, doctors, social workers etc. Over 1,000 WTE posts were required to meet demands of the 2005 investment programme in the disability services.

A comprehensive review of manpower needs in the health sector has been carried out by the Skills and Labour Market Research Unit in FAS. The Healthcare Skills Monitoring Report (FÁS Report) was published in 2005. The report was developed in association with a working group from the Department of Health and Children. It provides an analysis of the labour market in health care and identifies current and future shortages of healthcare skills up to the period 2015. Another report which has had a significant impact is Current and Future Supply and Demand Conditions in the Labour Market for Certain Professional Therapists (Bacon, 2001).

A joint working group has been established with the Health Service Executive to effectively monitor and address workforce needs within the public health service. The group will focus initially on emerging needs in the areas of care of the older person, people with a disability and those with mental illness, in the light of significant service developments in these particular areas. The work of this group will be greatly informed by the work already undertaken by FAS. One of the first tasks for the working group will be to identify those professions which are in most danger of being in short supply if new service developments continue at the same pace as in recent years.

A Therapy recruitment drive was launched in March 06 to oversee the recruitment of Physiotherapists, Occupational Therapists and Speech and Language Therapists for the HSE and some non statutory service providers. This drive was deemed necessary due to the projected high number of development posts and the fact that many of the new therapy schools would not be working at full capacity until 2007 and after. It incorporates a centralized application system for the 272 therapy graduates in 2006 to ensure that they have full access to suitable employment opportunities.

A fast track work / visa authorization scheme was introduced in 2000 to facilitate the recruitment of suitably qualified non-European Economic Area citizens to work in sectors with acute skills shortages. Nurses were included in this scheme since its inception and a broad range of health and social care professionals and associate professionals (such as medical practitioners, therapists and medical scientists) were added in 2002.