Colm O'Gorman, Amnesty

Amnesty believes discrimination on the grounds of mental health is the hidden, permissible ‘-ism’ in society, reports Aoife Connors

A new mental health study carried out by Dublin City University (DCU) of more than 300 people has found that 95 per cent have experienced some level of unfair treatment because of a mental health problem.

Launched last month, the report found that 86 per cent of respondents had experienced some level of distress as a result of unfair treatment, 64 per cent reported unfair treatment in making or keeping friends, 63 per cent of people reported having been avoided or shunned because of a mental health problem, while a further 61 per cent reported being treated unfairly by their family.

The study was carried out by DCU’s School of Nursing and was part of Amnesty International Ireland’s (AI) mental health and human rights campaign ‘Hear my voice: challenging prejudice and discrimination’.

Findings also highlighted that 44 per cent of people said they were treated unfairly in terms of personal safety, 36 per cent reported being unfairly treated in finding a job, and two-thirds of participants stopped themselves from applying for work because of the manner in which they were treated.

The new research findings highlight the need for Government action to challenge mental health prejudice and discrimination, according to Colm O’Gorman, AI Executive Director. “Unlike racism, sexism or ageism, there is no ‘-ism’ to describe discrimination on the grounds of mental health. It remains the hidden, permissible ‘-ism’, but it must be challenged.”

He added that at the heart of the ‘Hear my voice’ campaign was not the statistics or the analysis, but the human stories. “For example, when you hear about the job offer that disappeared at the mention of a mental health problem. Or someone else explaining how their opinion, once respected, suddenly had no value because of a mental health problem. And another outlining so simply, yet so powerfully, the dramatic effect a mental health problem had on their social life. ‘No telephone calls, no visiting, no invitations to visit.’

“We are used to hearing about society’s hostile attitudes towards people with mental health problems. But in Ireland to date there has been little research about the nature, extent and impact of discrimination that people with mental health problems face,” O’Gorman said.

The Amnesty report makes a number of recommendations to Government, including that Ireland should ratify the Convention on the Rights of Persons with Disabilities and its Optional Protocol without further delay.

The Office for Mental Health and Disability should also adopt immediate, effective and appropriate measures to combat prejudice and raise awareness of the impact of discrimination, while the Equality Authority should collect, analyse and disseminate information on the prevalence and nature of discrimination against people with mental health problems.

Amnesty has also recommended the development and implementation of specialised education programmes targeted at key state agencies to improve attitudes and conduct of officials and to identify indirect discrimination against people with mental health problems that may be occurring as a consequence of the application of laws and policies. Measures should then be undertaken, and monitored, to redress this discrimination.

An Bord Pleanála suggets the timescale for the planning process for the new children’s hospital may be unrealistically ambitious. Aoife Connors reports

There was a misunderstanding that the entire planning application process for the new national children’s hospital could be done and dusted by 2011, a spokesperson from An Bord Pleanála has told Irish Medical Times.

He said that this would be an “amazing time frame”, adding that “you can’t take the time frame of this particular case for granted — that it will be fast-tracked”.

Referring to recent media reports, the spokesperson told IMT reports that the National Paediatric Hospital Development Board (NPHDB) would be approaching An Bord Pleanála on September 28 regarding the pre-application planning stage were significant because the 2010 Act that made the changes relating to strategic infrastructure only commenced on that date.

“At pre-application stage, the object of the exercise is to decide if the application to build is, or is not, strategic infrastructure. That involves meetings with the promoters of a project and during those meetings, the developers explain their scheme and explain their justifications or arguments for their scheme being strategic.”

The ultimate decision is based on the quality of the information provided. Generally, of the 90 pre-application projects currently before the Bord, less than half will come to fruition, the spokesperson said. However, if the project is well-formed, the pre-application process can be short, he commented.

“If the Bord was to decide that it wants additional information, it can depend on how long it takes for that additional information to come in. It could be weeks, it could be months; it’s not possible to put a date or time frame on the pre-application stage.”

He added that the point about this case was that it was the only one of its kind to be looked at under strategic infrastructure, with newly constructed thresholds, and because of this there would be issues that would need to be “teased out”.  “If [An Bord Pleanála] decides that the project is strategic, the next stage of the development will be back to the Development Board. The developer will be informed by letter and the Board will be free to make a formal planning application,” he said.

The public can then become involved as there is a six-week notification period, during which the public can make submissions and at the same time the documentation for the application will be published by the developer.

Once the developer submits the application, the notification process begins and the public are brought into the mix. This would normally involve an oral hearing, which would be notified later on in the process after the material has been fully collated, with the aim of the process being completed within 18 weeks. However, you can “never tell how long it is going to take”, added the spokesperson for An Bord Pleanála.

Artist's impression of the new Children's Hospital

“We’ve all seen in the press that there are highly developed plans for this project, so that should ease the process passage through. But I wouldn’t like to gauge weeks; that’s all to do with the interaction between the developer and the Bord’s team, and the final decision-making process about whether it is strategic infrastructure,” he added.

Meanwhile, IMT has learnt that the NPHDB is seeking to employ “public relations advisory, management and consultancy services for the development of a facility of a similar size, nature and complexity as the children’s hospital of Ireland project”. The public contract will last for five years. A so-called accelerated type of procedure is being used for the urgent PR contract, and the tenders were to have been submitted by last Friday, November 5.

More projects

Beaumont Hospital also submitted a pre-application proposal to An Bord Pleanála on October 19 for the development of a 44-bed acute psychiatric unit within the grounds of the hospital. An application for the relocation of the existing HARI facility on the grounds of the Rotunda Hospital, Parnell Square, Dublin was also lodged on October 12 to commence the pre-application planning stage under strategic development.

University College Hospital, Galway has also submitted a pre-application case to An Bord Pleanála for the relocation of the acute adult mental health unit at the hospital.

Dr Susan O'Reilly, newly appointed Director of the NCCP

With Dr Susan O’Reilly firmly in place at the National Cancer Control Programme, Gary Culliton reports on the latest breast-cancer figures

It is expected that there will be a 20 per cent increase in the number of women attending clinics in the eight cancer centres this year compared with 2009, according to National Cancer Control Programme (NCCP) figures.

A total of 31,700 women were seen in the clinics last year and projected figures for 2010 show that by the end of the year, more than 38,000 women will have been seen at the specialist breast clinics.

A total of 9,413 women were seen within two weeks of their initial GP referral, figures from the NCCP Symptomatic Breast Service show. On average, over 180 women a week were seen in specialist breast clinics on an urgent basis, with a further 341 being seen every week on a non-urgent basis.

The NCCP has secured six additional consultant medical oncology posts. Most of these appointments are on a joint basis and will involve appointments to Sligo/Galway; Mater/Cavan; Drogheda/Beaumont and Cork/Tralee, as well as to Letterkenny (linked to Galway University Hospital) and Limerick. “It is clear therefore that we are building our network of medical oncology and will continue to expand the range of services that patients will access closer to home through the work we’re doing in the community,” the NCCP’s new Director Dr Susan O’Reilly told the Inaugural National Symptomatic Breast Cancer Services Forum earlier this month (October 8).

While the number of cancers being diagnosed remains relatively static — 2,600 women are expected to be diagnosed in 2010 (with 2,100 diagnosed within the public symptomatic breast service) — the rate of survival continues to increase, the programme claims.

Averaging one a week
By the end of August this year, more than 25,340 women had been seen at over 1,400 clinics in the eight centres. Before 2007, symptomatic breast clinics were averaging one a week in hospitals across the country. Women are now being offered appointments at the eight specialist breast clinics operating five days a week in some centres, with many offering evening and weekend appointments, the NCCP stated.

According to a HIQA standard, the centres should be seeing 95 per cent of all urgent cases within two weeks of their initial GP referral and 95 per cent of non-urgent cases within twelve weeks.

The most recent data shows that those targets are being met: at the end of August, 99.8 per cent of all urgent cases were being seen within two weeks (10 working days) and 98.3 per cent of non-urgent cases were being seen within 12 weeks.

Ireland has already experienced a significant increase in survival rates over the past two decades and the country’s five-year survival rate of 80 per cent is expected to steadily improve over the next ten years.

According to Dr O’Reilly, standardisation is a vital component: “We now have clearly defined patient care pathways in our centres. The process — starting when the patient is first referred by their GP — is mapped out, clearly defined and standardised. It is the same in all eight centres.

“But more importantly, we have put in place systems that allow us to gather information on every significant aspect of that pathway. We have agreed a core set of standards that must be in place. We require our centres to apply those standards and report back on them to us.

“It should be noted that while the transfer of surgical and diagnostics in the area of breast cancer is now complete, the NCCP is continuing to expand and develop in other areas. The majority of our rapid-access clinics for prostate and lung cancer are now open — providing swift access for patients and facilitating earlier intervention. We also are preparing to open our new radiation oncology units at St James’s and Beaumont hospitals as part of the St Luke’s Radiation Oncology Network,” Dr O’Reilly said.

She added that the Programme was also committed to developing medical oncology services. “Medical oncology involves outpatient treatments such as chemotherapy which often require months of treatment for our patients, but it should be remembered that these services are available in a network of hospitals across the country.

“For patients in the south east, for example, while the designated cancer centre is in Waterford Regional Hospital, patients receive chemotherapy treatments in Wexford, Clonmel and Kilkenny. In the west, chemotherapy is provided in the satellite unit in Letterkenny; in Sligo General Hospital; Mayo General Hospital, Castlebar; and Portiuncula Hospital, Ballinasloe; as well as in the two designated centres in Galway and Limerick. Kerry patients who now travel to Cork University Hospital for breast-cancer diagnosis and surgery are also facilitated in receiving chemotherapy treatment in Kerry General Hospital in Tralee,” said Dr O’Reilly.

Latest data project
The latest data project a 60 per cent increase in the number of women seen by the Symptomatic Breast Services since 2006, and the recent Forum examined the challenges that such increases have posed.

Confirming that the Forum will become an annual gathering, Dr O’Reilly said that the NCCP was planning to introduce similar events for other cancers, and she called for “greater standardisation, greater audit and greater examination of the services we are delivering”.

Gary Culliton

Minister Mary Harney has announced that changes are to be made in order to increase Ireland’s attractiveness for overseas NCHDs, writes Gary Culliton

New initiatives to attract NCHDs from overseas – involving two-year rather than six-month contracts, central recruitment and relaxing of visa restrictions – will make Ireland “more attractive and will deal with the pressure points”, the Minister for Health Mary Harney has claimed.

Among the initiatives being pursued are 80 additional specialist training posts in emergency medicine to deal with shortages, 38 posts in general practice and 85 in surgery.

Approximately 260 of the 4,638 NCHD posts are currently vacant, but many of these posts are being filled by locums or those on other short-term contractual arrangements; in particular, high-priority service positions. The moratorium on public-sector recruitment is not a factor in these NCHD vacancies, the Minister insists.

Most of the vacancies at NCHD level are being filled by temporary locums, but “there is much more vigilance in this area now than might have been the case previously”, Minister Harney told the Dáil. “The shortages that arose on July 1 are being dealt with through dialogue between the Medical Council, the HSE and the training bodies.”

Short-term NCHD contracts have proven unattractive relative to Northern Ireland and Britain and have “put us at a disadvantage”, the Minister accepted.
She revealed that the Public Appointments Service was currently recruiting 89 consultants, and since 2008, the HSE has created almost 500 new or replacement consultant posts. As of June 2010, approximately 223 contracts had been issued to individuals taking up HSE consultant posts. This reduces potential vacancies to approximately 275.

While the remaining 186 approved posts are recorded as being vacant, the large majority of these are in HSE-funded agencies, including voluntary hospitals, where the recruitment process has already taken place.

The HSE has been asked to establish how many of them have been filled, the Minister added.

The IMO has said it has “serious concerns regarding the implications of the NCHD shortage on NCHDs currently working in the HSE and on patient care and safety”. Further to a meeting between the IMO and the HSE in June 2010 on this issue, a survey of NCHD representatives, and consultants during the summer months and via representations from a number of IMO members, the doctors’ union says it is aware of a number of hospitals where NCHDs are required to “work excessive additional hours to cover vacant posts – which has serious safety implications for both NCHDs and patients alike”.

Impact of shortage
The IMO is currently verifying the impact of the NCHD shortage at local level. It has issued a survey to all members to quantify the impact on all specialties and grades in all hospitals.

One of the main recommendations of the National Task Force on Medical Staffing in 2003 was to increase the number of consultants and to implement a corresponding decrease in the number of NCHD posts in order to create a consultant-provided service. At the time of publication, the consultant-to-NCHD ratio was 1:2.27. The Task Force concluded that a team-based, consultant-provided service was required to ensure high-quality patient care and achieve compliance with the European Working Time Directive. It stated that this would entail a significant increase in consultant numbers.

The move to a consultant-provided service was reflected in the 2008 consultant contract. This provided for consultants to work as part of a team over an extended working day of 8am to 8pm, an increase in the length of the working week and structured weekend work. It is also provided for in the HSE’s employment-control framework, which allows for new hospital consultant posts to be created by the suppression of two NCHD posts. This has been amended and the two suppressed posts may now include one NCHD and one other post.

As of September 2010, the approved number of consultant posts was 2,410. This represents an increase of 679 posts, or 39 per cent, since the Task Force reported. The current ratio of hospital consultants to NCHD posts is 1:1.7, compared with 1:2.27 in 2003. Both ratios exclude interns.

Moratorium
The process of recruiting consultants continues unaffected by the moratorium, the Minister said. “The first report on this matter was the 1994 Tierney report, which was to get us there ten years later. We have made good progress since 2003,” she said.

While NCHD posts were vacant as of July 28, the HSE has said it is sourcing NCHDs from outside Ireland to fill non-training service posts. The HSE has also said it is working to ensure that ongoing service reconfiguration takes account of changes in the NCHD workforce.

According to a spokesperson, the HSE “has been working for many months and continues to work on a daily basis to address the issue of shortage of NCHDs across the hospital system”. Its priority, it says, is to maintain patient services throughout this period.

While every effort is being made to fill NCHD vacancies and progress is being made, each post must be filled by a doctor who possesses the competencies necessary to provide a safe service to patients, the HSE said.

HSE CEO’s Cathal Magee has put forward a scathing indictment of the Executive’s accounting and reporting systems. Gary Culliton reports

Cathal McGee, HSE CEO - in front of the PAC last week

The HSE’s new CEO Cathal Magee has said the Executive’s accounting and reporting systems pose a “huge risk” and are a “major weakness in the governance of what is €14 billion of expenditure”.

The HSE is to target back-office administration to achieve savings, Mr Magee has pledged. The domain in which efficiencies must be sought — where “productivity gains and perhaps reductions of overheads may be achieved” — is the administrative area, the CEO told the Dáil Public Accounts Committee (PAC) last week. Cuts here would “not have a direct impact on healthcare settings and this is obviously a priority and an objective”, he added.

There was fragmentation across all the agencies that were integrated into the HSE at the start of 2005 and this is probably still a problem today, Mr Magee conceded. The PAC is enquiring into controversial spending on foreign travel associated with the HSE’s SKILL Training Programme, aimed at upskilling support staff and line managers across the health service in non-clinical services such as portering, house-keeping and catering.

The CEO said his concern, as the accounting officer for the HSE, was that there were “multiple financial systems”. “We have separate accounting systems, in relation to financial control, banking, accounts payable and procurement. These are clearly legacy systems from each of the agencies that existed prior to the setting up of the HSE,” he said.

“We don’t have a single financial accounting, procurement, planning and payment system. That, to me, is a huge weakness in the governance of what is €14 billion of expenditure. Until that capability is in place, then satellite financial control arrangements are high risk in relation to governance, control and acceptable standards,” he accepted.

Fragmented system
The CEO said there was a “huge amount of manual intervention” in the development, consolidation and reporting of our fragmented financial system. “There is a huge cost associated with the processes that are in place to pull together monthly reporting. It is quite a tortuous process. In many ways, I commend the financial team within the HSE, that they have been able to fulfil the accountability requirements in so far as they can, using what is a fragmented, multiple system.”

There is a link between systems and back-office staff and there are “enormous resources engaged in manual reconciliation, manual reporting and manual assembling of these basic reporting systems”, the Chief Executive said.

He added that the HSE had to balance the considerations of having systems in place which were “the proper backbone to run a national organisation of this size and complexity”, with the ability to “release resources away from the administration systems that are involved in consolidation, manual reconciliation and checking”. In the absence of a single system, there were “vulnerabilities”, he said.

Part of the difficulty in relation to the SKILL Training Programme was that there was “a satellite – or, as the internal audit called it, a silo – which also had access to an accounting and cheque-issue arrangement”, Mr Magee said.

“Such arrangements are always the high-risk areas – where you have devolved, fragmented control systems in place. I see a huge requirement within the HSE to build a single, integrated financial control system.”

The CEO said that he would expect this to be a two- to three-year project. “It’s a high-risk project because it involves a very large IT configuration. It needs very good project management.”

Nervousness
Replying to Labour Deputy Pat Rabbitte, Magee said Ireland’s poor experience with integrated public sector IT system installations explained why the “ambition” to put a single system in place has not been realised. “There is nervousness about the ability to execute this. Nonetheless, I think it’s an imperative.

“This system is required for efficiency purposes, but it’s also a basic element in financial control. Certainly, as accounting officer for that spend – and given expectations that I would have of financial control from the Chief Financial Officer – it’s mandatory to have a single ‘line of sight’ through the system, from payroll to cheque issuing through to procurement, and also for overall financial control,” said Magee.

“Part of the challenge around driving efficiencies into healthcare is that these systems are in place, particularly in relation to procurement. Without a single procurement system, we can’t actually leverage the benefits of a national organisation.”

The Secretary General of the Department of Health Michael Scanlan was asked by Deputy Rabbitte if he was disturbed at HSE CEO’s “sober judgement” on the capacity of the organisation after five years of the HSE’s existence. Mr Scanlan said he was not surprised, but he shared Magee’s concern.

“Do we have problems? Yes,” he replied. “Do we need an IT system? Yes. My understanding is that we got a proposal in August that’s being evaluated. Will it be risky? I think Mr Magee is right. Our track record is such as to make people nervous. I’m not sure how to do this, but you have to balance the risk of implementation with the risk of not doing it.”

Gary Culliton

Gary Culliton opens up the books of the controversial SKILL programme

The HSE’s internal audit of the SKILL project has unearthed a bizarre money trail, revealing how HSE funds were ultimately used to buy, for instance, business class airfares connected with the Shankill/Belfast regeneration project (€5,000) and laptops for union members (€30,000).

The ‘Securing Knowledge Intra Life Long Learning’ (SKILL) programme debacle, which had its origins in the days of benchmarking, is first mentioned in a letter from Mr Finbarr Flood, on behalf of the Labour Court, dated October 17, 2003. The letter is appended to the internal audit report, which was compiled by Dr Geraldine Smith, the HSE’s Assistant National Director of Internal Audit.

The recommendations from Mr Flood referred to a number of disputes then current, involving the Health Service Executive Employers Agency (HSE-EA) on one side and SIPTU, the ATGWU and IMPACT on the other. The Labour Court recommendation states that “a discreet training fund of €60 million over five years will be established”. This fund was to be a set amount (not index linked) and cover the years 2004 to 2008. Thereafter a fund of €12 million (index linked) was to be provided on an annual basis.

An independent review of the operation of the “training and development initiative” was to be undertaken after three years. This all formed part of a deal which saw a new pay-band structure applied to a number of non-nursing staff grades.

The quid pro quo was that – in line with the Sustaining Progress pay deal – no cost increasing claims would be made or processed by the trade unions or employees. Strikes or other forms of industrial action were precluded for the period of the agreement.

Ongoing funding
Since 2005, the HSE has paid out €250,000 annually for the purpose of “maintaining support for SIPTU’s human resource/personal development schemes and the development of management/union partnership in health enterprises”. The HSE internal audit revealed that the union had written to the Department of Health in August 2004 requesting that the annual funding provided “be put on a firm footing going forward”.

The Department confirmed that €250,000 yearly had been earmarked. The money “provided in HSE base funding” was to be channelled through the (then) Midland Health Board. In August 2006, the Department of Health confirmed that “ongoing funding of €250,000” was provided in HSE base funding in respect of the SKILL programme.

Dr Smith wrote to the union in September 2009, saying it was a matter of concern that funds provided by the HSE had “not been controlled or accounted for”. Relevant financial records were not held on the premises but instead were held by an employee off-site, Dr Smith wrote. It was acknow-ledged that officials from the Departments of Finance and Health were involved in the Steering Committee of the SKILL programme.

Dr Smith wrote to the union last November, stating that she could not accept its “contention that the bank account (SIPTU National Health and Local Authority Levy Fund account) to which cheques were lodged” was not an authorised union account. In March of this year, Dr Smith wrote saying that the HSE was still waiting for audited extracts of accounts in respect of Exchequer funding provided to the union.

Proper accounts
Documentation to support the reimbursement of costs totalling €348,000 was also sought, together with a list of payments totalling   €10,000. Documentation provided at a meeting on March 3 “could not be deemed to represent the provision of accounts, as it does    not contain the standard accounting and disclosure information and certification”, it was revealed in the audit.

The HSE had sought “accounting policies, a detailed income and expenditure account, detailed balance sheet, notes to the accounts,   a trustees’ report and an independent auditor’s report”.

An employee of the union supplied boxes outlining categories of expenditure and requests for expenditure. A total of €30,000 was g    given to buy laptops for union members. The information in the boxes indicated that €73,000 was spent on third-level degree  courses for union members; €10,000 was spent on literacy training; a total of €32,500 was spent on a “disability event”; a convener  for an intellectual disability service provider received €50,000; while another intellectual disability service provider received €5,000  for “travel to Kennedy Fellowships”.

Seed money of €5,000 was supplied to a Northern Ireland union for “north/south partnership”. A consultant was also paid €17,500 per union official for a seminar entitled: ‘Partnership Working and Structures in the Health Service’. Another consultant received at least €9,600.

The audit also revealed that one consultant received €7,500 to prepare a report on the care of older people. “Leadership, communications and team development training” for the union’s officials attracted €6,700 in funding, while public relations material for the union’s “role in the development of learning” attracted €10,000.

The cost of an annual “computer forensics retainer” contract was €15,000 between 2009 and last year. Promotional videos for the SKILL training programme also cost another €18,500.

Overseas trips
Under the heading “Overseas Academic Links”, some €20,000 was paid as a contribution to an American university’s ‘Advancing the front-line of healthcare’ project. The same college’s ‘How to engage front-line staff’ attracted €15,000 in funding.

There were three union attendees at one of this university’s New York workshops, at a cost of €5,000 per employee. An academic from the university received €10,000 in payments.

Miscellaneous hotel and travel costs associated with visits to another American university were greater than €2,000 per union official, while sponsorship of a foundation degree at a university in the UK cost another €15,000.

Susan Delaney, Bereavement Services Manager with the Irish Hospice Foundation, presents a model of how different people respond to bereavement and how GPs might respond to the needs of bereaved patients

Normal grief (Level 1) can be defined as the state that occurs when a person is affected by the death of a significant person in their life. Typically, the symptoms include intense yearning or intrusive thoughts and images, and/or dysphoric emotions.
In early bereavement, people may describe changes in eating and sleeping patterns, bouts of crying, difficulty concentrating and feeling low. However, these symptoms subside over time and interest and engagement in daily activities are renewed.
This movement towards adaptation can be noticed from about three months after the loss, as natural resilience promotes a return to equilibrium. As this integration occurs, painful feelings lessen and thoughts of the deceased person cease to dominate the mind of the bereaved.
The symptoms can reoccur on important dates such as birthdays and anniversaries, but the bereaved person will report that overall they are coping better.
Most people find their own way through bereavement with the help of supportive family and friends. Current bereavement thinking indicates that there are no set stages or patterns to grief; rather it is an individual process and will follow its own course and rhythm.
In this author’s clinical experience, some of the typical worries that people express are, ‘Is what I am experiencing normal?’ and ‘Why am I still feeling so low?’. They may be surprised that grief can be so physical and concerned that they are not grieving the ‘right’ way. Sometimes, reassurance that their grief is within normal limits and a validation of the impact of the loss can be the only intervention needed from professionals.
Suggestions for responding to patients presenting with Level 1 bereavement needs would include: to acknowledge the loss; and provide information on the grief process.
A model of bereavement that this author has found useful when working with clients is the Dual Process Model by Strobe & Strobe. Briefly, this model describes how in bereavement, a person needs to attend to their grief while also getting on with life.
Styles of grieving can differ, and some patients who can easily talk about their loss and be open with their emotions may struggle with the practical challenges that the death brings to their daily life.
Similarly, a more action-oriented person may cope by keeping themselves busy, but might need a reminder to also allow themselves time to grieve. Bereaved people can typically relate to this model and grasp the concept of balancing these two processes: moving towards grief, and moving away from grief.
l Bereavement leaflets are available in hard copy form from the Irish Hospice Foundation (IHF) or they can be downloaded from www.hospice-foundation.ie;
l The HSE (www.hse.ie) and the Citizen’s Information Board (www.citizensinformationboard.ie) both provide information on bereavement;
l The IHF lending library is available to professionals and the general public. This includes books that give further information on bereavement and stories of people who have faced bereavement. Call (01) 679 3188 for further information.
Level 2 bereavement
Some bereaved patients, while presenting with a ‘simple’ bereavement, do not have the network of family and friends to support them through bereavement. This may be because their family does not reside in Ireland, they are estranged from their family or everyone in the family is struggling to cope with the loss.
In this case, a service that can provide a listening ear, or internet-based support, may be an appropriate intervention. Bereavement support groups are typically run by volunteers who have been trained in listening skills and have been bereaved themselves.
When it comes to offering suggestions for responding to patients presenting with Level 2 bereavement needs, bear in mind the suggestions for Level 1 and also provide information on community and web-based resources. Useful resources would include:
l Hospices (and some hospitals) provide bereavement support for those bereaved in their care. The individual social work departments will have details;
l Bereavement counselling services: phone (01) 839 1766 for a listening service run by trained volunteers in several centres around Dublin;
l Bethany Bereavement Support Groups: call 087 9905299 for a parish listening service run by trained volunteers;
l Rainbows (01 4734175): a national peer-support programme to assist bereaved children and adults;
l Console (01 8685232): a national support service for those bereaved by suicide;
l Living Links (067 43999) offers outreach support to those bereaved by suicide;
l Isands (01 872 6996) provides help and support to parents whose baby has died or is expected to die;
l Barnardos, at (01) 473 2110, offers a helpline regarding bereaved children. It also offers counselling services for bereaved children.
Some useful web resources would include: www.anamcara.ie (a resource for bereaved parents and siblings run by bereaved parents); crusebereavementcare.org.uk; and griefnet.org.
Level 3 bereavement
A minority of people (10-20 per cent) experience difficulty in adjusting to their loss and may present at the surgery either with ongoing grief symptoms, or physical symptoms that relate to the loss. Emotional support alone does not ameliorate the presenting symptoms and they may report a worsening of symptoms as time goes on.
Frequently, there is a sense of persistent and disturbing disbelief regarding the death. There are often feelings of anger, bitterness and resistance to accepting the reality of the death.
Intense yearning and longing for the deceased continue, along with frequent pangs of intense, painful emotions.
Thoughts of the deceased person continue to dominate and preoccupy their day. Interest and engagement in ongoing life, including hobbies and family events, is limited or absent, and there may be avoidance of a range of situations and activities that serve as painful reminders to the loss.
This presentation is often called complicated grief. It is likely that it will be listed as a disorder in the new DSM V, which is due for publication in 2013, with the title ‘prolonged grief (PG)’. While most practitioners seem to agree that there is a qualitative difference in the presentation of this minority group, and this is backed up by fairly robust research (see Prigerson, 2006), there is mixed feeling in the bereavement field about moving bereavement to the status of an axis 1 disorder.
The risk factors for developing a prolonged grief include:
l Deaths that are sudden, unexpected or perceived as preventable can put someone at risk of developing PG;
l People who have previously had difficulty coping with change or loss, or who have a history of emotional difficulties, can be at risk of developing prolonged grief;
l Also at risk are people who suffer several losses contemporaneously or have been at risk of death themselves;
l Finally, those who have, or perceive themselves to have, limited social support are vulnerable to developing PG.
There is no single circumstance that leads to PG, but when the above factors are present, the likelihood of developing prolonged grief rises.
Some practitioners find it useful to employ a checklist to diagnose PG; others question this method of information gathering and stress the need to engage the bereaved person in any assessment of bereavement.
Two factors that have been found to reduce the risk of PG are advance preparation for the death and a strong network of support. Interventions geared towards preparing caregivers for an imminent death, as well as building up a strong natural network, can reduce the likelihood of PG developing. Traditional, person-centered counselling has been shown to be minimally effective in treating PG.
Patients appear to respond better to interventions that enhance coping skills, and specific therapies that conceptualise grief as trauma also appear to be useful, but there is little currently published on intervention efficacy.
While PG may have some overlapping symptoms with depressive illness, drugs that have been found useful in treating depression have not been found to be particularly effective in treating PG.
Suggestions for responding to patients presenting with Level 3 include bereavement therapy, which aims to resolve the deeper emotional issues that can be created or revived by a significant loss, and specific therapies that conceptualise grief as trauma, which have been shown to be the most effective to date.
Early studies (such as Shear, 2005) are confirming the efficacy of this approach, with PG patients reporting improvements in symptoms of depression, anxiety and general impairment.
For resources and referrals, see those listed under Levels 1 and 2. Also:
l Refer patients to well-trained and accredited practitioners who have specialised training in the area of prolonged grief;
l If the death was through a hospice or hospital, there may be appropriate services available;
l The Psychological Society of Ireland (01 4749160) can provide a list of qualified psychologists;
l The Irish Association of Counselling and Psycho-therapy (01 2723427) can supply a list of qualified therapists;
l Counselling training courses often offer reduced-rate services for their students. This can be a good resource for patients on a limited budget.
l Susan Delaney, Psy.D. is a clinical psychologist and the Bereavement Services Manager with the Irish Hospice Foundation.
l Prigerson, H and Maciejewski, P. (2006). A call for sound empirical testing and evaluation of criteria for complicated grief proposed for DSM-V. Omega: The journal of death & dying, 52, 1-7.
l Shear, K. (2006). The treatment of complicated grief. The Australian journal of grief and bereavement. Vol. 9: 20, 39-42.
l Shear, K, Frank, E, Houck, P and Reynolds, C. (2005) Treatment of complicated grief. JAMA, Vol. 293, No. 20.
l Stroebe, MS, Hansson, R, Stroebe, W and Shut, H. (2001) Handbook of Bereavement Research: consequences, coping and care. APA, Washington.

The HSE is introducing measures to ensure that consultants sign health-insurance claim forms as quickly as they should, writes Gary Culliton

The Health Service Executive is introducing incentives for consultants to sign their insurance claim forms on a timely basis, along with a major crackdown on those consultants who do not, IMT has learned.
The HSE has secured agreement with the major health-insurance providers for the signing off of claims by a secondary consultant clinician (in six pilot sites) where the primary consultant has failed, for whatever reason, to sign off in a timely manner.
This pilot was up for review in April 2010 and the HSE is now extending it to a further six sites. Specifically, the HSE is now considering the possibility of directly billing patients in cases where the consultant has not signed the claim form within 30 days after discharge. It is also considering possible limitations on admission rights, if there is no improvement over time.
Following a request from Health Minister Mary Harney, Vhi Healthcare paid an advance of €50 million in respect of private insurance-claim income that was owed to the HSE. This payment was made in November 2009 and was money that was due to be paid to the Executive in any event over the year, and which the Vhi agreed to advance, as requested.
As part of the agreement, the HSE has now said it was always the case that the Vhi would deduct the advance from each hospital, from the claims received, over a five-month period running from last Wednesday, June 30, until later this year — November 30.
Budget sanctions
To counter the effect of this deduction of the advance, the HSE has taken steps to accelerate cash collection. Hospital managers have been instructed by senior management to reduce their debtor period to 60 days initially and budget sanctions will be imposed on managers who fail to reach this target in 2010. The HSE’s ultimate target in this regard is to move to 30 days. Targets for income for all hospitals in 2010 will be based upon a reduced number of days and this will be implemented through the budgeting process.
A concentration of effort on private insurance income collection as the largest single area of patient debt has been ordered by the HSE Chief Executive, Prof Brendan Drumm. The focus at individual hospital level on the issue will be concentrated on the following up of private insurance claims that have been submitted already, but not yet settled.
Any outstanding queries are to be addressed as a matter of urgency. Hospitals must in future compile and clear any outstanding claims that are awaiting submission to the health insurer.
Hospital CEOs and finance managers/accountants have been reminded of the importance of addressing outstanding private insurance payments and all other outstanding debt, the HSE said. Clinical directors are being asked to assist, as necessary, in addressing difficulties that may arise at individual consultant level.
This initiative resulted in a number of improvements already in 2009. An additional €30.8 million claims approximately were submitted between 23 October and 16 December last year. Cash received in the final quarter of 2009 was approximately €22.3 million higher than average for the previous three quarters of the year.
A high-level group, with representatives from HSE Finance and voluntary hospitals, continues to negotiate with the private insurance providers on business processes and the reduction of debtor days. The aim is to streamline transaction processing and data exchange. Parameters for private and semi-private charges by public hospitals, both voluntary and statutory, will be set. Billing and payment methods and the implications of the new consultant contract are being considered. The level of debt, administration of private-insurance claims process and service-level agreements are all being discussed.
The ultimate focus of the high-level group is to formulate a national service level agreement with private insurers, to streamline agreed business terms and ensure payment of hospital accommodation bills within 30 days. This agreement is currently in draft format and under discussion.
Negotiations are ongoing with insurance providers to implement electronic exchange of data to speed up the claims and payment process. The HSE is working with the Departments of Health and Finance with a view to implementing electronic submission of claims data in the larger voluntary and HSE hospitals, in the first instance.
HSE billing system
Approval has been obtained from both these Departments to commence the centralisation of the entire HSE billing system, which will streamline this process and focus attention on collecting all outstanding debts. Tender documents for this project are being prepared.
The HSE is working with the Department of Health and Children with a view to implementing flexibility in the private-bed designation of individual hospitals throughout the public hospital system, notwithstanding the fact that it is Government policy not to increase the overall number or percentage of private beds. This will facilitate maximum generation and collection of private-patient income.
Debt collection is now a standing item on the agenda for the HSE Audit Committee and the focus continues to be on the performance of individual hospitals in the management of their patient debt. Hospital managers have been informed that failure to improve on their debt-collection rates, where applicable, will result in budget sanctions that “equate with the level of non compliance”.

An Bord Snip Nua has recommended that 6,168 staff in the health service should be axed in order to make savings of €1,230 million a year. This amounts to more than 5 per cent of the entire workforce.
With health service employees currently at the record level of 111,800 — an increase of 18,804, or 20 per cent, over the past eight years — initial reductions on this scale are the ‘minimum that must be achieved’, Colm McCarthy’s group has stated.

Compulsory redeployment and, if necessary, redundancy must also be considered.
The Group has also recommended that staffing at the Department of Health, currently at 526, should be reduced by 10 per cent a year for the next three years as demand allows. This could save €11 million a year.
The Report of the Special Group on Public Service Numbers and Expenditure Programmes welcomed recent efforts to reduce the spiraling public service pay bill, including the Incentivised Scheme for Early Retirement, the Special Incentive Career Break Scheme and the Shorter Working Year Scheme.
However, it will be necessary to go further than this if the numbers issue is to be addressed effectively, the report stressed.
“Critically, while work efficiencies and redeployment should allow for broad continuity in the delivery of key public services, in other cases full savings will only be delivered where there is a political and public acceptance that the State can no longer afford to continue some services at previous levels, or at all.”
Furthermore, the Group has recommends that staff flexibility and redeployment should be on a ‘compulsory basis’ if necessary, in the best interest of patients. Redundancies would have to be considered to facilitate outsourcing of non-routine services, where these could be delivered on a more cost-effective basis.
Staff representatives did not escape criticism either. The report claimed that ‘restrictive agreements and work practices’ involving trade unions and staff organisations had been a major inhibitor to staffing and pay efficiencies in the health sector, and a ‘block to good quality patient-focused care’.
“The Group considers that such practices have no place in an efficient, modern health system that is operating under severe budgetary constraints, and in which the needs of patients should be a paramount consideration.”
In relation to changed working patterns, the report has recommended that all staff should be required to work 8am to 8pm on a five-day over seven-day basis (i.e. where Saturday and Sunday form part of the normal working week), and that no premium payment should be made to hours worked within that span.
Straying into the clinical arena, the report went on to recommend that the ‘unnecessary demarcation’ between grades that prevents nurses from carrying out routine medical procedures performed by NCHDs and healthcare assistants carrying out routine nursing duties should be removed.
Various semi-state bodies – and even one entire Government Department – were singled out for either the chop or merger. In Health, it is recommended that the Ombudsman for Children be merged with the Office of the Ombudsman, the Health Research Board be integrated into a single stream of science funding and that the Health Insurance Authority merge into the Financial Regulator.

Dr Andrew Rynne takes a look back at the history of men’s sexual health over the last 40 years and concludes that we have come a long way

It is funny, the things that you never forget. It was 1968 and we were gathered in the lecture hall of the Rotunda Hospital. The speaker was a much-loved character from the Dublin obstetrical fraternity, Dr Raymond Cross. He was then, by default, Ireland’s leading expert on impotence, as it was then called The more politically correct term of erectile dysfunction (ED) had yet to be invented. His task was indeed a thankless one for there were, if you will forgive the pun, no tools for his trade.
The lecture was hilarious, and it was a light relief from the more serious topics of placenta previa and persistent occiput posterior. The fact of the matter is that forty years ago, there was no effective treatment for ED, and the subject was treated as a bit of a joke.
I still remember the lecturer holding up a kind of a wire splint he had fashioned and into which the patient was supposed to place his penis before attempting intercourse. The thing had all the technological sophistication of a wire coat-hanger…but was not as useful.
Folk remedies
When this yoke failed to be effective, for one suspects that it occasionally may have done, we were then quickly reduced to folk remedies. Chief among these, of course, were oysters. Oysters, Dr Raymond Cross told us, were (according to the Dublin mythology of the day) even capable of raising an erection on a dead Archbishop! More hilarity.
Fast-forward ten years to the pioneering research of Masters and Johnson, with their classic work, Human Sexual Response. This rapidly established itself as the foundation of all sex therapy, as it remains to this day. Perhaps their greatest contribution was the recognition of performance anxiety as a major contributing factor in all ED, but most particular to that affecting younger men. Sexual dysfunction had at last come of age. The laughing had stopped.
Now fast-forward another ten years, to penile injections. Papaverine, injected directly into the corpus cavernosum, as an inducer of erections, was discovered by accident, but quickly established itself as a highly effective, if somewhat uncomfortable, remedy for most ED. Combined with phentolamine, its efficacy was increased. Both papaverine and phentolamine have largely fallen into disfavour due to their propensity for inducing priapism and penile fibrosis.
Today, both of these chemicals have been replaced by alprostadil or PGE1 presented, in the main, as Caverject 5mcg to 20mcg. Where higher doses of 50mcg or even 100mcg of PGE1 are indicated, you may have your local compounding pharmacy make them up for you. Suffice here to know that today, 95 per cent of all ED of whatever etiology can be successfully and safely managed by this modality of treatment.
A fanfare of publicity
Now, fast-forward another ten years, to 1998 and, to a fanfare of global publicity that could hardly have escaped the attention of our neighbours on Jupiter, we get sildenafil or Viagra and the answer to a maiden’s prayer at long last. Well, maybe not a maiden’s prayer, but you know what I mean. For here, finally, was the ultimate aphrodisiac, the rhino horn and monkey gland all rolled into one little blue tablet, an oral preparation that could induce an erection in men. Utopia had indeed arrived.
Today its two first-cousins Cialis and Levitra have joined Viagra, and together these three oral preparations form the bulwark of pharmaceuticals in the management or treatment of ED. Unfortunately, with their easy and illegal availability on the Internet, they are frequently abused as recreational drugs or pressed into service to treat ED when behavioural therapy might be more appropriate.
When it comes to diagnosing the cause and deciding on a treatment of any given case of ED, it is worth remembering the results of the Massachusetts Longitudinal Ageing Study. Here they found that about a third of men with moderate to severe ED recovered full sexual potency over time, without any treatment.
Rule of thumb
I also use this rule of thumb: between the ages of 20 and 40, 75 per cent of ED will have a psychogenic factor underscoring it, while over the age of 50 years, 75 per cent of ED will be physiological. In all cases of ED, performance anxiety must be addressed and explained – even when it is often the last thing the patient wants to know about. Men often see performance anxiety as a weakness and as being somehow their own fault, hence the rejection.
A word about my old friend, testosterone replacement therapy or TRT. Recent peer-review published studies (Carruthers et al.) have shown that when older men fail to respond adequately to the PDE-5 inhibitors alone, the addition of testosterone, given as a transdermal gel (Testogel) or deep intramuscular injection (Nebido), will significantly improve their response to these medications. Do not give up on older men; they too deserve to be taken seriously.
The same researchers (Carruthers, Trinnick and Wheeler) in a paper in The Ageing Male in September 2007, showed androgen blood assay to be a very poor marker for testosterone deficiency syndrome. Yet we still have practitioners adhering to this expensive and largely useless test.
Another consideration when dealing with older men with benign prostatic hyperplasia (BPH) and ED is the use of tadalafil 20mg taken daily. In an article in last October’s Journal of Urology, it was unequivocally shown that Cialis 20mg taken daily had equal efficacy to an alpha1 blocker also taken daily. Since we know that alpha1 blockers have no effect on ED and tadalafil has proven efficacy, the latter as a treatment for BPH in the presence of coexisting ED might make sense. Other pharmaceuticals for ED are in development. As to whether these will prove to be an advancement on our present repertoire remains to be seen. One thing is for certain. In the space of a mere forty years, we have come an awfully long way from wire penile splints, oysters and dead Archbishops.
Andrew Rynne is Medical Director of the Clane Sexual Health Clinic and www.testosterone.ie. Appointments at 087 2455957. Further information from: andrewrynne@eircom.net