Joint Committee on Children, Equality, Disability, Integration and Youth debate -
Tuesday, 18 Jun 2024

Apologies have been received from Deputies Funchion, Murnane O'Connor and Sherlock, and from Senators Ruane, Ned O'Sullivan and Clonan. Deputy Pauline Tully will substitute for Deputy Funchion. We congratulate Deputy Funchion on her recent election to the European Parliament. The Deputy will do an excellent job. I have no doubt the other members of the committee share this sentiment. The minutes of the public and private meetings of 21 May 2024 were agreed at a private meeting of the committee this afternoon.

The agenda for this afternoon is a discussion with the Minister of State with responsibility for disability, Deputy Anne Rabbitte, on the implementation of the recommendations provided in the report of this committee on assessments of need for children. Joining the Minister of State are Ms Deirdre Comiskey, principal officer with the disability children's services unit, and Mr. Jason Doran, assistant principal officer with the disability children's services unit. They are all very welcome to the meeting.

I will give some background to the meeting. On 14 February 2023, the committee published its Report on the Assessments of Need for Children. Included in this report were 39 recommendations agreed by the committee. Members are hoping to receive an update this afternoon on any progress made in implementing the recommendations. In the event that recommendations cannot be implemented, members would welcome an explanation as to the reason for this decision.

Before we begin, there are a few housekeeping matters to go through. I advise members that the chat function in MS Teams should only be used to make the team on-site aware of technical difficulties or urgent matters that may arise during the meeting and should not be used to make general comments or statements. I remind members of the constitutional requirements that they must be physically present within the confines of the Leinster House complex in order to participate in public meetings. I will not permit a member to participate where they are not adhering to this constitutional requirement. Therefore, any member who attempts to participate from outside the precincts will be asked to leave the meeting. In this regard, I ask that any member partaking via Teams would confirm prior to making a contribution that he or she is in the grounds of the Leinster House campus.

In advance of inviting the Minister of State to deliver her opening statement, I advise everyone of the following in relation to parliamentary privilege. The evidence of witnesses physically present or who give evidence from within the parliamentary precinct is protected pursuant both to the Constitution and statute by absolute privilege. Witnesses and members are reminded of the long-standing parliamentary practice that they should not criticise or make charges against any person or entity by name or in such a way as to make him, her or it identifiable, or otherwise engage in speech that may be regarded as damaging to the good name of the person or entity. If their statements are potentially defamatory in relation to an identifiable person or entity, they will be directed to discontinue their remarks. It is imperative that they comply with any such direction. The opening statement will be followed by a question-and-answer session with members. This completes our housekeeping matters. I invite the Minster of State to deliver her opening statement.

I thank the Leas-Chathaoirleach and the committee members. I welcome the opportunity to meet with the Oireachtas Joint Committee on Children, Equality, Disability, Integration and Youth on the progression of recommendations in the joint committee's Report on Assessments of Need for Children, and to provide members with an up-to-date picture of the situation as regards assessments of need for children and the delivery of therapy interventions. I thank the committee for this comprehensive report, which was informed by the testimony and the lived experience of families and therapists, as well as the HSE, the Department of Health and other experts, and by a joint meeting with myself, the CEO of the HSE and the Joint Committee on Disability Matters.

As Minister of State with responsibility for disability, I am committed to the delivery of appropriate accessible services for children with disabilities and their families and to delivery of radical transformation in the disability sector.

The transfer of functions from the Department of Health to the Department of Children, Equality, Disability, Integration and Youth in March 2023 provided an excellent opportunity to undertake this transformation through the lens of equality and human rights, and to target those most in need.

My Department is working collaboratively with the CEO of the HSE to jointly drive substantial reform in service provision for children and families through the progressing disability services, PDS, roadmap 2023-26. There is ongoing engagement to ensure stronger and more consistent performance across the CHOs with a particular focus on driving down the outstanding AONs. It is important to also acknowledge the intervention of the Taoiseach in recent weeks in ensuring that I got extra funding so that we could deal with the long waiters. Both my Department and the HSE remain committed to the delivery of appropriate services for children with disabilities and they will work with families and staff to develop services that meet their needs.

My Department provided a detailed and comprehensive update on the committee's 39 recommendations and outlined the work being undertaken in line with each of the committee's recommendations. I will provide an update to the committee on AON for children and the delivery of interventions in line with the key sections of examination and recommendations in the committee's report. I acknowledge that demand for AON is escalating, with a 25% year-on-year increase in the number of AON applications received in 2023. At the end of March 2024, the total number of applications overdue for completion stood at more than 9,900. The HSE advises that this represents an increase of 115% on the figure for the end of 2022. Waiting lists are growing as demand outstrips capacity. Approximately 8,500 applications are being received annually, while the HSE expects that approximately 3,200 to 3,400 AONs will be completed each year by its staff.

The Government announced funding to accelerate an AON waiting list initiative on 21 May 2024. As part of this announcement the Government also agreed to explore the feasibility of involving the National Treatment Purchase Fund, NTPF, in an effort to maximise system capacity and ensure access to assessments. To address the waiting list for AONs in an equitable manner, I am progressing an option whereby the HSE will reimburse clinicians and directly procure capacity from approved private providers, targeting long waiters, by CHO area. I am pursuing this option as opposed to a direct reimbursement scheme as I want to avoid a situation where parents are required to make an upfront payment and then are retrospectively reimbursed. I believe this is a more equitable approach as it means parents who do not have the financial means to go private will also be supported. This initiative will assist families, on a CHO basis, by targeting those children waiting longest for an AON, and by allocating AONs by order of application in line with statutory obligations. This waiting list initiative will result in 2,500 privately sourced AONs. I emphasise that this amount of €6.89 million, which is proposed to target 2,500 AONs, is in addition to existing HSE core funding of €5 million, allocated for the procurement of private assessments, also targeting 1,800 AONs for completion. To be clear, additional funding was sought for 2,500 AONs and the HSE is procuring private assessments for 1,800 children, while at the same time the capacity within the CDNTs is for approximately 3,200 to 3,300.

In addition, I have been regularly meeting the heads of disability in the nine CHOs to discuss their plans for 2024 to tackle respective AON backlogs. Plans are under way at a local level, with a range of measures involved, to specifically target AON waiting lists and I will continue to hold monthly meetings to monitor progress. My Department is exploring the feasibility of involving the NTPF in procuring private assessments as a long-term solution and engagement with key stakeholders is currently under way.

The issue of AON is challenging and a review of the current model is needed. There is political will across all parties in acknowledging that a better model is needed. In my view, perhaps a model developed through consensus would best support children and their families. An independent review of the CDNT service model is also currently being undertaken by the National Disability Authority.

The key to unlocking capacity for AON and therapy provision is to recruit more health and social care professionals to the CDNTs. Work is ongoing by the HSE to maximise the capacity of CDNTs via recruitment campaigns and other measures, including sourcing assessments through private providers. However, there are significant challenges with recruitment, with the staff census of 2022 identifying more than 700 CDNT vacancies, equating to a vacancy rate of approximately 34%. I have secured funding for additional posts to enhance the capacity of CDNTs and shorten the waiting times in recent years. The funding amounts to a total of almost 800 whole-time-equivalent posts, including the therapy assistant posts that were approved in budget 2024, with the recruitment of same being progressed this year.

The majority of CDNT retention and recruitment targets are now in train. The HSE launched a high-profile campaign, Be part of our team, be part of their lives, across social media and radio in early January. This media campaign covered opportunities across the following disciplines: dietitians, occupational therapists, physiotherapists, psychologists, social workers and speech and language therapists. The campaign recently closed and information from the HSE is that approximately 500 applications were received. To date, the HSE advises that approximately 190 job offers have been made to successful candidates, with some 55 being in the final stages of the recruitment process.

I would like to confirm to parents and families, as I have done in the past, that a statutory AON is not required for access to health services in this country. Access to services is dependent on a child's needs and parents can get referred to the CDNTs via their GP or they can self-refer. I assure members that there is a clear focus on children's disability services by this Government, my Department and the HSE. I welcome the opportunity to discuss matters with the committee here today. I look forward to a positive engagement. I too wish to be associated with the good wishes to Deputy Funchion.

I thank the Minister of State very much. Normally Deputy Funchion, as Chair, reserves her speaking time for the end of the rotation, which is what I am going to do also. I will swap my third place with her 14th place and I will put her in third. She is represented today by Deputy Tully, who is substituting for her. I call Deputy Tully. Senator McGreehan will be next.

I have a few questions on the presentation given by the Minister of State. This might seem like a strange question. What is the primary reason for assessment? Is it for access to supports and services within the CDNT or the primary care service or is it for placement in an appropriate school setting? She stated that people can be referred by their GP or parents can refer children to the CDNT and that they do not need a statutory AON to access services. A lot of parents accept that and would be happy if they were getting the services and had ongoing assessment from an multidisciplinary team. Unfortunately, due to insufficient places in the school system, schools insist on an AON.

I thank Deputy Tully for her question, which is a valid one. To be honest, it is part of recommendation No. 19:

A clear plan must be communicated to parents regarding the situation with AONs going forward, including timelines and information on what measures are being taken, budgetary and otherwise, to get children the services they need.

On the next page, recommendation No. 25 states: "An education campaign should be launched to provide parents, care-givers and children with accessible information about the AON process." To be very fair to the Department of Education, two years ago it removed the criterion for an AON to be provided for children with additional needs to access mainstream education, but they do need to have an AON to access a special class. That is the caveat. The HSE says that an assessment is not required to access services.

People have a statutory right to an assessment but do not need to have that assessment to access services. It is important to say that with regard to financial supports, people need a diagnosis to get the domiciliary carer's allowance. We have a family with a child and parents, with three different sets of criteria. The overarching umbrella of it all is that if people had an assessment of need, it would perhaps give a quicker mechanism to get a special class and financial supports, but it does not say that they will get quicker interventions. In fact, clinicians would prefer to deliver interventions.

I know the Minister of State is saying she has additional funding going to CDNTs outsourcing assessments. Is there capacity in the private sector to actually carry out the assessments? I am hearing that there is not and that parents who can afford the assessment cannot actually get one because there are not enough psychologists and so on. I think it is going the wrong way. It is one sector where we see most people opting to go into the private sector rather than the public sector. It is usually the other way around. What is the cost differential in paying someone in the private sector as opposed to giving a further incentive to employ someone in the CDNT?

Nobody wants any child to be waiting. That is why extra funding has been sourced and why there is a twin approach - for example, if the CDNT does not have the capacity or there are long waiters and the CDNT has not met its statutory requirements. We have to be honest that, in some cases, children have been waiting for up to two and a half years since the last backlog was cleared. It is incumbent on us to find whatever solution is available to ensure that. I talked to the head of disability, Bernard O'Regan, before today's meeting. Four years ago, when we had the Covid pandemic, we managed to clear the backlog of 6,500. There was a different environment at that time. Much of it was done online so a child could have had assessments online. It was part and parcel of it. People gave out that they were not able to support or see children in their environment of education so we have gone away from providing some of that assessment online, which can speed up the process. Some of our CDNT staff are deciding to leave and go into the private space, because they feel there is a more flexible option for them.

The recruitment in CDNTs is very slow. It is a number of months since the Minister of State informed me of that recruitment drive and people still do not seem to be in situ and there are still significant vacancies. I talked to parents in one session who said that people are applying for these positions, being offered them and not taking them, because all they want to do is show on their CV that they were offered the position, which is difficult for everybody. Has the Minister of State plans to address the section 39 pay parity issue, which is still affecting some CDNTs worse than others? What other incentives is she putting in place to get more staff into CDNTs?

One issue that we have discovered is that people qualifying out of college need to ensure for their CORU registration, until they get comfortable and have enough experience, that they have clinical oversight. That was significant when progressing disability services was first rolled out. There were not enough senior clinical governance posts. Different disciplines did not have clinical governance. That was a significant issue, which we are addressing at the moment. The clinical governance issue is being addressed. We are recruiting for it. The HSE is working with clinicians who would provide that. That would mean that junior staff coming on stream have the supervision and confidence that their CORU registration would at no time be impacted. In the same way, when the HSE is looking to expand the model into therapist assistant roles, who does the risk for clinical governance sit with? We have often heard about holding the risk. The risk will perhaps sit with the CDNT manager for therapist assistants. On the pay parity conversation, the talks finished last October. Some 500 out of the 1,100 have filled out the KOSI application. I know the employers and unions will be back with the WRC either on Monday or Tuesday next week to look at the next round of pay negotiations for section 39 organisations.

I wish our former Chair, former Deputy Kathleen Funchion, now an MEP, the very best of luck and the best of health in Brussels. The Minister of State is welcome. It is always good to have a Minister in front of us. The assessment of needs, as she knows, has been a topic of conversation in both this committee and indeed the Joint Committee on Disability Matters. We have had many conversations over the past couple of years. I have a few questions, which I will go through one by one if that is okay with the Minister of State and Leas-Chathaoirleach. How has the HSE been navigating the roll-out of assistant therapists to the CDNTs? I think they could play an important role on CDNTs but they do not seem to be materialising yet.

It has navigated this very poorly. It has not put enough thought into it. While it is fantastic to have the role of assistant therapist, which I agree will play a pivotal role in supporting a finite resource of clinicians, when the role was put in, I was of a firm belief that the assistant therapist needs to not just be a generic title but an assistant therapist in occupational therapy, physiotherapy and speech and language, so they can work alongside the clinician who will write the programme. I am disappointed that it has been watered down too much for my liking to be a generic assistant therapist. I know the HSE is really trying to work with the national tertiary office in working with ETBs to stand up the roles of assistant therapists. In Cavan-Monaghan, we have quite a number of assistant therapist posts, but they are really going to older persons. We had the opportunity for assistant therapists in Cork, for occupational therapists, physiotherapists and speech and language therapists, with really good opportunities, but unfortunately they are swallowed up into the acute system. We are able to recruit and provide supervision for assistant therapists in acute and older persons' services, but we are struggling to find the mechanism to embed them in CDNTs.

I see the HSE is slow to appoint therapists. There seems to be a significant blockage in appointing therapists in special schools, particularly when there is evidence abroad that this works. It shows good results. Even back as far as 2009, the HSE's own reports and policy documents state that parents could and would work between schools and health centres, but even with its own policy documents, it seems to be focused on the centralised model. Members across parties come to the Minister of State about therapists being taken out of schools and trying to get them back into schools. Why is the HSE so slow to support that bi-location of therapists?

I thank the Senator for the question. I have no doubt Deputy Coveney will be asking a question in a similar vein. To be quite honest, it is one of the greatest challenges I have had since becoming Minister of State. We recognised back in 2021 the removal of therapists in May and June of that month was a levelling-down of services and there was a pause put on it. With that pause there was also funding secured for 86 therapists to be put back into schools. There is a region of the country where we have failed to get that delivered. We are still working on it and it is a priority of the Taoiseach, Tánaiste and a priority for all the elected representatives in that region. To date 123 whole-time equivalents have been filled in special schools, but the problem here was it is down to understanding and roll-out. Aligning to a CDNT is not putting in a school. Aligning to a CDNT is language that does not say the school has access to the same therapist regularly.

Progressing disability services is not working to the goal of the policy, but we know not all of it is not working. Has the HSE examined the flexibility in relation to unpicking those parts of PDS that are working and amending the stuff that is not? It is not a complete failure. We had people speaking to us at the disability matters committee very recently about how it is a good policy document. What is there is good. It is a good concept and there are parts working. Policies are meant to be flexible and dynamic. That dynamism is not in that policy. It is not in the HSE's remit, it seems.

If you lived above in Inishowen, which is a huge challenge for us at the moment, you should be able to access a community-based disability team that has a speech and language therapist, an OT, a physiotherapist and access to psychologist. It should not be all urban-based, so to be very fair to the HSE 91 of those teams have shown flexibility. The flexibility is the teams of specialism where we now have a PDS team for children who are hard of hearing. We now have specialist teams for children who have vision impairments. We have also expanded what the definition within PDS of how respite would look with PDS, the after schools model, the breakfast clubs, working with the toddler groups and working with weekends and siblings.

To be very fair, there are elements of it that have worked really well and worked outside that centre-based approach. However, it is about when we go back to certain fundamentals of it where people need continuous interventions - and it is not just all children in special schools, as there are children in mainstream education who have highly complex needs as well and need a team that has full capacity and resourcing on it. That is why I will go back to the assistant therapy piece. When we have a finite resource of therapists we need to have that agility to be able to have somebody as an OT, physiotherapist or speech and language assistant who can roll out the programme that can assist the teacher and the parent but, most importantly, can provide that intervention for a child. I will give an example of it. Verbal dyspraxia is one of those pieces where if you have regular intervention for a two-year term you can actually help promote the language and it is a very successful piece. When we were doing PDS and taking all the therapists out of schools people forgot that primary care had therapists in 63 mainstream schools around the country. They are still in operation. They are still delivering speech and language therapy to junior and senior classes in primary education. It is working really successfully. There are class sizes of seven. The outcomes are phenomenal. That is a really good model that should be built upon. When I see what has happened I keep pushing the boundary here to reinstate all the 221. I am not saying education holds the clinical governance. The CDNT should hold that at all times, but they should be in the schools during the school day to ensure the children get the interventions that are required.

The Minister of State is welcome. I have five questions and the first is a general one on recruitment. Among the recommendations in the report this committee produced were a lot of asks for money and the Minister of State delivered an awful lot on those at budget time. However, what of the ask around effectively designing a new recruitment process both at home and abroad? It would be good to get a response on what is happening, because this is a competitive space. Lots of countries, by the way, are recruiting abroad but we need to be in that space too to bring the skills we need here for what is an increasing demand all the time.

The second question is on the outsourcing policy, effectively, because that is what it is. We are putting funds together to try to get private therapists to do the job because we do not have enough public therapists in the system. If the numbers the Minister of State gave us are correct we have a capacity in the HSE to do 3,800 assessments of need a year and then a €5 million fund to be able to source from the private sector another 1,800. Then there is a further fund of €6.89 million she mentioned to source another 2,500 from the private sector, so we are now effectively sourcing more assessments of need from the private sector than we are from our public system. That seems extraordinary. If we can find this skill set in the private sector then they are in the country. Why are we not able to recruit them given the certainty and permanence we can offer in the public sector? It is a serious question that needs an answer, though perhaps not today. We need to understand how to solve this within all the confines we must work in when it comes to public sector pay and all the rest of it. Anybody who says we should just pay them more quite frankly does not know what they are talking about, because that disrupts the whole balance of public sector pay. However, there are mechanisms and tools we can use to incentivise people working in the private sector to come into the public system and we need to be pursuing that.

The third question is my most important one. It is about the mismatch between school communities and communities CDNTs are serving. The Minister of State will be very familiar with my part of the country when it comes to some of these issues. New special schools have been set up in Carrigaline, Rochestown and a new one is planned for east Cork without the necessary therapies. Many of the children in those schools come from multiple different CDNT regions, which are geographic regions. Some of them are lucky enough to have therapists available and others are not and they are in the same classrooms. It is pot luck based on address. Some kids in a class are getting therapy and in some cases assessments of need and others are not.

We need to think about how we match school communities with CDNT communities. Everyone is trying to do a good job but the new special schools set up are, essentially, accommodating children who might come from 30 km or 40 km away, from different regional-based areas with different levels of support. There is then a difficult situation for the school and teachers in which some in their classes are getting the therapies they need at home through the CDNT structures and others do not. They do not have the resources in access to therapists in the school to manage that. That is a systemic problem in how we support schools with appropriate therapies being available versus this regional-based or area-based model in which network teams are doing their best with limited resources. It is a structural issue that needs to be addressed. It is only partially addressed by just giving schools more therapists. That helps but it does not deal with the fundamental mismatch. The reason this has become a problem is that there was a real shortage of places in special schools and we were forced, in some cases by parents going to court, understandably, to demand education for their children. We set up new special schools at relatively short notice which provide an educational resource for children who could not get into schools in their areas but sometimes travel very long distances as a result, from different geographical areas in terms of CDNTs. There is an issue in that regard that needs a response. In the short term, it is outsourcing, which is what the Minister of State has been trying to do. To be fair, I think she has been hugely frustrated in trying to solve this problem. The special school in Carrigaline still has the same problem it had nearly two years ago. There are 48 children there, a small number of whom have access to the therapies they need.

The next question relates to the input of families and people with a disability as we develop policies. It is an important principle. The Minister of State is extremely approachable, meeting families and so on. Perhaps it is already, but it should be structured into the decision-making process. If we are changing or improving models, there needs to be a panel of families and people who manage disability in their lives and families so that we can test the practicalities of the changes and improvements we are trying to make.

The other question is technical. Recommendation 23 states that we have a national ICT database around assessment of need. Perhaps it already exists. Do we have a clear picture of who is asking, who is getting, what the gap is and where it is? Is there a live database that gives us that information? If we do not, it is very hard to plug those gaps quickly.

I will start with the live database. There is an ICT system, 50% of which is functioning as we speak. All the HSE organisations are talking to each other but there is a GDPR issue regarding section 38 and 39 organisations and how they can plug into the system. It is still a paper-based approach. The question is how to then identify those waiting a long time in section 38 or section 39 organisations. The answer is the assessment officer, who keeps a record of it, will be able to identify those waiting for a long time and can feed it in to the disability managers, of which there are only nine. They will be able to feed in all of that reporting. We can capture that data, which is critical to ensuring we get to those waiting for a long time.

On whether we have an entire system talking to itself, the answer is no, we do not. We have a HSE system that talks to itself but the HSE is only 50% of the providers. Enable Ireland has 20 of the teams and after that, it is all of the other teams. There is a data concern. Work is ongoing. Having met with the board of the HSE, it is working to address that data issue but we can capture that.

The next part is the input of families and the structure. When PDS was being rolled out, there was work with the family forum in which there would be family representatives. To be quite honest, they do not meet regularly enough. Some work well, but some do not. They are trying to bed them down. Having the voice of the family and the continuation of needing a service and transition points, having two family representatives might be a bit of a narrow window on a team. They are looking at expanding it more. Without family input, one cannot get a clear line of the needs and frustrations. They have built in a mechanism called the family forum.

On the mismatch, the Deputy is right. When schools were built, the conversations were not had with the HSE. The schools landed and all of a sudden there was no process which stated that we have now moved from 129 special schools to 132, or an examination of how to align them as part of the teams. Parents were not clearly told at the time that they had a choice - closest to home or closest to school. If you were a parent trying to make a decision as to where you would have the best services or where you could get direct intervention, you would assume that attending a special school would be the place of choice. I note in Dublin that 90% of children do not choose closest to home. They choose closest to school to receive therapy interventions. It is the local CDNT that does that.

The Deputy used the example of Carrigaline. There could be ten different teams trying to support children in one school, which makes no sense. You are better off having the closest team supporting all. How does one then ensure that the children coming from all the different areas have access to respite? To be fair to the HSE in CHO, 4, it was the first that did it. It did a regional respite forum, so that everybody was on an even pitch. Regardless of who would have been your provider in the past, you had equity of access to respite. That is important. Getting interventions is one piece but getting access to respite is the other. It is the only CHO that has a process to monitor and ensure somebody is not getting 22 nights while somebody else might only get one night every three months. It is addressing it well in the Cork area but it is down to understanding. Perhaps it is to do with trust and the fact that the teams were not fully staffed. If you got a service previously, why would you walk away from a service if you knew that CDNT nearest to your school did not have enough staff? That is why we are putting more staff closer to teams that have a special school in their areas. We are looking at stepping up more staff on teams associated or aligned to schools.

I do not think it was offered in the Deputy's area, to be quite honest.

On the point raised, and this is where I need assistance - Ministers sometimes need assistance and I have no problem in asking for that - it is correct to say there is capacity. If I am able to procure 1,800 therapists or interventions and 2,500 interventions in the private market, it tells me we have therapists available. There is no denying that and that sits under the HSE framework. These professionals are all on the island of Ireland. We sometimes bring in psychologists from Northern Ireland to assist with finishing some complex cases. We did it in the past. However, without breaking public pay or upsetting it all, there must be mechanisms by which we could make it attractive. I would certainly love to take everybody in the private system to come and work within my CDNT teams. All I do is spend money in the private area that I am not able to resource in the public system. I have 700 fully funded vacancies, but the money I spend on the other side is money that I would prefer to be spending on recruitment and putting staff in place. I am only moving the money around so that children get the intervention, but if there were a more attractive way of recruiting, or if the HSE could come up with more novel ways to recruit, or if we allowed more flexibility to the likes of the Cope Foundation or the Brothers of Charity to attract in staff onto their teams that are part of our assessment of needs or are a part of their CDNT teams, I would certainly take it.

The final piece on recruitment is that we offer very attractive relocation packages from abroad. We track where people have gone for speech and language therapy or physiotherapy, in Holland or wherever they have gone because they might not have got the crazy points to go onto a team or go into college here, and work on how we might bring them back. We are looking at how we can work with CORU in ensuring that their regulation meets it, so to speak. The relocation package is €4,500 to bring a person home to work on one of our teams. We are also working with the colleges, as students are exiting, to capture them at the end. We need, perhaps, to change how we finish college work. If a person is training in nursing or as a nurse, that person will finish up their degree qualification on the ward. With our health and social care people, we bring them back into college. We break the link with wherever they had been last. Normally in fourth year, students show their preference or where they would like to specialise, for example, they may be in disability. Maybe we need to work on actually keeping them in their position as opposed to them going back into college and not breaking the link. It is something I am working on with CORU to see how we could make that happen. We are at all times trying to find novel and pragmatic ways to attract people into disabilities. I carried over a vacancy level of 189 posts from last year and I was fortunate enough that I could do so on top of the 700. At the start of the year, I had at the guts of 900 vacancies across disability.

I thank the Minister of State. She has finished where I wanted to start. As Deputy Tully said, I often hear from families who have tried to source an assessment or intervention in the private market and are unable to do so or are still facing long waiting lists. There is a wider issue of recruitment and, as the Minister of State has said, therapists are a finite resource. There is a challenge with lots of allied professionals in that, while capturing them when they exit college is very important, they are not joining college in the first place. This is for a variety of reasons, one of which is addressed in recommendation 7, which reads, "Student therapists must receive remuneration for their internship and placement work." Recommendation 8 talks about the need for special grants towards fees and costs associated with training. Having spoken to academics and people in a couple of different allied health professional fields, there is a challenge that they cannot get students in the door. If we cannot even get students in the door, whatever we do to try and capture them at the other end is not going to produce any excess in the number of therapists. I appreciate this is in some ways a matter for the Department of further and higher education, but I would like to hear some more about recommendations 7 and 8. We need to progress these recommendations. All the work the Minister of State is trying to do to capture students at the end of college is not going to make a difference if they are not going in in the first place. I will leave it there for the minute.

This gives me the leverage to acknowledge the new apprenticeship model that was launched in Cork in recent weeks with the Minister, Deputy O'Donovan, where there were 35 spaces, of which 24 were taken up by Tusla and 12 or 13 were taken up by the HSE. It is the apprenticeship model in social work. First and foremost, it is an opportunity to attract people who might not have been able to afford the opportunity of third level education without the learn and earn apprenticeship model. It also allows for people who would have the lived experience to bring to the table. These people will achieve their goal of the learn and earn apprenticeship piece and achieve their full qualification while being in situ. I must acknowledge the role of Kate Duggan from Tusla, who came to the table saying Tusla was struggling to recruit and attract people and asking if the apprenticeship model be looked at, which Tusla did and stepped forward. The HSE has also come on board, and from a Cork point of view, the ETB and UCC are fully behind it and are playing a pivotal role in the whole design with the tertiary office. I must compliment the Department of further and higher education on what it has achieved here.

There is a lot to be learned from what has been achieved in this apprenticeship model. While professions like to keep their profession as a finite resource, and that is important to say - sometimes when I wonder how numbers are kept tight, it is the profession that keeps the numbers tight - perhaps there is an opportunity here for speech and language, OTs and particularly physios to look at the same earning and learning model, working with the colleges and ensuring the HSE can provide that clinical governance in placement, which would be no different than the social work team in Tusla having to provide the clinical placement. CORU is very excited by this model and is fully on board in ensuring this happens. Being fair to the Department of further and higher education, it has pivoted to the needs of where we are really under pressure as a State and, last year, it went outside of the State to get speech and language opportunities. It would be fantastic to have an earn and learn model apprenticeship approach with proper clinical governance in the State in those three disciplines.

The apprenticeship model is excellent and will certainly help with recruitment. Again, however, many of social work courses, for example, have vacancies in them. The colleges are not able to fill the courses themselves. It is not like the social work profession or colleges are trying to keep it as a finite resource. Students are not even going into college. One of the big challenges is that they will not be paid for their placement whereas nurses are. There is always going to be a recruitment challenge if we are not training enough people. We are not training enough people because we are not paying and making training affordable for them. I look at recommendation 7 where it states they must be paid for their placement work. The apprenticeship model may get us there for some of the way, but it does not address the recommendation as a whole, which would be a positive thing to raise with the HSE and the Department.

It is great to raise it with the HSE and with the Department, but approval for that will have to come from the Department of public expenditure. That is the place where that decision could be made. We see the difference it makes to nursing and to the skill sets.

To be honest, my daughter is a trainee occupational therapist and last year she was placed in Dublin. She had been training in Galway, pays her rent on her accommodation and then she is gone for eight weeks and has to find other accommodation for those eight weeks, along with the travel and everything else. I am speaking as the mum of one and I am no different. Every other person experiences exactly the same. It is important that they are able to travel to get the experience within the State. She was very privileged to do it in the National Rehabilitation Hospital, NRH, but those who cannot access such opportunities are reducing their capacity to learn. I agree with the Leas-Chathaoirleach.

Going back to the school issue that Deputy Coveney raised, there is a situation in Cavan where there is a special school that accepts students from Cavan and Monaghan. There was an OT coming in from one of the CDNTs and that OT was only allowed to deal with the students from that particular county. The school talked about the benefits of hiring an OT itself, which the board did a few years ago for a period of time, and the tremendous work that OT was able to do with the children, and with the staff, teachers and SNAs observing, they too were able to use those coping mechanisms. The school inclusion model is an excellent one that should be held up as an example. I think it was piloted in CHO 7. Consideration should be given to the roll-out of the model, as was supposed to happen. Perhaps the Minister of State will indicate whether it was rolled out.

I was told by the NCSE that where that model existed, the demands on the CDNT in the community reduced dramatically. We need to take a helicopter view. It has to be child-centred, where there are supports for the child in the school and in the community rather than services operating in silos. There is currently education, the CDNTs, primary care and CAMHS and they are all working against one other. I was talking to a mother today whose child was referred to CAMHS for an ADHD assessment. CAMHS then referred him back to the CDNT because it said he needs OT and speech and language therapy. If he needs everything, he should get everything. If he needs the assessment and he needs the supports he should be getting them all. I do not see why it has to be one or the other. I talked to somebody within the HSE about this and was told they do not talk to one other. That is the main issue here. We need to get these people talking to one other because it should be about the child rather than about the particular team and where the funding is coming from. It is all Government funding. Could we see a more co-operative approach and more working together between all of the teams? Is there a mechanism to do that? The Minister of State indicated that an independent review of the CDNT service model is being carried out at the moment by the NDA. Is there a timeline for that? Is that going to be part of the focus of the review? Will it focus on how the different parts, such as CAMHS, primary care, etc., can work better together?

There is a lot in that. At all times, my focus and that of the Department is to ensure that the child at the centre gets the intervention he or she needs in a timely fashion. I will be honest. We talk about the special schools. I was in Wexford over a year ago with Deputies James Browne and Kehoe and I visited a special school. I met with the principal, the board and some parents who were part and parcel of the delegation that was there. They spoke exactly to the Deputy's point. Parents were paying themselves to bring in the OT to support the children. To me, that is totally wrong because I have the resources to ensure therapists can go in if we can get them. With the help of the principal, we developed a Wexford model where three therapists - an OT, a physio and a speech and language therapist - were going in. They were reporting back to the CDNT team. There was no breach of data. The parents had chosen the closest school as their option. The therapists were able to report back if they met with Johnny or Mary on how they were doing. Those therapists were going in for the five days. That is the model to which I still aspire. It is a simple model. Where we do not have a CDNT fully resourced, and when I say resourced I mean it cannot attract the required staff for whatever reason and there is a special school or a need, we should be able to recruit therapists, place them within the school and have them report back to the CDNT so there is a follow-up connection. When the staff do come to the CDNT, they have a full picture of what therapies and interventions the child has received.

I have seen in Longford the model to which the Deputy referred, where parents pay for therapists to go into the school. In fact, we can align it to the CDNT team. There is understandable concern within the Department of Education about who holds the clinical governance responsibility. The Department of Education does not want to hold it, nor should it have to hold it. We want to hold it within the CDNT team. All we are saying is that while we are recruiting, it is an interim measure. It is not a permanent solution but it is while we are recruiting the staff within the CDNT team until such time as they can go in.

The Deputy referred to all the different silos. To be honest, the HSE has developed its own national access policy, NAP, where they all are talking to each other. Some CHOs talk to one other better than others and you have the whole mix of it, but I have seen huge improvements under the leadership of Bernard Gloster in respect of the NAP piece. That is where primary care, disabilities, mental health and acute medicine are all talking, not just in disabilities but in older persons and right across the board. They are implementing their own policy and it is far more co-ordinated and child-centred. The whole purpose of the NDA review is to find where are the gaps, what looks good, where are there good performances and where are the better outcomes because where we have good working we need to actually look at that to scale it into other areas. The other piece around the review is to identify why we are struggling to recruit staff into some CDNTs. Why can we not raise the bar there? What is wrong there? Is it a clinical governance issue? That is why we are holding the review.

Just a quick question on the family forum, to which the Minister of State referred. In my own area they are not working well because the meetings are called at a time that does not suit the majority of parents. For example, one meeting was called during the midterm break, when children were at home from school, at 10.30 a.m.. Even though parents made clear that this is an issue, the meetings are still being arranged for silly times that do not suit the majority. It is almost like the CDNT does not want the parents to attend. It should be a collaborative approach where they are all working together for the benefit of the children. There are still a lot of issues in some CDNTs. Some of them are working better than others. The NDA review will point out and what is working well and where in order that others can replicate that.

I do not think a family forum meeting at 10.30 a.m. on a Tuesday, Wednesday or any other weekday morning is conducive to working parents. They only meet once every second month and I do think there has to be flexibility shown on the side of the CDNTs. They should understand the pressure families are under.

I have a question on the assessment of needs and the progressing disability services, PDS, system as a whole. We are talking about reviews and the system not working. Some clinicians have expressed to various committees, or to members of committee delegations that have visited CDNTs, that an assessment of needs is not the best way for them to be seeing children. They would rather treat children, examine them and see what they need. They want to undertake focused assessments and therapies there and then.

Has any political party, group or expert body put forward any workable alternatives to what we have at the minute? I am no expert and I do not think anyone present is a clinician but something has to dramatically change because we have such a backlog. There are millions of euro in resources going into assessments of need but the children are not getting therapies. Is the Department looking at an alternative to assessments of need?

To be honest, no other party has come forward with other suggestions as to how best we can do this. To be fair to the previous Government, it did come up with the SOP proposal because it could see where we have landed today. To be fair, that is where the SOP came from. I totally understand how the SOP came about. The SOP was challenged and it was lost in the High Court, and I understand that. However, since then, I have not had any other suggestions, other than myself, the HSE and the Department trying to be pragmatic and agile and running a recruitment campaign to try to attract people. The Senator's synopsis is correct; what we have is not working either. It is important to say that.

Interventions are far more valuable than assessment. If it takes 30 hours to do an assessment of need, the same number of hours of an intervention is over a half a year of intervention. That could make a fundamental difference to a child. These are one hour sessions. That is a missed opportunity and all the while we are waiting while lists are growing. We are also struggling to get that balance between how much time is spent on assessment and how much time is spent on intervention. We are bound by a law that states that assessment is prioritised and trumps intervention. That is the way it is.

Does Ms Comiskey want to come in?

There are a couple of elements to the assessment of need challenge we are seeing, and the Department recognises that. One thing is the drivers of assessment of need. There is a big thing between the statutory assessment of need piece and, as one of the members was saying, the reason people are looking for it. Sometimes that is for a school reason. They may not need the whole 36 hours assessment. They may need a simple diagnostic piece from an educational perspective. That is one thing we are discussing with the Department of Education.

In my Department, we have held a number of workshops with stakeholders, specifically in relation to assessment of need and the challenges we are seeing. We are also looking to see about moving towards a single point of assessment and talking to the HSE. There is something about a child coming in and parents taking the "no wrong door approach", when maybe what they need is primary care, CAMHS or disabilities. However, they should be pointed in the right direction. At the moment, there is a lack of communication at times and parents are not clear on the pathway they can follow. All these things are being addressed through PDS roadmap and the workgroup. We have one on the communications piece which will look to put out better communications for parents in relation to that, in that they do not have to go for statutory assessment of need and that they can self refer to CDNTs and then get started on the intervention therapies quicker. The Department is also going to seek to look at research internationally as to how assessment of need is done in other jurisdictions and whether there are lessons to be learned from that.

We are very aware of the challenges and we are actively seeking to look at the drivers and see where we can move that needle, so that children are getting therapy intervention and the focus of resources is not solely on the assessment of need piece. We all understand that what the children really need is to get the therapies.

It is a separate but very much related issue and it is to do with the rights of students with disabilities and the need for extra accommodations. The Minister of State's Department is responsible for the public sector duty and the UNCRPD, as a lead Department. Recently I have been highlighting the barriers students with disabilities face during the leaving certificate in terms of access to materials and access to reasonable accommodations. There seems to be a blockage by the State Examination Commission in being ambitious, flexible and open to creating a more equitable system for children with disabilities.

For example, I had a young lady with me last week, Niamh Kilcawley, and I am sure the Minister of State has met her over the years. She is blind and she has no guarantee of getting Braille papers or an extra hour for English or history over the three hours provided. I refer to earlier or later starts for State examinations. There is this 5.30 p.m. cut off for postage of examination papers that has to be adhered to. This goes back to the silo that is each Department.

The Minister of State's Department is concerned with the rights of persons with disabilities. What support has the State Examinations Commission requested from the Minister of State because her Department has much expertise in what children with disabilities need and what they have been asking for for years and in terms of the responsibilities in relation to the UNCRPD and the public sector duty? I know that was a sideways question but it is very important because a lot of people are looking for this.

It is a very valuable question. We talk about reasonable accommodations. I know Niamh and she highlighted something to me that occurred during her French junior certificate exam. In the French exam, there were pictures but Niamh is visually impaired. It was down how somebody described the pictures and Niamh could have lost or gained marks because of what was on the paper. The Sate Examinations Commission could have had a caption saying you are looking at an adult working on a computer. The assistant in the room could have clearly identified that and said what it was or was not.

Has the State Examinations Commission engaged with me? No is the straight answer to that. Should there be reasonable accommodations? Of course, there should be reasonable accommodations. If there is a 5.30 p.m. cut-off for postage, that is fine. Logic tells you to just start earlier.

If I go back to this piece around flexibility. It is where people come out of rooms, or meet in between, that the bond of secrecy as to what is on the paper is broken. Niamh was probably in a special room as she had an interpreter with her.

On equal access to participation in exams, the NDA has done a huge amount of work in this space on how children with additional needs who have the capacity to participate in our examinations are accommodated. It has written a whole review on this, but perhaps I can ask the NDA to look again at how the State exams are equipped to ensure they meet the rights of students with disabilities under the UNCRPD. That is something we can take away and ask the NDA to review.

I have two brief points. The first is on the issue I asked about the last time as to whether parents have this choice of opting into different CDNTs, whether it is around the school or the home. It is important the HSE communicates with parents to make sure they know about that. That is not a criticism; it is a suggestion, in that we need to make sure all the parents know that is an option for them and that the CDNT needs to accommodate that.

The second question is on effectively outsourcing the therapies to the private sector while we are trying to fill some of these vacancies. There is a potential tension between the school, parents, the CDNT and in the case of Cork, the CETB. It is unfair to ask people who do not have medical expertise in this area to take on the responsibility of signing off on bringing in a private therapist.

That is the job of the experts in the area, namely, the HSE or the children's disability network team, CDNT. In the case of Cork and the special schools there, which the Minister of State is very familiar with, we thought we had a solution to this many months ago whereby the education and training board would effectively be given money to take on private therapists to fill the gap temporarily. It is understandably uncomfortable with that without effectively getting the approval of the HSE for the individual therapists to ensure there is a consistency of standard for therapy for the children it is responsible for in those schools. It is very important, if we are now reverting to requiring that fund to be managed by the network teams, that actually happens, because there are multiple network teams linked to the one school. That is going to be a problem with other new schools which are also planned.

We have been quite critical of the model which has been adopted, and perhaps unfairly so, because the model may well be fine. The problem is that if one has 900 vacancies, how does one expect any model to work? We have to be careful here that we do not look to reshape a model that may not be that flawed if it had the resources and staffing as it was designed to have to actually work. We need to careful that in trying to fix this problem, we are not restructuring something that may not be as broken we think it is, if it had the human resources needed to fill these 900 vacancies which the Minister of State said still need to be filled.

I am just expressing a word of caution there. I am not saying that it is the perfect model. I have spoken to many parents who are deeply frustrated trying to get supports for their children, many of whom have gone to court, which has been the trigger for the establishment of some of these special schools. Let us be honest because it has been legal cases which have forced the State's hand. They will go to court again, just like I would if I was a parent in this situation, to get to try to get their child the supports they need from the State.

I do not have the answer here but we do need, and I am sure the Minister of State has teams looking at this, to ensure that the model is right and that there are not mismatches and so on, by geography. Let us not change the model until it is given a fair chance with the resourcing needed.

The biggest message I would send is that we have to get some of the skills which are currently available in the private sector into the public system. We must find a way of doing that but in the meantime we just cannot be promising parents something and 18 months later be still trying to figure out how to do it. A great deal of effort is going into this. I am from a part of the country which has an acute problem with a number of schools but the State has to do better.

I thank the Deputy for that contribution. He is right that while some things might work in one area, they might not work in another area. The most important thing any parent or teacher would want is that there is proper clinical governance. That is the most important piece. I totally understand why no principal, board or organisation would take on that risk as it is not their field. The risk of the clinical governance should sit with the HSE.

The point here is that we would have had conversations in the past three months on grant-aiding schools and that perhaps that would have a quick effect. There is a real understanding that the parents of children in some of the special schools are totally frustrated that there has been no intervention since their children have gone inside the front gate. I totally understand that but to be fair to the Department of Education, the Minister, Deputy Foley, and the Minister of State, Deputy Naughton, they are not prepared to take on that responsibility and risk as it is the risk of the HSE. They are saying they want the HSE and the CNDTs to do the recruitment or to do the placement of the private therapist in the schools and to let them own the risk. That is what is happening in the Cork situation and I hope that it will come to an end fairly soon.

The National Disability Authority, NDA, review is ongoing and will look at staff teams and see how the model actually works because we have 91 teams and they are positioned all around the country. There are two specialist teams. We are also looking at a paediatric team for children who are discharged from hospital. We are working up that team as well.

The Deputy is correct in that it is very hard to judge a model when it is not fully staffed. I would like to think we are in this interim space where we are trying to fill those vacancies, to make it attractive, to look perhaps at the apprenticeship model and to do whatever we can to fill the vacancies. One can then make a fair assessment as to whether it works or does not work. It is not fair on the staff who are working flat out to ensure there is a service there. They are working very hard as are all the teams around the country but they are working under extreme pressure in not having fully staffed teams.

I would not be doing my job if I did not spend money procuring services where I can procure them to ensure families get interventions.