Head 9, section (1) (a) - Standards setting

The NDA recommends that in working towards ensuring the highest possible levels of quality and safety in service provision for everyone in the State, all standards set by HIQA for mainstream health services, as well as disability specific services, take account of standards of service in respect of people with disabilities.

In relation to disability services, the NDA recommends that HIQA issue, as mandatory standards, the draft National Standards for Disability Services (2004), developed by the NDA and the Department of Health and Children, at the earliest possible date.

The NDA also recommends that specific reference is made to:

• Section 10 of the Disability Act 2005 and Section 5 (5) of The Education for Persons with Special Educational Needs Act 2004 in regard to standards for needs assessment (assessment cannot commence in the absence of standards);
• Other potentially relevant legislation, for example: The Mental Health Act, 2001 (Part 3, Section 33 (1) and (2)).

It would be important, also, to have due regard to the role envisaged for HIQA in The Health Strategy - Quality and Fairness (2001) and the National Health Information Strategy (2004), in relation to information and health technology.
Finally, the Bill needs to specifically address the important potential role for HIQA in setting and monitoring standards for health services, products or systems provided or developed by private enterprise without exchequer funding.

Head 9, section (1) (b) - Monitoring the level of compliance with standards

It is important to clearly state (i) how the Minister and Executive are to be advised of levels of compliance with mandatory standards (mechanisms and required frequency of reporting) and (ii) what enforcement powers the Minister and HIQA will have to ensure that remedial action is taken in cases or areas of non compliance.
Action 111 of the National Health Strategy (2001) refers to the development of a reporting system on the national performance of services against specified national standards. The NDA recommends that the Health Bill 2006 should make explicit reference to this function.
It is essential that HIQA is given a strong statutory remit to require that all health and personal social service providers be required to comply with relevant mandatory standards, such as the draft National Standards for Disability Services. In addition, HIQA should identify which accreditation or quality improvement programmes and activities service providers may participate in on a voluntary basis.
(The Bill ought to make explicit reference to the complementary nature of the various roles and functions of the NDA, HIQA and the Office of the Chief Inspector and the need to adopt a collaborative and coordinated approach, in this regard. See page 12 of this Submission.)

In order to ensure that services comply with mandatory standards, HIQA should be given the remit to:

• Establish and maintain a register of approved services;
• Approve a service or refuse to approve a service, remove or add a service to the register of approved services;
• Attach different conditions to the registration of services;
• Publish the register of approved services;
• Collaborate with statutory bodies, such as the NDA, to identify and report on issues of key strategic importance.

It is vital that the Bill provide for a comprehensive system of regulations, setting out procedures/arrangements for registration, inspection, reporting, enforcement and sanctions - including the allocation of additional statutory enforcement powers for HIQA and the Office of the Chief Inspector.

Head 9, section (1) (c) - Investigate the safety, quality and standards

The NDA welcomes the investigative role proposed for HIQA. We would, however, recommend that the exact reporting mechanisms and (as indicated in the previous section) the enforcement powers of HIQA and the Minister, be further clarified.

• In regard to reporting, it is worth noting that the UK Health and Social Care (Community Health and Standards) Act 2003, contains a detailed reporting process for the Commission for Health Care Audit and Inspection.
• An effective system of enforcement and sanctions is vital. This would necessitate the allocation of additional statutory enforcement powers for the Health Information and Quality Authority (HIQA) and the Office of the Chief Inspector, in particular in relation to the publication of findings and reports, the registration of services as approved services and financial penalties.
  
  

The NDA also recommends that the legislation should allow for HIQA initiating and launching an investigation of its own accord, e.g. in response to a serious complaint made either to HIQA or SSI, by service users or their personal advocates, regarding the standard of service they receive (cf. the investigative powers granted to other statutory bodies such as the Office of the Ombudsman and the Food Safety Authority of Ireland).

Head 9, section (1) (d) - Review resources to ensure best outcomes

The recent Comptroller and Auditor General's Value for Money Report on the provision of disability services by nonprofit organisations (March 2006) clearly indicates the need for ongoing review and control of resource allocation and deployment.

The report also highlighted the need for the implementation and monitoring of standards. The report (section 2.26) states that 'The changes taking place in the health sector generally and in the disabilities sector in particular, present challenges to the Department and the HSE to .... put into practice standards of care for persons with disabilities'.

Earlier statements regarding the NDA's concern at the apparent lack of formal reporting structures and enforcement powers in Head 9 refer. Again, the NDA also recommends that the legislation should allow for HIQA initiating and launching a review of its own accord.

Head 9, sections (1) (e) and (f) - Accreditation of services and the operation of schemes to ensure quality and safety

As outlined above, the Health Bill 2006 should promote the strategic vision of ensuring quality by implementing and inspecting mandatory standards and promoting excellence through voluntary processes, such as voluntary accreditation schemes.
The NDA recommends that the Regulatory Impact Analysis referred to in the Background Paper for this Bill, should contain a thorough review of the role, function and merits of the operation of a variety of schemes, programmes and inspection processes. At present there are many quality and regulatory bodies operating in Ireland. In this respect, the establishment of one central body, HIQA, is to be applauded. However, the impact of the continuation of existing schemes and programmes still needs to be evaluated.
See earlier notes on pages 4, 5 and 9 of this Submission.

Head 9, section (1) (g) - Evaluate and advise on clinical and cost-effectiveness of health technologies

The role of HIQA in relation to the development and promotion of Health Technology Assessment (HTA) as originally outlined in the National Health Strategy (2001) and the Health Service Reform Programme (2003) differs significantly from the function outlined under Head 9, section (1) (g). The NDA recommends that the Department amend this section of the Health Bill 2006 and strengthen the function of HIQA in this important area. The Bill should include a statement on the role of HIQA in overseeing the development of HTA and the promotion of its use.

Head 9, section (1) (h) - Evaluate information on health and personal social services

The NDA recommends that the Department ensures that this section on information is in line with the original action plans outlined in the National Health Strategy (2001) and the National Health Information Strategy (2004). The role and function of HIQA in the area of health information as currently envisaged in the Health Bill is inadequate and should be amended. The amendments should reflect the proposed role and functions of HIQA such as the development of health information, the approval of major health information developments and promoting the education, training and skills development for information staff.
In addition the HSE has important new functions vis a vis the identification and specification of needs, using the aggregate data from the needs assessments and service statements. HIQA must be cognisant of this new role of the HSE in its work on the development and promulgation of health information.
Head 9, (1) (h), Evaluate information available on health and personnel social services, should read: Evaluate information available on health and personal social services.

Head 9, section (1) (i) - Set and advise on compliance with health information standards

The NDA welcomes this section but we recommend that the Health Bill 2006 outline the actions that may be taken in relation to non compliance with the standards. We recommend that this section make provision for the assessment of information databases to ensure that the databases concerned are in compliance with standards, see also Action 4 in the National Health Information Strategy (2004).

Head 9, sections (2) and (3) - Remit of HIQA

As previously mentioned, the Health Bill needs to take into account the statutory functions of the NDA as outlined in the NDA Act 1999, in relation to programmes and services provided to people with disabilities - in particular, those of:

• acting as an advisory body with regard to the development of standards (s 8, c);
• facilitate and support the development and implementation of appropriate standards for programmes and services for persons with disabilities (s 8, e);
• preparing codes of practice (s 8, f), and, most especially,
• monitoring the implementation of standards and codes of practice (s 8, d) and
• making recommendations to the Minister for the review, reduction or withdrawal of any moneys provided by the Oireachtas for any programme or service (s 15, 1, 4).

Whereas the NDA does not have power to inspect, it can and does have right of access to information of relevance to its functions (Section 13 of the NDA Act, 1999 refers).
The NDA would recommend that the Bill (i) make explicit reference to the complementary nature of the various roles and functions of the NDA, HIQA and the Office of the Chief Inspector in relation to disability and (ii) clarify any apparent or likely overlap between the statutory remits of each. This would ensure both the avoidance of confusion and, or duplication of effort and the adoption of a coordinated approach to ensuring the delivery of high quality services.
The statutory role of the NDA should be explicitly mentioned and acknowledged under Head 9, section 2. The NDA strongly recommends that the National Disability Authority be listed as one of the public bodies (a) whose statutory functions HIQA shall not undertake to perform and (b) in consultation and collaboration with whom, HIQA should seek to perform both its unique and shared roles and functions.
The NDA should prove a valuable resource to HIQA in developing advice on issues of key value and strategic importance. NDA policy work is informed by an extensive programme of rigorous and robust research and complemented by the development of practical guidance and standards.
These considerations should be reflected elsewhere in the Bill, also, in particular in relation to:

• Membership of Board, Head 10 - We recommend that specific reference is made to the appointment of members with direct concern with or responsibility for activities relevant to the functions of HIQA, specifically in relation to disability interests and the interests of children and older people.
• Regulations relating to services, Head 56 - makes provision for the Minister for Health and Children to make regulations for registering residential centres for people with disabilities. We would recommend this provision should make explicit reference to doing so, in or following consultation with the NDA.

Head 41, (2) (a) - Monitor services

The NDA recommends that the roles and functions of HIQA and the Office of the Chief Inspector are further clarified in relation to their respective monitoring roles.
The Bill also needs to provide more clarity as regards the services covered under the inspection process. The NDA recommends that health and personal social service providers comply with relevant mandatory standards and that all such services are subject to inspection by the Office of the Chief Inspector.The Office of the Chief Inspector should be given additional functions in relation to the publication of the inspection reports.

Head 41, (2) (b) - Establishment and maintenance of a register of services

The NDA recommends that this function is given to HIQA to ensure a separation of inspectorial and approval functions. In other words, the Office of the Chief Inspector should make recommendations to HIQA in relation to the registration of services. In addition the Office of the Chief Inspector should be able to furnish a report in writing to HIQA in relation to the overall quality of care.

Head 41, (2) (c) - Inspection of registered services

The NDA recommends that a timeframe be included in this section (cf. the Mental Health Act 2001, section 51, which stipulates that each approved centre is inspected at least once a year.)

Head 41, (5) - Exemptions of designated services

The NDA recommends that the exclusion clauses contained under Head 41 are clarified further. For example section (5) (f) states that 'any service or premises which primarily provides or is primarily used for the provision of cultural, recreational, leisure or physical activities' is not included as designated centres. However the Bill does not provide a definition of 'cultural, recreational, leisure or physical activity' centre. A day activation unit for people with an intellectual disability might, for example, successfully argue that they are exempt of inspections.
The NDA strongly recommends that the exclusion clause for palliative care centres and centres for persons who are treated for acute illnesses is removed. People using these services belong to the most vulnerable groups in our society and need the assurance that the service they receive is regularly inspected.