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Position Paper 4 (continued)

Page history last edited by Ciarán Holahan 15 years, 6 months ago

6.    Disability supports and services

 

In an Ireland that is great to grow old in: Older people can avail of a full range of disability supports and services as needed, without discrimination.

 

6.1.    Context/rationale

 

 Census 2006 figures

The 2006 Census in Ireland showed that there were138,300 people with disabilities aged 65 and over. These were the people who reported that they had a long-lasting condition and/or difficulties with undertaking certain everyday activities. (CSO 2007)

 

This represents just over one-third of all people with a disability (35.1% in total) and almost 30% of all people aged 65 years and over.

 

Approximately 26% of people aged 65-84 reported that they had a disability, and this figure rose to almost 59% of people aged 85 years and over, showing how the likelihood of having a functional disability increases with age.

 

Women aged 65 and over were more likely than men to report a disability.

 

http://www.cso.ie/releasespublications/documents/other_releases/2007/equalityinireland.pdf

 

The disability profile is even more marked in Irish nursing homes (Falconer, 2007). Given the population projections with regard to the number of older people who will live longer in future years, together with the association between increased age and increased disability, it is clear that the number of older people experiencing a disability is set to increase.

 

Other aspects of disability

Some older people with disability will have had the disability throughout their lives, whilst others will have experienced ‘late-onset’ disability. Their experiences can therefore be very different.

 

As well as the link between older age and disability, there is an established correlation between disability and poverty and quality of life in general. This is re-iterated in Healthy Ageing: a Challenge for Europe (2007)

 

Ageing populations will lead to greater numbers of older people living with disabilities. Disability decreases quality of life, increases the risk of hospitalisation or nursing home admission and premature death. Prevention of disability in later life is therefore a major public health concern with concerted research and political activity.

 

http://www.healthyageing.nu/upload/Short%20version/Healthy_ageing_eng_web.pdf

 

A common agenda?

Given that a relatively high proportion of older people also report a disability, questions arise about a possible common agenda between people with disabilities and older people

 

A joint discussion paper from the National Disability Authority and the National Council on Ageing and Older People (Ageing and Disability, 2006) poses the following questions:

 

  • Do people with disabilities and older people have similar health, housing, social, and transport service needs? 
  • Do they want similarly structured services? 
  • Do they prefer separate or integrated services? 
  • Do they experience similar types of social exclusion? 
  • Do they have similar concerns when seeking to claim their social, cultural and economic rights?  

http://www.ncaop.ie/newsevents/AgeingandDisabilityPaper.doc

 

6.2.    Current situation

 

 State agencies and administrative structures

Currently within the health and social services systems in Ireland, people with disabilities and older people are considered as two distinct groups, and administrative structures reflect this. Services are managed by the Primary

 

Community and Continuing Care programme (PCCC) and in turn Local Health Managers, and there is an Expert Advisory Group to offer management expert advice in each area. 

 

Differences in the social welfare entitlements of the two groups create anomalies in welfare provision.   For example, when people with lifelong disabilities reach age 65, they no longer receive Disability Allowance; rather they then receive the Old Age Pension .

 

There are two main state agencies and bodies in existence with responsibilities in the areas of older people and disability.

 

The National Disability Authority was established to advise the Minister for Justice, Equality and Law Reform on disability policy; the NCAOP (National Council for Ageing and Older People) was a state agency established to advise the Minister for Health and Children on issues related to ageing and older people.   At the time of writing it was in the process of being integrated into the Department of Health and Children.

 

Given the boundaries set up by such administrative structures, questions arise as to ‘how best to address the needs of people whose issues relate to both ageing and disability’.(NCAOP 2007:1).’

 

Joint NDA and NCAOP initiatives

The NDA and the NCAOP first came together in 2004 to address the issues pertinent to both bodies and identified two key questions for future discussions and developments

 

How can we create a society that enables the full participation of older people with disabilities? 

How do we ensure that older people with disabilities receive the support they need in the manner they prefer?

 

http://www.ncaop.ie/newsevents/AgeingandDisabilityPaper.doc

 

A joint position paper was produced and a joint seminar held in 2006 to develop the paper and explore the issues further with relevant experts in the field.

 

http://www.nda.ie/cntmgmtnew.nsf/0/FBE570D7C6D435C28025710D004594B9?OpenDocument 

 

http://www.nda.ie/cntmgmtnew.nsf/0/B26AAD8BC1A8C9A7802571E200382DC3/$File/ageing_and_disability_02.htm  ]

 

The two organisations have urged:

 

When considering ageing policy it is important to ensure that frameworks promote the inclusion of all older people, whether or not they have impairments. ‘(NCAOP and NDA 2006: 6)

 

The NDA and NCAOP draw attention to deficits in information and data in regard to older people with disability. For example, the National Physical and Sensory Disability Database excludes those whose disability arises beyond age 66.

 

In terms of services, there are other difficulties: for instance, admission to the National Rehabilitation Hospital is restricted to those aged 65 or under.

 

The NCAOP also published in 2007 a report based on extensive consultations with older people, The Quality of Life of Older People with a Disability in Ireland. This report, the first of its kind undertaken in Ireland, provides support for greater integration of public policy in relation to both ageing and disability services.

 

6.3.    Current plans

     The National Disability Strategy has been in place since 2004, and addresses a wide range of issues related to people with disability.

 

The current Government has promised a Strategy on Positive Ageing, which is set to be accomplished in the period 2008-2010(DoHC Statement of Strategy 2008-2010: 28).

http://www.dohc.ie/publication: 28)s/pdf/en_strategy08.pdf?direct=1

 

7.    Residential care

 

     The most complex, frail and disabled group of older Irish people live in nursing home care, and although less than 5% of older Irish people are in nursing home care at any one time, international data suggest that up to 29% of men and 40% of women will spend time in a nursing home throughout their lifespan.  While the domestic/home-like aspects of nursing home care will be covered in Position Paper 6 “A place that feels like home” a major concern that has emerged in the international literature is that the health care needs of older people in long term care are not being given due recognition. International studies have clearly shown a failure for identification and pro-active management of the complex morbidity of older people in nursing homes (Hancock, 2006).

 

There has been disquiet for many years that the standards of care offered to this group in Ireland have been below best practice levels (O’Neill, 2001). Following an expert review of a nursing home scandal, the Department of Health and Children accepted a set of twelve recommendations which are set out in the Leas Cross Report.  Many of these relate specifically to health care matters and include:

 

  • For those who are not looked after by the GP who provided care while at home, the medical cover must be more clearly and unambiguously specified in terms of relevant training (at least the Diploma in Medicine for the Elderly or the equivalent), responsibilities and supports from the HSE;
  • Multi disciplinary team support must be clearly specified both in terms of meeting need and facilitation of team work and requires at a minimum;  physiotherapy, occupational therapy, speech and language therapy, clinical nutrition and social work;
  • Specialist medical support (geriatric medicine and psychiatry of old age) need to be developed to provide formal support to the medical officer, nursing staff and therapists.
  • An electronic version of the Minimum Data Set should be made mandatory for all patients in nursing home care to assist in the development of individual care plans, the monitoring of quality and the provision of national statistics on dependency, morbidity and mortality.

 

http://www.hse.ie/eng/Publications/Older_People_and_Nursing_Homes/Leas_Cross_Report.html

 

Subsequently, HIQA, in a broad consultation with users and professionals developed standards for residential care (HIQA, 2007) which address some but not all of these concerns. Independent inspection of the nursing home sector is expected to take place in 2009.

 

Further cause for concern was raised by the nursing home survey of the Irish National Audit of Stroke Care, which showed major difficulties in access to diagnostic and rehabilitative services. A recurring theme was the need for more physiotherapy, occupational therapy and speech and language therapy for residents with stroke, and a lack of input from community services or the PCT. An ongoing cause of confusion for  therapy and rehabilitative services is that the 1993 Nursing Home Act does not specify clearly whether such services should be provided by the health service or the private nursing home, and it is not clear whether the PCT’s remit includes private nursing homes.

 

In addition to concerns over the standard of healthcare in nursing homes, there are significant concerns over the lack of transparency to older people and their families about their eligibility to funded nursing home care following a Supreme Court ruling in February 2005. In the Ombudsman’s interpretation, in its judgment of 16 February, the Supreme Court held that the Oireachtas required health boards, at all times prior to the passing of the Bill, to make in-patient services available to all persons suffering from physical and mental disability. The Court also determined that the original intent of the legislature, to be found in section 53 of the Act of 1970, was to expressly confer on persons of full eligibility under the health acts the right (Ombudsman emphasis ) to in-patient services without charge. In addition, the Court also determined that because the statutory right (Ombudsman emphasis) existed, patients were entitled to receive the relevant services free of charge, and that this right persists so long as section 53 (1) of the Act of 1970 remains unchanged, as it does.

 

http://ombudsman.gov.ie/en/PressReleases/Name,1914,en.htm

 

8.    End-of-life support

 

In an Ireland that is great to grow old in: Older people can exercise choice about the end-of-life support they want

 

8.1.    Context/rationale

     There are many complex dimensions to the appropriate provision of end-of-life support and care to older people, including: provision of care prior to the end of life; the acknowledgement or recognition of the approaching death on the part of the individual and their family; individual choice; respect for the older person’s dignity; and appropriate responses to their vulnerability at this life stage.

 

Over two-thirds of people surveyed by IHF expressed a wish to die at home if at all possible, but the majority are denied this choice and actually die in acute hospitals or long-stay residential settings (Irish Hospice Foundation, 2004).

 

To support an older person’s preference to die at home, a wide range of primary health care services may be required, as well as considerable supports for carers. The availability of such care is variable, with some parts of the country benefiting from better levels of support for patients and their carers than others.

 

Palliative care

Palliative care was carefully defined by the World Health Organization in 2002 as:

 

An approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.

                                WHO 2002 (1)

 

In addition, one of the core principles of palliative care is that it should enable people to exercise genuine choice about the care they wish to receive.

 

Although most deaths occur in the over-65 population, comparatively little research has been carried out on their needs for palliative care. A WHO Europe report published in 2004, Better Palliative Care for Older People, points out that older people have particular needs and requirements in relation to palliative care, as their health problems are different and often more complex than those of younger people:

 

  • Older people are more commonly affected by multiple medical problems of varying severity;
  • The cumulative effect of these may be much greater than any individual disease, and typically lead to greater impairment and needs for care;
  • Older people are at greater risk of adverse drug reactions and of iatrogenic (drug-related) illness;
  • Minor problems may have a greater cumulative psychological impact in older people;
  • Problems of acute illness may be superimposed on physical or mental impairment, economic hardship and social isolation.

 

http://www.eapcnet.org/download/forProjects/Elderly/BetterPC.Older%20People.pdf

 

Irish national policy

The Irish government’s 1994 National Health Strategy recognised the role of palliative care, and gave a commitment to the continued development of services.

 

National policy on palliative care was then set out in the Report of the National Advisory Committee for Palliative Care (DoHC 2001). The Chair of the Committee stated that

 

Palliative care is about people; it is concerned with ordinary people who find themselves facing extraordinary difficult situations: the loss of independence, the loss of financial security, the loss of all that is safe and familiar, the loss of friends and family, the loss of future and, ultimately, the loss of life.

                                                                                                                                    DoHC 2001:5

 

8.2.    Current situation

Palliative care, both specialist and non-specialist, is provided in all care settings, including hospitals, specialist palliative care units and the community.

 

In Ireland there are currently eight dedicated specialist in-patient units operating throughout the country, and in addition a network of established home care nursing teams, which may or may not be linked back to a specialist unit.

 

Pace of death is strongly influenced by the provision of access to the full range of hospice and specialist palliative care services and settings.

 

Where comprehensive services are undeveloped, it appears that more people die in acute general hospitals. In contrast, where services are better developed, there appears to be an increased incidence of death in a hospice, palliative care in-patient unit, or home care setting (IHF/HSE Baseline Study 2005) .

 

Overall, the number of designated palliative care beds in the system is extremely low, as a new (2008) study from the Irish Hospice Foundation and the NCAOP shows.

 

http://www.hospicefriendlyhospitals.net/index.php?option=com_content&task=view&id=241&Itemid=35 

 

A crucial factor is training: currently few health care staff other than specialised palliative care staff have formal qualifications or have received training in palliative care.

 

A recent report from the Irish Centre for Social Gerontology (O’Shea et al. 2007) analyses the overall situation and makes five key recommendations in relation to the care of older people facing death and dying:

 

1.    Greater consultation is needed with older people in order to establish needs and preferences with respect to end-of-life care.

2.    Greater cultural awareness and understanding of dying and death, including consideration of the current disparity of esteem between younger and older deaths within the health and social care system, is needed.

3.    Policy reform is required to ensure that end-of-life care is recognised as an important public health issue, separate to palliative care but inclusive of many of its key elements.

4    Measures are needed to develop practice to ensure that end-of-life care for older people is integrated into the everyday life and work of acute hospitals and long-stay facilities.

5,    The testing of models that bring about a greater fusion between end-of-life care and gerontological care within all long-stay settings in Ireland is recommended

Specialist gerontological nursing as a key skill and resource in the provision of high quality end of life care may possibly be considered a worthwhile addition to the above recommendations .

 

8.3.    Current plans

     National Plan for Palliative Care 2009–13

 

In September 2007, it was agreed between the HSE and the Department of Health and Children that a National Plan for Palliative Care (2009 -2013) be developed, covering both capital and revenue requirements over this period. A key element of this initiative seeks to address, as a priority, the issue of service deficits on a national basis as identified by the IHF/ HSE Baseline Study of 2005.

 

Hospice Friendly Hospitals Programme

A further national initiative in palliative care is the Hospice Friendly Hospitals Programme, initiated by the Irish

Hospice Foundation, which seeks to change the culture of care and organisation provided in hospitals for people who face death, and their relatives who face bereavement. The Hospice Foundation has now established a national programme to mainstream hospice principles in hospital practice. 

 

The aims of the Hospice Friendly Hospitals programme are:

 

  • To develop comprehensive patient focused standards for all hospitals in relation to dying, death and bereavement;
  • To develop the capacity of acute and community hospitals to introduce and sustain these standards;
  • To improve the overall culture in hospitals and institutions in relation to dying, death and bereavement.
  • The key themes of the programme include
  • Integrated care
  • Communication
  • Patient autonomy
  • Design and dignity

 

The initial public call for expressions of interest in participating in the programme resulted in nine submissions covering 18 hospitals; half of them acute hospitals with emergency facilities. Three additional submissions, covering 19 non-acute community hospitals and facilities for older people, were also received.  There are now over 40 hospitals participating in the programme, of which 20 are acute hospitals.

 

Design and Dignity

‘Design and Dignity’ is one of the four main principles of the Hospice Friendly Hospitals Programme. At the time of writing, a consultation process is under way on new Draft Design and Dignity Guidelines, which will apply to any new or refurbished hospital buildings and ensure that the dignity of patients and their families can be respected in the layout of spaces and facilities within the hospital.

 

http://www.hospicefriendlyhospitals.net/index.php?option=com_content&task=blogcategory&id=24&Itemid=61

 

An essay outlining this principle, its practical applications, and the benefits for the dying person and their family, can be found on the HfH website.

 

http://www.hospicefriendlyhospitals.net/media/Honoured%20Guests%20December%202006.pdf  

 

All-Ireland Institute for Hospice and Palliative Care

Plans for this Institute, intended to ‘advance the provision of education, research and information in hospice/ palliative care across the island of Ireland’, were developed in 2007 by a steering group of interested parties. The ‘business case’ for the Institute can be found at:

 

http://hospicefoundation.biznetservers.com/up_documents/Institute_BusinessPlan.pdf

 

Funding for specialist palliative care

There is strong personal support from the current Minister for Health and Children in respect of palliative care, and she approved an additional €18m in new development funding for palliative care (including home care and community initiatives) for the years 2006 and 2007, with a further €3m to be allocated in 2008.

 

Other relevant initiatives

Efforts are continuing, in line with national policy, to broaden access to palliative care services. A forthcoming report from the Irish Hospice Foundation and HSE, Extending Access to Palliative Care, is expected to recommend pilot initiatives to extend access initially to patients suffering from cardio-vascular and respiratory diseases, along with those suffering from dementia.

 

9.    Issues for further consideration

 

     Themes and questions for further consideration include:

  • The role and responsibility of the state towards older people, the question of entitlement to services (underpinned by legislation) rather than eligibility, and the implications of this for more equitable provision.
  • Is there a case for an Ombudsman for older people?
  • A stronger focus on the gender dimension and the health of older women. The Women’s Health Council could contribute information on this theme.
  • Ireland’s changing demography - how will health and social services respond to older people from minority ethnic backgrounds? What will be the impact of the HSE’s new National Intercultural Health Strategy 2007-2012?
  • The necessity for age-aware and age friendly staffing and systems at all levels i.e. making gerontology central to training for administrators and public health professionals as well as medical staff which requires a shared language and shared assessment frameworks
  • How to maximise the effectiveness of the new geriatrician-led teams?
  • The increasingly important topic of hearing the voice of older people requires analysis of how existing and proposed communication channels can facilitate genuine dialogue. (Link advocacy channels to proposed consultation mechanisms? Broaden input to the Expert Advisory Group?)
  • Analysis and discussion of the funding model for health services for older people.
  • While the paper is able to quote statements of intent by the HSE in relation to expenditure and services, information on outcomes is urgently needed.
  • The Position Paper could include: the four general principles underpinning the National Health Strategy of 2001 and a conclusion within the framework of Practice-Policy-Research
  • Standards in all health care settings should be reviewed along with the role of HIQA
  • The need for tracking and monitoring of HSE expenditure, which is considered inadequate at present, so that evidence of expenditure is lacking, and gaps, time lags and deficits cannot be identified.

 

Appendix:  A

 

HSE and other supports and resources for older people

The following is a list, in alphabetical order, of services and supports available to older people, and mainly provided within the primary care framework.

Availability varies from one geographical area to another, and not all are entitlements in law; rather, some services provided on an eligibility basis.

 

 ‘Boarding out’

Although this service has not been substantially developed in Ireland, the HSE may make arrangements for the boarding out of a dependent person in a private house, providing standards are met regarding suitability of house and householder and adequacy of care in relation to the person’s needs. Agreed costs are usually shared between the HSE and the person him/herself.

 

Chiropody service

The HSE is not legally obliged to provide chiropody or podiatry services, but where it does, the service may be provided either by the Local Health Office or by voluntary organisations on behalf of the HSE. It is free to medical card holders and people with Hepatitis C.  and is valuable in maintaining older people’s mobility.

 

Community occupational therapy

Following a needs assessment by an occupational therapist, grants may be made for the provision of practical aids and for home adaptations, which can maximise an older person’s independence, health and general quality of life.

 

Community pharmacy service

Everyone of 70 years and over is entitled to a medical card, and to approved prescribed drugs and medicines free of charge.

 

Most pharmacies have an agreement with the HSE to provide services under the Primary Care Reimbursement Scheme, entitling individuals and their families who are registered with the Drugs Payment Scheme to a refund of all prescription-related expenses over €90.00 per month.

 

Community physiotherapy

Community physiotherapists and physiotherapy assistants are usually based in health centres or clinics. The service, funded by the HSE, is free to medical card holders and people with specified conditions, although the waiting period may be lengthy. Referrals are usually through a G.P. or public health nurse. 

 

Day centres /day care centres

Local day centres provide a range of services for older people, and for people with disabilities. Some provide recreational, sport and leisure facilities, while others cater for medical and rehabilitation needs. The latter, however, are less widely available.

 

Funding for day centres has increased since 2005, allowing for additional programmes for specific needs and for more opening days.

 

Individuals are usually referred to day centres by a GP or public health nurse. Access varies considerably across the country, with means testing applicable in some areas. The range of services provided also varies and may include:

 

Transport to and from the centre Health monitoring
Chiropody Personal care
Continence promotion Activation programmes
Rehabilitative training Advice for carers
Meals Laundry

 

In addition, in some areas there are a number of dementia-specific day centres, run by the Alzheimer Society of Ireland and the HSE.

 

Dental /aural /ophthalmic services

These services are provided through the Treatment Benefit Scheme of the Department of Social and Family Affairs, and are available to retired people with sufficient PRSI contributions . Medical card holders are also legally eligible for the scheme, but its availability varies from area to area. Under this scheme, a person may qualify for:

  • Dental benefit
  • Optical benefit
  • Aural benefit
  • Contact lenses
  • Hearing aids

 

Home help

The HSE may provide a home help service to older people but is not legally bound to do so. Home help is generally free to medical card holders, but in some areas a contribution from the older person may be required. Home helps undertake light housework, shopping, cooking and cleaning for older people, but generally do not provide hands-on nursing or medical care.

 

Home care/ nursing assistants

Home care or nursing assistants help with washing and bathing etc., and are trained for this role. Referral to the service is usually through a public health nurse.

 

‘Meals-on-wheels’

This service (known as ‘mobile meals’ in the UK), like home help and home nursing assistance, can enable people to continue living in their own homes. It is available in many, but not all, parts of the Republic. Generally provided by not-for-profit organisations with state subsidy, the service works closely with HSE primary care staff, and may be extensively supported by volunteers. Meal recipients usually contribute towards the cost.

 

Mental health service.

There is no systematic provision of state-funded services which promote and maintain older people’s mental health. Counselling and psychotherapy services generally are acknowledged to be insufficient to meet the needs of those in all age groups who could benefit from them. A number of voluntary organisations, such as GROW and AWARE, can support those experiencing depression and anxiety – often linked to bereavement, and/or loneliness and isolation - but these organisations are not available in all parts of the country.

 

Similarly, there are a number of voluntary organisations concerned with dementia, those who experience it, and their families, including the Alzheimer Society of Ireland.

 

Many older people experiencing mental health difficulties will first approach a GP, who will decide whether to treat the person him/herself or make a referral to a consultant psychiatrist or community psychiatric nurse for assessment.

 

Suicide Resource Officers, employed through the HSE’s National Office for Suicide Prevention, have training in relation to older people and the group/s most at risk of suicide, particularly older men.

 

Public Health Nurses (PHNs)

Public health nurses, usually based in the local health centre and assigned to specific geographical areas, are employed by the HSE to provide a range of health care services in the community: in schools, in health centres, in day care and other community centres and in people's homes.

 

In some areas, the public health nurses keep a register of older people and visit them as a matter of course. (see www.citizensinformation.ie )

 

Services provided by public health nurses include: basic nursing care; advice and assistance; planned essential weekend nursing; and in some instances a ‘twilight nursing’ service for terminally ill patients. They are an important point of access for other community care services, liaising with GPs, practice nurses, hospitals, hospices and other health service providers to meet the needs of the individual.

 

Respite care

Respite care, which is usually arranged through a public health nurse or GP, is provided both by the HSE and by voluntary organisations, though its availability varies. In addition, a Respite Care Grant is available to carers who fulfill the relevant conditions. Carers are offered a break, holiday or rest, for periods varying from a very short time to two weeks, according to need.

 

Social workers

Social workers may be employed by the HSE, by hospitals, and by specialist voluntary organisations.

 

HSE community care social workers are legally obliged to prioritise their child protection responsibilities, so that their services to older people may be limited. However, a recent HSE development is the employment of Elder Abuse Workers to focus specifically on this area of concern.

 

Speech and language therapy

Speech and language therapists, employed by the HSE in a wide variety of settings including local health centres, hospitals and schools, to assess, diagnose, and treat communication difficulties.

 

The services address speech, language, fluency, voice and swallowing difficulties and can significantly enhance the quality of an older person’s daily life. Unfortunately, there is a shortage of speech and language therapists at present, so that there are long waiting periods for the service.

 

Supports for carers

Grants, benefits and respite care can all support carers in their role. The grants and benefits available are: Carer’s Allowance; Carer’s Benefits; and the Respite Care Grant, and they apply in different circumstances, according to the situation of the carer and the person cared for. In 2006, a scheme for Carer’s Unpaid Leave was introduced, guaranteeing unpaid leave to carers who have a minimum 12 month employment record, the right to return to their job after a period of between 13 and 104 weeks.

 

Supports for Carers

There are a number of voluntary support groups for carers, including Caring for Carers and the Carers’ Association, while the Care Alliance, a national network of organisations supporting carers and lobbying on their behalf, has been in existence since 1995.

 

Appendix B:        Primary Health Care Services

     The Primary Care Strategy outlined in this document proposes a model of care which is based on an inter-disciplinary team-based approach to primary care provision. Arguing that primary care is the appropriate setting for meeting 90-95% of all health and social service needs, it proposes a rebalancing of resources from secondary to primary care, with an emphasis on integrated service delivery by multi-disciplinary teams and local diagnostic services:

 

The development of a properly integrated primary care service can lead to better outcomes, better health status and better cost-effectiveness. Primary care should therefore be readily available to all people regardless of who they are, where they live, or what health and social problems they may have. Secondary care is then required for complex and special needs which cannot be met solely within primary care.

 

http://www.dohc.ie/publications/primary_care_a_new_direction.html

 

Primary health care services are intended as the first point of contact for health and personal social services, and are delivered outside the hospital context. Primary care teams include GPs, nurses/midwives, health care assistants, home helps, physiotherapists, occupational therapists, social workers and administrative personnel. Wider primary care networks of other professionals, such as speech and language therapists, community pharmacists, dieticians, community welfare officers, dentists, chiropodists and psychologists are intended to support and service the population of several primary care teams.

 

(See Appendix for more detailed information on these services.)

 

In addition to promoting early intervention, prevention of hospitalisation, reduction in the use of Accident and Emergency Departments, and a holistic approach to health needs, primary health care services are also intended to assist in earlier discharge from hospitals. The delivery of home care packages is thus an important element in the delivery of primary health care services. However, currently there is much inequity across the system in the provision of these home care packages .

 

The HSE Estimates for 2007 state that each Primary Care Team will provide services to a population of approximately 4000-10,000 people, and each Social and Primary Care Network will provide services to a population of approximately 30,000-50,000.

 

The Irish government has recognised the importance of delivering services in an integrated and accessible manner, as reiterated by former Taoiseach Bertie Ahern at the launch of a report on older people in Dublin’s inner city in January 2008:

 

I have noted in particular the desire for a “one-stop shop”, where residents could access a wide range of health services and in particular the requests for chiropody, minor injuries and bereavement services. This is very much in keeping with the Government’s Primary Healthcare Strategy to develop care teams in the community. I expect the HSE to give full consideration to the views of the residents when determining its priorities for service improvements locally.

                                                                                         Speech at launch of Nascadh Report 22/01/08

Primary Health Care Teams and Networks

The HSE’s process of developing primary care teams and networks for the delivery of integrated services is under way across the country. However, provision so far has been variable, due to a combination of factors, including: the legacy of the former Health Board framework, where provision for older people varied from one Board to another; the absence of a new national strategy for older people; and the lack of legislation on entitlement to particular services, so that in some cases provision is discretionary, rather than entitlement-based.

 

In addition, the pace of implementation of this strategy has been slower than originally envisaged. The HSE’s target, in its 2006 Service Plan, was the establishment of 100 Primary Care Teams, with each of the 32 Local Health Offices establishing up to three Primary Care Teams each, a strategy requiring the recruitment of some 300 additional front-line professionals. This was itself part of a five-year programme to establish 500 Primary Care Teams across the country, with the potential to provide for up to 90% of the health and social care requirements at community level.

 

http://www.hse.ie/eng/Publications/corporate/HSE_National_Service_Plan_2006.html

However, to date this 2006 target has not been achieved, as a result of a combination of factors including the recruitment embargo, limitations in resources etc.

 

GP cooperatives/ out-of-hours services

The General Practitioner is a pivotal contact for older people, often providing ongoing general health checks, blood pressure monitoring etc. The development of GP cooperatives to provide out-of-hours cover has thus been an important aspect of the delivery of primary health care services to older people, as well as to the general population.

 

At the time of writing there are twelve such cooperatives in existence across the country.

www.icgp.ie

 

Community Intervention Teams

The aim of establishing Community Intervention Teams (CITs) at a local level is to prevent avoidable hospital admissions and facilitate early discharge from hospitals, by supporting people at home and addressing a range of their medical needs there.

 

The teams operate in addition to existing mainstream community services, and deal with matters such as ‘fast tracking’ non-medical care or supports for an interim period while mainstream services are being arranged for the individual. Patients include older people living alone, people who have had a fall with a subsequent fracture, or those who need nursing assistance to administer insulin.

 

The teams operate as an out-of-hours nursing service to deliver nursing care in the home, and as designated wound clinics, with referrals accepted from GPs, Public Health Nurses, and other health professionals or community services

 

Patients referred to a CIT receive these services for a maximum of ten days, and are then referred to the Public Health Nurse service.

 

Four such Community Intervention Teams were developed in 2006, covering a total population of 850,000 people in Cork city, Limerick city, Dublin North city and Dublin South city.

 

The strategy has so far yielded positive results, as noted in the Third Progress Report on Towards 2016 (2007):

 

In a high percentage of cases, admission to hospital is avoided through the intervention of the CIT – current statistics indicate that only 11% of patients under the care of the CITs were referred to hospital and the majority of these were admitted. The current uptake is at 71% of target. The breakdown of hospital vs. community referrals is 72% vs. 28%. Target capacity is 3,900 or 75 cases per week.

 

http://193.178.1.117/index.asp?locID=566&docID=3595 

 

Revising targets: primary health care teams

The current National Agreement, Towards 2016, and the Programme for Government 2007 both include the targets of 300 primary care teams established by 2008, 400 by 2009 and 500 by 2011.

 

However, the actual pace of implementation is reflected in the more modest corresponding targets and commitments in the HSE’s 2008 Service Plan. In this year, the intention is to achieve full functioning of the current 87 primary care teams, and ‘to progress development of an additional 100 teams’ (p.23).

- - - -

 

Acronyms

 

AWN        Ageing Well Network

 

CSO        Central Statistics Office

 

DoHC        Department of Health and Children

 

ESRI        Economic and Social Research Institute

 

HeSSOP    Health and Social Services for Older People

 

HfH        Hospice friendly Hospitals Programme

 

HIQA        Health Information and Quality Authority

 

HIPE        Hospital In-patient Enquiry

 

HPU        Health Promotion Unit

 

HSE        Health Services Executive

 

IHF        Irish Hospice Foundation

 

INASC        Irish National Audit of Stroke Care

 

NCAOP    National Council on Ageing and Older People

 

NDA        National Disability Authority

 

OECD        Organisation for Economic Cooperation and Development

 

PCCC        Primary, Community and Continuing Care (HSE Directorate)

 

SILC        (EU) Survey on Income and Living Conditions

 

SLÁN        Survey on Lifestyle, Attitudes and Nutrition in Ireland

 

TRIL        Technology Research for Independent Living   

 

WHO        World Health Organisation

 

Bibliography

 

The main texts referred to in this paper are:

International publications

Document Author  Date of Publication  Download or go to website  Read Abstract 
Ageing and Health Care Utilization: new evidence on old fallacies  Barer ML, Evans RG, Hertzman C, Lomas J.  1997     
Frameworks of Integrated Care for the Elderly: A Systematic Review  Canadian Policy Research Networks Inc.  2008     
Misconceptions and misapprehensions about population ageing  Gee, E.M. International Journal of Epidemiology  2002     
The needs of older people with dementia in residential care  Hancock GA, Woods B, Challis D, Orrell M. International Journal Geriatric Psychiatry   2006     
Towards an Integrated Public Service  OECD Publishing 2008     
Healthy Ageing, a Challenge for

Europe 

Swedish National Institute for Public Health  2007     
Charter for Health Promotion  World Health Organisation  1986     
Madrid International Plan of Action on Ageing  United Nations Programme on Ageing  2002     
National Control Programmes: Policies and Managerial Guidelines  WHO

Irish publications 

2002     
EU Survey of Income and Living Conditions   Central Statistics Office  2005     
Equality in Ireland   Central Statistics Office   2007     
Better Palliative Care for Older People  Davies, E. and Higginson, I. WHO  2004     
The Years Ahead: A Policy for the Elderly. Report of the Working Party on Services for the Elderly  Department of Health   1988     
National Health Promotion Strategy 2000-2005  Department of Health and Children  2000     
Quality and Fairness: a Health System for You  Department of Health and Children  2001     
Primary Care: A New Direction  Department of Health and Children   2001     
Report of the National Advisory Committee for Palliative Care  Department of Health and Children   2001     
Survey of Lifestyle, Attitudes and Nutrition in Ireland  Department of Health and Children    2008     
Statement of Strategy 2008-2010  Department of Health and Children  2008     
Your Service, Your Say: the National Strategy for Service User Involvement in the Irish Health Service  Department of Health and Children and Health Service Executive  2008     
Programme for Government 2007 - 2012  Department of the Taoiseach  2006     
Towards 2016: Ten-Year Framework Social Partnership Agreement 2006-2015  Department of the Taoiseach  2006     
Third Progress Report on Towards 2016  Department of the Taoiseach  2007     
Activity in Acute Public Hospitals in Ireland  Economic and Social Research Institute and Department of Health and Children  2007     
Comprehensive geriatric assessment for older hospital patients  Ellis G, Langhorne P. British Medical Bulletin  2005     
Profiling disability within nursing homes: a census-based approach  Falconer M, O'Neill D. Age andAgeing. Oxford University Press   2007     
The "silver-haired" general medical services patient. Clinical activity of the non-means tested over-70's during their first six months  Fitzpatrick F, Harrington P, Mahony D. Irish Medical Journal  2004     
Leas Cross Report  Health Service Executive  2006     
Guidance Document for Primary Care Developments   Health Service Executive  2007   

 

 

New National Service Plan 2008 Health Service Executive  2007    
Annual Report and Financial Statements 2006  Health Service Executive 2007    
National Strategy on the Prevention of Falls in Older People HSE, DoHC, NCAOP       
Fuel poverty, thermal comfort and occupancy: results of a national household-survey in Ireland Healy JD, Clinch JP. Applied Energy 2002    
National Quality Standards for Residential Care Settings for Older People in Ireland Health Information and Quality Autority 2008    
Baseline Study on Palliative Care Irish Hospice Foundation 2005      
A nationwide survey of public attitudes and experiences regarding death and dying Irish Hospice Foundation 2004    
All-Ireland Policy Paper on Fuel Poverty and Health

McAvoy, H. Institute of Public Health in Ireland

 

     
Irish National Audit of Stroke Care McGee, H., O’Neill, D., Horgan, F., Hickey, A. Irish Heart Foundation and Department of Health and Children      
East Wall Older Residents Needs Analysis Report Nascadh 2008    
Perceptions of Ageism in Health and Social Services in Ireland National Council on Ageing and Older People 2005    
Adding Years to Life and Life to Years: A Health Promotion Strategy for Older People National Council on Ageing and Older People 1998    
Health and Social Services for Older People National Council on Ageing and Older People 2007    
Ageing and Disability: A Discussion Paper National Disability Authority and National Council on Ageing and Older People 2006    
The Interface between Ageing and Disability: Seminar Proceedings National Disability Authority and National Council on Ageing and Older People 2006    
Care for Older People National Economic and Social Forum 2005    
Health and Social Services for Older People II (HeSSOP II): Changing Profiles from 2000 to 2004 O’Hanlon A, McGee H, Barker A, Garavan R, Hickey A, Conroy R. National Council on Ageing and Older People 2005    
Responding to care needs in long term care. A position paper by the Irish Society of Physicians in Geriatric Medicine O'Neill D, Gibbon J, Mulpeter K. Irish Medical Journal 2001    
Health care for older people in Ireland O'Neill D, O'Keeffe S. Journal of the American Geriatrics Society 2003    
An Age-Friendly Health Service O’Neill, D. 2008    
Maximising the demographic bounty O’Neill, D. Irish Gerontological Society 2008    
An Action Plan for Dementia O’Shea, E. and O’Reilly, S. NCAOP 1999    
Implementing Policy for Dementia Care in Ireland: The Time for Action is Now, Position Paper O’Shea, E. the Alzheimer Society of Ireland 2007    
End-of-life Care for Older People in Acute and Long-stay Care Settings in Ireland O’Shea et al. Centre for Social Gerontology 2007    
Older People in Poverty in Ireland: an Analysis of EU SILC 2004 Prunty, M. et al. Combat Poverty Agency 2007    
Ageing Societies a Comparative Introduction Timonen, V. Open University Press 2008    
Honoured Guests: An Essay to Promote Discussion on the Issues of Design and Dignity Worpole, K. Irish Hospice Foundation 2006    

  Barer ML, Evans RG, Hertzman C, Lomas J. (1997) Ageing and health care utilization: new evidence on old fallacies. Soc Sci Med. 1997;24:851-62.

 Canadian Policy Research Networks (2008), Frameworks of Integrated Care for the Elderly: A Systematic Review. Canadian Policy Research Networks Inc.

Gee, E.M (2002), Misconceptions and misapprehensions about population ageing. International Journal of Epidemiology, 31:750-753

Hancock GA, Woods B, Challis D, Orrell M, 2006. The needs of older people with dementia in residential care. International Journal Geriatric Psychiatry 21(1):43-9.

Organisation for Economic Cooperation and Development, 2008. Ireland: Towards an Integrated Public Service. Geneva: OECD Publishing

Swedish National Institute for Public Health, 2007. Healthy Ageing, a Challenge for

Europe. Stockholm: SNIPH.

World Health Organisation, 1986. Charter for Health Promotion. Geneva: WHO

United Nations Programme on Ageing, 2002. Madrid International Plan of Action on Ageing. New York United Nations

World Health Organisation, 2002. National Control Programmes: Policies and Managerial Guidelines. Geneva: WHO

Irish publications

Central Statistics Office, 2006. EU Survey of Income and Living Conditions 2005 (EU-SILC). Dublin: Stationery Office.

Central Statistics Office, 2007. Equality in Ireland 2007 (based on Census results 2006) Dublin: Stationery Office

Davies, E. and Higginson, I., eds., 2004. Better Palliative Care for Older People.

Geneva: WHO.

Department of Health 1988. The Years Ahead: A Policy for the Elderly. Report of the Working Party on Services for the Elderly. Dublin: Stationery Office.

Department of Health and Children, 2000. National Health Promotion Strategy 2000-2005. Dublin: Stationery Office.

Department of Health and Children, 2001. Quality and Fairness: a Health System for You. Dublin: Stationery Office.

Department of Health and Children, 2001. Primary Care: A New Direction.

Dublin: Stationery Office.

Department of Health and Children, 2001. Report of the National Advisory Committee for Palliative Care. Dublin: Stationery Office.

 

Department of Health and Children, 2007. Health in Ireland: Key Trends. Dublin: Stationery Office.

 

Department of Health and Children, 2008. SLÁN  2007: Survey of Lifestyle, Attitudes and Nutrition in Ireland. Dublin: Stationery Office.

Department of Health and Children, 2008. Statement of Strategy 2008-2010.

Dublin: Stationery Office.

Department of Health and Children and Health Service Executive, 2008. Your Service, Your Say: the National Strategy for Service User Involvement in the Irish Health Service. Dublin: Stationery Office.

Department of the Taoiseach, 2006. Programme for Government 2007 - 2012. Dublin: Stationery Office.

Department of the Taoiseach, 2006. Towards 2016: Ten-Year Framework Social Partnership Agreement 2006-2015. Dublin: Stationery Office.

Department of the Taoiseach, 2007. Third Progress Report on Towards 2016.

Dublin: Stationery Office.

Economic and Social Research Institute and Department of Health and Children, 2007. Activity in Acute Public Hospitals in Ireland (Results from HIPE and NPRS).

Dublin: ESRI.

Ellis G, Langhorne P, 2005.. Comprehensive geriatric assessment for older hospital patients. British Medical Bulletin. January 31;71:45-59.

Falconer M, O'Neill D, 2007. Profiling disability within nursing homes: a census-based approach. Age andAgeing. Oxford University Press. March 36(2):209-13.

Fitzpatrick F, Harrington P, Mahony D., 2004. The "silver-haired" general medical services patient. Clinical activity of the non-means tested over-70's during their first six months. Irish Medical Journal. April 97(4):111-4.

Health Service Executive, 2006. Leas Cross Report. Dublin. HSE

Health Service Executive, 2007. Guidance Document for Primary Care Developments (in line with PCCC Transformation Programme) Dublin: HSE.

Health Service Executive, 2007. New National Service Plan 2008. Dublin: HSE.

Health Service Executive, 2007. Annual Report and Financial Statements 2006.

Dublin: HSE.

Health Service Executive, Department of Health and Children and National Council on Ageing and Older People (forthcoming). National Strategy on the Prevention of Falls in Older People.

Healy JD, Clinch JP, 2002. Fuel poverty, thermal comfort and occupancy: results of a national household-survey in Ireland. Applied Energy, Volume 73, Issues 3-4, November-December 2002, Pages 329-343

Health Information and Quality Autority, 2008. National Quality Standards for Residential Care Settings for Older People in Ireland. HIQA.

Irish Hospice Foundation, 2005. Baseline Study on Palliative Care. Dublin: Irish Hospice Foundation.

Irish Hospice Foundation, 2004. A nationwide survey of public attitudes and experiences regarding death and dying. Dublin: Irish Hospice Foundation.

McAvoy, H, 2007. All-Ireland Policy Paper on Fuel Poverty and Health . Dublin: Institute of Public Health in Ireland.

McGee, H., O’Neill, D., Horgan, F., Hickey, A. Irish National Audit of Stroke Care (INASC). Dublin: Irish Heart Foundation and Department of Health and Children.

Nascadh, 2008. East Wall Older Residents Needs Analysis Report. Dublin: Nascadh.

 National Council on Ageing and Older People, 2005. Perceptions of Ageism in Health and Social Services in Ireland. Dublin: NCAOP.

 National Council on Ageing and Older People, 1998.  Adding Years to Life and Life to Years: A Health Promotion Strategy for Older People.  Dublin: NCAOP. 

 National Council on Ageing and Older People, 2005. Health and Social Services for Older People II (HeSSOP II). Dublin: NCAOP. 

 National Council on Ageing and Older People, 2007. The Quality of Life of Older People with a Disability in Ireland. (Report no.99). Dublin: NCAOP

National Disability Authority and National Council on Ageing and Older People, 2006.

Ageing and Disability: A Discussion Paper. Dublin: NDA. (published on website only)

National Disability Authority and National Council on Ageing and Older People, 2006. The Interface between Ageing and Disability: Seminar Proceedings. Dublin: NDA. (published on website only)

National Economic and Social Forum, 2005. Care for Older People. Dublin: NESF

O’Hanlon A, McGee H, Barker A, Garavan R, Hickey A, Conroy R, et al. (2005) Health and Social Services for Older People II (HeSSOP II): Changing Profiles from 2000 to 2004. Dublin: National Council on Ageing and Older People

O'Neill D, Gibbon J, Mulpeter K, 2001. Responding to care needs in long term care. A position paper by the Irish Society of Physicians in Geriatric Medicine. Irish Medical Journal March 94(3):72.

O'Neill D, O'Keeffe S, 2003.  Health care for older people in Ireland. Journal of the American Geriatrics Society September 51(9):1280-6

O’Neill, D., 2008. (2) An Age-Friendly Health Service.

O’Neill, D., 2008. (1) Maximising the demographic bounty. Irish Gerontological Society.

O’Shea, E. and O’Reilly, S., 1999. An Action Plan for Dementia. Dublin: NCAOP

O’Shea, E., 2007. Implementing Policy for Dementia Care in Ireland: The Time for Action is Now (position paper). Dublin: the Alzheimer Society of Ireland.

O’Shea et al., 2007. End-of-life Care for Older People in Acute and Long-stay Care Settings in Ireland.   Galway: Centre for Social Gerontology.

Prunty, M. et al., 2007. Older People in Poverty in Ireland: an Analysis of EU SILC 2004. (Research Paper 07/02). Dublin: Combat Poverty Agency.

Timonen, V., 2008. Ageing Societies a Comparative Introduction. Open University Press.

 Worpole, K., 2006. Honoured Guests: An Essay to Promote Discussion on the Issues of Design and Dignity. Dublin: Irish Hospice Foundation.

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