THE HEALTH Information and Quality Authority (Hiqa) should be given the power to set standards and regulate professional home care services, according to the Law Reform Commission.

In a report to be published today, the commission recommends that both public and private providers of home care services should be included in the regulatory regime.

It also recommends that the Social Services Inspectorate establish a registry of all professional home help carers.

These are among a list of 29 recommendations made by the commission.

Such regulation should not, however, include individuals such as relatives who provide informal assistance to elderly or vulnerable people living in their homes, it added.

The need for regulation was highlighted again last month when information released to The Irish Times under the Freedom of Information Act revealed the types of problems which can arise with home help services, going on complaints submitted to the Health Service Executive (HSE) by families.

In one case in Donegal, an elderly woman’s daughter complained that when the home help showed up for work, the complainant and her sisters could smell alcohol from the home help and knew she had been drinking by the way she “bounced off the walls”.

A HSE disciplinary investigation was carried out, and while the HSE said disciplinary action was taken against the home help in question, it would not specify what form this took.

In another case, in Limerick, a client of a private home care company complained to the HSE last January that a home help had told him to “f**k off, and [said] that it was because of him that she had to travel out in 4ft of snow”.

The Law Reform Commission points out in the report that the proportion of people living in Ireland who are aged over 65 has been increasing in recent years and is projected to increase at an even greater rate over the next few decades.

The overwhelming majority of people aged over 65 wish to continue living in their own homes for as long as possible.

The Government has committed to supporting this approach and has done so through home care support, primarily though the HSE.

Commercial home care providers have also emerged who can be contracted by the HSE to provide care.

However, no regulatory regime exists either for public or private home care providers.

Hiqa is the regulatory and standard-setting body under the Health Act 2007 for residential nursing homes, and in 2009 published standards to apply to them. However, they only deal with the 5 per cent of those aged over 65 in residential care.

The Act does not give Hiqa the power to set comparable standards for the provision of health care in the home, which would cover the remaining 95 per cent of the over-65 category, though they do not all require such care. The commission is therefore recommending that the 2007 Act be extended to allow Hiqa to regulate home carers.

The commission noted the importance of funding arrangements for professional home care but did not make any recommendations in this area, as this is a matter of ongoing Government policy development.

Carol Coulter – Irish Times

Home care regulation

WHETHER WE in Ireland look to Berlin or to Boston is a question that has lost none of its relevance over the years. It came afresh to my mind last week as I took part in a networking conference, Researchers in Ageing , organised by the Max Planck Institutes in a small town near Munich.

The Max Planck Institutes is an extraordinary collaborative enterprise spread throughout Germany (and sometimes farther afield) which has generated 17 Nobel laureates since it was founded in 1948. Largely funded by the German government, it is notable for its excellence and the breadth of vision of its 80 institutes – from astrophysics to anthropology, ornithology to oceanography, molecular biology to mathematics.

The institutes are not just concentrated in the major cities but distributed across the country in often modestly-sized towns, a remarkable achievement in its own right. Planned, consensual and – from the evidence of this meeting – very well networked, it is a phenomenon from which we in Ireland might have learned about real decentralisation.

Its institutes for research into ageing share this pattern. The prestigious Demographic Institute is based in the former East German port town of Rostock, with the Biology of Ageing due to move into a striking new building in Cologne: in addition, the network supports researchers in other institutes, such as law or phonetics, building a true interdisciplinary research base.

Their research has really opened new insights into ageing and generated hope for advances in supporting us all in our old age. For example, the Rostock researchers showed it is never too late to intervene for older people in a fascinating study which looked at death rates of very old people in West and East Germany before and after the fall of the Wall.

Prior to unification, East Germans in their 80s and 90s died much sooner than their Western counterparts. Exposed to West German pension, social and medical supports, within a few years their life expectancy dramatically improved to match that in the West: a rallying cry against nihilism and defeatism in the face of age-related disease and disability.

Last week’s meeting brought junior and senior researchers from across Germany together with a handful of international experts for a group immersion in the broad experience that is gerontology, the sciences of ageing.

As befits one of the most subtle and complex stages of life, the presentations covered a jaw-dropping amount of ground: ageing and death in classical civilisation from a professor of classics; the intersection of moral values and economics in the undertaking industry; older workers, economics and finances; suicide in later life viewed from the perspectives of developmental psychology and brain imaging; to name but a few.

Equally refreshing was the mix of nationalities, from as wide afield as Ethiopia and Armenia, and including an Irish researcher on secondment from DCU, and the interchanges at coffee breaks and dinner combined an academic ferment but also a lot of fun.

As one of my own specific interests is the illumination of the longevity dividend – ie, those things that we do better with age – I was particularly fascinated to learn of an anthropology study in an indigenous tribe which showed that the older hunters, despite running more slowly and firing arrows with less force, returned home with the highest weight of meat.

I came away enriched not only in knowledge but also in the sense of attachment to an international network of those who both care about ageing but also seek high standards of research to validate future policy and practice.

On a slightly sadder note, I reflected that we needed to more overtly look to Berlin in terms of cohesiveness, shared vision and openness in our research communities. My own experience in Ireland has been often dispiriting, with some sources of funding generating divisive and secretive behaviour within quite small groupings of researchers.

We are fortunate in the academic calibre of the increasing numbers of those interested in research in ageing in Ireland: what a force we might be if we could forge open, trusting and collaborative philosophies and networks that allowed us to harness this force for not only better ageing in Ireland, but also in Europe. My vote rests firmly with Berlin.

Irish Times

Prof Des O’Neill is a consultant in geriatric and stroke medicine

A new report on dementia in Ireland has found around 4,000 new cases are diagnosed here each year and the incidence is higher than cancer and heart disease.

The report says there are over 41,700 people with the condition – of whom 26,000 live at home – and the numbers are expected to more than treble over the next 30 years.

It says early diagnosis and sometimes any diagnosis is the exception rather than the rule and that Irish GPs, like their European counterparts, experience difficulty in diagnosing the illness and would welcome more training and resources.

The report recommends more emphasis on primary prevention and ways of avoiding or delaying the illness, particularly through reducing health disease and stroke.

Most of those with dementia living at home probably do not have a formal diagnosis.

The report was funded by Atlantic Philanthropies and was published today at a conference at Trinity College Dublin.

The conference is discussing the development of a national dementia strategy, which has been promised by the Government in 2013.

The report says there are an estimated 50,000 family carers looking after someone with at least one of six specified symptoms of dementia.

It suggests that around two-thirds of all long-stay residents have dementia, with many of those again not having a formal diagnosis.

The cost of dementia in Ireland is put at nearly €1.7 billion a year, 48% of which is attributable to informal care provided by family and friends.

A further 43% is accounted for by residential long-stay care, while other formal health and social care service contribute just 9% of the total cost.

The report says Irish home care services are not underpinned by legislation, nor are they provided on a statutory basis.

It also calls for greater public awareness about dementia.

The principal investigator for the research was Professor Suzanne Cahill of Trinity College Dublin.

Home Care, Dementia

Large numbers of older people may be on medicines, prescribed by their GP, that they do not need.

A recent study examined the extent of potentially inappropriate prescribing among 166,108 older patients and found a prevalence of 34pc in that population.

The investigation, carried out by researchers on both sides of the border including Trinity College and the Royal College of Surgeons in Dublin, found the drugs that were commonly wrongly prescribed included proton pump inhibitors, which reduce gastric stomach acid.

They were being taken at a maximum therapeutic dose for more than eight weeks by 17,931 patients.

Others included non-steroidal anti-inflammatory drugs, which can be prescribed for conditions including forms of arthritis, headache and migraine.

There were 14,545 patients on these drugs. Others were on long-term tranquillisers.

The findings showed that inappropriate prescribing was strongly associated with polypharmacy, in other words patients who were also taking several drugs already.

The study was carried out in Northern Ireland where drugs are free. Although patients in the south, where there is a mix of medical card holders and private patients, were not examined, it is accepted that older age groups here are also at risk of getting drugs they do not need.

Inappropriate medication use is a particular safety concern for elderly adults because they are vulnerable to side-effects or harmful reactions with other drugs.

Patients are not always taken off medicine when their circumstances change or when the guidance on the use of the drug is updated.

Although various solutions have been put forward, including better record-keeping, a basic safeguard is for doctors to regularly review their elderly patients’ medication.

Home Care

Confviagraion. Memory loss. Poor judgment. An inability to let the left hand know what the right hand is doing. Fleeting awareness of mistakes resulting in mood swings and erratic decision-making.

The mix-up surrounding the tax-demand letters from the Revenue Commissioners to pensioners has been disturbing to watch.

We should acknowledge, however, that the symptoms detailed above offer a much more accurate description of the behaviour of the authorities in recent days than the OAPs who received the menacing missives.

Not that you would have gleaned such an impression by following the controversy on the public airwaves. Far from it.

In their eagerness to condemn the latest bureaucratic blunder by the powers that befuddle, most politicians, commentators and vested interests once again opted to portray the elderly as helpless victims, a pitiful bunch of old dears caught in the headlights.

Ireland is having what might be described as a senior moment. Virtually everybody who has added even two cent to the row over the taxation letters, including the Revenue bean counters themselves, has wanted to be seen to be taking the pensioners’ side.

Yet despite all the goodwill, much of the language used to express this solidarity has served only to infantilise, demean and cretinise the old.

So, for the record, here goes a statement of what should be the blindingly obvious. Ageing is not a disease. Dates on a birth certificate tell us little about the capabilities, talents or attitudes of the certificate’s holder.

Reaching the age of pension entitlement is a milestone, rather than a millstone. A bus pass is not a one-way ticket to the knacker’s yard.

The relentless depiction of older people — especially by bodies that purport to represent older people — as physically and mentally frail is dangerously counterproductive, not to mention downright misleading.

Sure, there are many senior citizens who face acute problems because of illness, isolation or economic circumstances.

However, there is a much greater number who lead busy, adventurous lives and who are simply bemused by all this talk about their “vulnerability”.

In many ways, the early 21st Century is a golden age for those in their golden years. This is the era of active retirement and life-long learning, the silver surfer and the silver fox. Fitter, richer and stronger than their antecedents, most have much more to live for than many half their age.

Ironically, the fallout from this fiasco serves only to highlight the formidable force that is grey power. The speed and determination with which pensioners reacted to the letters was evidence of strength, not weakness.

The reason governments quake before any pensioner protest is because politicians understand how deeply politicised these people are. The elderly are the group most likely to vote. They are also exceptionally well informed.

OAPs were, for instance, among the keenest followers of the assorted corruption tribunals. It was they who filled the public galleries at Dublin Castle as details emerged of how politicians and the wealthy conspired for decades against the public interest. These people know how this country actually works and they won’t get fooled again.

Yes, some of the loudest, special pleading sometimes comes from old folks themselves. But that’s simply another manifestation of their political acumen.

They understand the game: you leave your opponents under no illusion about the seriousness of your demands, overstating the case if necessary. You brook no compromise and take no prisoners.

If all else fails, you kick up an unmerciful stink, calibrating your expressions of indignation to ensure optimum coverage on the evening news.

In truth, other sectors of society would be well advised to take a leaf from the pensioners’ playbook. As we venture deeper into a period of stark economic choices, in which the Government must confront the financial crisis by taking tough decisions, rather than picking on soft targets, the fortitude and self-confidence of the senior citizenry is an example to us all.

Never underestimate the wisdom of the ancients. Old people know how to live — they have, after all, been doing it longer than the rest of us.

Weekend Review

Elderly care

The Health Service Executive’s national service plan for 2012 says that a minimum of 555 public beds in community nursing homes will be shut this year.

It also warns that the Fair Deal nursing home support scheme may run out of funds, despite having a budget of over €1bn.

It details how hospital budgets will be cut on average by 4.4% and activity levels will fall by around 3%.

The plan says that home help hours for older people will be cut by 4.5% this year. The number of home care packages will remain at 2011 levels.

One of the biggest issues is the impact of the expected departure of 3,300 staff by February.

The service plan says it will be impossible to avoid an impact on frontline services.

The overall budget cut this year is €750m, coming on top of a budget cut of €1.7bn over the previous two years.

The use of agency staff is to be cut by half.

The plan promises that no patient should wait longer than nine months for a planned operation.

An extra 400 new staff are to be employed in the mental health services this year.

Funding is also being provided for priority replacement posts in primary care and more medical cards.

The budget for disability services will see a 3.7% cut.

Minister Reilly said the plan will see “more effective use made of the number of beds” in hospitals.

HSE Chief Executive Cathal Magee said: “2012 will be a very challenging year for the health services. In the last two years, reductions in health expenditure have been achieved largely through a combination of procurement efficiencies, successive drug price reductions and staff costs.

“A key driver of cost reductions for 2012 will be the exit of a further 3,000 staff from the health services.

“Together with a budget reduction of €750m, the challenge will be to accelerate the implementation of the National Clinical Programmes and the new models of care and continue to drive efficiencies in order to offset the impacts on frontline services.”

Age Action spokesman Eamon Timmins said the group is concerned about the impact the cuts will have on older people.

He said: “The loss of so many public beds and the scale of the cuts in the home help service provided by the HSE will undoubtedly be felt by the sickest of older people.”

Home Care

THE ONSET of dementia may start from the age of 45, much earlier than previously thought, research published yesterday suggests.

A large-scale study has found evidence the human brain’s capacity for memory, reasoning and comprehension (cognitive function) can start to deteriorate from the age of 45 and not 60 years, as had been believed.A large-scale study has found evidence the human brain’s capacity for memory, reasoning and comprehension (cognitive function) can start to deteriorate from the age of 45 and not 60 years, as had been believed.

The authors of today’s research, published in the British Medical Journal, say the evidence showing cognitive decline before the age of 60 has significant ramifications because it demonstrates the importance of promoting healthy lifestyles, particularly cardiovascular health, as there is emerging evidence that “what is good for our hearts is also good for our heads”.

British and French researchers, led by Dr Archana Singh-Manoux of the Centre for Research in Epidemiology and Population Health in Cedex, France, and University College London, examined civil servants aged between 45 and 70 who participated in the major Whitehall II study.

They assessed the cognitive function of some 5,198 men and 2,192 women over a 10-year period from 1997. Using tests of verbal and mathematical reasoning, short-term verbal memory and tests for verbal fluency and vocabulary, the authors found cognitive scores declined in all categories except vocabulary, and in all age cohorts.

There was a 3.6 per cent decline in mental reasoning in men aged 45 to 49, while males aged 65 to 70 showed a 9.6 per cent decline over a 10-year period. For women aged 45 to 49, the decline was also 3.6 per cent, but this was 7.4 per cent for women older than 65.

An estimated 40,000 to 50,000 people in the Republic live with some form of dementia.

Irish Times

MINISTER FOR Health James Reilly is to ask the Health Service Executive to redraft its service plan for 2012, which proposes wide-ranging cuts to frontline services.

Cuts in home-help hours were among proposals Dr Reilly found unacceptable in the draft service plan. He wants the HSE to redraft it before he presents it to Cabinet for approval.

The plan is the legal agreement between the HSE and the Government on how its €13 billion budget will be spent this year. It was presented to Dr Reilly last month and will be brought to Cabinet for final approval by January 13th.

Under the plan, the budget for primary care/community demand- led services was set to fall by €51 million. However, a new target to save €124 million on drug costs was also proposed. A 5.5 per cent cut in home-help hours was also included.

In the mental health area, the plan said there would be closures of core service elements such as acute in-patient beds, acute community services and high-dependency continuing care.

A spokesman for the Minister said Dr Reilly was hoping the HSE would produce a “more ambitious plan” which would “require the system to become more productive in a better and more innovative way”.

The cuts to home-help hours were unacceptable given there were already too many people in long-term care, he said.

Dr Reilly also wanted to see “more ambitious targets” for day surgery and changes to the way services were delivered, the spokesman said.

The draft plan envisaged cuts in funding for hospitals of between 3 and 7 per cent, depending on the financial deficit being carried over by each hospital. It suggested activity levels in hospitals may fall by 5 per cent next year.

Earlier yesterday Dr Reilly said he was unhappy about parts of the plan, in particular that “a 5 per cent cut in budget means a 5 per cent cut in activity”.

“That is not acceptable. We have to find other ways of achieving the budget requirements and at the same time maintain service to the best extent possible,” he said.

“I acknowledge there may be some reductions in service but to start off the year with the white flag up saying there is going to be a reduction of X per cent, to me that’s not acceptable.”

Dr Reilly said he was concerned about the departure of an estimated 3,200 HSE staff, who have expressed an interest in leaving by the end of February to avail of particular pension arrangements. He said the service plan would have to be reviewed in March when the extent of the departures was known.

Irish Times - 

FIONA GARTLAND

THE DEPARTMENT of Health is asking the Health Service Executive to establish a special fund to pay for services and facilities that would allow more older people to remain in their own homes rather than being moved to long-term residential care.

The special delivery unit in the Department of Health, established by Minister for Health James Reilly earlier this year, has written to the HSE requesting that the new fund be set up in 2012 “to provide for a range of intermediate options so that more older persons can be empowered to remain at home or to return home after convalescence”.

The department said yesterday the size of the fund had yet to be determined.

However, it said that among the measures the fund would look at would be elderly admissions units, specialised elderly care streams in hospitals, rapid access to assisted discharge packages such as home aids, home care packages, fast access to step-down rehabilitation and rapid re-entry to acute hospital services if needed.

However, money for the fund would have to come from existing HSE resources.

The department said work was underway to identify the multiple sources from which funding should be re-allocated to go into the fund.

Dr Reilly has said he is “most keen” for the development to be progressed. He said many people were currently assessed for their nursing home care while in acute hospitals where they were still ill.

“This is not appropriate. They should be assessed in an intermediate care facility while undergoing rehabilitation where a much clearer idea of their status will become apparent.”

The Minister said: “People should be allowed to stay at home for as long as possible, in their communities surrounded by their families. I don’t know of anyone who wishes to be in a long-term nursing home sooner than they need to be.”

It is understood that a recent audit of almost 1,200 common summary assessment reports on older people carried out by the HSE found that in 93 per cent of cases the patient was recommended for long-term residential care.

However, the HSE audit found that in 40 per cent of the cases it was clear the individual had not been considered for a home care package. In a further 40 per cent of cases it was not clear if the individual had been considered for a home care package.

The HSE audit also found that in 16 per cent of cases where people had been placed in long-term care they were described as having “low” dependency levels while in 29 per cent of cases the dependency level was described as “medium”.

Department sources said yesterday the “Fair Deal” or nursing home support scheme was intended to benefit persons of the highest dependency.

Since his appointment Dr Reilly has repeatedly expressed his concern that too many older persons, who did not need to be there, were being placed in long-term residential care.

He has also maintained that the State should move to give greater certainty that older persons are empowered to remain in their home for as long as they would wish to do so.

However, the proposals for the fund to keep as many older people as possible in their own homes comes at a time when large numbers of public nursing home beds are under threat of closure as a result of budget cuts, the staffing moratorium and new HIQA standards.

The Minister has suggested that smaller community nursing units with fewer than 50 places are vulnerable.

It also comes just months after the Fair Deal scheme ran into funding problems.

In a recent letter to the HSE, the chief operating officer of the new special delivery unit Tony O’Brien made reference to a meeting “to discuss a proposal to earmark a fund in 2012 from existing resources to more flexibly and appropriately address the needs of older persons in the acute hospital and community sectors”. He said the meeting agreed that the “proposal needed to be developed as speedily as possible”.

Irish Times

Home Care