DEAGLÁN DE BRÉADÚN Political Correspondent, in Glenties

Systems to provide long-term care for the elderly are largely chaotic, with many people confused about their rights and entitlements and subject to years of stress and crippling expense, Ombudsman Emily O’Reilly said today.

Although the newly-introduced “Fair Deal” Nursing Homes Support Scheme would improve things for many people, what effectively happened was the State now believed it had no further responsibility in this area.

Speaking to the MacGill Summer School Ms O’Reilly said she would shortly publish an investigation into the operation of this sector over the last number of years by the Department of Health and the Health Service Executive.

“It will tell of a largely chaotic ad hoc system, in which many people were not alone confused about their rights and entitlements but also suffered years of stress and crippling expense because of the deliberate failure of the system to clarify their rights to public care let alone provide for them.”

She added: “I am aware that the new system – the so-called Fair Deal system, the Nursing Homes Support Scheme – will make things a lot clearer and a lot better for very many people, but as my investigation will point out, what has effectively happened through the new legislation, is that the State believes it has now divested itself of the responsibility to provide nursing home care.”

She said while Irish people had fancied themselves as possessing “a great community sense” the fault-lines in the health and social services reflected the lack of a shared approach to the State’s responsibility to vulnerable groups.

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GENEVIEVE CARBERY – Irish Times

CALLS FOR the pension not to be reduced in December’s budget were made by three groups representing older people yesterday.

They argued that pensioners had already experienced income and service cuts and such a move would place more older people below the poverty line.

Income reductions already experienced by older people included the loss of the Christmas bonus, dental benefit and optical benefit, as well as the introduction of prescription charges and increased fuel costs, said Mairéad Hayes, chief executive of the Irish Senior Citizens Parliament.

Many older people were “hovering around the poverty line” with one in 10 pensioners living in poverty, Eamon Timmins, head of advocacy at Age Action, said.

Despite a public perception that older people had escaped cuts “nothing could be further from the truth”, he added.

Recent service reductions which have made life more challenging for older people included rationing of home help and meals on wheels as well as the cessation of local authority home adaptation and mobility grants, he said.

Increases to the State pension since 2001 were just playing catch-up, said Patricia Conboy, director of the Older and Bolder campaign. Reductions in the cost of living were largely based on lower housing costs which was “not widely relevant to older people . . . In the areas that do affect them, costs have been increasing.” The inequity of private pension tax relief might be a more appropriate focus for analysis, she added.

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The Irish Times – Tuesday, July 6, 2010

Beyond caring

HSE cutbacks are putting community health services under strain, causing widespread anguish, not just for the most vulnerable citizens of the State but also for those caring for them at home, writes MARESE McDONAGH 

INCONTINENCE PADS are being rationed, there are plans to put home helps on a stopwatch when showering elderly clients, and parents are fretting because some public health nurses are too stretched to carry out infant developmental checks.

Ward closures may grab the headlines, but advocacy groups are on red alert as HSE cutbacks put community health services under strain, causing widespread anguish, not just for the most vulnerable citizens of the State but for those engaged in the thankless task of caring for them at home.

Enda Egan of the Carers’ Association is not easily shocked, but he was appalled recently by the indignity inflicted on some of his members, in the name of saving the HSE a few euro.

Egan was horrified to learn that some carers who dared to ask for extra incontinence wear to make their loved ones more comfortable, were asked to bring in used “nappies” to be weighed.

A small number of so-called “incontinence managers” put carers through this trauma in a crude attempt to measure the amount of fluid passed, in order to calculate if they really did need more than the permitted quota of pads, he says.

“We have come across four cases in two months,” says the Carers’ Association chief executive, who has long waged a campaign to highlight the injustice of having incontinence wear subjected to the “luxury” 21 per cent VAT rate.

Egan believes the HSE is snipping away at community health services because, despite the lip service paid to the importance of caring for our elderly and infirm in the community, “it is an easy one to cut”.

His association estimates there are 160,000 carers in the State, most of them family members who provide three million hours of care per week. There are 40,000 full-time carers, slightly more than the 39,000 nurses in the Irish hospital system.

“Of course, you can’t spot them as easily,” says Egan, who believes the value of the 24-hour care provided by these people is incalculable – and worth a lot more than the maximum means-tested €212.50 weekly payment, which only a fraction of the carers get.

A study commissioned for the Jack and Jill Foundation earlier this year underlines that point. The independent Trinity College report, entitled There is No Place like Home , found that it is nine times more expensive to provide acute hospital care for children with severe intellectual and physical disabilities than to have them cared for at home.

The foundation supports 320 families who care for children at home. But just 19 per cent of its annual €3 million budget comes from the State – and recently it suffered a 6.5 per cent “value for money” cut. Last week, the Minister for Health allocated an extra nurse to the foundation.

But spokeswoman Carmel Doyle points out that recycled mobile phones are still its main source of income. While they have been a spectacularly successful source of revenue, she wonders how long vulnerable children, who in many cases cannot walk, talk, see or eat independently, will be able to depend on the nation’s cast-off phones in order to survive.

For financial reasons, the foundation can only support children up to the age of four but, according to Doyle, more revenue is urgently needed so that it can extend its remit to children aged up to six. “We don’t want to leave them high and dry at four.”

Sinéad Moran, paediatric co-ordinator with the Jack and Jill Foundation, said that 35 children on its books have reached or are about to reach the four-year-old threshold and negotiations are under way with a view to getting the HSE to replace the nursing hours these families are about to lose.

“Many just won’t cope if they don’t get this nursing care,” she says. Moran says there is also a huge issue now for parents of severely disabled children, who find that funding for specialist equipment is drying up.

“These children need special equipment, buggies which support their trunks, special chairs for feeding, walking frames which allow them to stand for maybe 20 minutes a day. They now have to wait months for these things and it is putting a lot of strain on families.”

The foundation provides a nurse two nights a week to the parents of Tommy Simon from Knockarush, Boyle, Co Roscommon, a severely disabled boy who requires round-the-clock care.

“They have been sent to us from heaven,” says Tommy’s father, Frank, who explains that without help at night he and his wife, Niamh, would never get any sleep.

“Our problem is that Tommy will be four in a few weeks’ time, so that is a big worry,” adds Frank. Other parents are worried too.

The Irish Nurses Midwives Organisation (INMO) has warned that the roll-out of the cervical cancer vaccine programme combined with staff shortages means that the ongoing problem of delayed developmental checks for babies will continue.

Labour’s Health spokeswoman, Jan O’Sullivan, says that in many parts of the State, checks which should be done at nine months and which are crucial for picking up hearing difficulties, are being delayed.

“We have also had reports that hearing and eyesight tests, which are usually done on junior infants, have not been done in some schools this year,” she says.

The abrupt closure of respite centres such as Bawnmore in Limerick is causing anguish for carers, many the elderly parents of intellectually disabled adults, who will now never get a break even when ill, she points out.

The closure of the Brothers of Charity facility, which catered for 63 families, has been described by the chaplain, Fr Joe Young, as “the greatest injustice I have experienced in 34 years as a priest”.

The HSE says no decision has been made that has an impact on developmental checks or routine vaccinations in order to facilitate the HPV programme, but some parents say there have already been significant delays.

The HSE acknowledges that last winter’s swine flu campaign, “the largest public health immunisation campaign ever undertaken in Ireland”, led to deferrals of some routine vaccinations and developmental checks. But it says catch-up campaigns have been in place since April.

Claire O’Connor, from Harold’s Cross in Dublin, says her son’s nine-month check is now a month and a half overdue and she is worried about his hearing because he has been getting repeated ear infections.

“I know I can bring him to the GP and I have done that,” she says. “But apart from the fact that it’s €55 every time and I am on unpaid leave from my job, GPs don’t specialise in paediatric care, and I was hoping to have him seen by someone with specialist training who would pick up any problems from a developmental point of view.”

The first time she rang her local health clinic she was told there was a huge backlog and to call back in a month if she was not called.

“I did that but the next time they did not even seem to have me on record and they were telling me that the check can be done any time from nine to 12 months,” she says.

Phil Ní Sheaghdha, director of industrial relations with the INMO, says that if the moratorium is not lifted, public health nurses, still playing catch up after last winter’s swine flu vaccination programme, will be so busy with the HPV vaccine that developmental checks will be further delayed, with potentially damaging consequences.

She stresses that PHNs doing these checks in the home also pick up on other serious issues such as post-natal depression and problems with breastfeeding.

Ní Sheaghdha says there could also be child protection implications if nurses are too stretched to visit vulnerable families. “Sometimes parents don’t want a social worker to call maybe because they are afraid of losing their children, but they don’t have a problem with a public health nurse,” she explains.

Ní Sheaghdha says staff shortages caused by the moratorium on recruitment means public health nurses are not calling to see vulnerable elderly people as often as they would like. “And we have been told that there is a waiting list for palliative care in Kildare. You cannot wait when you are dying,” she says.

Age Action Ireland recently highlighted proposed cuts to home help services, which many working in the sector say could actually put vulnerable people at risk.

The HSE draft guidelines proposed that home helps allocate just 10 minutes to getting older people up and dressed in the mornings, while 15 minutes was the recommended allotted time for helping someone shower.

Ten minutes should be spent getting breakfast and the home helps should spend their visit looking after the client’s “personal care” rather than doing housework or other tasks such as popping out for a litre of milk.

Public health nurses, who are themselves spending less time doing what they regard as essential “surveillance” work spotting potential health problems before they develop, are also horrified at the attempt to speed up home helps.

“How long would it take you to transfer someone from a wheelchair onto a shower seat and get them showered and back out again?” asks one nurse. “Apart from the stress this would put on any elderly frail person whether in a wheelchair or not, can you imagine the consequences if they slipped and fell and maybe broke a hip because someone was trying to meet a deadline?”

Noel Treanor, the INMO’s industrial officer in the northwest, says that early discharges from hospital means an explosion in the number of people requiring support in the community – at a time when the moratorium and the vaccine programmes mean PHNs are unable to do vital surveillance work.

“Not everyone is articulate enough to demand the assessment or the follow-up care they need,” says Treanor.

He points out that because manpower is so stretched, nurses in some regions have been given a list of priorities, which beg the question which services are being put on the back burner.

Maureen Kavanagh, chief executive of Active Retirement Ireland, says it is wrong to even contemplate putting a stopwatch on a home help who is assisting a frail elderly person to have a shower or to get dressed.

“I am concerned that these things are being done from an administrative point of view. Timing a shower is a paper exercise – it has nothing to do with the human.

“I would question whether we are losing the human touch in the health service. If we do, this will not be a good country to grow old in.”

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 Niall Hunter, Editor – www.irishhealth.com]

Our health service currently comes in two versions – the official one that tells us that real reform and progress is being made in delivering better care.

And then there’s the harsh reality that many of us are only too aware of, and which poses a major question mark over the safety of care being delivered.

Much of the HSE’s latest annual report read more like a glossy company report than an account of how a ‘patient-centred’ health service is being delivered. You cannot help but get the impression that there is more emphasis on financial rather than patient outcomes.

We are told that the HSE had delivered services 3% ahead of targets, extra services were provided within budget, that staff numbers came in below projected levels and that savings were achieved through efficiencies and cost containment measures.

The HSE trumpeted the progress it was making in (slowly) setting up primary care teams, in cutting waiting lists (although numbers are starting to rise again, which didn’t get a mention), in opening some new hospital units and services, and in treating 3.4 million outpatients, although again it was not mentioned that there are over 175,000 people on outpatient waiting lists.

However, HSE CEO Prof Brendan Drumm, in one of his valedictory statements as he enters the final lap of his tenure, also told us that staff were going that extra mile to provide ‘more care with less funding’. At first glance this sounds like a good thing – getting better healthcare value for money for our tax dollars.

And it cannot be denied that the HSE under Prof Brendan Drumm has had to live recently in straitened budgetary times, but has managed to root out some waste and inefficiency, as well as recording some successes such as re-organising cancer care.

However, might ‘staff going that extra mile to provide more care with less funding’ also mean ‘staff struggling to maintain safe and quality care with ever diminishing resources?’

Read another report, the latest HSE financial performance report, for the year up to the end of April, and you’d be inclined to take the more pessimistic view.

The report showed us that the HSE, which has suffered a massive €1.2 billion budget cut this year, is finding it difficult to deliver a reasonable standard of service within the unprecedented budgetary restraints it is now labouring under.

The situation is exacerbated by the fact that the pay cuts and income gathering targets aimed at meeting most of the deficit are not being met. The fact that the job reduction target is not being met means that new posts may be denied to vital new services in areas such as cancer.

The HSE’s financial report expressed concern about the effects of the recruitment moratorium on service delivery, indicating that vital frontline staff were not being replaced. The HSE’s deficit for the year is already exceeding €100 million, and while that is small in the context of a €14 billion allocation, in terms of a tight budgetary situation it can mean a lot. And further cuts may have to be made to deal with it.

The HSE has been learning to live on diminishing resources over the past few years. The obvious challenge is how much further can the budget cuts go before the HSE holds up the white flag and says it cannot guarantee a safe service for the money it has at its disposal.

Recent events would indicate that the level of cuts being imposed on the HSE are starting to compromise the delivery of safe and good quality care. And at this stage the warnings being given are not merely industrial relations or vested interest rhetoric.

These worrying developments include:
* Extra beds moved onto wards/beds on corridors to cope with increasing pressure on emergency departments (EDs). Traditional summer decrease in trolley numbers not taking place to any great extent.
* Ambulances delayed at a major Dublin hospital while their trolleys were used for the ED.
* Patients dispersed from an Alzheimer’s unit at a Dublin hospital.
* Some patients requiring MRI scans having to wait three to four months to get a scan.
* Delays in developmental check-ups for infants.
* Continuing cuts in acute bed numbers with no real evidence of transfer of resources to boost primary and community care.
* Growth in numbers on inpatient and day case waiting lists.
* Institute of Obstetricians indicating that maternity units may currently be prevented from sticking to best practice guidelines due to a shortage of staffing and resources.
* Threatened scuppering of plans to hire staff for new cancer services.
* HSE itself admits that it is concerned about the recruitment moratorium’s effect on service delivery.

The crisis the HSE faces in terms of delivering adequate services with less and less money will be the most immediate challenge facing new CEO, Cathal Magee, when he takes over on September 1.

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