Local authority nursing homes used to have an image problem but that is changing. One health board is developing a holistic approach to the care of older people, writes Carol Coulter.
The recent controversy about charging medical card holders for nursing home care offers an opportunity to consider how best the State can cater for the needs of older people, who have contributed to its wealth over many decades. One health board area has already been examining new ways of tackling this problem.
More than 13 per cent of the population of the North-West is over 65, compared with 11.1 per cent of the population in the State as a whole. Rather than seeing this as a problem, the North West Health Board has embraced it as an opportunity to develop a policy on the care of older people, which it called the Choice programme. Its booklet on the programme is proudly entitled, The North West - the best place to grow old.
Choice is described in the booklet as a philosophy of care with the older person at its centre. "It is holistic, looking at the person's total needs. It will mean that the needs expressed by older people will drive the planning and delivery of services," it says.
The programme began in 2000 with an examination at how the board was delivering services to older people. "We realised we were making decisions for them. The focus was on beds, on people's frailty and dependence," says Bridget Smith, area coordinator for services for older people. "We started listening to older people."
This began with a project, conducted by a researcher from UCD, where 113 older people in Sligo-Leitrim and the same number in Donegal were surveyed. "Ninety-seven per cent of them said they wanted to stay at home," Smith notes.
"Their vision of themselves was very positive, not frail at all. So we decided to support people at home as far as possible." The board then examined what contacts and supports were available for people staying at home, and developed a graduated system, ranging from people receiving support in their own homes, to accessing day centres and day hospitals, with medical supports in their own homes, and, when they eventually need it, to moving to full-time residential care.
However, that need not be a final move, and sometimes people move into residential care on a respite basis, or following medical treatment, and, when they are able to, they move home again. "We have a lot of people at home who are very dependent, getting a lot of supports," Smith adds.
"This means that the age profile of those coming into residential care is much higher than it was. People are staying at home until their late 80s or early 90s."
Jacinta Feeney, matron of St John's community hospital in Sligo, which provides residential care, agrees. "It also means people are not in residential care for 10 or 15 years, as they used to be. They are here for much shorter periods."
St John's also seeks to put the needs and wishes of its residents at the centre of its care policy, and try to keep them involved in the community.
"We used to have outings from here to places like Knock," Smith adds. "But when we asked people what they wanted, they wanted to go back to their own village or townland, to see the neighbours for a drink.
"We used to discourage people from going home, in case they wouldn't want to come back. We thought they'd abscond. Now people sometimes go home for a day, or a night, and we send a staff member with them."
Local authority nursing homes, or community hospitals as they are now called, used to have a bad image, and a stigma was attached to going there. Now people want to come to St John's.
Feeney acknowledges that some of the practices of the past undermined people's dignity. There was communal clothing up to 10 years ago, and people were rarely consulted about what they wanted. Much also remains to be done with the physical environment, with the building laid out in wards and about six residents sharing each ward. This arrangement offers very little privacy, and means that residents spend a lot of time sitting by their beds.
"We're moving away from the nursing model," Smith says. "We won't be building any more of these type of wards, and we'll be moving to individual apartment-type accommodation, with services brought in. But that will take time."
In the meantime, funding has been acquired for the revamping of existing wards, turning some rooms into communal dining and living areas for those who want to use them.
There are no means tests for older people accessing care in the NWHB region. People get care on the basis of need, and those in residential care are referred by GPs or acute hospitals. There are no waiting lists. Until the practice was found to be illegal, they paid for their care out of their income, which in almost 100 per cent of cases derived from their social welfare payments. There are few people in this region who could afford private nursing home care, and the private nursing homes themselves rely on tax-payers' money through contract beds (paid fully by the health board) and the nursing home subvention scheme.
"So much of what we do is not about money," Smith says. "It's about attitude and culture. How can we improve people's quality of life?"
If this, rather than the question of funding, is at the basis of the future debate around the needs of older people, then a national integrated policy with residential care as a last resort can be developed in a coherent way.
'We are trying to empower the residents'
One of the wards in St John's community hospital in Sligo is to become a practice development unit, accredited by the Nursing and Midwifery Faculty of the University of Leeds as a centre of excellence.
The ward, and others in Our Lady's, Manorhamilton and the community hospital in Killybegs, also run by the NWHB, are the only places in the State involved in this form of practice development, although the Leeds model has been taken to Australia and the US.
The practice development unit involves a team from the university co-operating with the staff from the ward in setting up an evidence-based system of care built around the needs of residents, as articulated by them. The privacy and dignity of the residents are among the criteria measured against standards drawn from the Leeds University model.
A co-ordinating group of people, drawn from nursing management, nurses, care staff, occupational and physio-therapists, household and catering staff and, of course, the residents, meet weekly.
Encouraging the residents to articulate their views, and, where necessary, their criticisms, was a major hurdle, and families are also involved to help push this forward.
"The residents forget they are at the centre. We're looking at ways of empowering them so that they play an active part," hospital matron Jacinta Feeney explains. "We're developing a questionnaire, we will have focus group meetings and one-to-one meetings, encouraging people to be more involved in consumer groups."
Already these consumer groups have identified the demand for a large screen showing old films, which are enjoyed in a social setting with a beer or a whiskey. Another innovation was Country and Western music sessions, again, with a drink for those who wanted one, according to Marian Flannery, assistant director of nursing.
"It's actually about changing the culture," according to Jacinta Gallagher, who, along with Mary Kilfeather, is in charge of the practice development unit.
"The emphasis is on the whole team. We have to make sure that all members of staff, at every level, feel they can speak out."
There is also a steering group for the unit of "critical friends", involving family members, a representative from St Angela's College, which provides an educational input, coordinator for services for older people Briget Smith, and representatives from the medical staff and management within the service. This will meet three or four times a year to review the progress of the unit and offer suggestions.
The experience of the practice development unit, assuming it achieves and maintains accreditation from Leeds University, will then be used as a basis for expanding this system throughout the hospital.