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Northern Ireland Forum
for
Political Dialogue
~~~~~~~~~
COMMUNITY CARE
&
THE HOME HELP SERVICE
- An examination by Standing Committee C
(Health Issues)
~~~~~~~~~
Presented to the Northern Ireland Forum for Political Dialogue
on 24 April 1998
Adopted CR28
Note
DRAFT REPORTS
This report has been prepared by Standing Committee C for
the consideration of the Northern Ireland Forum for Political
Dialogue. Until adopted by the Forum in accordance with its
Rules, this report may not be reproduced in whole or in part
or used for broadcast purposes.
ACKNOWLEDGEMENT
The Committee is indebted to those organisations and
individuals who willingly and generously gave of their
time and expertise to make this inquiry possible and we
extend our appreciation to all concerned.
CONTENTS
Section Page
1. INTRODUCTION 1
2. BACKGROUND 3
3. PRESENT SITUATION 5
The Home Help Service - A Perspective 5
Regional Strategy 6
Care at Home - Range of Services 6
Care Management 7
Domiciliary Care Services 7
Day Care 9
Nursing Homes 9
Training of Home Helps 10
Fire Lighting 10
Royal Commission 11
4. LIST OF CONCLUSIONS AND
RECOMMENDATIONS 12
APPENDIX
Page
Committee Membership 16
1. INTRODUCTION
1.1 This is the sixth and final report of Standing Committee C (Health
Issues) of the Northern Ireland Forum for Political Dialogue. All of the
Committee's other reports were concerned with Health issues of one
sort or another. This document deals with Community Care. In so
doing it is fair to say that the Committee has now touched upon every
aspect of its original remit. The now discharged remit is:
To examine the health needs of the community in
Northern Ireland with particular reference to health
care administration, acute hospital services,
community care services and access by the rural
community and report to the Forum.
1.2 This report is not so full as we would have liked but in the dying days
of the Forum neither can it be an interim report. The nature of our
findings and recommendations reflect the effort we have made in the
limited time available to us. We would have liked to have spent more
time on this subject but this was not to be. Bearing this in mind we
offer it primarily to the reader as a discussion document that hopefully
will begin a useful debate on this whole area. Clearly there is much
more to be said on what is really a very big and very fundamental
subject.
1.3 Evidence was taken from a number of Community Care providers,
namely:
1
Sperrin Lakeland Trust
Down Lisburn Trust
Newry & Mourne Trust
North & West Belfast Trust, and
Craigavon and Banbridge Trust
1.4 In addition we heard from Help the Aged, representing to some extent
the customer, and from UNISON - the trades union that, inter alia,
represents the Home Helps.
1.5 For the first time in any of our reports we have not printed the
evidence. This is entirely due to the time constraint imposed by the
impending closure of the Forum.
2
2. BACKGROUND
2.1 In the past families were responsible for caring for those unable to care
for themselves, but societal changes have brought about the move
towards the provision of domestic help under the statutory provision of
the 1949 Welfare Services Act.
2.2 The original service was meant to be a part-time or neighbourly help
service for the elderly and handicapped.
2.3 A New Model Scheme was introduced in Northern Ireland by DHSS in
1980. Health and Social Services Boards are required, under the new
provisions, to provide a service in their areas that assists the elderly to
maintain independent lives in their communities for as long as possible.
2.4 Boards contract with the Community and Combined Trusts who
provide the bulk of services on the ground, but it is a mixed economy
which includes the use of privately run Domiciliary Care Agencies.
2.5 Allocation of home help hours to clients takes place under the Model
Scheme which is interpreted in each case by social workers or care
managers who also review the client needs regularly.
2.6 Home helps themselves, we were told, have conditions of service that
are similar to those enjoyed by Social Services staff.
3
2.7 As a result of the People First legislation there are now less people in
institutional care, more people are being discharged from hospital and
more geriatric and psychiatric wards are closing down. More attention
is now focused on individual needs at home. Monies were transferred
from Social Security budgets to the Boards to fund this policy change.
2.8 At the same time however there has been a steady increase in the
number of emergency admissions to hospitals. One possible
explanation for this is that the burden of work placed upon GPs as a
result of People First has meant that they can barely contain the
demand for their services and are referring more people to hospital.
This development accentuates the ongoing tug-o-war for funds between
the community and acute services.
2.9 At least one Trust has developed a 24-hour responsive nursing service
to prevent unnecessary medical admissions. Under the scheme patients
could be admitted to Residential Home beds. It is often more
expensive to keep people at home but the whole idea is that choice
should be offered to the client within certain financial constraints.
Most Trusts, for example, will not provide Domiciliary Care that is
more costly than a Nursing Home bed. Other Trusts have different
yardsticks but the idea is the same.
4
3. PRESENT SITUATION
The Home Help Service - A Perspective
3.1 UNISON believes that the Home Help Service is the cornerstone of
any community care package and that its client base should be
extended.
3.2 The Union would also like to see the service becoming better
structured and trained and consisting of permanently employed staff,
although they admit that this is not a cheap option: "you cannot deliver
proper packages of care without proper funding".
3.3 They also believe that the Home Help Service could be extended to
looking after people with learning disabilities and helping families
generally, for example, instead of taking children into care they could
be left in their home and certain practical support mechanisms put in
place. This would in some cases be better for all concerned.
3.4 Some 15,000 women work in the Home Help Service. Most work on a
casual basis with no real security of employment. Happily some of this
is changing with some of the Trusts taking positive action to improve
the conditions of service of their Home Help staff.
5
Regional Strategy
3.5 The Northern Ireland Regional Strategy Document on Health and
Well-being in the Community is entitled 'Well into 2000'. One of its
aims is to ensure that elderly people, insofar as this is possible, should
be given assistance to remain at home. The document has set targets
for this. The Boards have also produced their own strategy documents
based on regional strategic requirements.
3.6 Care in the community is delivered via the Community Care and Home
Help Services of Trusts and by the voluntary and private sectors. It is
a patchwork that has no central co-ordination.
3.7 UNISON, during its evidence, made the point that time allocations for
elderly clients were insufficient and people were having to make
choices between having the house cleaned and having a meal made for
them. There was also the not to be understated question of human
dignity in all of this.
Care at Home - Range of Services
3.8 Care at home involves the provision of a whole range of domiciliary
services of individual packages of care provided, as has been said, by
directly employed staff or the voluntary and private sectors. The
number of directly employed home helps has fallen to around
two-thirds of the total as a result of the policies of the previous
government.
6
3.9 Trusts also offer respite and residential services for those who can no
longer remain with their families and the services of District Nurses
and Area Wardens.
3.10 Increasing numbers of frail elderly who are entitled to be in a nursing
or residential care home are opting to remain at home and be looked
after with intensive care packages. The home helps are being drawn
into this work.
Care Management
3.11 This is a process of individual needs assessment whereby
multi-disciplinary teams including doctors, nurses and allied
professions are set up to assess an individual's needs in terms of the
services and care they require. The credo it seems is "not just about
adding years to life but adding life to years".
3.12 UNISON, it must be said, feels that clients are not being properly
assessed when Social Services have to make "cuts".
Domiciliary Care Services
3.13 Generally domiciliary care services would include any of the following
or a variant thereof:
Home Care Support Workers/Home Helps
7
Nursing auxiliary visits where they provide input to the social care
package
Night sitting/day sitting
Night Warden Service
Domiciliary outreach
Domiciliary laundry services
Domiciliary meal service
Provision of emergency alarm systems
Any other support services provided in the home excluding those
offered by professionally qualified staff.
3.14 Trusts are always looking at new services that might assist in giving
people a better quality of life.
3.15 It will be seen that the Home Help Service operates within the
domiciliary care umbrella. Home Helps undertake the following tasks:
Personal care of clients, including dressing, toileting etc
Fire lighting
Making breakfast
Making mid-day meal
8
Shopping
Pension collection
Cleaning
Laundry
3.16 The Government follows a policy of 'best value' and we understand is
considering charging where feasible for the provision of domiciliary
services. There is already a means testing for the provision of Home
Help services in certain circumstances.
Day Care
3.17 There is an additional category of service - Day Care. This is provided
outside the home and its objectives are to relieve carers, improve or
maintain the functioning of attenders, or to slow down the rate of their
deterioration.
Nursing Homes
3.18 In the early 1990s some 18% of the elderly population was housed in
Nursing Homes but as a result of reforms funds were allocated to allow
people to stay at home. This figure has now halved.
3.19 We were told that by the year 2000 nearly 11,000 elderly people will
require nursing home accommodation at public expense. This
represents a financial time-bomb which will be difficult to diffuse. In
cost terms additional money of the order of £30m will be required
9
annually. Resources currently are having to be moved from the funding
of domiciliary services to fund residential and nursing home beds.
Training of Home Helps
3.20 Training of home helps varies from Trust to Trust but generally there is
a need for courses in basic food hygiene, lifting and handling, first aid,
control of substances and the specific needs of clients.
3.21 Some Trusts are also opting for paper qualifications for their home
helps, eg NVQ2 in Social Care. Others have produced handbooks for
their staff.
Fire Lighting
3.22 Traditionally one of the first tasks of many home helps is to light the
coal fires of their clients. We have heard evidence to suggest however
that in some areas where alternative means of heating is available
Trusts insist that these be used thereby saving on home help time and
effort which can then be channelled more usefully.
3.23 We are also very aware that electricity charges are still considerably
higher here than in the rest of the UK. Moreover, the cheap and clean
alternative - natural gas - is not available here.
10
Royal Commission
3.24 A Royal Commission on Long Term Care has been set up and is
currently taking evidence. Its terms of reference are:
"To examine the short and long-term options for sustainable
systems of funding of long-term care for older people, both in
their own homes and in other settings, and in what
circumstances the cost of care should be apportioned
between public funds and individuals."
3.25 The Commission will visit Northern Ireland (Queen's University) on
22 June to take evidence.
11
4. LIST OF CONCLUSIONS AND
RECOMMENDATIONS
4.1 We would urge the Government to bear in mind that the Royal
Commission on Long Term Care will report in approximately one
year's time and that no precipitant action is therefore advisable at
this time on the question of charging for services.
4.2 The Royal Commission is visiting Northern Ireland on 22 June.
We urge all those interested in Care of the Elderly to avail of the
opportunity of giving evidence at this time.
4.3 We recommend that those providers of home help services who do
not already do so, work in conjunction with Housing Authorities,
particularly the Northern Ireland Housing Executive, to ensure
that the homes of those who require, or are likely in the near
future to require, the services of Home Helps are equipped with
modern and automated modes of clean heating.
4.4 We call upon Government to take steps to bring fuel costs here
into line with the average for all United Kingdom regions so that
the frail and elderly of Northern Ireland cease to suffer from
'comparative disadvantage'.
4.5 We recommend that there should be greater contact between
Social Services and carers and between the Trusts, perhaps
through the establishment of a regular structured Forum whereby
best practice, ideas and approaches can be exchanged. It strikes
12
us that the needs of clients are assessed in different ways by
different Trusts and even by different social workers or care
managers within the same Trusts. This lack of uniformity creates
inequities and whilst some of these cannot be helped we believe
there is scope for improvement.
4.6 We recommend that where possible the fullest use is made of
'meals on wheels' services and lunch clubs across the Province in
order to release home help time used for food preparation for
more appropriate use. Meals on wheels in some areas is being
developed to cater for breakfast and evening meals and this is to
be encouraged provided it is done to the client's satisfaction.
4.7 Under the present system funds are allocated by the Boards to the
Trusts for community care services. Allocations vary in different
areas. In the case of Combined Acute and Community Trusts it is
possible that the Community side will suffer in order to better
fund the Acute side. An example of this can be seen within the
newly amalgamated Community Care and Acute Services in the
North Down and Ards area. This is a problem which Government
needs to tackle because it inevitably leads to differential treatment
within the Province's client base for reasons that bear no relation
to community need.
4.8 We were impressed by the quality assurance systems introduced
by Down Lisburn and North and West Belfast Trusts and would
urge all Trusts to contemplate similar arrangements.
13
4.9 The Committee was told that there are different charging regimes
for nursing and community care. If a person is assessed for the
former and their family is able to pay for the care then they are
charged at full cost. In the case of the latter, ie the assessment is
for a community care purchase whereby the patient remains at
home, there is no charge. This practice seems to us to be
indefensible and we recommend that the Department examines the
situation with a view to developing a consistent policy.
4.10 The Committee understands that it is usual for Trusts to restrict
house cleaning to what has been described as "health-related
cleaning" ie the cleaning of toilets, kitchen areas etc. This is done
in order to effect cost savings. However we feel that consideration
should be given to some relaxation of this guideline in the interests
of basic hygiene and that house cleaning should be carried out at
least on an occasional basis.
4.11 The Committee is aware of an anomalous situation whereby
charges are levied in certain circumstances to clients for the
provision of in-house home help services, but where services are
provided by private contractors, through the Trusts to other
clients in similar circumstances, no charges are made. We
understand that DHSS is aware of the anomaly in the guidance to
Trusts and is considering how this might be dealt with. It is an
intolerable administrative inequity and we look to DHSS to take
prompt action.
14
4.12 We learned of the low uptake of benefits by senior citizens in
Northern Ireland and wonder whether it might be possible for
closer liaison between Social Services and Social Security staff in
an effort to tackle the problem.
15
APPENDIX
16
APPENDIX
STANDING COMMITTEE 'C'
(HEALTH ISSUES)
Committee Members who were Active at the Time of Study
Mrs M Beattie DUP
Mr C Calvert DUP
Mr G Campbell DUP
Mr S Foster UUP
Mr S Gardiner UUP
Mr P King UUP
Mrs M Marshall Alliance*
Dr H McKee Labour*
Mrs J Parkes DUP
Mrs G Rice Alliance*
Mr T Robinson UUP
Mr H Smyth PUP
* Attend Committee on behalf of the Party under Rule 14(4)(a)
17
18