Evaluaciones registradas:

Phase One Interviews

Ten main themes were identified through the analysis of Phase One interviews. Aim and philosophy of service

Findings from the research indicate a clear ethos of enabling older people to stay in their own homes for as long as they wish, or as long as is possible. Two interviewees, however, felt that current care provision did not have a coherent philosophy informing it.

Social and cultural factors in the delivery of care

Several interviewees discussed the role of the medical model of health and personal care in Ireland, feeling it to be unduly dominant with consequent under-development of social services. Another issue that arose was the rapid change in family systems and

structures in Ireland. Emphasis was placed on the fact that families are now more widely dispersed, and the concept of the extended family is much less important than it once was. Finally, the need to increase awareness of ageist practices within the health boards was also referred to.

Services available for older people in the community

The main services available for older people in the community were identified as public health nursing, community mental health nursing, general nursing, home help, meals- on-wheels, physiotherapy, occupational therapy, social work, speech and language therapy, dietetics and chiropody. All these services were described as severely under- resourced and under-staffed. Speech and language therapy, dietetics and chiropody were seen as especially under-resourced. Interviewees also expressed concern about the lack of administrative and IT support available. This was regarded as placing severe strain on the ability of service providers to function effectively.

The process of delivering care

Referral pathways: a variety of referral pathways were described by interviewees, including self-referral, referral via social workers and consultants, or by word-of-mouth. However, public health nurses, general practitioners and consultant geriatricians emerged as key referral agents.

Eligibility: two main criteria emerged as key factors in deciding whether someone was eligible for public services or not. The first criterion was whether an individual was eligible for the ‘medical card’. The second criterion was the level of assessed need. However, there was a degree of flexibility on the part of interviewees in determining eligibility. Assessment: a variety of assessment tools were identified as currently in use in community service provision. These included the BARTHEL, Roper-Tierney and Winchester instruments. Some interviewees also referred to a number of initiatives whereby generic assessment tools are being developed and piloted.

Monitoring and evaluation: in the main, formal guidelines for monitoring and evaluation were not viewed as being in place, although interviewees from two health board areas did refer to plans to develop monitoring and evaluation guidelines and procedures. Feedback and complaints: two routes for receiving feedback and complaints were identified. The first is via informal communication networks (with the public health nurse regarded as the main contact). The second is via formal complaints and grievance procedures set up by the health boards.

Service flexibility: interviewees felt that current service provision, being so under- resourced, cannot easily adapt to the changing circumstances and needs of older people. Information dissemination: information was regarded as being of key importance in empowering older people to make fully informed choices about their care. Information is mainly disseminated through information booklets and leaflets.

Management structure and reporting relationships

In the main, health boards use a line-management arrangement alongside inter- professional management (such as multi-disciplinary teams). Services therefore tend to have discrete reporting relationships which connect only at certain points through multi- disciplinary arrangements. Control over budgets generally rests with middle or senior management, although some moves towards increased devolution have taken place. The public health nurse and the general practitioner were identified as key service providers in the community.

Communication

Communication between service providers was seen as playing an important role in current service provision. Communication was also described as operating on an

informal basis. However, some formal arrangements, such as hospital-community liaison meetings and multi-disciplinary teams, were described as an improvement. At planning and administration level, care groups and service planning groups were also mentioned as measures to improve inter-professional communication.

The role of the service user: although there was a general recognition that the dignity and rights of older people and their carers should be central to care planning, in general there were no formal guidelines identified for consulting them. However, services and carers have consequently established strong informal links with older people.

The relationship between health and social services and the voluntary sector: there was a general consensus that links between health and social services were under-developed. Health boards were described as being very dependent on the voluntary sector which provided services that the statutory sector could not.

Care and Case Management

Interviewees discussed some of the key areas of potential difficulty that could arise with the introduction of Care and Case Management. There was concern that it could be difficult to negotiate the existing reporting relationships and yet maintain the

acceptability of Case Managers. Another key issue that arose was the preferred professional background of Case Managers. There were a wide variety of opinions – some felt that Case Managers should have a nursing background, while others felt that the key skills of Case Management were not specific to a medical background.

Pilot projects

Thirteen pilot projects were identified which aim to improve care provision for older people. Nine of these were considered to be ‘near’ Care Management, with the

appointment of an individual to act as service co-ordinator, key contact for older people and their carers, and a designer of care plans (see Table 4.9).

The state of care in Ireland

Interviewees were asked to undertake a SWOT (strengths, weaknesses, opportunities and threats) analysis of current care provision in Ireland. The voluntary sector, the public heath nursing service and the home help service were cited as key strengths. Three main weaknesses emerged from the research: lack of resources and staff; lack of transport (especially in rural areas) and the gathering and dissemination of information. Only a few interviewees identified opportunities for service development and threats to service improvement. The opportunities cited included improving transport facilities; investing in community and home-based care; recruiting more registered general nurses to support public health nurses; reviewing the role of the public health nurse;

up-skilling staff such as care attendants to take over personal care tasks, and

increasing the flexibility of existing services. Threats identified (other than staffing and recruitment) were poorly organised referral pathways; a reluctance to identify older people, especially those with dementia, as a priority; communication and inter- professional collaboration difficulties, and high demands placed on informal carers. Staffing and recruitment problems throughout all sectors of health and social care were viewed as the single biggest obstacle to service development.

Staffing and recruitment

It became clear during the research that problems to do with recruiting and retaining staff were viewed as the single biggest obstacle to service development by those who took part in the first phase of fieldwork. It was evident that these staffing problems run through all aspects of care – in hospitals and in the community.