Second Opinion: Two cheers for the HSE on Ireland’s care for the elderly

Praising the HSE is assuredly a minority sport. Yet a sad aspect of recent years has been the sustained "talking down" of the Irish health service. Despite its travails, our health service has rated reasonably highly in international reviews in the past.

Savage budget cuts at a time of increasing need are eroding this standing, but these can be in part attributed to a pervasive negative public discourse about the health services.

By nourishing a perception that health is an organisational basket case, it diminishes the political impetus for adequate funding.

This was crystal clear last year when health took a disproportionally large budget cut compared with other major Government departments. A dismissive public rhetoric on the HSE cannot have aided in fraught Cabinet discussions with seasoned and professional politicians competing for scarce funding.

In truth, some barriers to improvement in the health services arise from a reluctance to change among the population and their public representatives.

Resistance to reorganise
This is vividly illustrated in the resistance to reorganising hospital services to a smaller number of larger units with a better likelihood of critical mass of both patients and services.

We are not good at acknowledging the wide range of motives underlying this resistance, not all are noble or wedded to modern concepts of healthcare.

In addition, public ambivalence continues about rules for eligibility for healthcare, as the debate over discretionary medical cards shows.

While I am personally in favour of universal healthcare and the diversion of revenue to pay for its increased cost, the current system generates insecurities, ambiguity and clientelism about what merits a “discretionary” medical card.

In the midst of all this, the systematic and worsening under-funding of the HSE can blind us to the wide range of experience, professionalism and enthusiasm in our health service.

While the smoking ban was one area where Ireland showed leadership, in the area of care for older people we have also made strides.

First report of elder abuse
In elder abuse, the health services moved rapidly in international terms, setting up a network of case workers within a decade of the first reports of elder abuse in the professional literature.

Following the Leas Cross report, standards for nursing home care and an independent inspectorate were instituted in a speedy and collaborative manner.

The latest major development is to address the pressing need in the Irish system for a unified system for assessing disability and vulnerability among older people accessing services, whether community, hospital or nursing home.

Following intense scrutiny of available measures by a working group representing older people and many professions, the only show in town was an impressive, intuitive and sophisticated assessment known as the interRAI, to be known in Ireland as the Single Assessment Tool (Sat).

The interRAI has been adopted by more than 30 countries, allowing for international benchmarking of quality of care, service developments and the degree to which services are "age-friendly". It is under continuous development and revision by a not-for-profit group of professionals from around the world, which will include Irish representation.

Evolving science
This is important as the science of caring for older people is evolving constantly, and assessment schedules need to take account of these changes in due course.

The assessment is clinically useful, reasonably brief, computerised, and fulfils four goals: it supports individual care plans for common conditions such as incontinence or memory problems, it can help generate dependency levels, it assists regulatory authorities and allows for the collection of meaningful statistics nationwide.

Widely used through the developed world, it is unique in its ability to support improved standards and research in nursing homes and community care, although it will not do so on its own, and needs to be implemented in a context which recognises the importance of appropriate philosophies of care, staff training and resourcing.

Irish innovation
A particular Irish innovation has been an extra assessment of carer needs, and this is likely to be invaluable.

With implementation aided by a significant grant from Atlantic Philanthropies, Ireland has an opportunity to make a big stride in age-attuning its services, and the development to this point has been very professional, with a first Irish study showing encouraging results.

For many, there will need to be a need for training and adaptation of how we work, but the longer term benefits will be significant.

At least two cheers for the HSE?

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