Although increasing age is associated with many positive qualities it is also a period of life when disease-related disability is at its highest prevalence. An increasing proportion of older people will require some support in maintaining basic and instrumental activities of daily living¹. Ideally every step should be taken to prevent age-related disability. Should such disability arise, every attempt should be made to ensure that that this disability is minimised through appropriate and full assessment and remediation. However, even when this process of prevention and intensive assessment and rehabilitation is carried out, there will always be a proportion of older people which will require long-term care: this proportion will increase with advanced age. An essential strategy in long-term care is that where possible the persons own choices should be followed and secondly that the supported provided should be appropriate to their care needs. This long-term care can be provided either at home or in institutional care and both The Years Ahead² and The Health Strategy³ have specified a preference for care at home wherever possible.

Currently there is no clear statement of policy on prevention, assessment, rehabilitation, standards of care and the maintenance of quality of care, independence and dignity for long-term care. This policy document intends to delineate basic principles and standards in each of these areas.

1.Gateways to Care

As age-related disease is the cause of all age-related disability, it is critical that all those with acquired disability should have appropriate assessment and remediation through either a Department of Geriatric Medicine or Psychiatry of Old Age. No binding decisions should be made on long-term care until the course of remediation is considered to be complete by the relevant specialist.

2.Equity, financial access

The current system of a combination of public, voluntary and contract beds in private nursing homes along with subvented beds in nursing homes is distinctly inequitable. There is no clearly-stated, consistent and transparent policy among the Health Boards about means testing and the disposal of assets. This means that in beds side by side in a nursing home, a patient and family may have gone to considerable distress and disturbance to dispose of assets and pay to make up the difference between subvention and nursing home costs, while in the next bed a patient with similar assets may be paying nothing at all as they are in a contract bed. A similar situation occurs with access to publicly funded beds. This anomaly should be clarified immediately and there should be a level playing pitch. It is the responsibility of the Health Boards and not of individual clinicians to clarify the financial entry criteria.

As the disabilities which give rise to the need for long term care are caused by age-related disease, the financial criteria for access to long term care should parallel those to other forms of healthcare. In the United Kingdom, the Royal Commission on Long Term Care for the Elderly has recommended that these services should be provided without cost to the patient⁴. The current system of funding may consume all of an older persons financial resources. Each older person in long-term care should be left a proportion of their income to cater for personal needs, as is currently the situation in the United Kingdom.

Where residual disability leads to a need for care it should be assessed as to whether this can be provided in the community by a package of care or in institutional care. The persons choice should be facilitated in this regard and the resources should be equivalent and adequate whether pursued in the community with a package of care or in institutional care.

3.Ongoing Health Needs

By nature of their age-related disease and disability, people who require packages of long-term care are compromised and are prone not only to exacerbations and deterioration of underlying disease processes but also to intercurrent illness. These health and ongoing rehabilitation needs will require expert medical and nursing and paramedical care⁵. We would recommend that in those cases where the package of long-term care (either residential or institutional) is not provided by the patients own family doctor with appropriate support, that this should be provided by a family doctor with a Diploma in Medicine for the Elderly. The input of medical care to patients receiving long-term care should be resourced to recognise the extra medical needs and demands on this medical service by this frail and vulnerable population.

There should be adequate training for the nurses and where possible should include a Higher Diploma in Specialist Care of Older People. There should be full and appropriate access to all members of the interdisciplinary team. At present, community therapy services will often not serve patients who are in subvented or contract beds in nursing homes and many public institutions do not have a full complement of therapy staff available: this is unacceptable.

Standards of good practice for health and social care patients should be clearly detailed in new legislation as these are not satisfactorily outlined in current legislation. These standards of care should apply to long-term care whether pursued in the community or in institutional care: if the latter they should be pursued equally in public, private and voluntary institutions. Ongoing audit of these standards of care will require an independent inspectorate and the position of an Ombudsman for long-term care should be instituted.

4.Environment

Current standards of residential accommodation for adults in the general community are that people have a room of their own unless they are sharing with a family or friend by choice. This principle should be adhered to in the provision of institutional long-term care. Patients who choose this route should have access to single rooms with en-suite bathroom unless they choose to share a room with a relative or close friend. The system should facilitate independence and dignity and should include the provision of the patients own clothes and should ensure the security of their personal effects so that they can create their own personal space in the nursing home.
The social and physical environment should ensure the fulfilment of needs for recreation, social interaction and stimulation. These needs should be individualised rather than treated in a collective fashion. It would be important that healthcare professionals are involved in the design of facilities for institutional care and it should be possible to design a template covering the minimum requirements.

Desmond ONeill
on behalf of the
Irish Society of Physicians in Geriatric Medicine

References

1. Fahey T, Murray P. Health and autonomy among the over-65s in Ireland. National Council for the Elderly, Dublin 1993
2. Working Party on Services for the Elderly. The Years Ahead A Policy for the Elderly. Stationary Office, Dublin, 1988.
3. Department of Health. Shaping a Healthier Future: a Strategy for Effective Healthcare in the 1990s. Stationary Office, Dublin, 1994
4. With Respect to Old Age: Long Term Care - Rights and Responsibilities. Royal Commission on Long Term Care for the Elderly, HMSO, London, 1999
5. OConnor J, Thompstone K. Nursing homes in the Republic of Ireland: a study of the private and voluntary sector. National Council for the Aged, Dublin, 1986