Irish Nurses Organisation
The Whitworth Building
North Brunswick Street, Dublin 7
Tel: (01) 664 0600 Fax: (01) 661 0466
To:
tel
Aine Breathnach
Clerk to the Joint Committee on Health and Children
Kildare House
Kildare Street
Dublin 2.
SUBMISSION
From
IRISH NURSES ORGANISATION
To
JOINT COMMITTEE ON HEALTH AND CHILDREN
Subject:
Primary Medical Care in the Community
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INTRODUCTION:
This topic is one which is broad and varied, and which will be approached from the
following points by the INO on behalf of its members working in Primary Care.

Firstly, an overview of Nursing involvement in Primary Care will be given, both in
residential settings and in Community Home/Clinic based settings.

Secondly, matters specific to development of Primary Care Teams and Networks,
will be presented.

Finally, suggestions for development of Primary Care will be made, taking into
account recent legislation changes in the area of Nurse Prescribing and the need
for development of Advance Practice in Nursing in Primary Care.
1.
OVERVIEW
The INO represents 40,000 Nurses and Midwives. The main employment
locations of Nurses and Midwives who work in Primary Care include:(i)
Community based residential (Elderly Care) Units (HSE).
Nurses manage Care of the Elderly and lead the care provided in these
locations. Medical care is provided by General Practitioners.
Currently there is a real human resource issue relating directly to staffing
levels in Care of the Elderly settings. A number of independent staffing
reviews have been conducted which recommended improved staffing
levels, both Nursing and support staff. Due to the HSE embargo on
recruitment, it has not been possible to fully implement these
recommendations. A national committee independently chaired by Ms.
Rosemary Ryan is currently sitting, and is tasked with examining the
outstanding staffing review, with a view to implementation.
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This real crisis in staffing is directly affecting the potential for growth and
development of these services. Nursing led units have a high cost
effective potential. The Private Sector is providing Nursing Home care
also, but this is in the main for lower dependence patients.
It is imperative that Public Care of the elderly and care of the long term
chronic ill, is adequately resourced to ensure its development and
expansion. Expansion areas include best practice models for dementia
care, rehabilitation, as well as being able to provide care to an aging
population when it is needed, as day patients, in-patients or on a respite
basis. All of these services are Nurse led, and the development can be
enhanced by promoting specialist nursing and advance nursing practice in
this specific area.
This would undoubtedly reduce the current necessity of transferring
patients for any acute treatment to a General Hospital emergency
department, from the Care of the Elderly services.
The legislation introduced governing nurse prescribing also has a clear
potential to enhance lives of the elderly in these settings and further
reduce this current requirement for transfer to emergency departments of
acute hospitals for treatment interventions.
(ii)
Community based Residential Care setting for those with intellectual
disabilities, provided mainly by voluntary groups funded by the HSE, e.g.
St. John of Gods, Sisters of Jesus and Mary, COPE Foundation and
Daughters of Charity and others.
ID Services – Registered Nurse Intellectual Disability education in Ireland
is currently provided at honours degree level. Nurses work in community
houses, residential care settings, and day services providing care to
children and adults with an intellectual disability. The development of this
service is concentrated on person centred development and independent
living skills are promoted.
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The shortage of staff again impacts on the development of services, and
low funding is a constant issue.
There is increasing dependency level at an earlier age in this community
group and residential care for this population will be an ongoing
requirement. Respite care and day care services are also provided and
staffing levels – again impact on the availability of same. This is mainly a
non-medical led service and one which has high potential for enhancement
of services if adequately resourced.
Unfortunately the opposite is in fact the reality, with a decrease of student
Nurse’s places announced by the Government in October 2008 and a
focus on recruitment of Social Care Workers - by voluntary group - based
on inter alia cost and availability. The broad nature of the training and
education of Registered Nurses in Intellectual Disability – is clearly a cost
effective means of providing a person centred care plan to this population
and their families.
(iii) Hospice Care funded by HSE and HSE Hospice care.
Direct Hospice Care is provided by Nurses to patients at end of live stage.
Much care is provided in conjunction with and within agreed medical
protocol, i.e. pain and symptom management. Counselling and family
support services are also a large part of the nurse’s role in this area, and
support to enable families to care for a terminally ill family member at
home.
Nurses provide this care to in-patients in Hospice facilities and at a
Community home based level.
Hospice care is mainly provided by voluntary groups with HSE funding.
Hospice Nurses work closely with Public Health and General Community
Nurses in delivering care, particularly in areas where shared care is
required.
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The current focus of this care is cancer related illness, and the need to
expand into other areas of need – chronic heart failure etc., is a real
requirement, which can be Nurse led and delivered in conjunction with
Hospital based medical staff or G.P.’s. Again, the impediment is funding
and the recruitment embargo.
This service where it is provided, is highly beneficial to the families and
individuals concerned. It is also very cost effective as it allows for home
care and hospital discharge.
(iv) Public Health Nurses (PHN’s)
Public Health Nurses are specialist nurses educated to higher diploma
level in the specific area of public health. The services they provide range
from providing care from birth to end of life, to communities, focusing on
preventative services with a view to keeping the population as healthy as
possible. They also develop, in conjunction with Registered General
Nurses, care plans for patient, which are delivered by the Community
General Nurses and Nursing Assistants.
Public Health Nurses provide care to mothers and babies in accordance
with maternal and infant care scheme, and are obliged to visit every new
mother and screen newborns for metabolic abnormalities, within three
days of birth.
Other maternal health and breast feeding support and promotion, are also
the responsibility of PHN’s. Recently the requirement to be a midwife,
prior to being accepted as a candidate on the higher diploma in Public
Health Nursing, was removed. However most working PHN’s are
Midwives and provide pre and post maternal health care to women.
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Child health is a large part of the PHN role, including mandatory
developmental clinics, at varying ages up to age 6, and longer if
necessary.
Delivery of pre-school services, including involvement with primary
immunisation, parenting advice and support, particularly in an “at risk”
situation. School going children are entitled to avail of programmed
hearing and vision screening which is delivered by area medical officers
and Public Health Nurses. Public Health Nurses also provide individual
care to patients post discharge from Hospital and support family care in
these circumstances. They provide a variety of services to the elderly and
persons with disability and their carers in the home.
The Public Health Nurse is responsible for designing care plans and
providing direct care to communities. This ranges from preventative,
education and actual care provision. This is a Nurse led service which has
developed greatly since the Circular in 1966 outlining the functions.
Clearly the services provided can be expanded based on this existing
resource, and as the Primary Care team model is developed, this service
can be supported by other allied health professionals in the provision of
care.
Public Health Nurses get referrals from other nurses, pre-discharge from
acute hospital; Midwives pre-discharge from maternity services; General
Practitioners; Community Nursing Units and other allied health
professionals, i.e. Social Workers. PHN’s also refer patients directly to
these services.
The Commission on Nursing in 1998 recommended that PHN’s remain “at
the core” of nursing services being delivered in the Community. It
recommended that the PHN continue to be responsible for “People of all
ages and of every condition. However, the PHN will also act as a coordinator in the delivery of a range of services in the Community.” (C.O.N.
8.26).
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Again, unfortunately, poor staffing levels, particularly in urban areas, have
had a negative influence on the overall ability of PHN’s to deliver a full
range of services. The development of other nursing services in the
community, such as the introduction of Community General Nurses in the
early 1980’s and recent introduction of Community Midwives, is an area
which can, and should, develop the overall nursing services, but a coordinated managed approach to integration of these and potentially other
nursing services, is imperative and currently absent.
(v)
Community Registered General Nurses (CRGN’s) providing a range of
clinical nursing care, in the home and at clinic level (e.g. wound dressings,
post-hospitalisation support, medication supervision and administration if
necessary). CRGN’s also provide general nursing care to patients post
discharge and provide this care in accordance with a care plan developed
with the PHN.
This grade of Nurse was introduced to the community in a very ad-hoc
manner. No specific community based training was provided, prior to
working in the community. This is still a requirement which has not been
provided. If properly resourced, this group can facilitate increased home
based care and early discharge.
The Community General Nurse who has acquired a great deal of
experience in working in the community, could lead to the expansion of
this service. Recruitment to this grade must be enhanced to allow
expansion of this cost effective service.
(vi) Emerging services of Community Midwives, providing pre and post
partum care to ‘Mothers’. Community Midwife services are being piloted in
Dublin, Cork and Galway. The services range from independent midwifery
home birth services to pre and post maternal and health services.
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The large Maternity Hospitals are all experiencing severe capacity
problems which are leading to shorter stays in Maternity Hospitals
requiring early discharge and expert Midwifery services are therefore
becoming a requirement in the home.
Clearly the benefits of expanding this service need to be explored and
negotiated with the representative organisations as, providing early
midwifery services can facilitate early discharge from over capacity
Maternity Hospitals and provide a person centred home based care to
mothers.
Community Midwives are well placed to lead and provide this care as a
cost effective service which, will again, be enhanced by the legislation
governing nurse prescribing.
(vii) Practice Nurses – providing clinical care to patients attending General
Practitioners. Clinical based, can range from preventative - Well Health
Clinics, to diabetic management, weight/diet control clinics to Health
Screening Clinics, e.g. National Cervical Screening Programme. While
General Practitioners hold clinical responsibility for all smears taken, under
the new contract, Practice Nurses currently conduct smear testing and are
being registered as smear takers with the National Cervical Screening
Programme.
Ongoing disease management is also part of this role as is clinical Nursing
Care. The Practice Nurse is privately employed by the General
Practitioner. A grant of €42,000 per annum, is paid by the HSE to G.P.’s
who employ Practice Nurses and who provide services to General Medical
Care Scheme patients.
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2.
PRIMARY CARE TEAM/NETWORKS
Irish Nurses Organisation members, employed as PHN’s, RGN’s, Practice
Nurse and Midwives, as outlined earlier in this Submission, are working in the
Community providing Primary Care and are now being asked to change the
dynamic of this work into Primary Care Teams and Network Groups.
Midwifery Community based services have not been confirmed at Primary Care
Team level. It is suggested that they will be network based.
The Irish Nurses Organisation represents 1,600 Public Health Nurses, 560
Community General Nurses and in excess of 900 Practice Nurses who currently
work in the Community and provide a Community Healthcare service which is
based on delivering healthcare in the home or in a Community based Clinic.
Public Health Nurses and Community General Nurses work for the HSE.
Practice Nurses are privately employed by the GP.
The integration of the Public Health Service with the Private GP and Practice
Nurse services is important and the seamless interaction between Public and
Private will be necessary in order to provide integrated Primary Healthcare to
citizens.
The INO is in favour of Primary Care delivery of health care and its
enhancement but, have real issues relating to matters of the following:A.
Eligibility
B.
Public/Private Mix
C.
Integration and Co-operation between the Primary Health Care and
the Acute Hospital Services.
D.
Staffing Levels
These matters have been raised directly with the HSE and discussions are
ongoing in respect of them.
It is important however to briefly outline for the benefit of the Oireachtas
Committee what these concerns are.
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A.
Eligibility
Currently it is estimated that 30% plus of the population whose income
falls below a certain threshold, are entitled to a wide range, including
nursing services, of free services. The remaining percentage of the
population has limited eligibility.
In the case of Public Health Nursing services, they are provided to GMS
patients and maternal and child health care is provided to all, regardless of
GMS status.
The stated position of the HSE in respect of Primary Care Services is that
they will be universally available. The INO has requested the criteria for
access to services and have been advised that this is a governmental
decision, not yet made, but the stated objective of providing care to all
regardless of GMS status remains.
Clearly comprehensive eligibility criteria must be in place, notified to
Hospitals, General Practitioners, Voluntary Health Care Providers and the
general public.
A service can only be delivered on the basis of population size if the size
of the population is known. Staff planning and service planning cannot be
conducted in a vacuum and needs to be linked to eligible populations and
predicted increase to it. There are significant workforce implications that
need to be linked to eligibility criteria, and eligibility has to be categorised
into areas of care, for example; health promotion and preventative services
surely must be available to all, if the intention is to keep the population as
healthy as possible? If this is the case, the staffing resource allocation
must reflect this population number.
This is an area where Public Health Nurses have a large body of
experience in and where there is substantial room for cost effective and
long term savings associated with preventative and health promotion
programmes, led by and delivered by PHN and other Nursing grades.
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B.
Public/Private Mix
Again, as previously outlined, GP and the Practice Nurses they employ,
are not publicly employed. The configuration of the private employer into a
Public Primary Care Team will bring many benefits to both service
providers and the population receiving this service.
Currently, care is provided in conjunction with GP’s by Nurses in Care of
the Elderly facilities, and other community based care areas. Practice
Nurses provide care to both GMS and private patients of GP’s.
The role and responsibilities of the GP in a Primary Care Team setting is
important and must ensure the continuation of the good liaison relationship
between GP’s and Public Health Nurses, Community General Nurses and
others in the provision of Primary Care.
Publicly employed Nurses and privately employed Nurses will need to
have a clear comprehensive link in respect of care provision. The Primary
Care Team provides an opportunity for expansion of the role of Practice
Nurses in health promotion and prevention but again the issue of eligibility
will have to be agreed to ensure a seamless provision of service.
Likewise, information sharing will be enhanced by participation of privately
employed Practice Nurses in Primary Care teams.
Much discussion and negotiation needs to take place regarding this
integration and mix of public and private employees. The issue of equality
of conditions of employment being a very important factor, particularly as
pay and conditions for Practice Nurses are determined differently by each
GP and the provision of pension, is absent or not standard. Other
members of the Primary Care Team including PHN’s and Community
RGN’s are public servants and have nationally agreed salary and pension
arrangements, which allow for greater independence of service delivery.
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The provision of premises for Primary Care Teams is a matter of concern
also. It is understood that the premises will be in the main, privately
owned and leased to the HSE at a cost. Again, this is an ongoing cost and
is an issue that needs to be examined from the point of view of effective
utilisation of available funding.
C.
Integration and Co-operation between the Primary Health Care and
the Acute Hospital Services.
If the Primary Care objectives of; providing health care closer to the home,
lessening the current reliance on hospital based services and reducing the
need for referrals to emergency and out-patient departments are to be
met, it is imperative that real agreements regarding rapid access clinics,
access to diagnostic centres are in place and resourced immediately.
The alternative is that the Primary Care Teams, will invariably be reliant on
the Private Sector to provide this service at a premium rate – to the Public
Service.
The Public Hospital system which is constantly over capacity for
diagnostics and treatment, needs to have additional capacity of human
and capital resources made available to ensure Primary Health care is to
succeed.
Cost effective and good practice measures such as appointment of Liaison
Nurses to work between Primary and Secondary Care must be invested in.
there are a small number of these posts in place and prove very effective
in aiding discharge planning.
Additional support to hospital based discharge planning and enhancement
of the role of discharge planning nursing personnel, to allow discharge
take place within agreed protocol, is without question a cost effective
efficient system which needs to be introduced without delay.
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D.
Staffing Levels
Throughout this Submission, examples of service enhancement – Nurse
led, have been highlighted and the difficulties that arise in respect of
funding and employment levels.
Despite the fact that nursing led services are cost effective, enhance
patient’s experience of health care and add value to overall patient
experience and outcomes, the levels of employment of Nurses is reducing.
This is now also reflected in reduction in numbers being trained from 2009
onwards.
There is a large degree of research which suggests, that expanding
Nurses roles are under-evaluated particularly in terms of their costeffectiveness. The expansion of the nursing role in Primary Health Care is
imperative to its success. This investment would enhance an efficient cost
effective provision of non-hospital based care. This requires a Policy
decision to exclude front line nursing personnel from recruitment
embargos, and a clear focus on further educational opportunities to train
sufficient Nurses and to ensure advance practice in this area.
CONCLUSION:
Nursing personnel provide a wide and varied population based health care in the
Community (Primary Care).
Current public policy is focused on developing Primary Care, with a view to providing a
greater degree of Community based care and to reduce the reliance of the acute
hospital system.
This development has to be underpinned by;
 Clear eligibility criteria and clarification on policy of public and private care
provision.
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 Investment in greater co-operation between primary health care and acute
hospital diagnostic and rapid access clinics as well as liaison and discharge
planning enhancement.
 Enhancement of the potential of Nurse led services which are cost effective and
well placed to provide a range of community based care.
Currently the concern of the INO is that the focus of the HSE is on reaching targets set
nationally in respect of numbers of Primary Care teams in operation (97 by year end
2008).
This “achieving target” approach ignored the basic principle of planning;
 Population needs planning – based on eligibility criteria – not yet agreed with
government.
 Human Resource Planning to ensure delivery of services; there are significant
workforce issues not yet addressed, inclusive of grades and numbers assigned to
networks, not yet agreed, or indeed developed.
Job descriptions for Public Health Nurses and Community General Nurses who will be
assigned to Primary Care teams are currently being negotiated, yet the HSE claim to
have 87 working Primary Care Teams in operation.
Likewise, not all Primary Care Teams have GP involvement.
Overall, while this development is ongoing, greater attention is needed in the areas of
added cost effective value, which Nurses can bring to Primary care.
This includes the recent legislative change which allows for Nurse prescribing and as
previously described in this Submission, the very real potential this brings to
enhancement of Community based care.
Likewise the potential for Advance Nurse/Midwife Practice has not been explored or
focused on to any great degree in the Community setting. Statutory Regulation exist
governing accreditation standards for Advance Nurse/Midwife Practitioners, part of
these standards are commitment of the service provider to the post.
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There are currently 100 approved ANP/ANM posts in the Republic of Ireland. Only 32 of
these posts are approved in non-acute large band 1 hospitals. Of these 32, there is only
one post based in Primary Care.
Clearly this is an area that needs to be invested in and supported going forward.
The danger for Primary Care Teams is that the focus on getting practitioner together in
one place, reaching targets of 97 “operating” teams necessary by the end of 2008, will
not in itself, change the delivery of care in the community, and may not reduce the
reliance on the acute system.
This Submission has raised suggestions in areas of Nursing involvement and
development which we believe would enhance and promote a cost effective approach to
delivery of care in the Community.
We would welcome the opportunity to elaborate on any of the issues raised in this
Submission directly with the Oireachtas Committee.
PHIL Ni SHEAGHDHA,
Director of Industrial Relations,
Irish Nurses Organisation.
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