Appendix 1

• National policy context
• Current service provision

National policy context

Health Acts

The Health Act, 1970 established regional health boards for the delivery of health services. The operation of the health boards is centred around three core programmes: general hospitals; special hospitals; and community care programmes. The Health Amendment (No 3) Act, 1996 requires health boards to adopt service plans and to operate within these plans throughout the year. It also established the Eastern Regional Health Authority.

General Medical Services (GMS) Scheme

Persons who are unable without undue hardship to arrange general practitioner services for themselves and their dependants receive a free general medical service. When the GMS scheme was introduced in 1972 it was a fee per item based scheme. However, following a review of the operation of the scheme in 1989, the basic payment structure changed to a capitation system.

Blueprint document: The Future of General Practice in Ireland

This document was produced by the Department of Health in 1991. It made proposals for the future organisation and management of general practitioner services.

Establishment of National and Regional General Practice Units

These units were introduced in 1993 to facilitate, support and develop general practice as a whole. GP unit general practitioners were appointed in each health board area to support local general practice.

Indicative Drug Budgeting Scheme

At the same time as the setting up of the GP units an indicative drug budget was calculated for each GMS GP based on age-related prescribing averages. Any savings made on these indicative drug budgets were initially divided 50 per cent to GP unit and 50 per cent to doctors concerned. All savings made are invested in the development of general practice.

Review of public health nursing

A review of public health nursing was undertaken by a working party established by the Department of Health. The report Public Health Nursing, A Review, presented in 1997, set out recommendations for developments, which were used by the Commission on Nursing when considering issues relating to nursing in the community.

Departments of Public Health

Departments of Public Health were established in each health board area led by a Director of Public Health during the 1990s. The Departments of Public Health have a major role in health service planning, the introduction of best practice protocols and monitoring of services already in place. They are a significant resource in the areas of health promotion and health gain.

Commission on Nursing

The Report of the Commission on Nursing (1998) identified the need for integration of community care services and co-ordination of community nursing care. It recommended developments in the management structure for public health nursing, the development of specialist career pathways, developments in the midwifery services and removal of the mandatory requirement for midwifery as a requirement for entry to the higher diploma in public health nursing or registration as a public health nurse.

CEOs' review of general practice

This review was commissioned by the health board CEOs with input from the Department of Health and Children. The purpose of this review, which was completed in September 2000, was to identify measures necessary to meet
the challenges posed in the strategic development of general practice.

Working Group for Nursing and Midwifery in the Community

This group was established by the Department of Health and Children in March 2001 to prepare a revised strategy for nursing and midwifery in the community. It is envisaged that among other issues this group will address the need for integration of the diverse range of nursing services provided in the community. The recommendations made in the Health Strategy 2001 will play a key role in directing the Strategy for Nursing and Midwifery in the Community.

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A Vision of General Practice, 2001-2006

This IMO/ICGP document outlines a vision of the future of general practice. It makes a number of recommendations regarding practice development, funding, human resources, education/training and quality assurance in general practice.

Nursing and Midwifery Resource

The Nursing Policy Division of the Department of Health and Children is undertaking a detailed study of the Nursing and Midwifery Resource. The primary objective of the study is to forecast, as far as is possible, future nursing and midwifery workforce needs. The steering group for the study published an interim report in September 2000, which set out a series of recommendations pending the final report. Included among these was a recommendation to substantially increase the number of places on the public health nursing higher diploma programmes and the introduction of measures in relation to fees and salary to encourage uptake of places.

Current and Future Supply and Demand Conditions in the Labour Market for Certain Professional Therapists ('Bacon Report')

The Bacon Report (2001) identified significant deficiencies in the supply of chartered physiotherapists, occupational therapists and speech and language therapists. The principal gaps result from the number of unfilled vacancies, the number of posts that would be created if service in Ireland reached objectively set targets, the number of additional places that will arise due to demographic and survival trends and the number of new posts that will arise due to demands for an enhanced quality of health care service. The report indicates that there will be a need for increases of between 102 per cent and 328 per cent above existing supply of therapy professions to meet the requirements of the service up to 2015. The report set out a series of recommendations relating to finance, course places, clinical training, management and regulation, to ensure that the required increases are achieved.

Programme for Prosperity and Fairness

The Programme for Prosperity and Fairness (PPF) sets out the agreement between the Government and social partners, published in 2000. Health care is identified specifically under Frameworks I and III, which set out actions for living standards and the workplace environment and also for social inclusion and equality. The programme makes a specific commitment to the ‘development of new models to explore ways of moving further towards 24-hour seven-day primary care and a programme of refurbishment and upgrading of community health centres'.

National Development Plan 2000-2006

The National Development Plan allocates £2 billion (72.54 billion) over the plan period to address the capital needs of the health services. Part of this is intended to be invested in a network of health centres, resulting in a wide geographical spread of multipurpose health centres for the provision of a range of community health and personal social services.

Effective Utilisation of the Professional Skills of Nurses and Midwives

The Working Group on the Effective Utilisation of the Professional Skills of Nurses and Midwives (2001) recommended that the grade of health care assistant/maternity care assistant be introduced as a member of the health care team to assist and support the nursing and midwifery function. The group recommended that the title health care assistant (HCA) be adopted and employed uniformly across all health care settings.

A national 6-month training programme for health care assistants is commencing in November 2001. Pilot programmes are being delivered by the health services in conjunction with the Further Education Training Awards Council (FETAC). Community care is one of the areas included in the pilot programmes. Following evaluation the programme will be available nationally.

Current service provision

Access to primary care is based on a means-tested system of eligibility comprising two categories. People whose income falls below a certain threshold fall into Category I and are entitled to a wide range of free services. This group constitutes approximately 30 per cent of the population. The remainder of the population has limited eligibility and is classified as category II (70 per cent of the population). There is also a well-developed private sector, which can be accessed through insurance cover and/or direct payments (46 per cent of the population has private health insurance). There is some overlap between medical cards and those who are insured. Similarly, not all those in Category II have private health insurance.

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General practice

General practitioner services in the Irish health system have been described as ‘largely made up of a series of disparate personnel, with individual spheres of activity, relating to separate functional units and employed under a variety of different contracts’ (Caulfield, 2001). The public-private mix of entitlements complicates access to services. GPs are self-employed professionals who engage in service commitments, under a range of individual contracts with health boards, for delivery of services to either exclusively public patients or to a public-private mix under the Maternity and Infant Care Scheme or the National Primary Childhood Immunisation Scheme. They also provide services directly to private patients.

People in Category I can register with a doctor of their choice from a list of physicians participating in the scheme. GP services, prescribed drugs, medicines and appliances are then supplied free of charge to them and their dependants. Those in Category II (70 per cent of the population), who pay in full, are free to choose any GP or specialist. GPs are paid on a capitation basis according to the patient’s age, sex and place of residence.

Community nursing services

A nursing service, spanning the life cycle, is provided by the health boards, on a geographic basis and incorporates prevention, treatment and rehabilitation. This holistic service operates in the community and is delivered through public health nurses, general nurses, mental health nurses, practice nurses, midwives, specialist nurses, health care assistants, home helps and others.

The current public health nurse (PHN) service is based on a Department of Health circular on the ‘District Nursing Service’ (circular 27/66). The concept outlined in the circular was of a public health nursing role encompassing a broad range of preventive and caring functions. However, the role of the PHN has evolved in the thirty years since the circular of 1966. PHNs carry out a diverse range of nursing services responding to the needs of individuals, families and the community. The range of community nursing services provided by PHNs includes:

• support and advice to a parent or parents following the birth of a child. Such a service may be provided from shortly after the birth of the child and, if required, continues until the child is of school-going age

• the delivery of school health services

• the provision of personalised nursing care to patients who have been discharged from hospital

• the provision of a range of nursing services to the elderly and support for carers in the home

• the provision of nursing services and support in the home for persons with a disability (Commission on Nursing, 1998, p 150).

The Commission on Nursing (1998) identified the increasing trend where 'a number of other nursing groups have started to work in the community: these include general nurses, palliative care, psychiatric (other than community psychiatric nurses), mental handicap, practice nurses and other specialist nurses'.

Practice nurses are employed in general practices and deliver a broad range of nursing services such as immunisations, women’s health issues, ante-natal care, wound care, counselling and asthma care. Practice nurses do not visit people in their homes.

Community mental health nurses manage a case load and provide a wide range of nursing services including rehabilitation, social skills training, individual counselling, group work, psycho-education, family support, liaison work and mental health education.

Community midwifery service provision is currently being evaluated through three pilot programmes which have been established in Dublin, Cork and Galway to evaluate different models of care. They include a home birth service by independent midwives in Cork and outreach home birth and DOMINO (DOMiciliary IN and Out) births provided by community midwives employed in the National Maternity Hospital and University College Hospital Galway.

The Commission on Nursing recommended that the Department of Health and Children issue a revised strategy statement on the role of public health nursing. A strategy on nursing and midwifery in the community is currently in preparation. It will address the deficits in the current system by providing a plan for the integration of nursing and midwifery services within primary care.

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Maternity and Infant Care Scheme

This scheme provides for free ante-natal care for expectant mothers and medical care for infants up the age of six weeks, irrespective of eligibility category. It is operated by GPs who have agreements with health boards to provide the services in return for specified fees.

Child health services

Child health services are provided by a range of disciplines in a variety of settings (home, health centre, GP surgery) and are focused on preschool children and children at national schools. The preschool service encompasses both primary (immunisation, parenting advice and support) and secondary prevention (developmental and metabolic screening). The national school service is delivered on school premises and includes examination of school entrants and programmed hearing and vision screening at regular intervals until children reach 12 years of age.

Primary dental care

Dental services are provided by dentists employed by health boards and by private dental practitioners under contract to health boards. Children attending national schools (up to 14 years of age) are provided with dental services through school-based dental programmes.

Community pharmacy

Prescribed medicines are supplied by retail pharmacists free of charge to medical card holders (Category I). Under the Drugs Payment Scheme, persons who are ordinarily resident in the State and who do not have a current medical card can benefit. No individuals or families have to pay more then £42 (¤53)in a calendar month for approved drugs, medicines and appliances for themselves or their families. In order to benefit under this scheme, people must register themselves and their dependants with their local health board; each registered person is provided with a Drug Payment Scheme Card which carries a family identification number. New arrangements were introduced in November 1996 for the supply and dispensing of high-tech medicines through community pharmacies.

Under the Methadone Treatment Scheme, Methadone is prescribed and dispensed by doctors and pharmacists for approved clients. The GMS Payments Board pays capitation fees under this scheme to participating doctors and community pharmacists.

Long-Term Illness Scheme

On approval by health boards, persons who suffer from one or more of a schedule of illnesses are entitled to obtain, without charge, irrespective of income, necessary drugs, medicines and appliances under the Long-Term Illness (LTI) Scheme. The GMS payments board makes payments on behalf of the health boards for LTI claims submitted by pharmacies.

Health Board Community Ophthalmic Services Scheme

The Health Board Community Ophthalmic Services Scheme was launched in July 1999 to provide optometrist/ ophthalmic services to adult medical card holders and their dependants not entitled to benefit under the Department of Social, Community and Family Affairs Benefit Treatment Scheme.

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