Community Care

Dispensaries to GMS

The dispensary system had been introduced under the Poor Relief Act 1851.  The country had been divided into dispensary districts, each with a salaried doctor known as a District Medical Officer.

The doctor could also offer private practice services outside of the dispensary. The dispensary system had not been expanded in Dublin in line with the increase in population.

The Health Act 1970 introduced a choice-of-doctor scheme.  The primary driver was to eliminate the discrimination and stigma of attendance at the dispensary.  The dispensary system was reformed to provide treatment for patients by GPs under the General Medical Services Scheme. GPs were paid per consultation and per item.

This scheme was revised in the late 1980s to provide a capitation scheme providing a fee per patient. This varied in accordance with the age of the patient and usage of the service.  Measures were taken to incentivize doctors to reduce prescription costs.

The original criteria for medical card entitlement turned on an assessment of “undue hardship”.  This was, in turn, fleshed out with various means tests.  See other sections in relation to the modern revised eligibility criteria for medical cards.

The entitlement to medical cards has varied between 30 and 40% of the population. In 2001, automatic entitlement to a medical card based on criteria was introduced.  A revised form of medical care, the GP Visits Card, was introduced in 2005.  See separately in relation to these cards.

Community Care

Community health care, in its modern format, has developed since the 1970s.    A public health nursing system was developed, together with home health and other services, by Health Boards and voluntary organizations.

The Health Strategy 2001 emphasized primary care in the community as the focus of the healthcare service.  A strategy, Primary Care A New Direction emphasised this approach.  The primary care system was to play a more central role and to be the first and ongoing point of contact for persons with contact with the healthcare service.

The Strategy proposed the introduction of interdisciplinary teams, including GPs, nurses, midwives, health care assistants, physiotherapists, occupational therapists, social workers and administrative personnel.

A wider network would also include speech and language therapists, community pharmacists, dieticians, community welfare officers, chiropodists, dentists and psychologists.  It was proposed to establish 500 primary care teams across the country.

Medicines

Prior to 1972, medicines were generally supplied by dispensary doctors.  The pharmacist had attended the dispensary to issue medicines. Under the revised scheme, patients with General Medical Services Cards (Medical Cards) were entitled to prescribed medicines free of charge.

In tandem, a scheme was introduced in 1971, allowing recoupment of the cost of prescribed drugs over a particular level; the Drugs Payment Scheme.  This is not means tested but limits the overall costs per family to a particular limit.

There are prescribed free drugs for persons with long-term conditions.  This is the Long Term Illness Scheme.  It covers 16 types of conditions.

Older Persons

Prior to the 1970s, the needs of older persons whose families were unwilling to take care of them were provided by County Homes.  These were often former workhouses, and conditions were not high.

Of the 130 workhouses existing in 1922, almost 100 were closed, and the remainder remained as County Homes primarily for persons who were old and infirm. They also accommodated other persons who were marginalised, including unmarried mothers and persons who were mentally handicapped. Many had no running water and poor sanitary conditions.

In 1968, the Care of the Aged Report was published, which saw the beginning of a more appropriate approach to care for older persons.  It proposed that County Homes be replaced by Welfare Homes.  However, the primary focus was to be on persons remaining in their own homes as long as possible.

Community Care & Older Persons

The proposals effectively required community care services.  They required the development of day hostels with geriatric assessment units in general hospitals.  Community care services include a range of social work, occupational therapy, and medical and nursing care for persons in their homes.

The report influenced government policy over the next three decades.  The value of pensions was increased substantially.  Various schemes were introduced such as grants for house repairs to enable older people to continue to live in their homes.

Approximately 30 Welfare Homes were developed as sheltered housing.  Comhairle na nOspidéal recommended the appointment of a geriatrics specialist consultant. Home help services, including Meals on Wheels and day care, were provided.

The 1988 Report The Years Ahead Policy for the Elderly declared that County Homes had become geriatric institutions with much the same atmosphere as older institutions.  It recommended greater development of day-care and rehabilitation services. The report was influential.  Special care teams and coordinators of services were appointed to e community care districts. Community hospitals were developed further.

A review in 1998 found that little had been done to implement the provisions and recommendations in relation to community care.

Supporting Community Care

The National Social Service Council was established in 1971, which later became Comhairle and, later, the Citizens Information Board, to encourage the coordination of services.

A Carers Allowance was introduced in 1990.  It sought to provide  income maintenance for persons looking after aged and dependent relatives in their homes.

Public health nursing services began to develop in the 1950s under the Health Act 1947.  The purpose was to provide domiciliary services, particularly in the areas of midwifery, nursing for the aged and, to a lesser extent, the public health care of children.   It included an educational aspect and assistance to local medical practitioners.  It focused on patients needing care but not requiring treatment in an institution.

Dental services are provided by dentists employed by the HSE.  Ophthalmology, hearing, aural and dental services are provided as part of the community care program.

Supplementary welfare allowances were introduced in 1977 to replace home assistance.  This form of assistance had previously replaced a successor to the poor law system of the outdoor relief system. Supplementary welfare officers and former home assistance officers became community welfare officers.

Modern Primary Care

2001 saw the publication of Primary Care: A New Direction.  The aim is to provide a more seamless provision of health and social care services between home, hospital and the community.   The introduction of interdisciplinary teams in primary care provision was proposed.

Ten pilot primary care teams were established in 2003. When the HSE was established in 2005, one of its three central pillars was the Primary Community and Continuing Care section.  A key priority was to configure primary community and continuing care services so they delivered optimal results.  The strategy promised 500 — 600 new primary care teams around the country.

The arrangements for cooperation between doctors who are independent contractors and others who are employees of HSE in different divisions have been complex.  A number of GP practices have established their own groups with GPs and nurses.  The services of many other health professionals were not readily available in the private market.