Health Services Problems for the Elderly: briefings by Aged Care Network

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Health

17 September 2001
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HEALTH PORTFOLIO COMMITTEE
18 September 2001
HEALTH SERVICE PROBLEMS FOR THE ELDERLY: BRIEFING BY AGED CARE NETWORK

Chair: Dr. Nkomo (ANC)

Documents handed out
Aged Care Network Presentation (Appendix)
Minutes of the First AGM of the Aged Care Network

SUMMARY
The Aged Care Network, a community participation program based in the Western Cape, focussed on problems with the health service as applied to the geriatric population such as the lack of facilities specifically for older patients and shortages of chronic disease lifestyle medications. The suggested solution was an investigation of public/private partnerships, a move which the Network said was already being investigated in certain districts.

The presentation also drew attention to the need for clarification on the position of home carers, in terms of support, financial remuneration and insurance issues. Reference was made to the fact that the premature release of psychiatric patients into community care was having a disastrous effect on the elderly who are vulnerable to abuse. They are responsible for the care of their adult children who have mental illnesses which often manifest as aggression. In referring to this issue, mention was made of the need for the involvement of various departments, including the Department of Justice. Nutrition, in the form a 'meals on wheels', and the sidelining of older people in the emergency medical services were also raised as areas of concern.

Central themes running through much of the presentation were concerns about the rampant abuse of the elderly that is occurring throughout the country, and the lack of any legislation dealing specifically with the elderly. Various questions were presented by the members, all of whom agreed on the seriousness of the issues faced by the elderly.

MINUTES
Dr Daya, the Vice Chairperson of the Aged Care Network, presented (see document)

Discussion
Dr Cwele (ANC) thanked Dr. Daya for her presentation, agreeing that it raised certain serious issues which needed to be addressed. He asked Dr. Daya to elaborate on the background for the proposed Public-Private Partnerships, since he felt that in many parts of South Africa, there were insufficient services available, whether public or private and in this context, affordable out-sourcing would prove difficult.

Dr Nqodi (ANC) asked for clarification on a similar matter - how out-sourcing to GPs was envisioned, including how it would be remunerated and what the logistics of such an initiative would be.

Dr Jassat (ANC) raised the issue of the lack of training for medical staff in geriatric care, saying this needed to be investigated at both undergraduate and postgraduate level and that there were strong motivations for such training. He suggested that the organisation could play a key role in training, since there was a lack of understanding around the specific requirements of older people.

Dr. Daya agreed with Dr. Jassat that the issue of training was an important one and that it was lacking at both levels of study. She went on to say that she had twenty-three years of experience working with the Academy? And felt that it would be possible to use this certification and accreditation as a forum for advancing this issue. For example, by developing workshops which could be compulsory for certification.

In response to Dr. Cwele's question, Dr. Daya said that she understood that the primary healthcare budget was already overstretched and that it seemed as if she was there begging for more money. However, she proposed that what was needed was not more money, but rather a more efficient use of existing resources, taking into account the needs of the elderly. She described a program that had been set up where elderly people in the community could attend an old age home to receive their chronic medication, from a clinical nursing practitioner. There could also be periodic visits to the home by a general practitioner, at a capped rate. GPs had shown an interest in this, saying that they would accept R20 or R30 as a capped figure. At least one district was interested in this idea, according to Dr Daya. The advantage of such a system was that it made services accessible to the elderly in their community.

Dr Cwele agreed that in such an environment, such a partnership could work but that at a national level, many areas did not have the resources, such as parts of the Eastern Cape and KwaZulu Natal. He emphasised that this was the particular difficulty that the Committee faced, in trying to develop programs and policies that took account of the needs of all areas in the country. It would not be acceptable to support a policy which favoured regions which already had infrastructure over regions with nothing.

Dr Daya's response was that there had been consultation with Dr de Villiers at Tygerberg, who felt that it might be feasible to develop some sort of roll-out throughout the country.

At this point, Dr Nkomo explained that the meeting was not meant to degenerate into adversarial positions, but rather to bring issues to light so that they could be noted and addressed.

Ms. Kalyan (DP) stated that it was clear that the responsibility for these issues was collective and solutions would require inter-departmental co-operation. She then asked Dr Daya if she had seen the report on Elder Abuse, and asked if she felt that not much had been done to address the issue.

Ms Dudley (ACDP) asked what the response had been to the research that the Network had conducted.

Dr Daya indicated that in-depth research had not been done yet, and that the feasibility of the projects needed to be examined, but that two out of eleven districts in the Cape Town metropole had expressed interest. She also indicated that one of the major problems was the supply of essential drugs from the CMD.

In terms of the elder abuse issue, she indicated that the chairperson of the group could make more input. She said it had been recommended that the elderly make use of the Domestic Violence Act, but that this was inadequate since many old people found it difficult to make use of. She also said that elder abuse continued because of the lack of infrastructure.

Ms Storm, the Chairperson of the Aged Care Network, said that the organisation had developed because of the frustrations members had felt at the resources which were spent on hearings and reports, when no change was observed at the grassroots level. She noted that there was no legislation specific to the elderly although the Network was aware of the Status of Elderly Persons Bill, on which they were hoping to make some input to the Department of Social Development.

She elaborated on the reasons why the Domestic Violence Act was inadequate, saying that Justice Department personnel needed training and a special desk in the Department of Justice should be formed to handle the concerns of the elderly. She underlined the fact that the legal system was not accessible enough to the elderly.

In relation to the Mental Health Care Bill, she said that part of the problem with elderly people and their mentally ill adult children was that the patients in the community often refused to take their medication. She related one story of an elderly woman whose son had threatened to kill her if she tried to have him certified. This issue was related to the lack of facilities. She asked if it were not possible to require people to report to a clinic for medication, and if they failed to do so, whether action could be taken. She said that the police could remove the person for a day or two, but that when they were released, the situation for the elderly was actually worse. Another problem that Ms Strom identified was that the South African legal system did not allow anyone over twenty-one to testify in-camera, and that this discouraged the elderly from testifying against their children. These issues highlighted the need for a multi-sector response.

A committee member asked what the obstacles were to service provision, as well as the real needs and requirements. She suggested that a step-by-step plan was needed to address the most immediate concerns.

Ms Baloyi (ANC) asked whether the presentation had been made to the government of the Western Cape, in particular the Departments of Health and Social Welfare. She also asked which CBOs and NGOs were involved in the Network. She reiterated the fact that these issues were viewed very seriously, and viewed as a matter of urgency. She reassured the delegation that the Department of Health had taken the issue on-board and was working with the Department of Social Development in, for example, improving the facilities available on pension days.

Ms Mnumzana (ANC) asked if research, particularly a need analysis had been done to determine whether there was the infrastructure to make the proposed changes sustainable, in particular. She also asked what the group viewed home-based care in the context of high levels of elder abuse. She asked whether they were recommending centres, for example.

Dr. Nkomo suggested that the issue raised by Ms Mnumzana, that of step-down facilities, was particularly important. He suggested the possibility of home-based care, with the assistance of professionals.

Dr Daya said that the program had been started because of the need for a program for the elderly. She suggested that the view had always been that there would be some form of roll-out. With regard to the issue of research, she said that there was a lot of research, but that the information was not readily available and in particular, was not reaching the service providers. There was a need for the existing research to be structured and summarised to improve the quality of life for the elderly. Within the Western cape, there were meetings and numerous groups at the grassroots level, and the consensus was that despite the research, the situation was worsening.

Ms Storm said that the Network would like to form a partnership with the government. There was a socio-economic partnership between the five stakeholders - Black Sash, All Pay, Social Welfare, Human Rights Commission and the Aged Care Network and that meetings were being held with the communities to keep them informed of the developments. She said that the vision was to have similar partnerships with all the key role players in health, as well as all the key role players in housing.

At this point, Ms Christians asked if she could say something. She introduced herself, saying she was Trevor Manuel's mother-in-law. She said that, when it came to wine, the older it got, the more expensive it became. Similarly, vintage cars became more expensive with age. And antiques were highly prized. But when it came to old people, they were discarded or ignored. For example, with the issue of bone transplants, the government said that they were too expensive. She said she was well into her seventies, and that her generation were the ones that had suffered, they were the ones who had put their shoulders to the wheel and fought to overcome oppression. She said that it was not good enough for the government to give them (the elderly) a line in an act, and then just forget about them. She said prisoners and young people were all well-looked after in the new dispensation, and the elderly should receive their due recognition.

There was general applause at this speech, and a member of the committee recommended that she make the same speech to her son-in-law, to which she replied that she had.

Dr Daya said, in conclusion, that she would like to know where the National Health Bill was at present, because she would like the Aged Care Network to be included in the process.

Dr Nkomo said that the Bill was in its fourteenth draft and would only be dealt with next year. He also said that the former president had indicated that Parliament should be the voice of the people, with an open door policy and it was this which had facilitated today's meeting. He said that the Bill would go to the Department of Health and then to the Executive. He added that the Network had initiated this meeting, but that the committee would initiate the next one. He went on to say that the Mental Health Care Bill would be processed in this session, and welcomed interaction. He concluded by saying that they (the committee) had taken note of the 'antiques'.

Dr Daya asked how older people could make input, and Dr Nkomo referred her to the administrative staff.

At this point, the delegation from the Aged Care Network left, and the meeting moved on to housekeeping issues, which were closed to the public.

 

Appendix
The Aged Care Network is a Community Participation Program.
The Vision of this network is to ensure that the
voice of the marginalized, almost forgotten and disadvantaged older persons will be heard.
In it's Mission the Network stands together to serve the holistic needs and interests of the older persons.

The Constitution of SA (ACT 108 of 1996) has a Bill of Rights which is the cornerstone of our Democracy. This right enshrines our countries values of human dignity, equality and freedom. Section 27 affirms access to Health, Sufficient food and water and the right to Emergency Care. Is this not the right of our Older persons as well?

The policy that governs these issues is in the Health Policy Bill (still in a White Paper format) section 2.5 Involvement of Community 2.5.1a. (vii) " Rights to Health", the Aged Care Networks will advocate and continue to lobby to have older persons recognition addressed by the Ministry of Health. In Section 2.5.3 we should expect the Department of Health to provide the public with regular updates on progress. The results emerging seems to have fallen short with this Health policy Bill which has remained static since 1997.

In Chapter 21 reads the" Year 2000 Health Goals, Objectives and Indicators for South Africa" "21.5 " Care for Older Persons " reads ;
Goal : To improve the quality of life for older persons.
Objective: Increase accessibility to and availability of Health Services.
Indicator: Proportion Geriatric Services integrated with PHC.

The extreme lack of these Geriatric services have disadvantaged older persons further. The lack of availability of Essential Drugs and Chronic Medications and the frequent stock-outs at the Primary Care Centres and at the Central Medical Depot, running at a deficit in the capital provided for its running to keep minimum stock levels of drugs at the correct level for their usage. The Chronic disease lifestyle medications are in frequent short supply and these poor folk return day after day to await the arrival of essential drugs.

There is shortage of pharmacists ! added to which there is a chronic lack of applicants for these professional posts at primary care level. Added to which there is the practise of early and premature discharge of patients from the hospitals in their downscaling efforts, in order to keep costs low, affects the lives of these elderly citizens Has this not an adverse impact on the quality of care of the Older Persons?

A solution would be the enactment of the PUBLIC PRIVATE PARTNERSHIP.This would provide additional help for the already over-stretched CHC services. There is also a constant short supply of the Clinical Nurse Practitioners and the situation is made worse in trying to update and train them and keep them in the public PHC service employ. Should these chronic disease patients not be out-sourced to the Private Practitioners, at a capped fee for a consultation service only . The essential drugs and medicines would be allowed on the prescription and could be collected by the patient from the Community Health Centres. That would assist the aged with physical accessibility and help with the transport problem and costs for them could be partially alleviated.

Primary care lacks posts for Chiropody services which the elderly require e.g. the mandatory foot care for the diabetic patient or for onychogryposis. The lack of social workers posts and geriatric nurses who could assist with Elder Abuse Issues in this crime ridden environment would help to enhance the quality of care to our older persons.

This province has caught up on the backlog with the cataract operations for the elderly, enabling them to remain ambulant and independent. The "stroke" or CVA patients need rehabilitation clubs where they support and encourage each other at these clubs, but government financial assistance is necessary.

 


HOME CARER AND FRAIL CARE
The lack of co-ordination between the Social Welfare and Health Departments leaves the support and financial remuneration of the home cares in abeyance, The infrastructure necessary for the home carer to travel, to care for the sick, and supplies like surgical gloves and dressings,the support and debriefing required to assist them with counseling issues are sorely lacking. In this pandemic of HIV and AIDS clients the older persons are the child minders of their dying children
Whosoever should supply the budget requires clarity of vision.
The insurance issues and workmen's compensation if they contract HIV, are they casual staff? Do they qualify for compensation, these questions must be answered.

MENTAL HEALTH
The early or premature discharge of so called 'Stable" but aggressive psychiatric patients from the mental institutions, and their relapse back into the acute phase in the precarious home environments, only exposes the older persons at risk for further abuse. The aged become the carer of these mentally challenged adult patients, and as they often refuse medication causing further deterioration of their condition and once again the old and insecure parent is saddled with this difficulty person. There is little or no support from the justice system in re-certifying this mental patient. The old age homes are the dump grounds for these difficult mental patients as they are often a danger to the community, but the residents of the homes are subjected to sexual and physical abuse from these now unstable patients. What admission criteria are there to avoid this abuse inflicted upon the aged? IS that not a sure way to expose the aged to STI, HIV and Aids infections?

NUTRITION
The Health Policy White Paper section 21.6 states the "goal is to improve the nutritional status". Surely the objective is to eliminate micro-nutrient deficiencies disorders . Does this not preclude that some form of meals on wheels or out-sourcing of a basic warm meal to the elderly, who are unable to prepare meals and surely this should be provided in some way. If 55% of the population live in abject poverty, are the elderly not deserving of this warm meal?

EMERGENCY TREATMENT
The definition of an emergency is "that which is needed to treat a sudden and unforeseen, life threatening but reversible deterioration in a persons health status". The older folk are sidelined at the Emergency Trauma Units as the patients for resuscitation take precedence and the wait for the elders to be attended to by the doctor takes sometimes hours. The solution would be to subsidize emergency beds at the selected frail care homes and the General Practitioners be out-sourced at a capped fee to attend to these patients. ELDER ABUSE is rampant in our society, should not an infrastructure to assist e.g. HEAL (Halt Elder Abuse Line) be further networked and financially supported. An integrated service with social security and the justice system be established so as to co-ordinate services and make them " user friendly" for the older persons.

In Conclusion the AGED CARE NETWORK wishes to engage in a partnership with and around the issues for Older persons. As in the Socio- Economic partnership with the 5 stake holders viz. All Pay, Black Sash, Social Welfare, Human Rights and AGED CARE NETWORK around the pension pay-outs to our elders, we would appreciate an inclusivity into the Health Priorities for our Older Citizens of South Africa.


Dr. B. DAYA
CHSO
September 2001

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