Office of the Nursing. and Midwifery Services Director. Office of the Nursing. and Midwifery Services. Director.

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1 Office of the Nursing and Midwifery Services Office of the Nursing Director. and Midwifery Services Director. Report HSE SOUTH Prepared for the Management Team on Public Health Nursing Services. Public Health Nursing Services in the HSE South. Report Prepared for the Regional Development Team HSE South. January 2012.

2 Office of the Nursing and Midwifery Services Director. Report Prepared for the Management Team on Public Health Nursing Services in the HSE South May

3 Table of Contents Page IntroductIion Executive Summary 3 Introduction 9 o Section 1 Clinical Governance 10 o Section 2 Demography of the Public Health Nursing Services. 13 o Section 3 Child and Family Health Service. 17 o Section 4 School Health Service 20 o Section 5 Older Persons Health Service 22 o Section 6 Disability Service (Children Young People and Adults ) 24 o Section 7 Palliative Care / End of Life Care (Adult and Children) 26 o Section 8 Chronic Disease Management 27 o Section 9 Health Promotion and Nurse/ Midwife led Clinic Service. 29 o Section 10 Education and Training 30 o Section 11 Selected Public Health Nursing Services Initiatives - 31 HSE South Concluding comments 35 Appendix Expert Advisory Group Members 36 This report can be cited as follows: Office of the Nursing and Midwifery Services Director (2012) Report Prepared for the Management Team on Public Health Nursing Services in HSE South.; Report prepared by Patricia O Dwyer, Project Officer to the Expert Advisory Group on Public Health Nursing Services 2

4 Executive Summary The HSE commitment to the reconfiguration of services to support integration and enhanced responsiveness to client needs is articulated in key policy documents. The shift of the focus of care from secondary to primary care is being actively progressed and is supported by the continued development of primary care teams in tandem with the implementation of the transformation programme, focusing on increased emphasis on care in the community and integration of services. 1 In the context of care and reform and the current drive toward an Integrated Health System 2 treating and delivering care to patients in more appropriate settings is an integral part of the role of the Public Health Nurse (PHN) and Registered General Nurse (RGN) working within the primary care team. PHN Services within the PCT are fundamental to the provision of safe, high quality healthcare services in the community. The Regional Directors of Operations (RDO) requested an analysis of Report on Current Public Health Nursing Services per RDO Area to include the following: the emerging themes from each section of the Report on Current Public Health Nursing Services from a regional perspective; to identify exemplars of best practice in each RDO Area; to identify urban versus rural deprivation areas in relation to WTEs and work practices; to identify the role of PHN Services per RDO Area in relation to travellers' health and to outline the projected number of nurses leaving the service This report describes the Public Health Nursing (PHN) Services that are provided in the HSE South using both the information provided in the findings from the Survey on the Review of Public Health Nursing Services and additional new information as required. The Survey was completed by the Directors of Public Health Nursing (DPHNs) in seven of the nine LHO areas in the HSE South. Emerging Themes from each section of the Report on Current Public Health Nursing Services. 1.1 Clinical Governance - The ultimate aim of the PHN Services is to try to ensure that people receive the right care, at the right time by the right person in an open, safe and caring environment. 3 In all areas in the HSE South, service users are involved in the development and implementation of their own care plans in partnership with the nurse based on the Philosophy of Nursing Care. The PHN Service has systems in place to monitor, analyse and respond to patient safety incidents. 86% of respondents indicated that their service has guidelines on report writing and record retention and annual service audits are currently being conducted in over 70% of respondent areas. However the management of risk associated with vacant PHN area is a major challenge for the DPHNs in the current health care environment. 86% of PHN service areas have structures in place for developing, auditing and reviewing developed documents. Although all respondents currently have guidelines in place to support areas of clinical practice, including child health, not all areas have guidelines developed for the management of chronic diseases, which may have a negative impact on the timing of the implementation of the planned National Clinical Care Programme. 1.2 Demography of the Public Health Nursing Services in the HSE South Demographic data on the population sets the context for health and for the planning and delivery of health services. The changing demographic profile of the HSE South with a rapidly growing population, up to 7.5% increase, together with an increase in the birth rate nationally to 16.1/1,000 4 will impact on the Health Service in fulfilling their statutory obligations to children and their families as required in the Health Act (1970) 5. 1 Health Service Executive (2012) National Service Plan. 2 Health Service Executive (2008) Integrated Services Programme, 3 Health Service Executive 2011 Draft National Clinical Programmes, Clinical Governance Checklist 11 th Oct Central Statistics Office (2011) 5 Department of Health (1970) Health Act 3

5 The number of people over the age of 65 years is projected to more than double over the next 30 years with the greatest proportional increases occurring in the 85+ age group. 6 These figures, together with the technological advances in care delivery resulting in an increased number of complex cases being cared for in the community setting, the increased number of people suffering with chronic conditions together with the reductions in length of hospital stay will impact the delivery of a safe and quality PHN services within Primary Care Areas of deprivation in the HSE South. Within the HSE South there are eleven areas categorized as high deprivation with a deprivation index score of >6 as reported by Health Services Research (SAHRU). On average there is a ratio of 1 WTE PHN per 2,132 populations, with the support of a RGN based on assessed needs. All of these areas are urban and consequently the associated work practices are targeted at the needs of the population. These practices focus on the needs of unsupported lone and teenage parents and include paediatric screening and appropriate interventions; community parents support programmes and working in conjunction with substance abuse programmes. Other work practices focus on working with the community development groups and voluntary agencies to respond to population led demands including the asylum seekers and traveller communities. In contrast in areas of rural deprivation with an index score of 9, there is, on average a ratio of 1 WTE PHN to population of approximately 2,994, these areas also have the support of an RGN based on assessed need. Targeted services are provided in areas of rural deprivation based on assessed population needs. PHN Services link with voluntary services targeting rural isolation, depression and nutrition. Day Care centres provide services for older persons including those with mental health needs. PHN services work with voluntary agencies to address disadvantaged groups including unsupported parents, mothers of children with disabilities and mental health needs. The ratio of PHN and RGN staff in urban and rural areas of deprivation is similar to the ratio of staff in all other areas Traveller Health Travellers are recognized as a distinct minority group in Irish society with a health status far below the general population and having specific health needs. 7 National and regional traveller health structures have facilitated the development of traveller health initiatives at local level. The Traveller Primary Healthcare Projects (PHCTP) act in partnership with the HSE and organise training programmes to develop the capacity of travellers to become traveller community health workers. There are thirteen PHCTPs in the HSE South who conduct local needs assessments for travellers and the findings are used to develop joint projects and initiatives with local health services. In the nine LHO areas within the HSE South, there are currently no PHN posts dedicated to traveller health whereas previously almost all LHO areas had at least one PHN dedicated to traveller health. The responsibility for the nursing care for the traveller health has reverted to the area PHN. In some LHO areas the PHN is involved with the PHCTP and support health promotional projects such as Health Action Zone. Additionally PHNs provide targeted services to travellers including developmental examinations and immunization clinics for children and health checks for adults as required. Furthermore PHNs deliver train the trainer programmes to traveller community health workers on the child safety awareness programmes. A number of Assistant DPHNs are members of local Traveller Health Area Committees, involved in health promotion projects with travellers. 1.3 Child and Family Health Service Responsibility for the provision of Children s health services up to 6 years of age and to pupils attending primary school has been devolved from the Health Service to the PHN service as outlined in the Health Act (1970) 8. The timing and the content of the health examinations are guided by best practice and outlined in Best Health for Children (2005) 9 a national child health assessment, screening and surveillance programme. The role of the PHN in the provision of this service includes conducting a postnatal visit and assessment at hours post discharge from the maternity services and subsequent developmental examinations up to 3.5 years. 6 Health Service Executive (2008) Integrated Services Programme, 7 All Ireland Traveller Health Study (2010) UCD 8 Department of Health (1970) Health Act 9 Denyer S. (2005) Best Health for Children Revisited. Report from the National Care Child Health Programme. HSE 4

6 Compliance with national performance indicators (PI s) for Child Health in the HSE South demonstrates a high level of service delivery, on a five day week service, 10 with all respondent areas on target (99%) at completing the first postnatal visit at hours post discharge. Similarly a high level of service delivery with four respondent areas on target (90%) for completing the 7 9 month developmental examination and all other areas achieving within a 10% range of the target. The PHN Service ensures that the National Blood Spot Screening test is completed and all babies residing in the area are offered screening. The role of the PHN service in safeguarding and protecting the health and wellbeing of children is provided for in legislation (DoH 1991). 11 The PHN service offered to children less than 5 years of age is critical to the early identification of health and social problems that threaten the welfare of the child and the family in need of early intervention. In the HSE South all respondent areas provide an early intervention service and appropriate referral for children and families where a concern is identified. One of the main benefits of direct referrals between professionals working in the multidisciplinary PCT is demonstrated not only in savings in time for the service user, but also in facilitating a team approach to the planning and delivery of services. To date Child and Adolescents Mental Health Service have yet to agree to direct referrals between professions within PCTs in all areas in the HSE South. 1.4 School Health Service The provision of a schools health service is legislated by the Health Act (1970). 12 The school health screening and immunisation programmes are currently being delivered by school immunisation teams (Area Medical Officers and PHNs) in many areas nationally. In order to enhance the delivery of the immunisation programme PHNs are currently being educated to immunise under medication protocol and it is planned that this will be a nurse led programme in the future. The expansion of the school immunisation programme is an important, successful and cost-effective public health measure. The high uptake for the HPV immunisation in the HSE South (82% for the 2010/2011 cohort) is consistent with the need to improve our immunisation uptake as highlighted in the 2012 HSE National Service Plan. However the organisation and delivery of school services is not standardised across the HSE South and the focus on the additional immunisations programmes has had a negative impact on the school screening and health promotional activities. 1.5 Adults and Older Persons Health Service Life expectancy in Ireland currently exceeds the EU average. The death rate in Ireland is less than 30,000 per year indicating an increase in those 65 years and older which is currently at 6.3/ The decreasing mortality rates from major diseases together with reduced length of hospital stay have impacted on the organisation, management and cost of the delivery of a safe and effective PHN service. Health policy endorses maintaining older adults in their own environment where possible and the PHN service provides a home nursing service in order to meet this aim. The implementation of home care packages including the completion and review of the Common Summary Assessment Record (CSAR) is an integral part of the PHN service. The need for standardisation in the delivery the PHN service is underpinned by the lack of consensus on the criteria for eligibility to the service. 1.6 Disability Service to all care groups The entitlement of an assessment of need for children under 5 is provided for in legislation and this is to be extended to all adults with disabilities after Applying the 2006 CSO figures, it is estimated that in excess of 11,000 children under the age of 18 years required Multidisciplinary team (MDT) services, which is equivalent to 4.07% of the total population of children and young people in the HSE South. 15 The PHN service is responsible for the assessment and 10 A planned essential nursing service is provided at weekends. 11 Department Of Health (1991) Child Care Act 12 Department of Health (1970) Health Act 13 Central Statistics Office (2011) 14 Department Of Justice, Equality And Law Reform (2005) Disability Act 15 Department of Children and Youth Affairs (2010) The State of the Nation s Children Ireland. 5

7 coordination of nursing care needs of children and adults with disabilities. This service is provided in conjunction with the Disability Care Group Coordinator, MDT team and the voluntary agencies as required. It is planned that clients with disabilities will have their need for assessment and interventions met at the PCT level and will be referred only depending on need, therefore the demand for services at PCT level will be on the increase. 1.7 Palliative Care/End of Life Care Nursing Service to all care groups The delivery of palliative care to children and adults at the end of life is one aspect of the role of the PHN services in the HSE South. The numbers of patients availing of palliative care in the community in 2011 in the HSE South was 2800 approx which equates to 0.26% of the total population of the HSE South (1.08 million), and 27% of the total number of palliative care patients being cared for in the community nationally. 16 This figure is comparable to the percentage of palliative care patients per population in the remaining three HSE areas. The PHN service, in conjunction with the specialist palliative care service and the GP provide the palliative service including nursing and medication needs, to all care groups in the HSE South. In two of the respondent areas the community palliative care services are managed by the Director of PHN service whereas in the remaining areas the service is manager within the Specialist Palliative Service led by a Palliative Care Consultant. 1.8 Chronic Disease Management The principal causes of premature death in Ireland are diseases of the circulatory system and cancer, many of which are preventable. The HSE are implementing the Integrated Services Programme 17 which will facilitate the integration of health and social services per geographical area. The implementation of the National Clinical Care Programmes will enhance the standardisation of the management of chronic diseases across the services. In the HSE South PHN services are currently involved in the management of clients with chronic diseases, although structures and guidelines required for the delivery of specific Clinical Care Programmes are not yet implemented. There are a limited number of PHN dedicated to chronic diseases prevention and management including diabetes and cardiovascular diseases. 1.9 Health Promotion and Nurse-Led Clinics Within the scope of PHN services, as well as opportunistic health promotion on an individual level, targeted and effective health improvements are sought by identifying and prioritising the health needs of the population.within the HSE South the targeted services, including nurse-led clinics are being delivered to population groups across all ages include services for preschool children and families such as antenatal classes, community mother s programme, well baby clinics and postnatal depression groups. Services targeted at Primary and Post Primary school population include healthy schools initiative, obesity prevention, enuresis clinics, lifestyle behaviours and suicide prevention. Specific services for the older persons include falls prevention programme, diabetes clinics, tissue viability clinics, continence clinics and cardiovascular support groups Education and Training Staff development is crucial to ensure that staff maintain the competencies necessary to provide high quality, safe and effective care in the community. All respondents in the Survey indicated that they have a system for identifying professional development needs as well as having clinical supervision available to their staff. However the need for professional practice development personnel as well as the implementation of performance management systems in all LHO areas was reiterated. Education and training for the delivery of services to children is concentrated on the national child health assessment, screening and surveillance programme. 16 HSE (2011) Corporate Planning and Corporate Performance (CPCP) 17 Health Service Executive (2008) Integrated Services Programme, 6

8 1.11 The projected number of nurses leaving the service It is important to ensure that a balanced supply and demand of adequately skilled community based nurses will be available and will deliver a high qualify and safe service in an efficient and economic manner to the service user. A total of thirty retirements from the PHN Services is estimated for the HSE South for 2012 which is 25% of the total estimated retirements from the PHN service nationally 18. The majority of retirees are PHNs (16) spread across six LHO areas, which is 4% of the total PHN WTE s for HSE South that will impact the delivery of front line PHN services PHN Service Initiatives in the HSE South The samples of projects outlined demonstrate effective team working, efficient use of resources and collaboration of acute and community services. Diabetic Prevention Programme HSE South, West Cork. A population health approach utilising the integrated model of care to create an environment in the community that supports health promotion and care is the Diabetic Prevention Programme in West Cork. The primary aim of this programme is to halt the progression of diabetes. The estimated cost for the delivery of this programme for 173 clients in 2011 was less than 50,000 which amounts to 289 per person for this programme. This amount, when compared to the estimated cost of one bed in an acute hospital for a night 883 ( 6181 per week) considering the savings on bed days is estimated in the long term, demonstrates efficient use of resources. Wound care HSE South-Carlow/Kilkenny, West Cork, North Cork, Kerry and South Tipperary. In 2008 it was estimated that the average annual cost of the treatment of leg ulcers to the Irish Health Service was 9.9 million euros. As the management of wound care is very labour intensive and time consuming, the PHN Services in the HSE South has utilised the model of nurse-led, community wound management clinics in a number of areas including Carlow/ Kilkenny, Kerry, West Cork and North Cork. A total cost savings up to 200,000 p.a. was achieved with nurse-led wound clinics as indicated from similar study findings in Carlow/Kilkenny, Ennis and North Cork. Paediatric Nursing Service to Chronically ill children in their homes HSE South, Kerry. In order to provide support to children with chronic illness and their families, in the past five years, the PHN Services within Primary Care in Kerry have developed a paediatric Nursing Service to children with lifelimiting conditions and their families in their own homes. This service has been offered to a wide range from children with life-limiting conditions, those with palliative care requirements as well as to those children with clinical nursing needs including management of tracheotomies and ventilators. It is estimated that the annual cost of maintaining a child with a tracheotomy at home is 35,000 50,000 compared to the estimated weekly cost of a bed in an acute hospital which is The actual benefit to the child and family to have this service provided in their own home together with the net saving demonstrates the financial benefits as well as the effectiveness of this initiative. Kidscope Project Knocknaheeney HSE South, North Lee Kidscope is a paediatric assessment clinic for children in one of the most deprived areas in the HSE South. It is a partnership programme between teaching paediatric consultants and the Public Health Nursing Team. Although an identifiable need may be identified by the PHN through the Child Health Screening and Surveillance Programme, children may not meet the criteria for admission to the Community Early Intervention Team (EIT) and can be referred to the paediatric assessment clinic as an alternative. In 2010, in excess of 200 children were assessed in the clinic and referred to the appropriate services. 18 HSE: National Pensions Management National HR Services, Jan

9 Community Parent Support Programme HSE South, Kerry. The Community Parent Support Programme is a parent to parent home visiting support programme offered to parents in the Kerry area and co-ordinated by a public health nurse. It is offered to first and second time parents and includes lone parents, teenage parents, travellers, asylum seekers, and parents with learning and literacy difficulties. This service is being delivered at a cost of 37,000 pa. Currently the programme is being delivered to 230 families at any one time by 7 community parents. Child Health Information Services Project (CHISP) CHISP is an initiative that provides information to parents with the aim of enhancing their knowledge on all aspects of their newborn child s health. In addition to outlining the child s overall development from birth to five years, the books and CD also contains information on parenting. Local contact details for health professionals and organisations are also included. In summary this report presents an analysis of the PHN Services that are provided in the HSE South based primarily on the findings from the Survey of Review of PHN Services. A number of themes were identified including clinical governance, areas of deprivation, traveller health and projected retirees from the PHN service. In addition services provided to specific care groups by the PHN service are examined such as child health, including schools programmes, children and adults with disabilities, clients receiving palliative care services, older adults and clients with chronic diseases. Finally service initiatives across the HSE South were used to exemplify cost effectiveness while providing a safe and quality service based on identified population needs. 8

10 Public Health Nursing Services in the HSE South. Introduction There are four Regional areas of the Heath Service Executive: HSE South, HSE West, HSE Dublin/North- East and HSE Dublin/Mid-Leinster. These regional areas are central to the co-ordination of the health services and ultimately to the quality of patient care. The HSE Management team is responsible for performance management, translating national policies through the local areas and gathering and relaying information on a regional basis. These regions operate within the determined priorities and parameters of the health service nationally. Thus, cognisant of the mandate for the HSE Regions, the Regional Director of Operations (RDO) requested that the emerging data in each section of the Report on Current Public Health Nursing Services 2011(hereafter Review Survey) would be reported upon from the perspective of the HSE Regions. The RDO s requested the additional following information Identification of exemplars of best practice per RDO Area. Identification of Urban vs. Rural deprivation areas in relation to WTEs and work practices. Identification of the role of Public Health Nursing Services per RDO Area in relation to Travellers health. The projected numbers of nurses leaving the service. This report therefore describes the Public Health Nursing Services (hereafter PHN Services) that are provided in the HSE South using the information provided in the Review Survey and additional new information sourced to support the requests made by the RDO s. It is important to note that the Review Survey was completed by the DPHNs in 7 of the 9 geographic (former LHO) areas in HSE South. 19 Therefore, the data presented is not entirely complete. Even so, where possible the data for the two remaining geographic areas is included, where available from the HSE Health Stat database, to provide as complete a picture as possible, of the PHN Services in HSE South Region. The layout of this report closely follows the layout of the Report on Current Public Health Nursing Services. The context and the methodology for the Review Survey are presented in the Report on Current Public Health Nursing Services and will not be repeated here in this Regional Report. 19 One Review Survey was completed anonymously. It is not possible to identify whether the anonymous respondent is from Carlow/ Kilkenny or Wexford. Therefore it is not included in the data reported for HSE South. The data in this report is taken from the completed surveys returned in November

11 Section 1: Clinical Governance. Health care service providers are responsible and accountable for delivering safe, high quality and costeffective care that achieves the best health outcomes for the people to whom they provide the service. 20 To that end, the Health Service Executive (HSE) has embraced the concept of clinical governance. Clinical governance means corporate accountability for clinical performance built on a model of CEO/ GM working in partnership with Clinical Directors, Directors of Nursing and allied health professional leads. Clinical governance is about people receiving the right care, at the right time by the right person in an open, safe and caring environment. 21 Ultimately, clinical governance creates an environment that realises improved clinical outcomes for patients/ clients/ service users. The Health and Information Quality Authority (HIQA) which was established in May 2007 is responsible to the Government and the public to drive continuous improvements in the safety and quality of care and support for people using our health and social care services. In this regard HIQA monitors the performance of service providers against standards to demonstrate that they are providing good quality, safe and reliable care in services right across the country. To that end the new draft National Standards for Safer Better Healthcare developed by HIQA is awaiting the approval of the Minister for Health. These standards, when implemented, will drive substantial improvements in the safety, quality, governance and reliability of healthcare services. Based on national and international best practice, there are eight quality themes in the National Standards for Safer and Better Health Care, each with underpinning standards. These are Person Centred Care; Safe Care; Effective Care; Better Health and Wellbeing; Governance, Leadership and Management; Use of Information; Use of Resources and Workforce. It is anticipated that these standards will be the underpinning standards for the licensing of designated healthcare facilities/services when licensing is commenced. 22 From a Public Health Nursing Services perspective, a safe and quality environment is created by having and sharing a common understanding of a vision for the service. The Commission on Patient Safety and Quality Assurance hold the view that the vision for a health service governance structure should be based around knowledgeable patients receiving safe and effective care from skilled practitioners in appropriate environments with assessed outcomes. Mindful of this vision and in order to gain an insight into the clinical governance structure development, in the PHN services, the survey sought information from DPHN respondents on 4 themes drawn from the National Standards for Safer Better Healthcare Person-centred care 2. Safe care. 3. Effective care. 4. Staff development 1. Person-centred care happens when service users needs and preferences are at the centre of service design, planning and delivery Based on the information in the 7 surveys returned from HSE South, 7 DPHNs reported that their service has a Philosophy of Nursing Care statement. 4 DPHNs reported that their service has a patient charter. 7 DPHNs reported that their service users are involved in the development and implementation of their own care plans in partnership with the nurse. 5DPHNs reported that their service has self-assessment tools to support client s self-management of their condition. 2. Safe care happens when service providers protect the safety, health and welfare of service users. Based on the information in the 7 surveys returned from HSE South 7 respondents reported having a system to monitor, analyse and respond to patient safety incidents. 20 HSE 2010 Achieving Excellence in Clinical Governance Towards a Culture of Accountability. 21 HSE 2011 Draft.National Clinical Programmes Clinical Governance Checklist 11 th October. 22 HIQA Presentation to the Joint Oireachtas Committee on Health January 19th HIQA 2010Draft National Standards for Safer Better Healthcare. 10

12 6 reported that their service has a guideline on record retention. 6 reported having a guideline on record keeping and report writing. 5 reported carrying out an annual audit of service user records. 4 reported having a guideline on obtaining written informed consent from service users for examination and treatment in health care. 1 respondent reported that their service has a policy on vacant caseload management. Respondents indicated that, where there a vacant caseload exists, services are prioritised by category and workloads are reviewed.. 3. Effective care happens when service users assessed needs are based on best available evidence and information. Based on the information in the 7 surveys returned from HSE South. 6 reported that their service had a structure in place for developing, auditing, and reviewing clinical policies procedures protocols and guidelines. 7 reported up to date/ current guidelines to support the provision of elements of clinical care interventions for adults. These covered areas such as assessment, infection control, wound management, self-neglect, prescribed medications, and referral to other services. 6 reported up to date/ current guidelines and policies to support the provision of child health screening. In the main these covered areas such as New Blood Spot Screening, Immunisations, Children s First Child Welfare and Protection and guidelines of the content and timing of screening programmes. The emerging National Clinical Care Programmes prompted a question about guidelines for the Clinical Care and Management of Chronic Disease (Asthma, Coronary Syndrome, COPD, Diabetes, Epilepsy, Rheumatoid Arthritis and Stroke) in primary care. Based on the information in the 7 surveys returned from HSE South. No respondent reported having a guideline to support the Clinical Care and Management of Chronic Disease in primary care. 4. Staff development: High quality safe care happens when service providers recruit staff, maintain, and support the competencies necessary to provide the care that is required. Based on the information in the 7 surveys returned from HSE South 7 DPHNs reported that their service has a system of professional development for identifying professional development needs of staff. 7 reported having an orientation package for post graduate students 7 reported having an orientation package for new staff. 7 reported that clinical supervision is available to staff in their service 5 reported having an orientation package for undergraduate student nurses. 5 reported having a formal mentoring scheme for new staff members. 3 reported having a staff performance review/ appraisal system in place. 2 reported that their service has a professional practice development person. The purpose of using 4 themes from the 8 themes that are identified by HIQA, in their National Standards document for Safer Better Healthcare, in the Review Survey are two- fold. Firstly, the 4 themes (Person Centred Care, Safe Care, Effective Care and Staff Development) used in the Survey were to help understand, as an initial exercise, what structures are in place for the Public Health Nursing Service in the primary care setting. Secondly, other themes linked to quality and safety, such as leadership and management, were examined in the questionnaires sent to the Directors and Assistant Directors of the service and will be 11

13 reported on at a later date. Each of the 4 identified themes highlight a lack of uniformity across the LHO areas in the HSE South on matters that concern the quality and safety of patient care. The provision of person centred care is premised on the PHN service providing care based on the needs and preferences of their patients. This involves providing patients with information that helps them make decisions to self-manage their care. In terms of patient self-management of their own condition, the PHN service in all LHO areas do not use or have not developed patient self-assessment tools. This aspect of the management of patient care is important, particularly in the context of chronic disease management. Therefore, what is required across all Public Health Nursing Service areas in HSE South is an approach to person centred care that is consistent with the standards set out the National Standards for Safer Better Health Care. Safe care is premised on minimising risks to patients while recognising that all risk cannot be eliminated. The Public Health Nursing Services in HSE South have structures in place to address areas of risk. However, the service should actively look at ways to make its care provision safer, this includes ensuring that they have Guidelines on Service User Consent, undertake annual audit of patient records, which are currently not in place in all LHO areas. The greatest risk to safe care is posed by the absence of a policy (across all LHO areas with one exception) to manage vacant PHN area caseloads, in a planned and safe way, at times of severe caseload pressures. Effective care is based on clinically sound and cost effective care. What this means for the PHN service is delivering evidenced based care. While, the majority of LHO areas reported that they have structures in place to audit and review clinical policies procedures protocols and guidelines there is a significant gap in the lack of guidelines for the clinical care and management of chronic disease. Staff development is crucial to the delivery of safe and effective care within the resources that are available. In planning and developing the PHN service the DPHNs must consider staff performance and staff development needs with the support of a practice development person. In the absence of mechanisms to appraise performance and to develop practice across all LHO areas, it is unlikely that the PHN service in any given area can take the appropriate action to address any identified gaps. Key message, the HSE South should give consideration to proofing the standards that pertain to patient safety and quality from the perspective of the PHN services 12

14 Section 2: Brief overview of the current geographic organisational structure of the Public Health Nursing Services in HSE South. Demographic data on the population sets the context for the planning and delivery of the health service. Preliminary data from Census 2011 shows that the population in Cork and Kerry increased by 6.8% since 2006 and the population of Carlow, Kilkenny, South Tipperary Waterford and Wexford by 7.9% in the same period. A key component of this section of the report is to provide a demographic profile of the environment within which the Directors of the Public Health Nursing Services (DPHN) strategically and operationally plan the delivery of the nursing services to meet the health needs of their respective populations. These data are important in describing the parameters of the Public Health Nursing Services in HSE South. The data allows us to be more specific about the range of services and contexts when discussing the Public Health Nursing Services. There are 9 geographic Public Health Nursing Service areas in the HSE South. These areas are co-terminus with the former LHO areas. This regional report provides a summary of the responses from 7 of the 9 former LHO areas in HSE South. Table 1 HSE South Geographic Areas and Respondent Geographic Areas. Geographic Areas 1. Cork City - North Lee 2. Cork City South Lee 3. North Cork 4. West Cork 5. Kerry 6. South Tipperary 7. Carlow Kilkenny 8. Waterford 9. Wexford Respondent Geographic Areas 1. Cork City - North Lee 2. Cork City South Lee 3. North Cork 4. West Cork Kerry 6. South Tipperary 7. Waterford The population in a geographic area shows the number of people that the PHN Service is designed to cover. The age distribution in a geographic area is an important consideration in planning and delivering the PHN Service. Most population profiles are broken down into preschool children, school age children and young people, adults and older persons. These groupings, as the following sections in this report will reveal, reflect how the PHNs service is planned and delivered regionally and nationally. The Public Health Nursing Service is recognised as the main nursing service provider in primary care and is linked to primary care teams in several geographical areas in HSE South. As stated at the outset demographic data sets the context for planning and delivery of the health service. However, to obtain a full picture of the health of the population in a geographical area the information should come from a variety of sources. In addition to data on births and deaths, data on morbidity/chronic disease is essential information. Links between morbidity and deprivation is considered to be more important in terms of planning for health service need than data on mortality and births. The National Deprivation Index for Heath and Health Services Research (SAHRU) is a valuable source of data regarding the areas of deprivation in Ireland. The SAHRU index is based on 4 (previously 5) 2006 Census indicators; unemployment, social class 5 and 6, no car ownership, rented accommodation. Each Electoral Division (3,440 nationally) receives a score based on a weighted combination of the 4 indices. These scores are then ranked and divided into deciles or tenths. A score of 1 = least deprived area 10= most deprived area. The following table shows the location of the most deprived Electoral Divisions (EDs) in HSE South based on Census 2006 data. 24 West Cork has 7 offshore islands. Heir Island population =35, Long Island population= 8 Dursey Island population=9 Cape Clear population = 120, Sherkin population =113, Beara population = 280 Whiddy population =

15 Table 2 Location of the most deprived Electoral Divisions (EDs) In HSE South based on Census 2006 data. Sorted by population number in EDs labelled 10. (SAHRU). AREA No of EDs Total No of EDs in Population in Percentage in the Area Population in Decile 10 EDs in Decile 10 population in Decile the Area 10 Cork City , , Waterford City 37 45, , Wexford , , Tipperary South Riding 95 98, , Cork County , ,900 4 Carlow 54 50, , Kilkenny , , Kerry , ,132 8 As can be noted from the following table most of the areas of deprivation are in urban areas. This does not necessarily imply, however, that there is no deprivation in rural areas. The SAHRU Index may underestimate rural deprivation as the CSO does not, for reasons of confidentially release the small area population statistics (SAPS) on some sparsely populated areas in the country. Table 3. The following is a list of the most deprived areas in HSE South starting with the most deprived areas NB All of these are index level 10. Electoral Division Name Local Authority Deprivation Population WTE PHNs WTE RGNs Score Knocknaheeny A &B Cork City Ballybeg North Waterford City Mayfield Cork City On needs basis Gurranabraher C Cork City The Glen A Cork City On needs basis Shortcourse Waterford City Morrisons Road Waterford Gurranabraher B Cork City Larchville Waterford City Custom House A Waterford City Mount Sion Waterford City Churchfield Cork City Farrenferris B Cork City Fermoy Urban North Cork Fermoy Rural Mallow North Mallow South North Cork Mitchelstown North Cork Work practices are about processes, benchmarks, patterns and decisions. These work practices are reflected in the manner in which the PHN services are provided nationally and regionally. The ratio of public health nurse to population size is the way in which the service is resourced. It has long been recommended that PHNs are assigned to populations of 2,500 people (PHN survey 1975). This figure of 2,500 is uninformed and that there is no scientific basis for it. The data obtained from DPHNs on the number of WTE PHNs working in areas with the 5 highest deprivation scores reveals on average 1 WTE PHN to a population of 2,132. While it is accepted that population size is a crude measure of workload, (historically1phn:2,500 population) the figure of 2,132 masks the significant levels of deprivation in urban areas of HSE South. In contrast in areas of rural deprivation with an index score of 9, there is, on average a ratio of 1 WTE PHN to population of approximately 2, The areas with the highest deprivation scores are not any more likely to be supported in their work practices (with vulnerable children, children at risk of neglect and abuse and older 25 This figure includes 15 electoral divisions in West Waterford which are part of South Tipperary Health Area. 26 The ratio of PHN to populations sizes in deprived rural EDs needs to be compared in more detail to similar populations sizes in deprived urban EDs 14

16 vulnerable adults), by other nurses. 27 The use of benchmarks/ performance indicators as a work practice can be of great benefit in that one can only improve that which can be accurately measured. The performance indicators statistical data scores that are gathered, as part of PHN work practices with children, may be directly or indirectly affected by factors outside its scope and could be considered for recalibration in areas with high deprivation scores and the largest population of children as identified in the data in Table 3. Public Health Nursing Services The Public Health Nursing Service has evolved over the years to meet the demands of a changing society. The DPHN respondents in the HSE South indicated that, (see table 4 below) in addition to their Children and Families, School Health and Older Persons Services they also have operational and strategic responsibility for, the nursing element of other services, for example, the Traveller population and Asylum/ Refugees groups. Population groups that are outside the general population have specific obstacles in accessing the health services and have been the focus of specific health improvement measures by the Public Health Nursing service in collaboration with community development initiatives in the primary care setting. Whether the DPHN has responsibility for Traveller Health in addition to the Travellers who are settled or who live in halting sites in an area depends on whether the PHN service is involved with the Primary Health Care for Traveller Health Projects (PHCPs) and has a PHN assigned to the project. 28 The most recent Traveller Health Study states that there are 13 such projects in HSE South. PHNs are not assigned to all these projects. Another possible reason for the variations is the availability of other professionals to manage the services. Table 4. The services that the DPHNs in the7 geographic areas have (YES) have not (NO) responsibly for in addition to the core care groups. 29 SERVICES Asylum Refugee Service CORK CITY NORTH LEE CORK CITY SOUTH LEE NORTH CORK WEST CORK KERRY WATERFORD TIPPERARY SOUTH YES YES YES YES YES NO YES Community YES YES NO NO NO NO NO Intervention Teams Day Care Service YES YES YES YES YES NO NO Home Help YES NO YES YES YES YES NO Service Home Care YES NO YES NO YES YES NO Assistant Service Home YES YES YES YES YES YES NO Care Package Scheme Palliative Care Service NO NO NO NO YES NO YES Pre School Service YES YES YES YES YES YES YES Traveller Health YES NO NO YES NO YES YES Infection Control NO NO NO NO YES NO NO Rehabilitation NO YES YES NO NO NO NO Team Twilight Nursing Service YES YES YES YES YES NO NO Staff Resources Respondents were asked to give details of the number of Whole Time Equivalent (WTE) staff in their service for different nursing grades. Respondents were also asked to give details of the number 27 When compared with PHNs working in less deprived areas or more affluent areas with similar population sizes. 28 Difficult to get precise information on the level of PHN involvement with the different PHCPs in the different LHO areas. 29 Children and Families, School Health, Older Persons Services 15

17 of WTE staff vacancies in their service for different nursing grades. Also included in Table 7 is the projected PHN Retirements for HSE South in February Table 5. The DPHNs appointed and in an Acting capacity for 7 of the 9 geographic areas in HSE South. Geographic Area Appointed Director of Public Health Nursing Service Acting Director Public Health Nursing Service Cork City North Lee NO YES Cork City South Lee YES North Cork NO YES West Cork YES Kerry YES Waterford YES Tipperary South YES Carlow Kilkenny No data No data Wexford No data No data Table 6. The total number of WTE PHN Nursing Service Grades and vacancies for 7 of the 9 geographic areas in HSE South. January Geographic Area WTE Assistant Directors 30 Vacancies WTE Assistant Director WTE PHNs Vacancies WTE PHNs WTE RGNs Vacancies WTE RGNs Cork City North Lee Cork City South Lee North Cork West Cork Kerry Waterford Tipperary South Carlow/ Kilkenny No data Wexford No data Total WTE Table 7 The Projected PHN Retirements for HSE South in February 2012 based on data received from HR, Manorhamilton Geographic Area DPHN Assistant Directors PHNs RGNs To be determined 4 1 Cork North Lee 3 1 Cork South Lee 3 North Cork Kerry 4 Waterford Tipperary South Carlow /Kilkenny Total Summary A common theme in this section is the variations in the services that the DPHNs are responsible and accountable for and the variation in staffing resources. 30 This is a total number of ADPHNs and includes ADPHNs in specialist posts for example ADPHN Preschool service, ADPHN immunisations. 31 This figure includes 1.04 RGNs working in the Day Care Service. 16

18 Section 3: Child and Family Health Service. The Health Act, 1970 is the principal legislation providing for children s health services in Ireland. Section 66 on the 1970 Act, devolves this statutory obligation to the Public Health Nursing Service (amongst others) who provides the service to children up to the age of 6 years and to pupils attending national school. The Health Act, 1970 itself does not prescribe the timing and the content of the health examinations; these details are guided by best practice 32 and set out in Best Health for Children Revisited Table 8 shows results the percentage of new-born babies visited by a PHN within 48 hours and 72 hours of hospital discharge in the 3 rd quarter 2011 for all 9 geographic areas. The HSE health stat target for this performance indicator (P.I) is 100%. Table 8 Child Health Performance Indicators: Q3 2011: PHN 48 hour visit and 72 hour visit. HSE South Number of New Born Babies Discharged (for the first time) from any hospital to the reporting area during the reporting period Number of New Born babies visited by a PHN within 48hours of Hospital Discharge % of babies visited within 48 hours of hospital discharge The number of new born babies visited by a Public Health Nurse within 72 hours of hospital discharge % of babies visited within 72 hours of hospital discharge North Lee % % South Lee % % North Cork % % West Cork % % Kerry % 7 1.4% South Tipp % % Carlow/Kilkenny % % Waterford % % Wexford % % Totals 4,266 3, % % The DPHNs respondents were asked whether they provide a 7 day (Monday Sunday) postnatal service. Table 9 indicates the level of service provision HSE South Is the service provided a 5/7 day service Is the service provided a 7/7 day service North Lee YES NO South Lee YES NO North Cork YES NO West Cork YES New-born blood spot screening carried out 7/7 day service Kerry YES NO South Tipperary YES NO Carlow/Kilkenny YES NO Waterford YES NO Wexford YES NO The HSE gathers specific data on child development. The percentage of children who receive a 7-9 month child development health check by 10 months of age is a metric that is a prioritized by the PHN service and the HSE. The graph below shows the percentage of children who received their 7-9 month Development Health check by 10 month of age in the 3 rd quarter The HSE health stat target for this P.I. is 90%. 32 The recommended health examinations/ assessments are in the immediate postnatal period at 48 hours following discharge from the maternity services, at 3 month, 7-9months, months, 3¼- 3½ years. 17