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

Transcription

1 Office of the Nursing and Midwifery Services Director. Report Prepared for the Management Team on Public Health Nursing Services in HSE West.

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

3 Table of Contents Page 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. 20 o Section 4 School Health Service 23 o Section 5 Older Persons Health Service 25 o Section 6 Disability Service (Children Young People and Adults ) 28 o Section 7 Palliative Care / End of Life Care (Adult and Children) 31 o Section 8 Chronic Disease Management 33 o Section 9 Health Promotion and Nurse/ Midwife led Clinic Service. o Section 10 Education and Training 36 o Section 11 Selected Public Health Nursing Services Initiatives 37 HSE West. Concluding comments 42 Appendix 1 Expert Advisory Group Members 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 West.; 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 the Report on Current Public Health Nursing Services per RDO Area to include the following: the emerging themes from each section of the report 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 West Region 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 6 of the 7 LHO areas in the HSE West. 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 There is evidence in the Survey of positive developments in HSE West in the development of clinical guidelines and assessment tools to support the safety and quality agenda, in primary care. In the HSE West two areas reported involving service users (in the wider care groups) in the planning and delivery of PHN services and one area reported that their service use client self-assessment/self-management tools. The PHN service provides a range of services to clients with chronic illnesses however the implementation of clinical guidelines and standards is required in order to enhance the delivery of the Clinical Care Programmes. One challenge identified in the context of reporting/responding to health and safety incidents was the risk associated with the management of vacant PHN area caseloads. 1.2 Demography of the Public Health Nursing Services in HSE West. 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 the HSE West is in excess of 1million which has increased by 67,754 (6.2%) since the 2006 census. 4 Within the HSE West the Mid-west area has grown by 4.8%. The population in the cities of Limerick and Galway decreased by 0.4% and 4.1% respectively however the hinterlands of both cities have increased by 8.3% and 10% correspondingly. This increase in the population size, overall, combined with the reduction in the staff resources in 2012 will impact on the health service in terms of its statutory obligations to children and older persons as required in the Health Act, Areas of Deprivation. In the HSE West 55% of the population of Limerick City and 35% of the population of Galway City live in the most deprived areas in the region. Nine of EDs in Limerick City fall into the extreme disadvantage category, with a SAHRU score of 10. These 9 EDs extend over the South, North and East of Limerick City and represent 44% of the total population of the city. 54 In examining individual EDs the work practices of the PHN are influenced by the high percentage of single parent families 1 Health Service Executive National Service Plan (2012) 2 Health Service Executive (2008) Integrated Services Programme, 3 HIQA 2011 Draft National Clinical Programmes, Clinical Governance Checklist 11th Oct. 4 HSE West Service Plan National Deprivation Index for Health & Health Services Research (SAHRU Technical Report Dec 2007) 3

5 with dependent children, young children with disabilities and Traveller families. There is a high percentage of children 0-5 years who are deemed to be at risk, and a smaller population of older adults > 65 years with chronic disease and disability in the EDs. In the deprived areas in Limerick City there is on average a ratio of 1 WTE PHN to population. The PHNs in Limerick Southside deliver their service without RGN support whereas in Limerick Northside the PHNs are supported in their role by an RGN when available. A significant challenge is in relation to tracing, in particular at risk children and families, is a feature of the transient nature of families in these deprived areas. In Galway City there are 7 EDs with a SAHRU index of 10. The deprived EDs extend over two network areas East City and West City Networks. In the East City Network the population of the deprived EDs represent 32% of the Network population. There are 3 PHNs attached to Ballybaan and Doughiska, with a ratio of 1 WTE PHN to 3290 approx. The PHN work practices are influenced by large populations of dependent children in single parent families, child protection concerns, migrant/ foreign nationals and Travellers. The PHN in these areas have the support of an RGN when available. However, there are insufficient numbers to enable RGNs to be caseload holders. The West City Network has 4 Primary Care Teams (PCT). The 4 deprived areas in this network are concentrated in 1 PCT and represents 71% of population of the PCT. There are 3 PHNs with a ratio of 1 WTE PHN to approx attached to this PCT with the support of.5 WTE RGN. The work practices of the PHNs in these deprived areas are characterised by the population profile which includes a high percentage of 0-5 years age group, with associated child protection concerns and non-attendance at clinics, acute and post-acute clinical nursing care and a settled Traveller population. In Clare there are 5 EDs with a SAHRU index of 10. The deprived areas are characterised by a high population of children and older persons. 40% of all Child Protection Notifications in the Clare area are generated from the Shannon area. In Kilrush Urban and Rural the PHN service is delivered across a range of client groups to a mixed population. A significant challenge involves PHNs travelling to provide a comprehensive service in very isolated areas. There is a ratio of 1 WTE PHN to population approximately in the deprived urban and rural areas in Clare. In Donegal within the Dungloe Network there are small pockets of deprived areas and access to services was identified as a challenge for rural communities. There is one main General Hospital, Letterkenny General Hospital, for the North West area. The offshore islands are a feature of Donegal, Galway and Mayo. There is a 24/7 day PHN service on Tory island in the Northwest coast and 2 islands off both the Galway and Mayo coast. A GP visiting service is provided fortnightly from the mainland to the Tory island. 6 The ratio of PHNs to population size in the most deprived areas in Limerick City and Galway City are comparable with a ratio of 1WTE PHN to similar population sizes with mixed populations. Currently PHNs are not always supported by an RGN in areas of high deprivation Traveller Health An interagency/intersectoral strategy for Traveller health was adopted at a National level in Over time, Primary Health Care for Traveller Health Projects (PHCPs) have been established in conjunction with Traveller organisations and the HSE where a significant Traveller population resides. In HSE West there is a Regional ADPHN Co-ordinator (Traveller Health Unit), for the counties of Galway Mayo and Roscommon. In Limerick, West Limerick, North Tipperary and Clare there are 3.8 WTE PHNs working with the Traveller population. The average number of births for the Traveller population in the Midwest is 140 per annum. In Limerick City the designated PHN has a caseload of 150 Traveller families, in West Limerick the PHN (.8 WTE) caseload is 120 families, in North Tipperary the PHN has a caseload of 188 families and in Clare the caseload is 200 families. The designated PHN work practices with the Traveller population include child health, child protection, a nursing service to adults, older persons, including referrals to services and advocacy work. All of the Designated PHN s in the Midwest are linked to a Primary Health Care Programme in their area, where they provide Nursing advice/assistance, training and 6 The PHNs on the islands are first responders to all emergencies on the islands. 4

6 support for the Traveller Community Health Workers. In Mayo, there are approximately 2000 travellers in the county. A designated PHN is based in Castlebar with a strategic brief for the Traveller Community, with a caseload of approximately 88 traveller families. Integral to this role is the development and ongoing review of the Primary Health Care projects in the area, one in the Ballina area which is operational and one in the Castlebar area which is in the final stage of development. In Galway 7 the health needs of the Traveller community are part of the area PHN caseload and in the Tuam area the PHNs provide education sessions for community workers to support the Traveller Health Primary Care Group. In addition, there is either an ADPHN or a PHN representative on each of 3 Primary Heath Care Traveller steering groups, the regional Traveller Health unit and the working group between the community and the maternity services 1.3 Child and Family Health Service. The PHN service is responsible for the provision of a child health service up to 6 years of age and to pupils attending primary school as outlined in the Health Act The timing and the content of the health examinations are guided by best practice and outlined in Best Health for Children Revisited (2005). The role of the PHN in the provision of this universal service includes conducting a postnatal visit and assessment at hours and in that context ensures that babies/parents are offered the Blood Spot Screening when the test is not performed in the maternity hospital prior to discharge. Subsequent developmental examinations are scheduled until the child reaches 3.5 years. Compliance with national performance indicators (PIs) for Child Health in HSE West demonstrates that 6 areas are within a 5% range of the 100% target of completing the first postnatal visit at 72 hours post discharge. The remaining 2 areas are within 10% range of the target. The 7-9 month development clinics are AMO led in 5 geographic areas and PHN led in one area. The target of 90% for the 7-9 month child development check is attained by 3 of the areas and another 2 areas are with the 15% range of the target. The need for standardisation of child health systems and processes was identified. In HSE West the opportunities for PHNs to intervene early and refer to the multidisciplinary team are apparent in the Primary Care setting. The Mental Health Services in the HSE West have yet to agree on direct referrals between professions within PCTs. 1.4 School Health Service. The provision of a primary schools health service is legislated by the Health Act, The school health service includes health screening and an immunization service which is provided by a team comprising of PHNs and Area Medical Officers in many areas nationally. The Public Health Nursing service in HSE West provides a service to the children in primary and post primary schools. The number of primary schools range from 93 to 243 and 9 to 52 post primary schools. In the majority of areas in the region there is designated School PHN Service. The uptake of the HPV is 82% for 2011/2012 in HSE West which exceeds the target of 80 per cent. Overall the Survey findings suggest a strong School Health Programme with defined referral pathways. However, the focus on immunisation has had a negative impact on the school screening programme and other health promotion activities. 1.5 Adults and Older Persons Health Service. The main objectives of primary care are to maintain the health of adults and older persons at their first point of contact with the health service and to enable the successful transition of care from one service to another, as appropriate. In the HSE West, the early discharge from hospital to home is facilitated by a combination of services: PHN discharge planning service, Nurse-led Community Intervention Teams, rehabilitation team and the Home Care Package Scheme (HCPS) and the extended role of RGN caseholders in a number of areas. The need for standardisation in the delivery of the PHN services is underpinned by the lack of national consensus regarding eligibility, as provided for in the Health Act, Disability Service (Children Young People and Adults). The obligation to provide health services to people with disabilities rests with the State. The Disability Act, 2005 provides for an assessment of need for children under 5 and this is to be available to all adults with disabilities after 2011.Children and adults with disabilities have their intervention and treatment needs co-ordinated by the Disability Services in the Region. Where children and adults with disabilities have nursing care needs, these are co-ordinated by the PHN 7 According to the All Traveller Health Study 2010 there are 1,030 Traveller families in Galway, total population is 3,351 people. 5

7 Service. The PCT model of service provision for children and adults with disabilities is essential in light of the mainstreaming of persons with disabilities, changing demographics and client expectations. The role of PCT in co-ordinating the health and social needs of adults with disabilities is re-iterated in the recently published New Directions document, 8 which prioritorises the need for adults with disabilities to have access to primary care teams and multidisciplinary team specialist services. 1.7 Palliative Care/End of Life Care Nursing Service (Adult and Children). Palliative care services are provided directly by the HSE and in partnership with voluntary agencies. The services are structured in a way that enables patients, to die at home if agreed and to have their care needs met by the Public Health Nursing service in partnership with the palliative care specialists. Based on the information available in the HSE West Regional Service Plan 2012, the expected activity target for specialist palliative care services in the community is 941 patients for This is an indication of the Palliative Care Services provided in the community that includes the Public Health Nursing activity in the end of life care in the region. Though, there is some variation in the structure of palliative care services provided in the community in the HSE West, all areas provide generalist and specialist palliative home nursing services. There are strong professional links between the Public Health Nursing Service and the Palliative Care Home Nursing services for adults in the Region as evidenced through the developments in shared patient care practices. In the absence of similar developments in paediatric palliative care service the needs of children and young people are provided for within the adult service model. 1.8 Chronic Disease Management. The projected demographic changes and epidemiological trends in chronic disease will result in more people being cared for in a primary care setting. These trends are complementary in that living longer and maintaining adults and older persons at home is also associated with managing chronic disease pathology in the community. The HSE are implementing the Integrated Services Programme which will facilitate the integration of health and social service per geographical area. In the HSE West the PHN service provides a range of services to clients with long term diseases, although structures and guidelines required for the delivery of specific Clinical Care Programmes are not yet implemented. The management of chronic diseases are dependant on the skills mix of nurses in primary care. 1.9 Health Promotion and Nurse Led Clinics. Health promotion and nurse led clinics are inextricably linked to all areas of PHN service provision across all client groups in primary care. Health promotion activities are directed at the level of the individual while simultaneously maintaining a population focus. Health promotion tailored to the needs of individual with chronic disease is an integral part of the role of the PHNs and RGNs. Health promotion and health protecting activities are targeted at preschool, primary and post primary school populations and older persons. Section 11 of this report describes some of PHN service developments in HSE West in response to the evolving health care needs of clients in the region Education and Training. A skilled and knowledgeable workforce is required to provide high quality safe and effective health care in primary care. The majority of respondents reported having a system in place to identify staff development needs and to having clinical supervision available to staff. The on-going education and training needs of PHNs was also identified. The majority of areas, apart from Galway, have been provided with the required child health screening education and training programme. The need for the provision of the medical module including screening for Developmental Dysplasia of the Hips (DDH) was identified The 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 quality and safe service in an efficient and economic manner to the service user. A total of 40 retirements from the PHN Services is estimated for the HSE West for The majority of retirees are PHNs (32) across the region which is 7.8% of the total PHN WTE s for HSE West that will impact the delivery of front line PHN services. 8 New Directions Support Services for Persons with Disabilities Review of HSE Day Services and Implementation Plan HSE: National Pensions Management National HR Services, Jan

8 1.12 PHN Service Initiatives/Developments HSE West. The PHN practice initiatives described below are used to exemplify areas of service and practice development which adhere to the key principles that guide the HSE West Regional Service Plan These guiding principles seek to ensure a safe and quality service that is patient centred, to make it easier for people to access the care they need (service integration) and the effective and efficient use of resources PHN Service Developments HSE West - Limerick /North Tipperary/Donegal Limerick Adult/ disability Health Service Developments Donegal Cancer Care Nurse prescriber Suprapublic catheterisation, male urethral catherisations Complex Disability (both paediatric and adult) including traceostomy care and mechanical ventilation in the home. Nurse-led Community Intervention Service - expansion into OPAT Service (Out Patient Anti Microbial Therapy) to support early discharge/hospital avoidance The PHN service has undertaken training in care of CVADs 11. This allows the PHN to change the dressing on the CVAD and disconnect Chemo pumps in the patient s own home or local health centre reducing the number of appointments to Letterkenny General Hospital. The PHN on Tory island of the Northwest coast provides a 24/7 day service with the GP visiting fortnightly from the mainland. The PHN on Tory island is currently undertaking the Certificate in Nurse/Midwife Prescribing in order to improve the delivery of health care in an isolated area. PHN AND RGN ROLE EXPANSION SERVIC E INTEGRATION SAFETY AND QUALITY 2. PHN Service Developments Discharge Planning HSE West - Galway. The benefits of integrated discharge planning are well documented and include reduced length of hospital stay and the prevention of unplanned hospital admissions. 12 The liaison PHN service (2 WTE PHNs + 1 RGN) in Galway co ordinates all discharges (general, paediatric and hospice) between hospital and primary care. Following the identification of expected discharge date (EDD) the PHN liaison service undertakes the following: Initiates discharge planning procedures. Nursing referral is activated. Plan of treatment is discussed and agreed with the patient and/or carer as appropriate. Nursing referral is reviewed. Identifies any deficits in patient care and education. Risk management needs discussed in relation to health/safety in the home, moving and handling, and infection control. Formal and informal care identified Verifies that the patient has the required equipment organised Links with other informal and formal and supports including Home Care Package Manager area PHN, Tissue Viability PHN and Clinical Nurse Specialists Palliative Care. This model was proven to be extremely successful in Northern Ireland with savings on 1064 bed days over a 15 month period Health Service Executive HSE West Regional Service Plan Central Venous Access Devices. 12 Cited in the Health Service Executive (2009) Guideline for Nurse Midwife Facilitated Discharge Planning, Changing Practice to Support Service Delivery. 13 Kane, K How caseload analysis lead to the modernization of the DN Service. British Journal of Community Nursing 14 1 pp

9 3. PHN Role Expansion Community Oncology Service HSE West- Galway. In order to provide an integrated oncology service in the community fourteen PHNs completed a National Cancer Control Programme for Community Oncology Nurses. This six month training programme was delivered through the Centre of Nursing and Midwifery Education in Galway. The programme had a theoretical component as well as the development of clinical skills under supervision with the application of these skills in the community. These PHNs will be providing a phlebotomy service as well as facilitating patients to receive chemotherapy treatment at home as appropriate. 4. Health Needs Assessment in Primary Care HSE West - Mayo. A Health needs assessment study was carried out to provide a baseline profile of the health needs of the people from within four Primary Care Teams in Mayo in order to plan services that are appropriate, accessible, value for money and based on best practice. A summary of the main findings a. Morbidity for Cardiovascular Disease in County Mayo - 41% Cancer - 24% Respiratory -18% b. Highest prevalence of diabetes is in the Western region at 5.25%. c. Incidence of people with continence difficulty was higher at 12.5% when compared to national reported incidence of 7.5%. For men continence issues were severely under-reported. d. Bedwetting in children a main health concern for parents. e. Mental health issues suicide, postnatal depression and rural isolation As a result of the above findings the following initiatives have been commenced in the Mayo area: Desmond programme; COPD programme; Men s Continence Programme; Home Help Training in Caring for a Dementia Client; Common Sense Parenting Programme; Enuresis Clinic and STORM suicide prevention training. Summary In summary this report presents an analysis of the PHN Services that are provided in the HSE West 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 the retirees from the PHN service. In addition services provided to specific care groups by the PHN service are examined such as child health, including the schools programmes, children and adults with disabilities, clients receiving palliative care services, older adults and clients with chronic diseases. Finally, PHN initiatives are used to exemplify areas of service development within the region which observe the principles that guide the HSE West Regional Service Plan

10 Public Health Nursing Services in HSE West. 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 Regional 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) at a recent HSE management team meeting requested that the emerging data in each section of the Report on Current Public Health Nursing Services (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 West using the information provided in the Review Survey and additional new information sourced to support the requests made by Regional Director of Operations. It is important to note that the Review Survey was completed by the DPHNs in 6 of the geographic (former LHO) areas in HSE West. 14 Therefore, the data presented is not entirely complete. Even so, where possible the data for the one remaining geographic areas is included, where available from the HSE Health Stat database. 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 have already been presented in the Report and therefore will not be repeated. 14 One survey was completed anonymously. It is not possible to identify whether the anonymous respondent is a DPHN in HSE West. Therefore the data is not included in this report. The data in this report is taken from the completed surveys returned in November The data for staff resources has been revised to reflect the position in February

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. 15 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. 16 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 Better Healthcare 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. 17 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 6 surveys returned from HSE West. 5 DPHNs reported that their service has a Philosophy of Nursing Care statement. 6DPHNs reported that their service users are involved in the development and implementation of their own care plans in partnership with the nurse. 2 DPHNs reported service users are involved in the planning and delivery of PHN services 1 DPHN reported the use of client self-assessment/ self-management tools. 15 HSE 2010 Achieving Excellence in Clinical Governance Towards a Culture of Accountability. 16 HSE 2011 Draft.National Clinical Programmes Clinical Governance Checklist 11 th October. 17 HIQA Presentation to the Joint Oireachtas Committee on Health January 19th HIQA 2010Draft National Standards for Safer Better Healthcare. 10

12 2. Safe care happens when service providers protect the safety, health and welfare of service users. Based on the information in the 6 surveys returned from HSE West. 6 respondents reported having a system to monitor, analyse and respond to patient safety incidents. 4 reported that their service has a guideline on record retention. 3 reported carrying out an annual audit of service user records. 3 reported having a guideline on record keeping and report writing. 1 reported that the development of a guideline was in progress on obtaining written informed consent from service users for examination and treatment in health care. None of the respondents reported that their service has a policy on vacant caseload management. A number of actions are taken to address the management of a vacant caseload including cross cover arrangements, re-allocation and prioritorisation of caseloads. The management of the clinical caseload and elderly care is provided by RGNs and child development screening including birth notification is provided by PHNs. The implication of a vacant post, including risk assessments and inability to meet agreed targets are submitted to management. 3. Effective care happens when service users assessed needs are based on best available evidence and information. Based on the information in the 6 surveys returned from HSE West 6 reported that their service had a structure in place for developing, auditing, and reviewing clinical policies, procedures, protocols and guidelines 19 6 reported up to date/current guidelines to support the provision of clinical interventions for care of the elderly/persons with disabilities and adults< 65 years 6 reported up to date/current guidelines to support the provision of care to the new-born infant and family and child health screening The National Clinical Care Programmes were addressed with a question regarding 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 6 surveys returned from HSE West One respondent reported having a guideline to support the Clinical Care and Management of Stroke 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 6 surveys returned from HSE West. 5 reported that their service has a system of professional development for identifying professional development needs of staff. 5 reported that clinical supervision is available to staff in their service. 3 DPHNs reported having an orientation package for new staff. 3 reported having an orientation package for post graduate students. 3 reported having an orientation package for undergraduate student nurses. 2 reported having a formal mentoring scheme for new staff members. 2 reported having a staff performance review/ appraisal system in place. None of the 6 DPHNs reported that their service has a professional practice development person. 19 The formal structures no longer in place in some areas following the recent staff retirements. 11

13 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 Centered 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 reported on at a later date. The provision of person-centred care is premised on the PHN service providing care based on the needs and preferences of their patients. There is evidence in the Survey that in 2 areas in the West service users are involved in the planning and delivery of PHN services. Similarly one area reported that their service used client self-assessment/self-management tools. These initiatives could be replicated in other areas in region. The PHN service provides a range of services to clients with chronic illnesses however the implementation of clinical guidelines and standards is required in order to enhance the delivery of the Clinical Care Programmes. This requires a Regional co-ordinated approach to the use of evidence based self-care tools that are disease specific and consistent with the standards for person-centred care in 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. All Public Health Nursing Services in HSE West with one exception reported to have adequate risk management structures in place within their geographical areas. The challenge posed in reporting/responding to health and safety incidents in areas without risk management structures indicates a possible gap in the framework for the management of safety and risk in primary care. 20 It was acknowledged that the requirement for audit of patient records, report writing, record keeping and service user consent are not currently in place in all areas, that these are necessary safeguards that need be in place in all areas. 21. Effective care is based on clinically sound and cost effective care. All areas in HSE West have structures in place to audit and review the services in order to deliver safe and effective care. In the HSE West, the staff are involved in the development of clinical guidelines, and assessment tools to support the quality agenda, though a gap exists in guidelines for the clinical care and management of chronic disease service. Staff development is crucial to the delivery of safe and effective care within the resources that are available. Knowledgeable, skilled and competent staff are required in order to deliver safe, effective nursing care within the Primary Care framework. Five DPHNs reported having a system in place to identify staff development needs and to having clinical supervision available to staff though in practice. 20 Reports sent to clinical indemnity if potential for claims or entry into STARSWeb. 21 For the purpose of the survey the term vacant case load was defined as follow if there is no substantive post holder ( i.e. PHN RGN School Nurse) allocated, because of sick leave, long term sick leave, planned leave, maternity leave, vacant post for secondment, for more than 4 weeks. (NHS, Outer North East London Community Services, 2011). 12

14 Section 2: Brief overview of the current geographic organisational structure of the Public Health Nursing Services in HSE West. 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 the Region is in excess of 1 million which has increased by 67,754 (6.2%) since the 2006 census. 22 Within the HSE West the Mid-west area has grown by 4.8%, the population in the cities of Limerick and Galway decreased by 0.4% and 4.1% respectively, however the hinterlands of both cities have increased by 8.3% and 10% correspondingly. 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. Within a geographical area, age distribution is important and most population profiles are categorised into the following care groups: preschool children, school age children and young people, adults and older people. In the main this reflects the way in which the PHN Service is managed and delivered. Yet, it is the epidemiological data more than the demographic that is driving the planning and delivery of the service. Increasingly the links between morbidity and deprivation is now considered to be as important in terms of planning the PHN service as the data on birth rates and deaths. This is a fundamental shift in the focus of the service as the findings in this report will reveal. These data are important in describing the parameters of the PHN service as it allows us to be more specific about the range of services and contexts when discussing the services in HSE West. The HSE West administrative area includes: Limerick, Clare, Tipperary (North Riding), Galway, Mayo, Roscommon, Donegal, Sligo/Leitrim/West Cavan. Currently there are 7 geographic Public Health Nursing Service areas in the HSE West which are co-terminus with the former LHO areas. This report provides a summary of the responses from 6 of the 7 former LHO areas in HSE West Table 1 HSE West Geographic Areas and Respondent Geographic Areas. Geographic Areas 1. Limerick/ Tipperary North Riding 2. Clare 3. Galway 4. Mayo 5. Roscommon 6. Sligo/ Leitrim/West Cavan 7. Donegal Respondent Geographic Areas 1. Limerick/ Tipperary North Riding 2. Clare 3. Galway Mayo Roscommon 6. Sligo Leitrim/West Cavan 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 HSE West indicated that, in addition to their core services (Children and Families, School Health, Older Persons Services) 25 they also have operational and strategic responsibility for, the nursing element of a number of other services (see table 2 below). 22 HSE West Regional Service Plan Includes 4 islands with 160, 198, 268, and 890 populations. 24 Includes three islands. Clare Island pop= 130, Inistuck pop= 70 and Inisbiggle pop= The core services are described in greater detail in Sections 3, 4 and 5 respectively of this report. 13

15 Traveller Health: In HSE West there is a PHN assigned to work with the Traveller Community in areas where there is a significant traveller population. There is a Regional ADPHN Co-ordinator, Traveller Health Unit, for the counties of Galway, Mayo and Roscommon based in Castlebar. 26 In Limerick, West Limerick, North Tipperary and Clare there are 3.8 WTE PHNs working with the Traveller population. The average number of births for the Traveller population in the Midwest is 140 per annum. In Limerick City the designated PHN has a caseload of 150 Traveller families in West Limerick the PHN (.8 WTE) with a caseload of 120 families, which increases to 400 during the months of December and January. In North Tipperary the PHN has a caseload of 188 families and in Clare the caseload is 200 families. The designated PHN work practices with the Traveller population include interventions in child health, child protection, providing a nursing service to adults and older persons, including referrals to services and advocacy work. All of the designated PHN s in the Midwest are linked to a Primary Health Care Programme in their area, where they provide Nursing advice/assistance, training and support for the Traveller Community Health Workers. In 2012 the focus of this work will be on promoting access to the National Screening Programmes as per HSE policy. All 4 of the designated PHN s have specific Interagency Traveller Actions in line with the local interagency plans that include Men s Health Projects, Violence against Women and Parenting. The PHN s are involved in a range of local initiatives such as Needs Assessments, Delivering Mental Health Promotion, and Promoting Breast Feeding and Smoking Cessation. In Rathkeale there is an Annual Triage Clinic each December. The objective of the Triage Clinic is to provide a complementary nursing service to the mainstream General Practice in the Rathkeale area over the Christmas period due to the large numbers of transient members of the Traveller Community who return to the area during this time. The Designated PHNs in Limerick City and Rathkeale provide the majority of nursing input into this Clinic. In Galway the health needs of the Traveller community are included in the area PHN caseload. 27 There is a higher percentage of Travellers residing in the Galway City and East Galway areas in comparsion to other areas in the city. In the Tuam area the PHN works with the Traveller Health Primary Care Group and provides education sessions for community workers. There is an ADPHN or a PHN representative on each of 3 Primary Heath Care Traveller steering groups, the regional Traveller Health unit and the working group between the community and the maternity services. In Mayo, there are approximately 2000 travellers in the county. A designated PHN is based in Castlebar with a strategic brief for the Traveller Community, with a caseload of approximately 88 traveller families. Integral to this role is the development and ongoing review of the Primary Health Care projects in the area, one in the Ballina area which is operational and one in the Castlebar area which is in the final stage of development. All other Traveller families throughout the county are managed by the area PHN. Refugees/ Asylum/ Migrant Services In HSE West there 1 Clinical Nurse Specialist (Asylum Seeker Health) Preschool Service The HSE is responsible for inspecting pre-schools, play groups, nurseries, crèches, day-care and similar services which cater for children aged 0-6, under the Child Care (Preschool Services) Regulations The regulation inter alia places a responsibility on the health board to secure the health safety, welfare and promote the development of children attending preschool services. This requirement is fulfilled by inspectors attached to the HSE LHO areas. The team comprises of a Public Health Nurse and an Environmental Health Officer. In Sligo/Leitrim/West Cavan there is 1 Assistant Director PHN (ADPHN) designated as a pre-school inspector. 26 Regional co-ordinator ADPHN reports to the DPHN in Mayo. 27 According to the All Traveller Health Study 2010 there are 1,030 Traveller families in Galway, total population is 3,351 people. 28 The majority of preschools are privately owned and the remainder are community based 14

16 Table 2. The services that the DPHNs in the 6 geographic areas have (YES) have not (NO) responsibly for in addition to the core care groups. 29 SERVICES Limerick/ Tipperary Clare Galway Mayo Roscommon Sligo Leitrim West Cavan Asylum Refugee Service NO YES NO NO NO NO Community Intervention Teams YES YES NO NO NO NO Day Care Service NO NO NO NO NO NO Home Help Service NO NO NO NO NO YES Health Care Assistant Service NO YES NO NO NO NO Home Care Package Scheme NO NO NO NO NO NO Palliative Care Service NO NO NO YES YES NO Pre School Service Inspectorate NO NO NO NO NO YES Traveller Health NO YES NO YES NO YES Infection Control NO NO NO NO NO NO Rehabilitation Team YES NO NO NO YES NO Table 3 Location of the most deprived Electoral Divisions (EDs) In HSE WEST based on Census 2006 data. (SAHRU). HSE WEST No of EDs in the Area Total Population in the Area 52, ,441 65,983 No of EDs in Decile 10 Population in EDs in Decile 10 Percentage population in Decile 10 Limerick City Limerick County Tipperary N.R ,741 4,955 8, Clare , ,532 9 Galway City 22 72, , Galway County , , Mayo , ,733 9 Roscommon , ,559 3 Sligo Leitrim Cavan ,845 28,876 63, ,680 1, Children and Families, School Health, Older Persons Services 15

17 Table 4. The following is a list of the most deprived areas, in HSE West with their population size, number of assigned WTE PHNs and RGNs. All of these are at index level 10. HSE WEST Johns A Galvone B Prospect B Glentworth Ballynanty Rathbane Killeely A Johns B Shannon B Clenagh Local Authority/ Network Limerick City East Limerick City South Limerick City South Limerick City South Limerick City North Limerick City South Limerick City North Limerick City East Limerick City South Shannon Primary Care Team Co Clare Deprivation Score Population WTE PHNs WTE RGNs No RGN support No RGN support No RGN support Occasional RGN support No RGN support Occasional RGN support WTE PHNs attached to PCT pop RGN support x 4 days/ week Kilrush Urban Co. Clare PHNs.33WTE RGN Kilkee Town and Hinterland Clare PHN.2 WTE RGN Ballybaan Doughiska St Nicholas Newcastle Rahoon Claddagh Dangan Galway East City Network Galway West City Network Least deprived WTE PHNs No RGN support The data obtained from DPHNs in HSE West is examined from the perspective of deprived areas with SAHRU index 10 scores WTE PHNs.5 WTE RGN 16

18 In Limerick City there are 24 EDs with a SAHRU index of 10. The 9 most extremely deprived EDs (table 4) represent 44% of the total population of the City. The EDs are situated on the Northside, Southside and Eastside of Limerick City. Using the population numerator for the EDs in Limerick Northside (5041) and the allocated 1.04 WTE PHN this represents a ratio of 1 WTE PHN to 4847 population. Likewise using the population numerator for the EDs in the Southside (5370) and the allocated 1.37 WTE PHNs this represents a ratio of 1 WTE PHN to 3919 population. The population numerator for Limerick Eastside EDs is 2264 and the allocated 0.7 WTE PHN would indicate a ratio of 1 WTE PHN to 3234 population. This indicates a ratio of 1 WTE PHN to population. Together these 9 EDs are marked by extreme disadvantage. In examining individual EDs the work practices of the PHN are influenced by the high percentage of single parent families with dependent children in John s A and Prospect B EDs and young children with disabilities and Traveller families in Galvone B ED. There is a high percentage of children 0-5 years who are deemed to be at risk, and a smaller population of older adults > 65 years with chronic disease and disability in the EDs. The PHNS in Limerick Southside deliver a nursing service without RGN support, whereas the PHNs in Limerick Northside are supported in their role by an RGN when available. A significant challenge is in relation to tracing, in particular at risk children and families, is a feature of the transient nature of families in these deprived areas. In Clare there are 5 EDs with a SAHRU index of 10. These EDs are Clenagh (Shannon) Kilrush Urban, Ennis Urban 1 and 2 and Kilkee. There are 4 PHNs attached to Shannon Primary Care Team, with a population of 14,000 (which includes Clenagh SAHRU 9), this represents a ratio of 1 WTE PHN to 3500 population. The population is characterised by a high population of children and older persons. The 4 PHNs attached to the Shannon PCT are supported by one RGN x 4 days/week. 40% of all Child Protection Notifications in Clare are generated from the Shannon area. Kilrush Urban and Rural is incorporated into a larger population network of There is on average 1 PHN to 2766 population with.33 WTE RGN support. The PHN service is delivered across a range of client groups to a mixed population in the Kilrush Urban and Rural area. A significant challenge involves PHNs travelling to provide a comprehensive service in very isolated areas. This indicates a ratio of 1 WTE PHN to population approx in Clare. In Galway City there are 7 EDs with a SAHRU index of 10. The deprived EDs extend over two network areas East City and West City Networks. The East City Network has a population of 41,280. The most deprived EDs are Ballybaan and Doughiska (9871) and Caisle-n-Gearr (3523). The population of the deprived EDs represent 32% of the Network population. There are 3 PHNs attached to Ballybaan and Doughiska with a ratio of 1 WTE PHN to 3290 approx. The PHN work practices are influenced by large populations of dependent children in single parent families, child protection concerns, migrant/foreign nationals and Travellers. The PHN in these areas have the support of an RGN when available. However, there are insufficient numbers to enable RGNs to be caseload holders. The West City Network has 4 PCTs with 11 PHNs and 2.5 RGNs for a population of 58,000. The EDs of St Nicholas (population of 2677) Newcastle (1999), Rahoon (2920) and Claddagh (2814) are most deprived, whereas Dangan (4206) is considered to be an affluent area and is in the PCT catchment area. The total population covered by the PCT is 14,470. The population of the 4 deprived areas represents 71% of the PCT population. There are 3 PHNs with a ratio of 1 WTE PHN to 4823 approx, attached to this PCT with the support of.5 WTE RGN. The work practices of the PHNs in these deprived areas are characterised by the population profile, which includes a high percentage of 0-5 years age group, with associated child protection concerns and non-attendance at clinics, acute and post-acute clinical nursing care and a settled Traveller population. This indicates a ration of 1 WTE PHN to population. In the more affluent areas, the PHN/RGN provides a service to an increasing number of older people living alone without family support. The Home Care Packages is one of the services that elderly people apply for, however due to the high volume of applicants in Galway, there is a delay in conducting assessments and processing applications, necessitating the need for waiting lists. 17