We will now meet a delegation from the Domestic Care group. I welcome Ms Liz Ensor, Dr. Paul Megarity, Mrs. Leslie Megarity and Mr. John Ferguson. Their paper has been circulated and we are fascinated by the work they do. I ask them to make a brief presentation, after which we will have a question and answer session.
Community Meals Service: Discussion with Domestic Care
Dr. Paul Megarity
I thank the Chairman and members for giving us the opportunity to make a presentation. I am chairman of Domestic Care. Mrs. Ensor is group operations director, Mrs. Leslie Megarty is the chief executive and Mr. John Ferguson is a non-executive director. Mrs. Ensor will make the presentation.
Ms Liz Ensor
Domestic Care was established in 1993 to provide a pilot community meals service in north County Down. This was in response to the Government's People First initiative. Domestic Care not only provides a community meals service, it also cares at home for those persons who are older, physically disabled or have dementia, Alzheimer's disease or learning disabilities. It provides nursing care for both frail and elderly mentally infirm residents in a purpose-built facility. In short, it is a community care provider in every sense of the word, providing a service for over 5,000 persons daily.
We are here to demonstrate how the community meals service can fit with the needs of the similar client group in the Republic of Ireland and potentially address such issues as elderly malnutrition, reducing hospital admissions, shortening lengths of stay and expediting discharge, while delivering real cost savings to commissioners of services. In 2008 the National Council on Ageing and Older People launched its report, The Role and Future Development of the Meals-on-Wheels Service for Older People in Ireland, which was commissioned with the Social Policy and Ageing Research Centre in Trinity College, Dublin. The report examined in depth the nature of community meals service provision across the State and made recommendations. Domestic Care's cook-chilled service was the subject of one of the case studies included in the report. The research confirmed the need for change and the introduction of a provision to meet the needs of a rapidly ageing population. There are wide variances in service provision across the State, with a significant proportion of services being delivered by ageing volunteers or community service organisations, some in receipt of funding, others not, or through the use of the home help service.
Our proposal is that a fully professional workforce should be used to deliver and manage the service which could be used to complement a review of home care provision, substituting part of the service currently provided at high cost and enabling more efficient use of the most expensive of all resources, staff. A system similar to that operating in Northern Ireland could be replicated in the Republic, tailoring meals services to clients' needs and providing from one meal a week to a full seven-day service. The use of local food production, with menus tailored to meet the Irish palate, would be ideal in achieving acceptance among the client group. The use of a chilled, locally produced meal is preferred in achieving this.
How would the service be run? Clients would make their choice of meal; the meal would be produced to nutritional and dietetic guidelines agreed with the commissioner; and the service would include a full range of specialist diets, for example, diabetic, gluten free and altered-consistency diets. Local depots would deliver meals within agreed timeframes. Systems would be agreed with commissioners to ensure reporting protocols and financial and management information were provided. Our service is supported by custom-built computer software and effective management systems covering all aspects of service delivery. Our quality system is externally audited annually both in regard to food hygiene and management systems.
What would all of this cost and what are the efficiencies to be achieved? We have outlined in our submission the extent of the savings achieved under the original pilot scheme in County Down. Assuming that home care was commissioned at a rate of €23 per hour and that the time allocated for meal preparation as part of a package of care was between 30 and 45 minutes a day, the cost would equate to between €11.50 and €17.25.
We have assumed that in the home help model, clients would purchase their own food which would then be prepared by the home help group. Assuming a continuation of that principle, we regard €3 as a typical client contribution to the cost of a two-course meal. Taking all of this into account, we believe we could deliver savings in excess of 50% on the current cost. There are few opportunities within the health and social care system to deliver such a saving, while improving equality, accessibility and reliability of a service.
On admission to hospital repeated studies have reported that more than 40% of the over 65s are malnourished. The report of the National Council on Ageing and Older People has expertly detailed the extent and causes of this and the wider issues around malnutrition in the community that lead to ill health. Malnourishment on admission inevitably leads to slower recovery, a prolonged length of stay and increasing demands on the stretched secondary care sector and contributes to bed blocking. The reason offered for bed blocking is often the lack of community resources to aid discharge. Such a meals service could respond within 24 hours to a request for service and might reduce the pressure on the secondary care sector through the adoption of a flexible approach and genuine partnership.
Domestic Care's service has been proved over a period of 17 years in Northern Ireland, with satisfaction ratings in excess of 90% throughout that time. It is possible to demonstrate, through the use of pilot schemes, the effective, efficient service we are confident we could deliver. We would welcome the opportunity to work with the committee to demonstrate the feasibility of introducing such a service in the Republic of Ireland.
I thank Mrs. Ensor for her fascinating proposal.
I welcome the delegation. I am fascinated that Domestic Care believes it could deliver a professional service as cheaply as it has outlined. Are there other groups or agencies doing similar work to Domestic Care? How did the initiative start 15 or 20 years ago? We call it meals on wheels in this country. Our service is significant, but it is organised by various groups which are not operating under one umbrella group. I take it from what Domestic Care has stated there is a chain of command in working with local communities. Does Domestic Care put out to tender the supply of food? This is of great interest to many groups in the Republic.
I thank the delegates who are very welcome. Many of my queries have been addressed. What would constitute a pilot study? Who would comprise the target group? Would it include people discharged from hospitals or residents of day care centres? In acknowledging the study stating over 40% of over-65s presenting at hospital are malnourished, I remember that, in the course of my training quite some time ago, this was a recognised syndrome. It was always a recognised factor and was listed as one of the criteria when somebody presented to hospital. In the present climate there are many people who may be forgoing proper food because they have not got the money to buy it. The price listed by the delegates seems quite reasonable. How does the system work?
That was a most interesting presentation on domestic care. I wonder how we can roll it out in the South. As Deputy Connaughton stated, we deliver meals through what is called the meals on wheels service or perhaps through the Society of St. Vincent de Paul. In the North, is the service just for the elderly or is it for others who find themselves in financial difficulty or poor circumstances? Is the service state-funded? Are all the service providers volunteers or are they paid by the state?
A question was asked about costs. How is the service co-ordinated on an urban-rural basis? I am from a rural area. Is the service rolled out in rural areas or is it just rolled out in cities and towns? How is the service co-ordinated throughout the Six Counties? The Republic has 26 counties, many with very rural areas.
I warmly welcome the delegation to Dublin. Its presentation was very much to the point. I would like it to develop its ideas a little further, particularly regarding costs and suspected numbers. The delegates referred to a nationwide service. I would like a further breakdown of the costs. Do the delegates expect that State funding will be required to meet costs? If so, it will have consequences for the rest of the health budget. Given the current financial constraints, the system would be difficult to introduce. The overall idea is good and I believe it represents a good way to proceed at some stage. I foresee difficulties in the current climate.
Deputy Reilly had to leave so he sends his apologies. I am a visitor to the committee and am not present at all its meetings. I was intrigued by what the delegates put forward.
The delegates' submission refers to a "safe and well" check. How does this work? They stated local depots would deliver the meals within agreed timeframes. Does Domestic Care run and own the depots? Does it contract the work to hotels or other providers?
Is Domestic Care a voluntary or not-for-profit group? How is it structured? Who are its members? Its proposals seem quite exciting and interesting and should be considered in more detail.
I apologise sincerely for my absence earlier and hope the delegation will not take offence. We have had a rather hectic day. No disrespect was meant; we were genuinely held up. I apologise for Deputy Jan O'Sullivan, who is still on duty. We will read all the papers and revert to the delegates.
I join the members in congratulating Domestic Care on its presentation. It has 19 years of success in the Six Counties and serves 5,000 clients. It is obviously asking the committee to advocate that the HSE and Department of Health and Children consider a pilot area. Where would it be and how large? What population would it have?
How does Domestic Care propose to deal with the fragmented nature of the service that exists in the Republic? Volunteers, largely working with church organisations or community groups, go out to deliver meals, and home help is provided by the HSE. There are other help services also. How does Domestic Care identify its client cohort and, given the rather complex system we have, how would it move in and provide a service? How does it relate to the agencies or groups in an area that might already be providing such a service?
Dr. Paul Megarity
On the question of what sparked off Domestic Care, I will ask Mr. John Ferguson to answer.
Mr. John Ferguson
I was the chief executive of North Down and Ards Community Trust. We were under pressure to effect efficiency savings of 2% to 3% year-on-year. That meant that every service we were providing in the community, including social services and primary care services, had to be scrutinised. The service that presented the greatest difficulty was that of meal provision for frail elderly people in their own homes.
We had a home help staff of approximately 600. When we considered what they were providing, we found a number of difficulties, one of which was that they did not have proper contracts of employment. Second, they were doing shopping, lighting fires, and preparing and cooking meals. This was costing a lot of money. At the weekends, the staff were on time and a half and on Christmas Day they were on triple time. The more we considered this, the more we realised it was a service we could not afford and that we had to come up with a different way of providing it.
What I describe was occurring shortly after trusts were established in Northern Ireland and we were encouraged to be innovative in service delivery. I shared my views with Dr. Megarity, who was on the planning team in the trust. After much research and investigation by Dr. Megarity and Domestic Care, we decided there was a better way to proceed, namely, by providing a cooked chilled meal to the homes of the clients on a daily basis. We approached the Eastern Health and Social Services Board and it agreed to fund the pilot service. We started off in Newtownards and this allowed us to iron out any difficulties or problems. The service was an outstanding success right from the beginning.
There was concern that many home helps would lose their jobs. They had very casual part-time employment arrangements. We worked very closely with the union and it was very supportive. We retrained the great majority of the home helps and gave them contracts for 20 hours per week. They were trained to become care workers in people's homes and to provide personal care rather than meals.
What sparked the service off was the drive to lower costs and find a better way of proceeding. We found that not all our home helps were wonderful cooks.
Were cooked chilled meals delivered daily or were clients given a week's supply?
Mr. John Ferguson
It depended on the client and whether he or she wanted a meal daily or every other day. It depended on the clients' needs. In many cases, the meals were provided for seven days or five days per week. It was a matter of choice.
Dr. Paul Megarity
There was always a daily delivery and one did not receive a week's meals together as a pack. Not everybody received a daily service because some people visited their families at weekends or went to luncheon clubs. There was a variety of reasons.
Did it save the trust in terms of the percentage?
Mr. John Ferguson
In terms of savings?
Mr. John Ferguson
It was only a small part of north Down. In today's prices, the saving was approximately €1 million per year. Over the Six Counties or the Republic, the savings would be very considerable.
Dr. Paul Megarity
There were a number of questions on other groups doing similar work. I ask Ms Leslie Megarity to answer them.
Ms Leslie Megarity
Our business is a tendered business. There are specifications set by the relevant trusts and the business is competitively put out to tender. We have won each tender we applied for. There are some small groups providing services on a very localised basis but the problem that exists and existed in this regard is that there is no standardisation of service. Issues associated with hygiene and nutrition arose and in this regard the trusts and health authorities in the North believed they needed to standardise further and provide equality of access to services. The groups doing the kind of work we do are really very small.
Another aspect of the question concerned a tender to supply food. We have sub-contracted food production. At present, we have a large production unit producing all the meals. That is covered in a number of the questions. We do not obtain meals from hospitals, hotels or pubs. There is a specific contract in place to produce the food to a given standard. That standard is laid down by the dieticians for the health service. There is an agreement between our group and the health service on the nutritional value of each meal.
Dr. Paul Megarity
The food production standard is one that a major supermarket chain would use. It is a fully audit-controlled service with hazard analysis and a critical control points system. There is no "back-of-a-van" activity. It is a professional, fully audited service. If there is ever a problem, all the batches can be traced. There is full traceability. There is what a person who investigated the system called the "farm to fork audit trail". That is the way it works.
Senator Prendergast asked about malnutrition among the elderly. There are various studies on clinical malnutrition. They usually investigate people on their day of admission to hospital. A study in the North that I remember very well showed 43% of people over 65 were clinically malnourished on the day of admission to hospital. This is a reflection of their status in the community prior to admission.
Clinical malnutrition is not necessarily about people who are very thin. It often affects people who have sufficient calories in their diet but whose diet is poor in vegetables and minerals. Calcium is one of the big areas. People who are clinically malnourished have slower post-operative recoveries and are more prone to fractures. They are more prone to infection and often have extended stays in hospital as a result. It is well documented that well-nourished people do better in health stakes than poorly nourished people. There is no great breakthrough in knowledge in this regard.
May I ask one other question? With regard to home help, the Republic seems to have the same sort of model as in the North, apart from the nutrition aspect. It often strikes me that home helps are very limited in what they can do, despite their being trained to be almost personal assistants. Who does the housework for a very elderly, frail person with no family? Who lights the fire and ensures the kitchen floor and front room are clean and that the sheets are clean? How is this managed? In Ireland there are excellent home helps who would do all these jobs but who are barred from doing them.
Ms Leslie Megarity
I do not know if that is something the meals service does. Our experience of delivering community care as part of another part of our business is that the care worker in the main does those tasks. Generally, there is a domestic aspect to personal care packages in the North to ensure the client's total well-being. This is one aspect of a package of care.
The question will be explored by our HSE colleagues when they join us.
Ms Megarity used to the term "business". Will she outline the structure of her group?
Ms Leslie Megarity
It is privately-owned company and is limited by shares with a board of directors, some of whom are present. It is a for-profit company. That said, we take our corporate responsibility very seriously and we sponsor and fund various initiatives through other entities not directly run by ourselves.
A question was asked on how we would roll out our service in the South. The current meals on wheels service in the South is very vulnerable. The report produced by the National Council on Ageing and Older People was very clear that the current service is having difficulty in sustaining its viability. It is largely run by groups of elderly volunteers who are probably well into their 70s or 80s. Younger volunteers are not replacing them so the service is falling out of availability.
The report of the National Council on Ageing and Older People was launched in the spring. The report demonstrates that the service is working well in some parts of the country but not in others. There were many small groups.
To which groups does the report refer? Are they named?
Ms Leslie Megarity
The groups are not named in the report but there were people at the launch to whom we had an opportunity to speak. The issues the people were experiencing are referred to in the report. We were really focusing on the question of people no longer being able to obtain services because there is a limited number on offer, and on the vulnerability of the services.
What population cohort is required to conduct a pilot programme?
Dr. Paul Megarity
It is difficult to say the population. We would probably need to be delivering approximately 2,000 to 3,000 meals per week, which would probably mean 500 people requiring services. The average would be approximately five meals per week for 500 or 600 people. It would be important to examine both a densely urban area and an urban-rural mix because the service is the same. The logistics behind it are quite different. That would cover all the bases in Ireland in terms of demographics.
Do members wish to ask supplementary questions?
In terms of urban-rural mix, is the group providing a full service to rural as well as urban areas in the Six Counties?
Ms Leslie Megarity
Yes. We provide services everywhere from Belfast to the Border areas of County Armagh——
In remote areas.
Ms Leslie Megarity
——and the Sperrin Mountains. If the Deputy can name it, we are there.
Is there any division among the age groups? Is it only elderly people the group cares for or people who have——
Ms Leslie Megarity
It is mostly elderly people but there are people in receipt of the services who are house-bound for some other reason or who have social needs and the service has been put in for that reason. It can be the young physically disabled or those with a mental health problem. We provide the services where the person is assessed as requiring nutritional support.
What state funding is involved? I realise the group is a private company but is there any state funding involved?
Ms Leslie Megarity
There is a contribution from the health and social care trust concerned.
What is the percentage?
Ms Leslie Megarity
It depends. It would pay about 50% of the cost of each contract. The client contributes the balance.
The client must pay so much towards the cost.
Ms Leslie Megarity
They would buy the food anyway.
I hope we are all happy with that. I thank the representatives for their presentations. It is a matter that the committee will consider in greater detail. We will await the next group from the Health Service Executive to join us.