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Seanad Éireann díospóireacht -
Wednesday, 28 Mar 1984

Vol. 103 No. 7

Adjournment Matter. - Care Services for Homeless People.

I am grateful to have the opportunity to raise this matter. While it is a very specific problem it is one that deserves an airing. I will go through what I had intended to say with the utmost brevity and in a fairly abbreviated form.

There is an accumulation of evidence, and indeed the Minister's office have a report to this effect, of inadequacies in the areas of follow-up for people who are being discharged from hospitals. The Minister has the report. "Homeless and Vulnerable" produced by the Simon Community national office. The problem is that significant but not enormous numbers of people are turning up at shelters and hospitals around the country. They are discharged from hospitals and, considering the accommodation they are moving to, are not at all fit to handle that accommodation. The Simon Community report in Cork dealt with one person who was discharged from hospital and who could hardly walk when he arrived at the doors of the night shelter, and of another person who, complaining of severe backache when he was discharged from hospital, took to his bed for two-and-a-half weeks before he could do anything about it.

A problem has arisen because of the change to community-based medicine in the sixties. It was of itself a very worthwhile, important and positive adjustment but in the process of doing so it lost sight of certain vulnerable groups who almost by definition are not suitable for this development of community medicine because they do not have a community. Those are the people I have a certain interest in, the homeless. There is only a very limited amount of information available on this failure in community-based medicine to deal with the homeless. Dr. Ferdnandez, who is operating a programme for the homeless in St. Brendan's Hospital, has written as follows:

Our programme has come across chronic long-stay hospitalised patients who have been discharged from prolonged institutionalised care to nonexistent community care facilities and often without rational follow-up plans by discharging personnel. Many such individuals are clearly incapable of surviving in the community. In time, there is likely to be a greater demand for this type of facility and we are forced to confront the inevitable ageing of those able-bodied mentally ill who, devoid of community support, were placed outside the hospital during the rush to community care.

This is a comment by the only medical specialist in the area of hostel care for homeless people and of their after-care.

To our knowledge there is only one formal study of after-care for discharged psychiatric patients. This is by Petrina Keane and T.J. Fahey. It appeared in "Psychological Medicine" in 1982, Volume 12, under the title "Who Receives After-Care". It showed that of the people discharged under this community-based programme only 8 per cent actually improved their condition after leaving the psychiatric hospital and a frightening 40 per cent got worse. There is also evidence from work done by the Medico and Social Research Board that homeless people are discharged quicker from psychiatric hospitals than members of the settled community, whereas one would imagine the alternative would be the case.

The matter I was trying to raise, when the hour was more sane and when we were all less exhausted, was that what are defined and described as community-care programmes are not working for people who do not really have a community to come from or to go to. It is because of this a group I am associated with, the Simon Community, made some inquiries from health boards on what were their follow-up procedures for homeless people and the replies were quite illuminating.

One hospital in the North-Eastern Health Board area pointed out, "We regret we are unable to make adequate provision for these patients who are discharged." In other words, people are being discharged into the community who are known to be homeless. Another in the same area advises, "There are no provisions for homeless persons on discharge." In the southern region, someone associated with the Cork Simon Community reported, "The social worker attached to the North Infirmary in Cork faced quite regularly the problem of discharged patients with nowhere to go. There were no facilities for alcoholics and there is no dry-out unit in Cork. No special provisions were made for homeless people and no social workers were attached to the hospitals in the region."

As a result, homeless people, as those involved with them suspected, were left to fend for themselves. Therefore, the problem arises that many people coming to psychiatric hospitals or night shelters have illnesses that, in ideal circumstances, would require hospital treatment but because of the development of community-based medicine and because they are not part of the community either, they are not in receipt of any assistance whatever.

We have talked in one 12-month period about 78 psychiatric illnesses, 43 TB cases, 30 cases of ulcers, 30 cases of chest infections, 22 cases of heart disease and 15 cases of skin infections. These are people who cannot be catered for adequately through the present community care programmes.

The issue here is that certain illnesses which should be treated through a community programme are not reaching people because they are outside the community. Certain people who, because of the accommodation into which they would be discharged, should be kept in hospital for longer periods are not being kept because of the emphasis on community-based medicine. Efforts have been made to cope with this problem. The magnificent model done on a fraction of a shoestring is what Dr. Fernandez has achieved in St. Brendan's. He developed a comprehensive system of pre-discharge checks. I think they are a model and should be put on the record. They will not discharge patients until they have been checked for the availability of medical cards, clothes, income, accommodation, a letter for the labour exchange, notification of general practitioner and so on. It is so self-evident one would think that it would be normal practice but to my knowledge there is only one hospital in the country which operates a comprehensive pre-discharge programme like that. That is St. Brendan's Hospital and it is to their credit.

I would like to see the Department encourage other health boards and hospitals to pursue this matter with what the Minister referred to in his speech earlier today as a marginal group, identify the gaps in their programmes and develop the sort of check lists I have just referred to. The medical problems of homeless people are problems that until recently went without notice. In 1975 there was a report written by a nurse and a doctor working with homeless people and the illnesses of 638 homeless people were documented. The authors reported in 1975 that most of those ailments had never been properly treated and untold misery was being caused as people were let loose into a hostel network, substituting one form of institutionalisation for another. Their physical and mental health, bad at the beginning, ended up in ruin purely, in many cases, to satisfy gross overall statistics for the depopulation of mental hospitals.

What was serious in 1975 is probably even more serious today. A real effort is required. The Minister has a detailed report at his disposal on this issue and I urge him to take action that is required. The cost is not significant. The real requirement is recognition of the problem and the provision of a check-list system like the one that is now operating in St. Brendan's Hospital. It will enable the sort of occasional near-tragedies that occur to be avoided and it would ensure there was a programme of follow-up for people who would otherwise be discharged, not into the community but into a subsection outside the community, that is, the hostel network and all the consequences for their health as a result.

I wish to refute the statement that the community care services are remiss in carrying out their duties relating to the follow-up of homeless persons following their discharge from psychiatric or general hospitals.

The Department of Health conducted a survey in 1982 into the incidence of tuberculosis in district psychiatric hospitals, as a result of which it was established that the director of community care and medical officer of health, or a member of his team, is involved in the diagnosis, treatment and management of tuberculosis patients in such hospitals, if required. In certain psychiatric hospitals, the involvement of the public health service would not be required for these patients because of the existence of alternative arrangements which are equally effective.

In each community care area, regular out-patient clinics are available at which all tuberculosis patients who have been discharged from hospital — psychiatric, homeless and others — attend for further treatment and/or the monitoring of their condition. In the event of a person either not attending or having difficulties in attending a clinic, the community care services make a special effort to ensure that such persons complete their treatment. This would include, for example, visits by health board nurses to hostels for homeless people and the giving of advice and encouragement to patients to complete their treatment.

In view of the nature of modern therapy for tuberculosis, the motivation of the individual to complete his treatment is crucial to his rehabilitation. In this regard, alcoholics, psychiatric and homeless persons pose particular problems and difficulties for the community care services. In very many of these cases, the motivation required is absent.

The basic difficulties in getting the individual to complete his treatment regime is further compounded in the case of the homeless by the very nature of his existence. The movement of homeless tuberculosis patients between hostels within a community care area and between community care areas is an extremely difficult situation with which to contend, but the community care services have gone a long way towards minimising the difficulties by establishing liaison arrangements between the hostels and the services within community care areas and between the areas.

In relation to phychiatric patients particularly, I should point out that many of the long-term patients in our hospitals are there because they have nowhere else to go. Health boards before discharging patients have regard to their social and other circumstances and to their ability to maintain a reasonable existence outside hospital and do not press for their discharge.

Follow-up services for persons discharged from psychiatric hospitals are available by way of out-patient clinics, day centres, day hospitals and hostels. The extent to which these community facilities are available varies as between health board areas, and the further development of these facilities will continue to be the main objective in the psychiatric service for some years to come.

Psychiatric out-patient clinics are well developed in all health board areas. The clinics are held in towns throughout the catchment area of each psychiatric hospital so that people do not have to travel long distances in order to attend these clinics. Out-patient clinics are an important follow-up and maintenance service for mentally ill patients who have been discharged from psychiatric hospitals, and about 36,000 patients attend these clinics each year. Day facilities and hostels for the mentally ill have also been developed to varying degrees in all health board areas.

A special study group has been charged with the task of drawing up a realistic planning framework for the future planning, development and expansion of our psychiatric services. This study group will be reporting to the Minister for Health this year and its report will set out quantitative norms for the provision of various community psychiatric facilities, including day facilities and hostels. The study group will also recommend the ideal model for the delivery of psychiatric services and it will set out the practical steps required by the health boards to move towards the recommended model of service. I am very hopeful that the establishment of standard targets for the provision of services will help to even out the unacceptable regional variations which are to be found in the range and scope of services at present. I might add that the study group is generally agreed on the need for a marked intensification and expansion of our community psychiatric services and a reduction in the dominance of the hospital within our existing pattern of services.

The setting up of hostels and other types of accommodation in the community for the mentally ill is an essential requirement in developing a more community-oriented psychiatric service. A wide range of accommodation is needed together with varying degrees of supervision in order to cater for the different needs of mentally ill persons. This includes supervised and unsupervised hostels, family care or "boarding out" and independent flatlets. The provision of accommodation in the community has already facilitated the discharge from psychiatric hospitals of a considerable number of patients who were capable of living in the community but who had no homes to which they could return. This was possible as a result of preparing these patients for the demands of life in the community. In particular, patients who have been in hospital for many years become very dependent, and they need to learn again the basic skills of daily living which most people take for granted.

I am very conscious of the need to provide adequate support services for patients who are moved from hospital into accommodation in the community. The type of support required varies depending on the level of functioning of the individual. Some residents in community accommodation may be able to take up open or sheltered employment while others will need to be provided with occupational or social outlets, for example, at a day facility. The study group on psychiatric services has examined all of these questions and its report will provide useful guidance and advice for medical, nursing and administrative leadership in every service area throughout the country.

I am satisfied that the community care services are carrying out their functions in relation to the in-patient and out-patient management of homeless persons in so far as they possibly can. There are many factors which make this particular segment of the population extremely difficult to deal with, and it can be expected that problems will continue to present themselves in this area from time to time. I am confident, however, that the community care personnel have the motivation and the resources with which to respond effectively to any such difficulties.

The Seanad adjourned at 12 midnight until 2.30 p.m. on Wednesday, 4 April 1984.

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