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.