AGE IN ACTION (formerly SA Council for the Aged)
36 Long Street
Tel 426 4249
6 August 2003
ADDRESSING THE HEALTH NEEDS OF OLDER PERSONS
Age in Action welcomes the National Health Bill as an important step towards establishing a uniform health service. A national health system which covers the public and private sectors and provides the population of South Africa with the best possible health services that available resources can afford will be widely acclaimed.
Our concern is for older persons (aged 60 and over) who currently form over 5% of the South African population but whose numbers are growing, particularly the numbers of the very old who are the most debilitated. Two thirds of older persons have no formal schooling, one quarter are disabled (half having lost their sight) and 57% live in rural areas. In poor communities poor health and chronic diseases are manifested at an earlier age than in well-off communities.
Access of older persons to health services is a major challenge. Residential homes for frail older persons remain largely white and out of reach to persons from other groups. The abuse of older persons is increasing and occurs at the hands of family members, in public offices and in health facilities.
A feature of the health care of older persons is the lack of uniformity and the absence of coordination. In 1991 the Health Department started to develop an inter-departmental policy on ageing that would shift funding to community based care. The Welfare Department took up the issue in 1993 and in 1996 the Welfare White Paper promised to set standards for home care services and to collaborate with the Health Department. But little interaction took place between the Departments.
The main policy shift affecting older persons was the phasing out of subsidies for independent and semi-independent residents of homes. The budget thus saved was not redirected to community based services, subsidies to luncheon clubs have remained unchanged and for most it is a constant battle for survival. In addition subsidies to homes were frozen so that today few frail older persons on pensions can afford to stay in residential homes.
Most older persons thus have no choice but to remain in their own homes or move into private, unregistered homes which take their entire pension and give them a quality of care which is at best uncertain. Even abused older persons in need of urgent and safe accommodation are unable to access refuge in registered homes.
In 2000 the Minister for Social Development appointed a Committee to investigate the causes of abuse of older persons. It found that abuse and neglect was widespread and that a coherent, coordinated strategy to address this was lacking. The same year, the Department of Health published a National Strategy on Elder Abuse aimed at ensuring older persons would enjoy a life of dignity, respect, security, empowerment and equality. It included the need for inter-departmental collaboration, for medico-legal protection protocols. None of this features in the National Health Bill.
3. Current concerns
Age in Action would like to bring the following concerns to the attention of the Health Portfolio Committee before making detailed proposals on the National Health Bill:
a) Treatment of older persons in day hospitals and clinics:
Many older patients complain that staff show them no respect ;
There are few geriatric clinics and older patients have to wait all day for attention, sometimes being told to return the next day when they have to wait again.
"We are not well cared for. We have high blood but have to wake up early, at 6.30 you have to be there. An old person becomes tired. You sit there. They come at 09.00 even though you arrived at 6.30. You will leave at 14.00". (Comments from a group of older persons quoted in recent research)
Elderly patients in wheel chairs are left outside the day hospital by a family member and depend on strangers to push them inside. Sometimes they wait all day without being seen by a nurse or doctor.
b) Treatment of elderly inpatients:
Frail patients put heavy demands on nurses and they tend to be discharged while they still need a high level of care.
Rehabilitation is almost non-existent, outside private health care : Most stroke victims admitted to hospital are discharged home early because of pressure for beds. They have no access to step-down facilities which could restore their independence. Long term community rehabilitation and education to mobilize stroke survivors is not available and there is an increasing risk of secondary strokes, adding to the strain on the secondary level of health care;
Emergency services discriminate against elderly patients.
Elderly patients are excluded from tertiary hospitals and people with bi-lateral strokes and amputations, obesity, bed-sores or nasal gastric feeds are considered unsuitable for admission to residential homes as such patients require more intensive nursing which it is not possible to give due to the lack of adequate funding.
Older patients are denied surgery which would restore their independence on the grounds of cost.
b) Home-based care:
Home-based care services in most areas are only a skeleton service and receive little or no government funding although Health 2010 makes provision for such services. Such services are desperately needed by older persons caring for children with AIDS as well as for the frail elderly at home.
There is a high level of abuse and neglect of older persons in the community which only home-based services could detect and address.
Patients excluded from health and welfare establishments need supervised nursing care which most families are unable or unwilling to provide.
Service centers are unable to cope with incontinent and debilitated persons but these centers could be used as bases for community care or nursing services if the funding issue between government departments could be sorted out.
This is a critical part of any home based community service
20,000 carers have completed a six week course but many remain without work
There is uncertainty about the registration of courses , the SETA for nursing is not operational and the Health Department has no capacity to train.
d) Inspections of residential homes:
Inspections by Health staff are almost entirely limited to following up reports of abuse or neglect. A group of 5 homes in the Western Cape has received one visit in the past 7 years.
Although the assessment of frailty (DQ98) for admission to homes is based on health criteria it is administered by lay-staff;
Most care staff do not have nursing training or home-based care training and few homes keep registers of complaints and restraints;
There is little oversight of the health of the frail residents or their nutritional status and there are allegations of seriously ill, demented and incontinent residents left unattended and of essential drugs or medication being withheld or over-prescribed.
e) Access to free medical services and pharmaceuticals :
The promise that a free medical service was to be extended to disabled persons has not yet materialized. This has a major bearing on the large number of stroke survivors. The importance of chronic medication to those prone to multiple–pathology must be emphasized. The following are some of the problems experienced by older patients:
Basic drugs such as paracetamol ,cough mixtures and some antibiotics are no longer available at community health centers;
Incontinence aids are not provided – at a cost of R4.50 per pad this expense is unaffordable to most patients many of whom resort to sleeping on newspaper;
The tendering process for essential drugs or medication is inefficient hence supplies run out, compromising the health of those with heart disease and high blood pressure , leading to breakdown of psychiatric patients and to hording of medication by those afraid of supplies running out;
Chronic medication that has to be obtained from a hospital has cost implications for patients and leads to their omitting to take certain drugs;
Equipment and assistive devices from lending banks and depots including wheel chairs are in short supply.
4. THE NATIONAL HEALTH BILL
Amendment: "health services" (a) should read: health care services,
including reproductive health care and care of frail older persons , and emergency medical treatment……
Comment: "rehabilitation" This is a good definition. The problem is that the Bill does not address the provision of rehabilitation services.
Objects of the Act
Comment: We wish to draw the attention of the Portfolio Committee to the need to extend the categories which have access to free health care services so that the vulnerable group of frail elderly and those suffering from chronic health conditions receive specific attention.
Amendment: we propose the addition to Clause 2 ( c ) of a new sub-clause (iv) to read
"vulnerable older persons".
Comment: 4. Previously government notices were used for such purposes. This clause will delay the extension of free health services to disabled persons as promised by the President in January 2003 and announced by the Minister of Health as due to start on 1 July 2003.
Comment : This concept is not well understood either by service providers or by users. Users seem to believe that once they have presented themselves to a provider as in need of the service they place themselves entirely in the hands of that provider. Their only right is the right to go or not to go to the provider. The providers are so over-stretched that they have no time to examine patients properly or explain finer points to them. When an older person tries to ask the doctor something he has already moved on to the next patient. This reflects the inadequacy of the service. We suggest the following addition :
Amendment: 7(1) (f) the service provider shall take all reasonable and appropriate steps
to obtain the user’s consent
Amendment: The heading should read: Duties of users and providers
The following new clause should be added:
19A: A provider must:
(a) respect the dignity and privacy of the patient
(b) inform the patient of his/her condition to the best of his/her ability
(c) take appropriate care of frail patients
(d) not treat patients in a cruel, inhuman or degrading way (Section 12(1)(e) of the Constitution)
Amendment: The following sub-clause should be added:
20 (2)(b) (ix) health services for frail and chronically ill older and disabled
20(2)(f) Inter-sectoral and inter-departmental collaboration needs to be spelled
out clearly in the Bill as it does not happen . Mechanisms to ensure coordination at all levels are needed .
20(2)(k): facilitate and promote the provision of health services for the
management and control of communicable and non communicable diseases including chronic conditions.
Amendment 26(b): the NCHF must meet at least twice a year
Provincial health services
Comment: The Bill needs to address the problem of ensuring that provinces carry out national directives
Amendment 27 (2) (k): facilitate and promote the provision of port health services,
comprehensive primary health services including services to the frail older and community hospital services.
Comment: There are concerns that these bodies where presently constituted are
ineffective and make little or no impact on service delivery as their proposals are not followed up. Their meetings should be more regular, publicised and open to the public and officials should be obliged to report back to them.
District Health System
Amendment 35 (2) (e) Comprehensive services including frail and home-based care
Certificate of need
Comment: This section is welcomed by Age in Action as the intention is to promote equitable distribution of health services and certificates of need for health establishments are linked to quality of service and the implementation of national norms and standards and training.
One or more members of the community served by the health facility, including a person over 60 or a representative of older persons’ interests;
Amendment 48 (1) (a): minimum standards and requirements for the provision of
health services in locations other than health establishments, including schools, residential homes for frail older persons and other public places
Human resources planning
Comment: 57 (b) (c) and (d)
Since training is of critical importance all aspects should not be left to the Regulations, particularly the training of allied groups for home-based care. Uniform courses should be SETA approved and assessed.
Health Officers and compliance procedures
Comment 82 The creation of an Inspectorate of Health Establishments is welcomed as it will monitor and evaluate compliance with this Bill. However, in non-health establishments where health services are administered such as residential homes inspections need to be conducted jointly by health inspectors and staff from the relevant funding department.
The following clauses should be added:
82(2)(c) respond to reports of maladministration and abuse in health establishments
82(2)(d) liaise with relevant departments in monitoring health services in non-health establishments;
Comment 84 In order to inspect all health establishments and agencies at least once annually there will need to be considerably more resources spent on this. The current inspection process has no teeth and does nothing to reward excellence.
Comment : 84(6)(a) The implications of temporarily suspending the operations of a health establishment for resident patients needs to be considered and provision made for alternative accommodation or at the very least, they need to be given notice of such action.