Social support systems
Organisation and financing of social support to people with dementia and carers
Background information on the social/healthcare system in Malta
As Malta is so small (316 km2 with a population of 400,000), all policies are promulgated and passed by the national government. There are consequently no formal regional or district tiers of health care.
Nevertheless, there are 68 local councils. They do not have any policy making power but many have an elected person who is responsible for monitoring the provision and quality of services for the elderly.
In Malta the Civil Code clearly places the responsibility of caring for a spouse or parent with family members. According to the Maltese Civil Code (Book first of persons, art. 2), a married person who is in need of help with daily living can rely on maintenance from his/her spouse provided that they still live together. Maintenance is defined in article 19, paragraph 1 as including food, clothing, health and habitation. Children are bound to maintain their parents or other ascendants who are indigent. However, neither of the spouses can claim maintenance from their children if such maintenance could be provided by the other spouse (art. 5.3). No one is legally obliged to care for unmarried people or widows with no children. The State would be responsible for their care.
There is little interaction between state, private and voluntary providers but Forum Malta in Europe works to strengthen the interface between government and NGO’s.
The organisation of social support for people with dementia and carers
In 1987, the Government set up a Department for the Care of the Elderly which is responsible for taking care of the special needs of the elderly. The aim, in providing these services, is to enable elderly people and those with special needs to remain living within the community for as long as possible. Community services for the elderly and for people with special needs are heavily subsidised by the State. People receiving such services pay a nominal fee based on their income (Ministry of Health, 2002).
Services are not targeted specifically for people with dementia and they are slow to respond especially in times of crisis. Entry into a long stay government home may take months to arrange.
As mentioned above, social support, when provided, is organised through the Department for the Elderly and Community Care. Social Workers are responsible for conducting assessments for people in state hospitals or in the community. Requests for the homecare help service must be accompanied by a medical report. This is sent to the Department for the Elderly and Community Services, which then arranges for a social worker to visit the applicant in their home in order to assess their needs. The number of hours granted is dependent on each person’s needs.
There is a Ministry for Social Policy but this is more to do with families and children, disability affairs and addictive behaviour.
The overall funding of social support for people with dementia and carers
Health care and services are funded through general taxation. The health care system is publicly financed through general taxation and is free at the point of delivery although users may have to make out-of-pocket payments. Private healthcare is fairly common (Ministry of Health, 2002). National (social) insurance serves to fund pensions.
The government may also provide support for people with dementia through specific grants. Over the last two years, the Malta Dementia Society obtained a grant to attend Alzheimer Europe conference in Paris. They also obtained two other grants through a national charity event known as iStrina which takes place at the end of the year. The grants were for specific projects: the first for information leaflets and the second for a national helpline.
The legal framework surrounding the provision of social support
The main legislation that governs home care in Malta is the Social Security Act (Cap. 318). This law deals with the provision of benefits, assistance and pensions to the poor, sick, elderly and the unemployed. A Carer's Pension is payable to “all unmarried or widowed persons who are taking care, on their own of a parent who is bed-ridden or confined to a wheel-chair”. A legal notice entitled State Financed Services Rate Regulations (L.N. 259 of 2004) determines the amount that an elderly person residing in state financed homes shall contribute to Government for his/her care and upkeep. Care is classified as Level 1 care, where residential care with only minimal basic care is provided and Level 2 care where the residential service provided includes such level of care that goes beyond minimal basic care as certified by the Interdisciplinary Assessment Team within the Elderly and Community Services Department.
Relevant laws include the Social Security Act, Chapter 318 and the Mental Health Act, Chapter 262.
A white paper has been drafted which will regulate the work of NGOs and can be found at:
The suitability of social support for people with dementia and carers
Adequacy and accessibility in general
There is no problem with accessibility although many services need to be up-graded. Services in the community such as day care, respite care and community psychiatric nurses are scarce.
People living in rural areas
Since Malta is a small country, there are no difficulties with accessibility to services and support for people living in rural areas.
People with different types of dementia
There are associations for people with conditions that are at a higher risk of developing dementia e.g. Huntington’s disease or Down’s syndrome.
People from ethnic minorities
There are no special provisions for people with dementia and carers from minority ethnic groups.
Younger people with dementia
There are no specific services targeted at younger people with dementia. However, they would be able to access the regular services that are available in general.
Services and support for people with dementia and their carers
Types of care
There are 13 day centres mainly for people who are over 60 years of age. Priority is given to elderly people living alone, those who are not involved in social activities and those who could be at risk spending long hours on their own. The centres, which are open 5 days a week, offer physical education, social and creative activities and sometimes educational talks on relevant issues e.g. health, home safety and welfare services. Intergenerational activities are encouraged and outdoor activities are organised twice monthly. People attending day centres are required to pay a nominal fee (ranging from Lm 1 to Lm 2.5 a month depending on how many times they attend the centre) with an additional 50 cent charge being made for couples.
Although it is the responsibility of the national government to provide day-care centres, it is often on the initiative of local councils which in many cases also provide and furnish the actual building.
A new day centre is starting which will have 20 places for 3 times a week specifically for people with dementia. This is funded by the state. This centre, known as the Paul Cuschieri Activity Centre, was officially opened in July 2007 and is located within the grounds of St. Vincent de Paul Residence (a long-term institution). Staff members have received training on person-centred dementia care.
Respite care is mainly provided at Zammit Clapp Hospital, a specialised geriatrics assessment and rehabilitation hospital and at St. Vincent de Paul Residence, a residential complex. Both these units are state-run and free. However, places are limited and an application has to be submitted beforehand. Respite can also be organised in residential homes run on a profit making basis, as well as in church-run residential homes.
There are not enough respite care services even though there is an ever increasing demand. Night services are non existent and sitting services do not exist.
Respite beds are available at one hospital for 2 weeks and at one long-stay residence for 6 weeks. This service is provided by the government for free but it is never enough. Respite can also be organised in private homes (at the service user’s own expense).
Long-term residential care
In Malta, long term care is provided by the state and can also be church-run or private. The choice depends on the ability and preference to pay for these costs through self funding.
If the person does not have the financial resources to pay for their own care, then the only option is to apply for long-term care from the state. The government has two types of facilities. The Government Community Homes (totalling 7 small community homes with approximately 620 places) are intended for physically independent elderly people requiring scheltered accomodation. For those who enter into such schemes, 60% of their total income is levied by the government. Those who have more nursing needs are admitted to the St. Vincent de Paul Residence, a long stay facility of approximately 1000 beds. This residence provides a mixture of nursing/long-stay beds in around 27 wards. For these residents, 80% of their total income is levied by the government.
For those who can afford and prefer to fund their own care, church homes or private homes are an alternative. There are about 10 church homes each housing between 50 and 200 elderly residents. Church homes charge smaller fees (around Lm 10 – Lm 15) but in view of their popularity, the number of places is limited and waiting lists for an available place are longer. Church homes provide care for both independent and dependent residents.
Private homes cost more than church homes and charges depend on the individual home and on care needs. Prices can range from Lm 15 for basic care to Lm 30 for highly dependent clients. There has been a lot of interest in this area. Consequently, several new private homes have been established to meet the inceasing demands. There are usually enough places available in the private homes.
The Malta Hospice Movement offers a comprehensive range of services to terminally ill people, most of whom are elderly. This is partly funded by the state and includes home care, day therapy, spiritual support, night and day nursing in the home, respite care, assistance with bathing and hairdressing. However, this is solely for terminally ill patients with cancer or motor neurone disease, not for people with dementia.
Monitoring in the home via alarm systems
There is a tele-alarm system, known as TELECARE, which is run by the government and the local telephone operator “GO plc”. The telecare service is partly funded by the state and is designed to enable subscribers to call for help when needed. It gives older people, those with special needs and also their friends and relatives a feeling of security and encourages subscribers to carry on living in their own homes. The service is available to elderly couples/people living alone aged 80 and over, people over 70 suffering from a chronic illness, people of any age living alone who are afflicted by a life threatening illness and people who are afflicted by a life threatening illness whose carers would benefit from the service. In case of emergency, the elderly person just needs to press a button on the unit itself or on a pendant worn round the neck and a call is made to the Control Centre which has full medical details as well as the contact details of the person, the doctor and two relatives, friends or neighbours who have a key. The service costs Lm 1 per month for single people and Lm 1.16 for two people living together. The Malta Dementia Society considers this a good service.
Assistive devices are not well developed yet. GO plc has a system of telephone linked alarms for gas leaks, smoke, flooding, theft, etc. There is a subsidised rental fee but it is highly subsidised by GO plc as the company’s commitment to social responsibility.
The Independent Living Advice Centre is an organisation run by volunteers which promotes the use of technical aids to enable frail and elderly people with disabilities to manage daily activities and retain their independence.
There is a procedure for people to obtain financial support to adapt a bathroom or to fix a stair lift. People with disability, including people with dementia, are eligible.
Personal assistance and home help
A community nursing service is provided which is a good service and reaches all those who need it. This is completely funded by the state. This community nursing services provide a range of nursing services including skin care.
Supervision of medicine is also available from community nurses who may visit patients for short courses of drug administration if required such as injections or pessaries. This is completely funded by the state.
Assistance with mobility is provided by community nurses but this service is not sufficient. Domiciliary visits by a physiotherapist can be organised for assessment and short courses of therapy. This is completely funded by the state.
An incontinence service is available to people over 60 years of age or younger people with special needs. Incontinence pads/diapers are heavily subsidised in order to permit people with this problem to continue living in the community. Nevertheless, there is a charge which ranges from 7 cents to 11 cents each.
The homecare help service provides non nursing care, personal assistance and help with light domestic work to older people i.e. over 60. The services are adapted to each person’s individual needs. People over the age of 85 are given priority. Other criteria include having special needs and the ability to live a relatively independent life in one’s own home if given assistance, being terminally ill or living alone with no formal or informal family support network. There is a nominal fee of Lm 1 per week for a single person and Lm 1.50 in the case of more than one person benefiting from the service. The preparation of meals incurs an additional charge of 50 cents for a single person and 75 cents for more than one person. This service includes housework, preparation of meals and assistance with shopping.
The Malta Dementia society reports that this is a highly abused service and is now being limited to 4 hours/ week.
Transportation services are only available to and from hospitals and out-patient clinics.
Meals-on-wheels are provided 7 days a week by the Maltese Cross Corps (a non-governmental organisation) and the Catholic Action Movement in collaboration with the Department for the Elderly and Community Services. People over 60 years of age and people with disability, who are unable to prepare their own meals, can benefit from this service. Each meal costs 95 cents (approx. EUR 2.2). When delivering the meals, the specially trained staff ask whether the elderly person needs anything and keep an eye on the person’s home environment. They are expected to report anything unusual to the organisers of the service.
Psychosocial support and training for people with dementia and carers
There is a general information centre for community services provided by the department of the elderly.
At Zammit Clapp Hospital (Geriatrics Unit of 60 beds and Day Hospital) there is a memory clinic. New patients and carers are enrolled on a “memory class” which provides group therapy for patients while carers attend for caregiving skills.
In addition, the social work unit provides psychological counselling, guidance and assistance to certain categories of elderly people including those with dementia and those living alone with a high level of dependency. The unit “deals with social casework, provides advocacy for clients, facilitates self-help management and develops action plans, performs crisis intervention work, provides assessments for residential homes, home care help service and assessments of Carer’s Pension for the Department of Social Security, and liaises with the geriatric, general and rehabilitation hospitals, the Health Department, police, Local Councils and other community organisations.” A medical report is necessary to benefit from this service. Once approved, either the social worker visits the person in their own home or the person has a meeting with the social worker at the offices of the Department.
There are some training opportunities for carers of people with dementia. These include the memory classes at Zammit Clapp Hospital and regular talks and video presentations to caregivers organised by The Malta Dementia Society. This is a free service.
There is no provision for people with dementia and/or their carers to take a holiday.
Work/tax related support for people with dementia
People with dementia are not entitled to protective measures if in paid employment. There are some early retirement schemes which may entitle them to tax refunds and benefits on the basis of personal incapacity. People with dementia are not entitled to direct payments to pay for services or for tax refunds or incentives for employing someone to provide home care services.
People with dementia in Malta are entitled to financial reimbursement for home adaptations following assessment by occupational therapy or social work departments. This is governed by the Social Security Act.
There are no entitlements for reduced cost television or radio licences or public transport on the grounds of dementia. However, a card, called the Kartanzjan card, is issued automatically to every person upon his or her sixtieth birthday. It must simply be collected at the local council office This card entitles its holder to obtain certain rebates and concessions e.g. free football ground tickets, reductions on bus fares, reductions on the Gozo ferries and other establishments, reductions on certain Air Malta flights, and telephone rebates. A second version of the Kartanzjan is issued upon the person’s seventy-fifth birthday which grants additional benefits (Government of Malta, 2007).
Work/tax related support for carers and carer allowances
Carers are entitled to take unpaid time off work for caring but not paid leave. Carers can apply for this responsibility leave, granted on a yearly basis, to take care of a dependent relative. They can also apply for flexible working in the form of reduced hours.
Carers are not entitled to free or subsidised pension contributions. They can, however, receive payment from the state for caring in the form of the Carer’s Pension. This is granted to an unmarried relative who all by him/herself and on a full-time basis cares for a dependent person living in the same residence. The applicant must not have capital resources exceeding Lm 6,000 (EUR 13,976). The weekly amount paid is Lm 35.82 (EUR 83.51). Additional bonuses of Lm 1.34 (EUR 3.12) per week and Lm 58 (EUR 135.10) per six months are also paid (Government of Malta, 2007).
Carers are not entitled to any other tax incentives or benefits.
Unless otherwise stated, information provided by Dr Stephen Abela and Dr Charles Scerri (Malta Dementia Society) between April and September 2007
- The website of the Government of Malta can be found at: http://www.gov.mt/index.asp?l=2
Last Updated: lundi 15 mars 2010