Health and social services for older people that can keep them out of long-term nursing home care should be available as a right. And this should be underpinned by legislation, according to the National Council on Ageing and Older People (NCAOP).
Ms Sinéad Quill, research officer with the NCAOP, says however such services are under-supported, only patchily available, too expensive for many and frequently inaccessible.
"The whole area of rights versus entitlements needs to be clarified," she says. "And now is the right time to do it. All the signs are that attention is finally being paid to the fact that there would be far less demand for acute services and long-term care by older people if the services they want in their community were there."
Since the 1968 Care Of The Aged report, the central component of stated Government policy has been to enable older people to live in their homes for as long as possible.
However, as Ms Janet Convery, director of service for older people with the East Coast Area Health Board (ECAHB), puts it, "the default has been that nursing home care has been the single solution".
Policy has been to encourage a dramatic increase in long-term residential care - particularly in the private sector - while community services remained underdeveloped, says the NCAOP.
The nursing home subvention scheme - where the State pays part or all of the cost of nursing home care - has been almost the only public financial help available to families of elderly relatives in need of long-term care. Meanwhile, capital allowances and tax incentives in the "industry" work to encourage entrepreneurs to build and run nursing homes rather than, say, day-centres or rehab clinics.
At the same time Irish voluntary organisations - which provide at least half of those services that keep people in their own homes, such as day centres and meals-on-wheels - are "less likely than those in many European countries to receive Government funding", according to the NCAOP. Carers, who provide care in the home to at least 97,000 elderly people, receive little or no respite and, says the Carers' Association, 62 per cent find the life financially burdensome.
According to the recent Mercer report, Financing Long-Term Care In Ireland, some 93,500 older people will need long-term care by 2011, compared with 84,000 in 2001.
And the majority, study after study shows, want to remain living in their own home. "Alternative options such as boarding out and residential care remain unacceptable to significant numbers of people," said the landmark 2001 Health and Social Services for Older People (HeSSOP) report.
More recently, a study by the North Western Health Board of older people's preferences for long-term care found 97 per cent wished to stay at home. Facilitating this is only beginning to happen.
"A lot of people in the board were shocked that so many wanted to stay at home," said Ms Bridget Smith, services manager for older people in the Sligo-Leitrim area. "And one of the other things that came out was that older people see themselves as healthy, vital participants in society."
This would appear to back up studies that found "many elderly people in long-stay units were there for social reasons" - i.e., they could, with a little assistance, stay in the community.
The Minister with responsibility for Older People, Mr Ivor Callely, has frequently expressed the opinion that placing people in institutions, who could live at home, engendered dependency.
The North Western Health Board is one of just three that are beginning to challenge the "default that nursing homes have been the single solution".
Since the end of 2001 the board has been piloting the Choice Project, which offers older people and/or their families the option of taking the subvention grant and using it to buy services into the home.
"We are endeavouring to keep as many people as possible at home," says Ms Smith. "We sit down with the older person and work out a flexible package based on what they need, whether that be help shopping, with their personal hygiene, with cooking, chiropody, things like that." The grants available range from €85 per week to a maximum of €190.
How things are working is monitored by the public health nurse.
Initially piloted in Sligo-Leitrim, the Choice Project has been rolled out to include Donegal and is now being availed of by 80 people, most of who would "without a doubt" be in nursing homes otherwise. "It is the most exciting and challenging pieces of work I have been involved in. It's definitely the right way to go," says Ms Smith.
And it is more cost-effective to keep people at home, argues Ms Convery of the ECAHB.
"In July we spent €1,416,000 on subventions and contract beds. So far this year we've spent €8,367,821 on contract and subvention beds. It's staggering and going up exponentially."
In a project similar to the Choice in the north-west, the ECAHB - in partnership with Royal Hospital Donnybrook, St Vincent's Hospital and Rehabcare - has been running Slán Abhaile, which again offers grants for an elderly person to buy in services. It costs €65,000 to support 60 older people at home under Slán Abhaile.
"That would buy only 12 to 13 beds in nursing homes for a month," says Ms Convery.
Mr Callely says he is determined to move away from the nursing home as the main source of long-term care, advocating the development of personal care packages - like Slán Abhaile and Choice.
"I'm going to make a serious stab at changing the unrelenting domino of subventions into nursing homes, with no rehab or the rest. I want older people to have a better quality of life.
"I want to see nursing home operators diversify and offer day services, such as occupational therapy and chiropody."
He does not, however, speak of introducing legislation to ensure these services as a right.