The recent uncovering of a strategy to fend off eligibility among vulnerable older people to funded nursing home care evoked deeply unpleasant memories for me. Returning to Ireland in 1993 as a consultant geriatrician, it was clear to those that took an interest that older people had eligibility to either a public nursing home bed, a contracted private nursing home bed or a subvented nursing home bed in a private nursing home.
There are two key aspects of nursing home care. The first is that residential nursing home care is a healthcare-related need: precipitating causes are nearly always due to a combination of diseases, ranging from dementia, Parkinson’s disease, stroke and arthritis, which have progressed to a point that supported care at home is no longer practical or feasible
The second is that older people themselves do not indulge in entry to nursing home as some form of social choice but rather understand that this is precipitated by the extent of care needs.
There was always an element of institutionalised dismissiveness of these factors in the attitudes and regulations at the time and this is continued to the present day. For example, even though every older person is a citizen in his or her own right, the 1993 regulations aimed to take into account the income of their children in a way that would be unthinkable for any other form of healthcare provision.
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The overall thrust of the healthcare system was to avoid making clear to older people the eligibility for funded nursing home care, and also to fail to support them should they wish to pursue this eligibility. Sadly, many doctors, nurses and social workers aligned themselves with this approach, often using the trope of “the hospital is under pressure for beds, there is no care available, and there are no public nursing home beds”, with the aim of directing people and their families towards self-funded nursing home care, a huge and needless burden.
One of the issues with subvented beds was that funding could only be applied for in advance of entry to the nursing home. This would entail a longer stay in hospital awaiting this, no different from waiting for surgery or chemotherapy. I would receive phone calls from the health board not to advise this: my reply was for them to put this in writing which, of course, they never did.
The Attorney General’s recent report makes for shocking reading, in effect making clear that property – pyrites and fire escapes – has a more immediate, generous and retrospective access to the public purse than the needs of vulnerable older people. It is also clear from the successful settlements taken by a minority of those affected that the spirit and letter of the regulations has been breached.
The disrespect continues across a range of issues in present-day provision of nursing home care, including the shutting down in June 2022 of the implementation panel of the ministerial report relating to the huge death toll and suffering related to Covid-19 in nursing homes with almost none of the substantive recommendations implemented.
The issue of extra charges is emblematic of the continuing shabby treatment of nursing home residents. At the preparatory meetings on introduction of the so-called Fair Deal (only seeming fair in the light of obfuscation of pre-existing eligibility to funded nursing home care), many of us asked senior Department of Health and Health Service Executive officials to clarify that all care needs, from laundry, equipment, incontinence wear, therapy and activities were included in the funding. The outcome was a master class in not answering the question, and the results only all too plain to see.
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For example, the so-called Fair Deal is supposed to leave residents with 20 per cent of their income for personal needs and desires. Yet one of our local nursing homes will only take residents who will pay €100 a week in addition for laundry and activities, far beyond one-fifth of the State pension. A new two-tier system now exists in nursing homes as well, either barring those of limited means and supports, or adding extra burden on to families who may already have provided support during care in the community. This diminishes greatly the principle of autonomy, centrality and right of access to care of the older person in their own right.
Failure to ensure that all elements necessary to care are contained in State funding schemes for nursing homes is a wrong that needs to be righted immediately. Contracting such aspects in a largely privatised system where the first call out of every euro is the profit line of the owners is a challenging task. But this needs to be developed as a first step in radically upgrading our care framework for nursing home care for us as we age.
Prof Desmond O’Neill is a consultant geriatrician at Tallaght University Hospital and undertook the review of Leas Cross Nursing Home in 2005-2006