Is it any wonder so many Irish people don’t want to end up in a nursing home?

In 2020, Dublin poet Rachael Hegarty, like so many sons and daughters of dementia sufferers, fretted as the Covid pandemic restrictions began to bite: “They Locked down all the nursing homes today. / The sign says Covid 19, No Access. / Ma, please, please, tell me it won’t end this way ... / Go to sleep. Dream of dance. We’ll be ok. / I swear to Good Jaysus, I’ll get access. / They locked down all the nursing homes today. / Listen Ma, I wont let it end this way.”

The families impacted by such trauma are bound to have many questions they would like answered by Ireland’s proposed Covid inquiry. There has been much speculation recently about the various areas such an inquiry might cover, and deaths in nursing homes are often mentioned in that context. Figures released by the Central Statistics Office in 2022 showed that between March 2020 and February 2022, 29 per cent of Covid deaths occurred in a nursing home-setting and many of the images we associate with the pandemic relate to the barriers between families and residents of the homes and the distressing isolation they caused.

It would be very helpful and constructive to look at how that challenge was handled, but to also take that opportunity to spark a wider debate about the treatment of the elderly and the reliance on institutional care. This is a pressing matter given that, in 2019, there were 73,000 people aged over 85 in the Republic and this is projected to rise to 301,000 by 2051. It would also be a timely discussion given the report this week from the Economic and Social Research Institute (ESRI), Long-Term Residential Care (LTRC) in Ireland. This 95-page report highlights in particular the closure of smaller nursing homes in rural areas and notes that “Since the onset of the pandemic, almost every county has seen a decline in LTRC beds. However, Dublin and commuter-belt counties have seen increases, driven by the opening of large (more than 150 beds) LTRC homes by private equity-funded owners and operators”. It emphasises that LTRC is “predominantly funded by the State but supplied by private operators. In 2022, in total, 83 per cent of all LTRC home beds were provided by voluntary/private sector LTRC homes, with private for-profit operators alone contributing 74 per cent”. There has been a decisive shift “towards a consolidation of LTRC homes under larger operator groups”, many financed by international private equity. There are crucial questions in this whole area about the balance between, as the report puts it, “the financial viability of providers, compliance with regulations covering health and social care needs, and the strategic planning of supply to meet demand across the country”.

But it is also about the scale of the reliance on the for-profit sector, and that raises crucial questions about power, cost, the stance of the State and the status of older people. In 2017, a social policy academic in UCD, Julien Mercille, published research that underlined the scale of the privatisation in this sector, pointing out that public nursing homes accounted for about 60 per cent of total beds nationally in the 1980s, while private for-profit homes accounted for about 25 per cent (the remaining 15 per cent were private not-for-profit). By 2017 public nursing homes accounted for just 22.2 per cent of total beds while private for-profit homes supplied 68.8 per cent. This momentum has continued and is rarely accorded the attention it needs. Some geriatricians have been vocal, including Des O’Neill, who wrote in 2022 that “‘I never want to end up in a nursing home’ is the most distressing phrase that I encounter in my work as an expert in ageing”.

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Such plaintive declarations highlight the fears of loss of status, autonomy and the consequences of increased longevity. One of the most renowned anthropological examinations of Irish society, Family and Community in Ireland, by the Americans Conrad Arensberg and Solon Kimball, was first published in 1940 and observed that “Ireland is in some ways an old people’s country ... They have power.” A vision of respect for the elderly was also contained in one of the most famous Irish speeches of the 20th century, Éamon de Valera’s “Ireland that we dreamed of speech” in 1943, when he spoke of intergenerational ties and dignity; a land “whose fire sides would be forums for the wisdom of serene old age”, and those firesides, it was imagined, would be “cosy homesteads” and not nursing homes.

The issue of LTRC is of course a complex one, raising questions about the availability of home care, available and trained staff, standards, costs and the social contract between State and people. But it is high time that we seriously examine the appropriateness of the institutional care of older people being so dominated by private for-profit operators and the implications for those who, in ever increasing numbers, will be at the mercy of a completely unbalanced system.