Recent debates on nursing homes have masked a wider issue - the lack of alternative housing and care options for the elderly here, writes Donal McManus
Government policy has traditionally been to assist elderly people to live in their own homes as long as possible, often with assistance from friends and families. When it is no longer feasible to live at home the only option for many elderly is to move directly to a nursing home.
Surprisingly, there has been virtually no discussion in recent years on the need for intermediate housing and care solutions for elderly people. One such option is that of sheltered housing which helps to bridge the gap between living at home and having to move to a nursing home.
The context in which the demand for future housing and care options for the elderly should be clearly understood. It is estimated that the number of elderly households will increase from around 440,000 in 2002 to almost 800,000 by 2025.
With improvements in health and lifestyle, life expectancy will also increase with the proportion of elderly aged over 75 estimated to increase significantly. Added to this is the reduction in informal or family caring, principally due to participation in the work force. Both of these demographic and structural changes will impact on how elderly people are going to be cared for in the future.
The vast majority of elderly people can and do live independently, with only around 5 per cent needing any form of institutional care.
The concept of sheltered housing has been developed in Ireland since the 1960s by non-profit housing associations and some local authorities. The possible lack of understanding of sheltered housing may derive from the fact that it has often been characterised by physical features such as housing projects having alarm systems and on-site wardens and less on its purpose.
In addition to providing accommodation, sheltered housing can comprise of a range of on-site social and care services such as access to group meals, laundry facilities, assistance with hygiene and visiting support from GPs.
The Years Ahead report, produced by a working group in 1988 for then minister for health Rory O'Hanlon, specifically recommended that where it is not feasible to maintain elderly people in their own homes, then sheltered housing should be seen as the first choice for them.
Subsequently, the introduction of the 1990 Health (Nursing Homes) Act actually reinforced the shift and bias towards nursing rather than community care solutions. The cumulative effect of the increased role of nursing home subventions and various tax incentives to build nursing homes has been to significantly increase the supply of nursing home beds. With the absence of intermediate options such as sheltered housing, elderly people are often forced to enter nursing homes prematurely to avail of on-site nursing care on a 24-hour basis, whether they need it or not.
Sheltered housing has been readily accepted in other countries as a mainstream intermediate solution between living at home and moving to a nursing home or other form of institutional care. Indeed, it has been a central plank of community care policy for the elderly in many EU member states.
Since the 1980s, non-profit housing associations in Ireland have developed over 7,000 homes for the elderly, with half of these deemed to be sheltered housing with on-site supports.
Successive health ministers, unfortunately, have failed to see the full potential of sheltered housing. Too often where there has been recognition of the role of sheltered housing, the emphasis has been on establishing the proverbial "pilot" or "best practice" project.
In fact, there is no such need to reinvent the wheel as many such 'pilots' already exist and have been provided by non-profit housing associations since 1984 through capital funding provided by the Department of the Environment.
In a report by the Irish Council for Social Housing (ICSH) in 2004 Sheltered Housing - an Overlooked Option in Caring for the Elderly, it was found that sheltered housing has developed in the absence of any formal integrated housing and care policy.
It also discovered that there was no clear co-ordination in the planning and delivery of sheltered housing between local housing authorities and the former health boards, and that over 70 per cent of non-profit housing associations received no State support towards the on-site care and supports costs in sheltered housing projects.
The latter was even more striking when it was discovered in 2003 that the Government spent over €110 million in nursing home subventions, whereas the cost of supporting elderly people in sheltered housing was estimated to be in the region of €3 million per annum.
The Government has established a high level group to examine the recommendations from the Mercer report on the Future of Financing of Long Term Care and the O'Shea report on Nursing Home Subventions, both of which were published in 2003. In these reports there was explicit recognition of the need for assisted independent living options such as sheltered housing.
This high level group is to report to the Minister for Health and Minister for Social and Family Affairs this summer. Any recommendations resulting from this group's work will be closely examined to see whether community care-based solutions, such as sheltered housing, are promoted, and if they represent a fundamental commitment to developing community care options for the elderly or whether they reinforce the status quo. Indeed the O'Shea report had argued that part of the problem was that with the over-professionalisation of care structures, this has led to the solution of the needs of older people more in medical and nursing terms than in overall social care terms
It is now time for sheltered housing to be mainstreamed as a housing and care option for the elderly. A rebalancing of housing and care options from a primary dependency on nursing home care to broader community care-based solutions that form a continuum of care for the elderly is urgently required.