Time is running out for action on a new model of care for our older citizens

MORE than 50 years ago, eight health boards were established under the Health Act of 1970. In 2005, the HSE was created and the, by then, 11 health boards were subsumed into one body which later created seven hospital groups and nine community health organisations.

Fast forward to this year and we may see the emergence of six regional health authorities as recommended in the all-party report Sláintecare.

Well might T.S. Eliot have written: ‘And the end of all our exploring,

Will be to arrive where we started

And know the place for the first time’ The 1970 Health Act provided that inpatient services should be free for those with full eligibility for a medical card. But, from 1976 until 2005, charges were being imposed on long-stay residents in public care facilities, despite the fact that these charges were known to be illegal.

In 2004, the State tried to make these charges retrospectively legal, but this was declared unconstitutional and so a limited Health Repayment Scheme was established in 2006 to repay residents in public facilities from December

1988. Significantly, the scheme did not cover people who had to fund their own care because of a lack of a public provision. It was because people chose to ‘go private’, but because of an initial lack of provision of quality public nursing home care and a subsequent systemic bias towards private provision.

IN 2009, the Nursing Homes Support Scheme (NHSS) was established to provide a legal basis for a system of co-payments towards care in both public and private nursing homes. In the same year, HIQA (Health Information and Quality Authority) began regulating and inspecting all nursing homes, spurred on by the Leas Cross scandal of 2005.

In 1988, a major report titled, The Years Ahead: A Policy For The Elderly was produced by a working party led by Dr Joe Robins of the Department of Health. This approach favoured supporting people to live in their homes and communities rather than in institutional or congregated care settings.

In 1997, the Department of Finance designated nursing homes as industrial buildings, enabling lucrative tax breaks for the building or refurbishment of nursing homes. The number of private nursing homes rose from 408 in 2003 to 447 in 2010.

The scheme ended in 2009, leaving an uneven pattern of provision across the country amid claims it was responsible for poor standards because it attracted investors who were purely in it for the money.

There were also many wellmotivated people who opened small nursing homes, some of whom are now closing under the strain of regulation and increased costs.

In 2016, two years after it was established, Sage Advocacy published a report on charges in nursing homes. It stated: ‘The fact that the care package provided for in the National Treatment Purchase Fund (NTPF) negotiated fee is frequently not adequate to meet the actual care needs of individuals is a matter of grave concern.’

Setting out in detail a range of issues with charges, including inadequate access to therapies, equipment and aids required by individuals, the report bluntly warned: ‘Given the number and type of issues outlined in this discussion paper relating to the role of the NTPF, and given its unique role and status, there is a strong prima facie case for the NTPF to appear before the Oireachtas Public Accounts Committee.’

IN a recent review of cases, Sage Advocacy has found evidence of growing levels of debt related to charges for services in private nursing homes, with some residents being charged over long periods for use of items that could have been purchased for a fraction of the charges.

One resident was charged for gloves to stop them removing their incontinence wear. In another case, a resident was faced with notice to quit because their family was unable to pay increased charges. We are also hearing reports that some nursing home residents are being charged for religious services.

In September 2020, informed by the experience of the pandemic, Sage Advocacy published Choice Matters. This examined how the ‘dangerous architecture’ on which the current system of care in congregated settings for older people is built, presented major difficulties in responding to the challenges posed by the pandemic.

Choice Matters set out an implementation roadmap for the development of a single tier Sláintecare social-care system, which could be considered by a Commission on Care for Older People promised in the Programme for Government.

This framework set out key underlying principles, important design features, a list of agencies that should be included in a multiagency approach, the new legislation and regulation required, the need to develop an alternative and sustainable funding model and, finally, what is required in terms of implementing a new model.

This Government has less than 24 months to act on this promise.

Negotiated fee is frequently not adequate to meet care