Preparing for caring for our ageing relatives

Eunice is on call around the clock, working five days and five nights a week in an elderly couple’s private home as a carer for a woman who uses a wheelchair and has dementia, and doing household work such as cleaning, making meals and doing the laundry.

The husband, who is in his mid-80s, assists Eunice in lifting his wife, and their adult children drop in to say hello, or to help at dinner time. She is responsible for monitoring all the woman’s medication and food intake.

The only time Eunice (not her real name) has away from her workplace is at weekends, when the couple’s adult children take turns to stay and she travels from the house in a rural area to Dublin, to the rented accommodation she shares and pays for with two other friends.

For what amounts to a 120-hour working week (being required to be onsite is now defined as working time under employment law) she receives €400, or just €3.33 an hour, plus board and lodging; although the advantage of the latter is offset by needing to pay monthly rent for the Dublin house that she uses only two nights a week.

It transpires in this interview that Eunice is unaware of how much the minimum wage is (€8.65 an hour) but, as an undocumented worker from the Philippines, she effectively has no employment rights. Yet it is clear she is not one to complain.

“I cannot say it is hard work but I cannot say it is easy; always lifting her is very hard because she is a heavy-set woman. Otherwise I am fine and the family is good.”

Unwelcome contact

However, she is clearly disturbed that in recent weeks she has started receiving unwelcome physical contact from the husband and is unsure how to handle it.

“He is tickling me and for me it is not good. I am not comfortable with it. It is my first time minding a couple; usually I just mind a lady. I don’t know how to say it in a nice way to the man.”

But there is nobody to intervene on her behalf, and she says she would find it very difficult to raise the matter with any of the adult children.

“I don’t think they will believe me. That’s understandable; it is their dad and it’s out of character.”

She got the job after being recommended to the family by another Filipino carer, The family never enquired about her immigration status. Her wages are paid in cash with no deductions.

Eunice’s experiences highlight some of the problematic aspects of homecare for older people in Ireland. She is complicit in the black-market arrangement because, being undocumented, it is the only way she can get a job and, for the family, it is a cheap way to get full-time personal care for a loved one that enables her to stay at home.

A reputable homecare agency would hire up to four carers to provide that level of round-the-clock care, working 12-hour shifts (with breaks), on a four-days on, three-days off basis. That would cost about €1,800 for five days of 24-hour cover – or €1,080 if the tax relief can be claimed at the higher rate of 40 per cent.

Elder homecare is an unregulated but rapidly growing sector where many of the issues seem to echo those in the childcare industry, for which the country was woefully unprepared when the demand for those services started to rocket in the late 1980s.

It’s clear there is a similar, impending boom now for the homecare industry. It has already quadrupled since 2000, with about 150 companies providing services around the country, in addition to arrangements that families make privately with individuals.

For a start there are the demographics: 12 per cent of the population was over 65 in 2011 but that is expected to rise to 28 per cent by 2046. At the same time, family size is shrinking, so there are fewer siblings to support elderly parents, and increased globalisation means they are less likely to be living nearby anyway.

Meanwhile, the traditional resource of women available to become unpaid carers to parents after, or in addition to, raising their own children, is also drying up as female participation in the labour force climbs. Between 2001 and 2011, according to CSO figures, the employment rate for women aged 55-64 in Ireland increased from 28.6 per cent to 43.7 per cent. Among the generation behind them, 78 per cent of women aged 25-34 were participating in the labour force in 2011.

So it's no surprise that migrant workers have been called on to meet the demands of the homecare industry and it is why the Migrant Rights Centre of Ireland (MRCI) has spent the past year researching both its problems and its great potential, in a project funded by the Irish Human Rights and Equality Commission.

“Migrant Workers in the Homecare Sector: Preparing for the Elder Boom in Ireland” is a policy paper to be published today that identifies the issues and makes recommendations to achieve a care industry that can ensure not only the rights of the older person needing the care but create a decent living for the workers who are providing it.

"Quality care is intrinsically linked to quality jobs," says the paper's author, Aoife Smith. "It is very difficult for somebody to give the best quality of care if their own needs aren't being met."

“Logical forward thinking” is needed, rather than ad hoc solutions with which families are currently struggling, Smith stresses.

Those employed behind the closed doors of private homes are vulnerable: and none more so than female migrants who may find it very hard to speak out about issues ranging from poor working conditions to safety concerns for clients. Some also experience blatant racism.

“Migrant workers are helping people to die with dignity but they are not being afforded dignity themselves,” she says.

On the radar

The MRCI, which is based on Dame Street, Dublin, has been working with domestic workers since 2001 but the issue of elder care in the home began to appear on its radar only after some years. Migrants working in childcare were increasingly being asked to move on to look after older family members and, as a result, the centre organised some training in elder care.

In 2009 the State stopped issuing employment permits for domestic work to non-EU migrants, except in exceptional circumstances. But Irish workers and migrants from the enlarged EU do not seem to be filling the gap.

Research across other European countries shows there is a care shortage driven by the “rapid silver tsunami” across the whole of Europe, says Smith. The situation was mitigated somewhat during the economic crisis but that is definitely changing as other jobs become more readily available and because care work is undervalued and underpaid.

“The disconnect between labour migration policy and employment demand has resulted in a growing undeclared and exploitative system,” she warns.

In a survey of 500 undocumented migrant workers, the MRCI found that 30 per cent of them were working in private homes as domestic workers; the majority of them, like Eunice, caring for older people.

There is no statutory right to homecare and many families struggle to pay for what’s needed.

“It is leaving people in situations where they are choosing to get the biggest bang for their buck and migrant workers are often the ones who do that,” says Smith.

Although they may be treated very well by the families, it is the heavy burden of the workload, the absence of training and lack of support which is problematic – both for the worker and the client. “Sometimes it is outright exploitation as well.”

Competition is fierce among the private homecare agencies and the best of these can be undercut by companies whose lower-priced offers inevitably come at the expense of wages and working conditions of the staff they employ, suggests Smith.

Home and Community Care Ireland (HCCI) is a trade association for private homecare providers and its members voluntarily implement agreed standards of care and observe a code of conduct.

The Health Service Executive, which provides the majority of care services to older people, through its own staff or through private agencies, drafted national quality guidelines for homecare support in 2008 and these are being implemented, although not yet finalised, says Smith. However, the powers of the Health Information and Quality Authority (Hiqa) do not extend to the homecare sector – although this has been promised by 2017.

Ever-increasing demand

The HSE is experiencing an ever-increasing demand for homecare services, a spokeswoman confirmed. Currently it provides 10.3 million homehelp hours annually to about 47,000 people, the vast majority of whom are older people. More than 14,000 people are in receipt of a homecare package (medium to high dependency supports) at any one time.

It has been reviewing its homecare and other community support services for older people and expects to finalise a “Service Improvement Guided Implementation Plan” by early 2016. There is no legislation for means-testing clients or requesting a financial contribution for these HSE services but budgetary restraints limit their availability.

In its existing form, the Nursing Home Supports Scheme, or so-called "Fair Deal scheme", could not be extended to cover homecare, the Department of Health tells The Irish Times.

Under the scheme, participants contribute towards the costs of their care in accordance with their means, with a large proportion paying 80 per cent of their income. This would not work in the community, a spokeswoman says, as service users would still have to meet their day-to-day living expenses.

However, Government policy is to facilitate older people to stay in their own homes and communities for as long as they viably can and it is well accepted that enhanced levels of home supports can help achieve this. “The Department of Health, together with the HSE,” she adds, “is committed to developing home-support services and to ensuring that available resources are most effectively focused on those who need them most.”

The Government has “to get real” about homecare, Smith argues; it can be privatised but it needs to be legislated.

“We have an opportunity here to create a decent sector that can provide quality care services in the home and also provide quality jobs.” It makes sense to invest in home and community care because it takes the pressure off acute and residential care settings.

“In some cases people are being forced to go into hospital or acute residential settings because they can’t get the care at home: that’s not working for the older person, the family or the State,” she points out.

Smith is hopeful that policymakers will get to grips with this before it’s too late. The MRCI is part of a collaborative group, along with Siptu and the Carers’ Association, striving to make sure the best information is given to Government for planning our future care needs.

Legislation is what’s most urgently needed, says Smith, for licensing, inspection and monitoring of homecare. Work permits for non-EU migrant domestic carers should be reintroduced and a system put in place for regularising undocumented migrants.

Currently, she explains, people like Eunice have no way of becoming legitimate members of the country’s workforce. The centre is sometimes contacted by families who want to ensure that somebody they are employing has an immigration status but there is no mechanism, she explains, to do this for somebody who has come in without a work permit.

Eunice came in 2013 and while she is “very scared” about her illegal status, she intends to stay in Ireland for at least another year or two. Far from resting in Dublin at the weekends, she minds children or does house cleaning; “whatever job is available”.

She tries to send about €500 a month back to the Philippines where she has two daughters, who are 20 and 23, and three grandchildren.

“My youngest daughter is still in college, so I take the risk,” she says simply. “It is very hard if you are a single mum like me.”

See mrci.ie swayman@irishtimes.com

Night work: 'They wake up at 1am, 2am, 4am, 6am . . .'

Filipina mother-of-four Ann came to Ireland in 2002 on a work permit to take up a childminding job in a private home.

Four years later she took a course in elderly care at the Migrant Rights Centre in Dublin in 2006 and started caring for a woman in her own home. She continued to work in private homes until 2013, when she registered with a homecare agency.

Currently she is working three 12-hour night shifts a week in a couple’s home, from 8pm to 8am, on an hourly rate that is 10 cent over the minimum wage. She has a baby monitor to look out for the couple’s movements: “They wake up at 1am, at 2am, at 4am, at 6am . . .”. The woman, who is recovering from a fall, has arthritis and finds it difficult to stand, so Ann assists her in going to the toilet at night.

The agency gave Ann training in manual handling last November and that qualification lasts for three years. She is not supposed to administer medication, as that is done by other carers, but sometimes she has to give a tablet from a blister pack last thing at night.

Agencies need to assess their clients well and give more pay, she suggests, to carers who are up and down regularly during the night. Clients’ families are inclined to say, “She sleeps through the night,” but how do they know, she wonders. They are not there.

In her current situation she was told the husband was fine, but he is in his 90s and uses a stick, and she worries he could fall at night too. Other carers come in during the day to prepare meals for the couple.

In general, Ann prefers working night shifts as it allows her to focus on a client. During the day there may be people dropping by, who she has to cater for, and also the client can get confused. From her previous experience as a live-in carer, she found it difficult to deal with a client when an adult child was also staying in the house. She was being asked to make meals and do the laundry for the other family member, even though it wasn’t part of her job.

Ann was back in the Philippines in March, for the first time in four years. Her four adult children and two grandchildren still live there.

Elder homecare: Know the law If you are thinking of employing somebody in a private home to care for a family member, you need to be informed, says Aoife Smith of the Migrant Rights Centre Ireland. "Know the law; know what you have to do, ask for supports. A lot of people don't understand or realise that they become an employer once they bring somebody into their home."

Families need to know what they can and can’t ask of their employee and that way they will get the best relationship between themselves, the parent and the worker, she says. Alternatively, if you are using a homecare agency, you should be asking about how their employees are treated: what they are paid, the shift patterns etc.

Agencies that are members of Home and Community Care Ireland (HCCI) will have signed up to that association’s agreed standards of care and code of conduct. See hcci.ie