State involvement at stake in review of 'Fair Deal' scheme for nursing homes


The crisis in funding surrounding nursing home care has broadened into an ideological debate over privatisation

THE DEPARTMENT of Health is undertaking its first major review of the scheme it introduced in 2009 to fund long-term residential care of the elderly.

At stake is whether the State should continue to play a direct role in providing care, or whether it should be largely privatised if it means saving money.

The review of the Nursing Home Support Scheme, or “Fair Deal”, is likely to be complete by early next year.

While some – notably public sector employees and some older people’s advocacy groups – argue that the care of older people simply must remain within the purview of the State, others, notably private sector representative body Nursing Home Ireland (NHI), and some within the HSE and Department of Health, say public provision is just too expensive.

The review of the Fair Deal was prompted in large part by the near catastrophe last year when it ran out of money. Its inherent flaw is that it is a demand-led scheme, with a budget cap.

Anyone, regardless of whether they have health insurance, can apply to it for funding for nursing home care. Following a means and care assessment, the patient is expected to contribute 80 per cent of their disposable income to the cost of their care while the State pays for the rest. They are then free to choose a public or a private bed that meets their needs.

In May last year the annual budget was exceeded. The department had underestimated how much money would be needed and had to close to new applicants, causing huge anxiety, until further funding was found and it reopened in June last year.

The Fair Deal review’s main term of reference, according to the department, is “to examine the ongoing sustainability of the scheme”.

It will also look at the “overall cost of long-term residential care in public and private nursing homes and the effectiveness of the current methods of negotiating/ setting prices” and to look at community-based alternatives to residential care.

Private beds are cheaper – an average of €865 per week, compared with €1,245 for a public bed.

“In a challenging economic climate where cost control is an understandable priority, the increased utilisation of the private and voluntary nursing home sector presents an obvious area of potential saving for the Government,” says Tadhg Daly, chief executive of NHI.

There are about 28,500 long-term care beds, of which about 6,500 are public and 21,500 private – up from about 14,000 private beds 10 years ago.

The HSE, under pressure to claw back an overspend in the first four months of this year of €200 million, plans to close up to 898 public nursing home beds this year, on top of the 758 it closed last year.

Mr Daly says lower wage costs in the private sector account for cheaper beds. “We don’t have the premium shift rates, the overtime rates, the sick pay.” The sector, he adds, has fewer nursing staff and more care attendants and generally does not cater to high-dependency patients.

He speaks too, however, of constant pressure from the HSE, which negotiates prices with individual private operators to drive down costs further, warning of an inevitable adverse impact on standards and questioning the capacity of some operators to stay in business.

Paul Bell, Siptu’s national health division organiser, is scathing about the HSE and the department’s approach.

“They have allowed a situation where the private sector have a monopoly on the care of older people. About 75 per cent of older people in care are in the care of the private sector. Twenty years ago it was about 40 per cent.

“There has been little to no investment in public sector homes since 1995 and you can see it in them.”

Many did not physically conform to health and safety standards, he notes. These public facilities should be invested in rather than paying millions of euro every year to for-profit nursing homes.

A wholesale stepping back from public provision, he says, would weaken statutory control over standards and “trample over the wages and conditions of workers”.

Arguing private sector care workers are “underpaid”, he points to other areas the HSE could address to bring costs down, such as the use of agency workers and non-generic drugs.

“There are some appalling private homes,” he continues. “The ones where Hiqa finds care is substandard are usually the ones where workers are treated badly.”

He is in no doubt that the department’s plan is to “transfer its moral obligations to the private sector” and describes as “alarming” statements by Minister for Health James Reilly that the HSE should “negotiate better value” with the private providers.

Gerry Scully, senior information officer with Age Action Ireland, speaks of a “creeping privatisation” of the sector. While he is not against private nursing homes, he warns that if this is policy it must have accompanying safeguards to ensure standards of care and protection of staff who may voice concerns.

A spokesperson for the Department of Health said it was not policy to privatise nursing home care.

“We must recognise that the HSE is facing challenges in respect of all services in 2012. In the case of community nursing units, these include challenges regarding staffing, funding and the age and structure of its units. In this regard, the HSE is carrying out a viability review of all its long-stay nursing homes.”

The loud campaigns around the State, such as those in Galway, Drogheda and Abbeyleix, Co Laois, to save community nursing homes is testament to the belief many have in the public system.

However, with continuing pressure from such bodies as the IMF, EU and Department of Health to cut costs, it remains to be seen whether such considerations will prove as pertinent as economic ones.