The hardest choice: A time to care

EVEN READING a guide to finding a nursing home must be a difficult and traumatic step. Nursing Home Care, It’s Your Choice is compiled by Nursing Homes Ireland (NHI), the representative body for the private nursing-home sector. “Home as you know it will be very different,” it tells the prospective nursing-home resident.

For people who have come to the painful realisation that they can no longer do everyday, essential tasks – get dressed in the morning, wash themselves, cook or take necessary medication – this could be the first source of information, and a source of optimism. “Living in a nursing home opens up a new world of opportunity,” it says. “Your home life will embrace a new community of people with shared histories, perhaps familiar faces from your local community and an opportunity to meet new people, round the clock medical care and support, safety and security.”

Current figures indicate 5 per cent of people over 65 will face the prospect of living in a nursing home, but this figure is set to grow, and planning for such an eventuality is becoming more complicated and uncertain.

The Nursing Home Support Scheme, or “Fair Deal”, was introduced in 2009. Since then, it has run out of money, been closed, re-funded, reopened and changed, and now it is under review.

The HSE, in this year’s service plan, said it would close up to 892 public beds by the end of the year, on top of the 758 closed last year. In April, the Department of Health announced it was reducing the planned increase in contracted private beds from 1,270 to 640 (a cut of 630 projected private beds) from the Fair Deal scheme. At the same time, the Minister for Health James Reilly continues to talk about the need to “negotiate best value” with private operators – this, according to NHI and trade unions representing public home workers, is a euphemism for driving down costs.

Tadhg Daly, chief executive of NHI, says such pressure could threaten the viability of private operators, which are already charging up to 50 per cent less for each bed than the public sector. It also raises questions about their capacity to meet long-term demand.

It’s not an environment in which the most vulnerable 5 per cent of an ageing demographic should have to plan.

The statistics are well established: the number of people aged 66 and older will increase from 467,926 in 2006 to 792,067 by 2021. The number with severe disabilities is projected to increase from 94,400 to 147,677, and demand for long-term care will reach almost 36,000 places by 2021, up from about 28,000 now.

Since 2003, the number of private and voluntary nursing homes in the State has increased from 408 (14,946 beds) to 445 (21,500 beds) today. There are 22,815 people on Fair Deal packages and 10,018 on homecare packages. With 115 public nursing homes in the State, private and voluntary nursing homes account for more than 75 per cent of all long term care beds in the country.

All nursing homes, whether public, private or voluntary, are registered with and inspected by the Health Information and Quality Authority (Hiqa).

The clear trend is a growth in private sector care, where beds cost the national purse an average of €865 a week, compared with €1,245 in public units. The difference is principally due to labour costs, says NHI, as the private sector can avoid premium shift rates and use a higher proportion of care assistants and fewer nursing staff.

Anyone – whether they have private health insurance or not – in need of long-term care is eligible to apply for Fair Deal funding, and to choose either a public or a private bed.

Once their needs and means are assessed, the cost to them will be 80 per cent of their disposable income, whether they choose a public or private bed.

The Fair Deal provides that the older person must contribute 80 per cent of their income to the cost of their care, with the State funding the balance. Its “fundamental purpose”, said then minister for health Mary Harney, was “to make long-term nursing home care accessible, affordable and anxiety-free”.

This demand-led scheme, however, is budget-capped, which led to anxiety among applicants last year, as it ran out of money. The Department of Health underestimated how much money was needed for the scheme; frail citizens had to go on waiting lists, while waiting for other frail citizens to die before they could get a bed.

The scheme had to close to new applicants for a few weeks and reopened in June last year amid accusations that the previous government had left “a hell of a mess” for Minister James O’Reilly and warnings of continuing “serious financial difficulties” for the scheme.

According to the HSE, all applications are now being processed within four weeks. However “huge levels of uncertainty about the scheme” remain, according to Daly, compounded by an absence of any national strategy on the long-term care needs of an ageing population.

Gerry Scully, senior information officer with Age Action Ireland, says “major problems” remain with the scheme. “It’s quite a complicated process to get a Fair Deal bed,” he says. Most people do not know where to start and are “very worried” about cost. “There is also an issue of the HSE or hospital choosing the home for a person, and there have been problems with people being placed in homes far away from their families.”

He and Daly say that in the past applicants’ funding was back-dated to when they applied. Now it is paid from the date of approval, leaving the older person either waiting in an acute bed, vulnerable at home, or having to pay for up to four weeks’ care. In some cases, nursing homes won’t take a new patient until funding comes through.“It seems obvious the State wants to fund nursing-home care but not provide it,” says Scully.