Nursing home crisis the result of a decade of policy mistakes

The deep crisis in Irish nursing homes during the Covid-19 pandemic has been a long time in the making. While not critical of the staff striving under very difficult circumstances, the plight of residents and staff arises from a deeply defective policy framework for the sector.

Health policy in Ireland is determined not by the HSE but by the Department of Health. For over a decade under ministers from Mary Harney to Micheál Martin, Leo Varadkar, James Reilly and Simon Harris, the department has pursued a policy of privatisation of the nursing home sector disconnected from the public health system without due debate and consultation.

The care needs of this group are complex, requiring sophisticated inputs including expert leadership, expertise in nursing older people, training in nursing home medicine, infection control, regimes of care and palliative care to mention but a few.

Contracts and parameters of care for medical input from the doctors, mostly GPs, were not clarified or standardised

Even an intervention sounding as straightforward as Covid-19 testing requires a plan for backfilling staff testing positive and support from microbiology, occupational health and public health.

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No clear direction or strategy has been given by the Department of Health as to how these complex needs would be adequately addressed, despiteconcerns expressed over many years from many quarters, including the Irish Society of Physicians in Geriatric Medicine.

Contracting with nursing homes for the so-called Fair Deal was left to the National Treatment Purchase Fund. While fine for contracting hip replacements and cataract operations from the relatively standardised private hospital system, there is no evidence to outsiders of any gerontological expertise or matching of funding to the needs of nursing home residents in their processes in what was effectively a range of SME businesses of varying profiles, sizes and capabilities.

Fair Deal funding

An unhelpful discourse has arisen about the difference between Fair Deal funding for the majority private nursing homes and public or voluntary nursing homes.

In fact, funding is low for both sectors, and it is notable that even therein that significant profit-taking has been extracted from the private sector.

This is reflected in the enthusiasm of UK investors for investing in the Irish nursing home sector: it is not clear to what extent, if at all, such profits were ploughed back into staff support and pandemic preparation.

The national standards and regulatory process for nursing homes through Hiqa were not set at a level sufficient to assess clinical leadership, expertise, resilience and reserve.

Contracts and parameters of care for medical input from the doctors, mostly GPs, were not clarified or standardised.

There is a widespread perception that pay and conditions for staff in the private homes are set at a level which does not support recruitment and retention of care staff, with significant withdrawal of labour due to this, fear of infection, in addition to those staff affected by, or in quarantine from, Covid-19.

Care standards

The end result is a variability of care standards and resilience that is out of step with other elements of the healthcare system: even the voice from within the system is split among the industry body representing owners, Nursing Homes Ireland, the Irish Association of Directors of Nursing and Midwifery, and the ICGP representing the majority of doctors working in the system, with advocacy from outside also arising from professional bodies representing specialist healthcare of older people.

A key element in resolving the crisis is the establishment of clear clinical leadership

The HSE has responded as quickly as possible to both this flawed structure and the extreme circumstances, with extra funding for agency staff provided by an arrangement between the Department of Health and Nursing Homes Ireland and HSE structures to support the nursing homes with advice, overview and staff where available from a very pressurised system to work with the director of nursing and GPs who have responsibility for the healthcare of the residents.

However, marrying the public system to such a diverse private system is no easy matter, as the ongoing challenges in incorporating out-patient services in the private hospitals into the public system illustrates.

Failed policies

There is an urgency to resolving the crisis arising from these failed policies, as there will be an ongoing need for new admissions to nursing homes where care standards, staffing, expertise and infection control are clarified and supported in a pandemic whose strictures may last 12 to 18 months. In addition, occupancy rates may need to be reduced to account for infection control and social distancing.

A key element in resolving the crisis is the establishment of clear clinical leadership, similar to the medical director role established in the US after nursing home scandals in the 1980s, with clarity on linkages to the broad range of specialist advice and services required for all nursing homes in a defined area.

Providing these solutions will require gathering the many elements of advocacy, care and policy together to urgently set out a new blueprint for nursing home care, with openness on conflicts of interest and funding, and inspired by a vision that we should all be able to trust in uniformly high standards, care and resilience for ourselves and our loved ones when we most need it.

Prof Des O’Neill is a consultant geriatrician at Tallaght University Hospital and Peamount Healthcare and author of the Leas Cross report in 2006