There is a conflict between the pursuit of profit and the provision of care

The recent revelations of mistreatment of small children in privately run creches have a wearying familiarity. They follow revelations of the mistreatment of elderly and vulnerable people in Leas Cross and other private nursing homes. Earlier we had a series of exposes of the abuse of children in residential institutions.

What all these revelations have in common – apart from the role of RTÉ in exposing them – is that they concerned vulnerable people being cared for by private institutions. For decades vulnerable and marginalised children were handed over by the State to institutions mainly run by the Catholic Church. No effective oversight was exercised. As we now know, thousands of these children were sexually, physically and emotionally abused and often forced to work.

At the other end of the age spectrum, by the 1990s the need for nursing home care clearly exceeded the availability of nursing home places. Many of the existing State-run nursing homes were in dilapidated and unsuitable premises, though they were staffed by highly qualified and committed staff. The choice facing the then government was to renovate existing homes and invest in more, or to encourage the private sector to take up the slack by offering tax incentives for building nursing homes, along with tax and other reliefs to those paying nursing home fees.

It opted for the latter course, combined with the now infamous "light-touch regulation". The outcome was entirely predictable. As the Leas Cross affair showed, many of those who invested in nursing homes for profit did not have the welfare of their vulnerable residents as their first priority. Unqualified and under-qualified staff were employed; they worked for low pay in poor conditions, leading to the abuse of residents.

Long-term benefits
The same attitude prevailed when it came to childcare. As was pointed out by Carl O'Brien last week, a 2005 report from the National Economic and Social Forum advocated large-scale State investment in early childhood education services similar to those in many European countries, suggesting that the long-term benefits would far outweigh the short- term cost. The government of the day disagreed, favouring a system of tax-incentivised private providers. Child benefit was increased to help parents pay fees and creches became a new home for investors.

Again, we had light-touch regulation, with no relevant qualifications required for the majority of those working with small children. Millions of State funds through tax incentives and grants were poured into the construction of private childcare facilities. Large profits were made. We saw the results – poorly qualified and unmotivated staff, overworked and underpaid, mistreated children at the most vulnerable stage of their lives and the reporting system in place was utterly inadequate to deal with this.

Surely by now we should realise there is a fundamental flaw in this model of care provision. It is not just an Irish problem. In the UK, where the care of vulnerable adults is being farmed out by the National Health Service to private contractors, a BBC Panorama investigation found very serious abuse of the residents of a home for people with intellectual disabilities. An inquiry by the South Gloucestershire Safeguarding Adults Board found that the company running the homes, Castlebeck Ltd, coincidentally owned at the time by a group of Irish investors, "appears to have made decisions about profitability, including shareholder returns, over and above decisions about the effective and humane delivery of assessment, treatment and rehabilitation".

This report got to the heart of the matter – there is an inherent conflict between the push for profitability and the provision of the care, stimulation and support needed by vulnerable people. The arithmetic is very simple – the difference between income, either from the State or service-users, on the one hand and expenditure on staff and premises on the other equals the profit, so there is a financial imperative to keep staff costs, in particular, to a minimum.

Care services are not the same as other commodities, like cars or restaurant meals. Those buying or using them are often not exercising truly free choices; they are forced by circumstances to rely on strangers to provide care in intimate areas of their or their relatives' lives. Those using them are rarely in a position to complain if they are dissatisfied. The laws of the market are a very inadequate mechanism to ensure such services are delivered to an appropriate standard and at an affordable cost. This is not to say that there are not plenty of good-quality creches and nursing homes in the private sector, run by individuals who are committed to providing a good service in a caring environment. Of course there are. But their existence is fortuitous. It is not guaranteed in a profit-driven system.

Recommended
It is unlikely in the short term that there will be the level of public investment necessary to create the kind of system of State-run preschool education and care for very young children that exists in many of our EU partners and was recommended eight years ago by the Economic and Social Forum. It is also unlikely that we will adopt the kind of policies that will mean employers and the State must allow the parents of young children the kind of flexible working, including lengthy paid career breaks, that would permit them to care for their children at home without inflicting fatal damage on their careers.

But if we have learned anything from the proliferation of scandals in the provision of care for the vulnerable and marginalised, it must be that the State cannot continue to offload its responsibilities to private entities and assume all will be well. If it requires the participation of others in the provision of such care, it must set the standards and make the rules, and there must be effective oversight and accountability.

Carol Coulter is former legal affairs editor of The Irish Times and director of the Child Care Law Reporting Project. This article is written in a personal capacity