More than half the people in residential care suffer from a dementia. The remainder are there for a range of reasons relating to frailty of some description. The vast majority are elderly and few want to be in care.
Official policy affirms ad nauseam the principle of "ageing in place". Prof Desmond O'Neill, a gerontologist based at the Adelaide & Meath Hospital, in Tallaght, says Irish families remain hugely supportive of their older members. But the infrastructure to support families isn't there.
"I don't see older people being dumped in hospitals by their relatives," says Prof O'Neill. "Out of about 4,500 people over the age of 65 who pass through here every year, only 100 to 150 go into long-term care. The rest are still living at home. Where it all falls down is the lack of support for the family. Here, care in the community is really a matter of grace and favour, where you live and luck. The major next step is some kind of clarification of people's statutory entitlement to community support."
The rate of disability among older people is dropping at the rate of 1.5 per cent a year. Older people are becoming fitter and healthier and living longer - a feat that should be considered a cultural triumph, says Prof O'Neill. Instead, the gloomy response is likely to be: "How are we going to cope with all those old people?"
Like many in this speciality, he believes we live in a society whose rampant ageism is worse by far than its racism and sexism, which garner all the coverage. "When more children lived past a particular age, we weren't saying, 'How are we going to cope?' " The problem, he says, is that we confuse age-related disease and age-related poverty.
About 44 per cent of the over-65s have chronic physical or mental conditions, with almost half of these experiencing mobility problems, according to research by Richard Layte and Tony Fahey of the Economic and Social Research Institute. But if an older person with a chronic illness - "itself an outcome of deprivation", according to the authors - also suffers from income poverty and deprivation, he has almost eight times the risk of psychiatric disturbance compared with an older person with none of these.
At a recent meeting involving care attendants - or home helps, as they were once known - it emerged that nine out of 16 of these poorly paid, undervalued but vital bridges to care in the community had left to take up better-paid, permanent employment in factories or supermarkets.
"That's all wrapped up in ageism," says one official who did not want to be identified. "If you want to put a value on old people, ask yourself: what kind of respect do we accord people who have lived good lives and are now in need of our support? How do you put this on an agenda with racism and sexism?"
In view of this, and of the enormous official bias - in the form of subventions and grants, in contravention of Government policy - towards residential care, it's a miracle that only 5 per cent of older people are in private, voluntary or public long-term nursing homes.
But while the figures are predictable, year on year, the waiting lists and angst surrounding the availability of long-stay beds has reached crisis point.
This is not just about distressed patients and their families. A startling analysis by Prof O'Neill and Tara Coughlan, published in the Irish Medical Journal a few months ago, showed that, on average, 127 older people each spent an extra 68 days in the Adelaide & Meath each year because they had nowhere else to go. Some people can and do spend a year or more in acute hospitals for that reason.
"The problem of overnight stays in casualty could have been totally abolished if only 65 per cent of these beds were free," they wrote. "Five hundred and sixty extra elective orthopaedic procedures and 1,212 extra transurethral prostatectomies could have been performed per year."
And despite the substantial rise in private nursing homes of contract beds - awarded individually and fully paid for by the health boards - this is not the answer, says Prof O'Neill. In the UK, there has been a move to the private sector, but this is underpinned by statutory obligations, under the Community Care Act, and stringent contracting between local authorities, the NHS and the owners of private nursing homes. No such network exists in the Republic.
The need for such stringency is highlighted by recent research from Prof O'Neill and John Brennan that suggests many private nursing homes are highly selective, choosing light-dependency patients over those with medium to high dependency. The research highlighted eight contract beds offered over six months last year; five nursing homes made six refusals to take these patients. Private nursing homes have their own problems, of course, difficulty in getting and holding on to staff being the principal one.
The National Health Strategy appears to set official policy back on track. As it will affect us all, intimately, sooner or later, it is something we should monitor with great care.
Tomorrow, nursing home locator Ann O'Dwyer highlights the best and worst of nursing home care. Plus, inspections, complaints and finance.
