Using nursing homes as ‘default option’ must end, experts say

Covid-19 has exposed Ireland’s over-reliance on an institutional model for elder care

Very few people make the decision to move into a nursing home voluntarily, or with a light heart, and that is not because of the quality of care. Photograph: Joe O’Shaughnessy

Very few people make the decision to move into a nursing home voluntarily, or with a light heart, and that is not because of the quality of care. Photograph: Joe O’Shaughnessy

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The coronavirus pandemic will accelerate changes already under way in how society cares for the elderly, according to experts.

A more rapid shift away from large nursing homes towards greater support for living in the community, is likely to result, they said.

“I’ve only ever met one person in all the research I’ve carried out, who voluntarily opted to move into a care facility,” says Assumpta Ryan, professor of ageing and health at Ulster University.

However, shifting care away from nursing homes should not be done at the cost of the physical and mental health of family members who are being asked to provide care, she says.

“If we look at it from only the narrow context of what is best for older people, there is a danger that we may be transferring a lot of the responsibilities onto families, in many cases to the detriment of their own health. So we need to be very mindful of that.”

That is not an argument for maintaining the model of having large care homes, separated from the rest of the community, she stresses.

“If you look at how we care for children, if you look at the way we care for people with intellectual learning disabilities, we have totally moved away from that model of care. No one would ever build a children’s home caring for 60 or 80 young children.”

There is a need to integrate nursing homes more into society. “They sit apart, and that may be part of why we find ourselves where we are in terms of the pandemic.”

The Government somewhat belatedly seems to be coming around to the same opinion. Taoiseach Leo Varadkar told the Dáil last month: “We . . . need to consider a move away from large, modern, newly built, 150-200 bed, single-room nursing homes towards smaller units, as we have done in the disability sector.”

He said “more and better home care” was also needed, while acknowledging this would be a financial challenge for the next government.

The way nursing homes have borne the brunt of Covid-19 infections has sparked a global debate about how society treats its older citizens, says Gerard Quinn, formerly the director of the Centre for Disability Law and Policy at the NUI Galway School of Law.

Society has changed its attitude towards how disabled people are treated but attitudes towards the elderly have lagged behind, he says.

“The evidence has been out there for a long time that this is not the right model, or a financially sustainable model, but it is becoming much more graphic now, because of Covid, unfortunately.”

A common narrative on old age is “Well, you won’t have a life, get over it, it’s over.

“But, in fact, you have your personhood, your humanity, you have your individuality. Of course you become dependent on other people, but in fact we are all interdependent.

“And so it is about breaking that old black-and-white division between old age and what preceded it, and reminding people that no matter how your capacities might decline, you are still a person, you still have a right to connect, and indeed younger generations have a right to your presence.”

Older people were relatively invisible in terms of policy-making up to now, he says. “And maybe for all the wrong reasons, [Covid-19] is pushing a consciousness of their humanity right to centre stage, where it should have been all along.”


Older people should remain embedded in the community. “It’s about going back to social connectiveness to give meaning to people’s lives as we age. This is challenging but it is the type of question we should be asking.”

For Sean Kennelly, consultant in geriatric medicine at Tallaght Hospital, the pandemic has exposed the vulnerabilities of the model we have for elderly care.

First of all, he says, most older people are well and don’t require a lot of social or medical support.

However, some older people do develop chronic conditions and require a high level of care. The problem is that the spectrum of care required by older people is very broad, but the care options don’t reflect this.

We “tip into the default option of residential care” earlier than other jurisdictions that both have better resourced home care and a bigger focus on housing needs for older people in the community, he says.

Very often the reason older people don’t want to leave their home is because they don’t want to leave the community in which they live.

The objective, he says, should be that people are first of all supported in their homes, then as close to their original homes as possible, and only then, if a person is no longer able to manage, should they be moved to long-term care.

“The thing about ageism is that it is the only ism that eventually affects us all if we live long enough,” he adds.

“When we talk about how we should provide long-term care, we should be aware that we are talking about the care that will be necessary for many of us and our relatives as we grow older.”

The Department of Public Expenditure and Reform estimates that by 2031, more than a quarter of a million inhabitants in the State will be aged over 80, and the Central Statistics Office predicts there will be nearly 1.6 million people aged over 65 in 2051, up from 630,000 in 2016.

In Kennelly’s experience, very few people make the decision to move into a nursing home voluntarily, or with a light heart, and that is not because of the quality of care.

“The reality is that most of us would much prefer to remain in our homes and in our community, and we must ask why we have moved away from that. It wasn’t always that people ended up requiring nursing homes.”

The societal changes that have led to this situation are common across Europe, he said. But some countries have better models, with more use of sheltered and supported living, and less use of nursing homes.

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