Urgent reforms needed for disability service provision, HSE says

Regulation of residential facilities driving cost increases as number with needs on rise

The rate of disability in Ireland is increasing with an additional 47,796 people reporting at least one disability since 2011.

The Government at present is providing an annual budget of about €2 billion for disability services.

However, a new top-level health service management report for the board of the Health Service Executive acknowledges there is considerable unmet need, suggests hundreds of millions in additional funding will be required in the years ahead and raises serious concerns about the sustainability of existing funding arrangements and the manner in which services are delivered.

In conclusion, it says demographic needs coupled with important policy objectives require that health and social care supports are reformed to meet the requirements of citizens in a more effective and cost-efficient manner.

“There is a confluence of factors underpinning this unsustainable approach, ranging from the lack of long-term investment planning, poorly defined statutory role/functions pertaining to health and social care provision as well as an overly intensified regulatory environment coupled with fragmentation and duplication of organisational delivery models.”

The HSE report says that shifting demographics, increased life expectancy and changing needs for those with physical, sensory and intellectual disability has led to a significant increase in the need for disability services across all settings, including day supports, residential, respite, personal assistant and home support services .

It forecasts that 540 additional residential places will be needed by 2025 as well as 7,200 additional day services.

‘Unmet need’

It says a shortage of funding between 2008 and 2013 – following the last economic crash – led to significant unmet need in the sector and when this is combined with new and emerging requirements for services and supports it is creating “a level of demand that current resources are not able to match”.

The report warns that “despite year-on-year increases in statutory funding, the approach to implementing the disability strategy and policy is financially unsustainable and will, arguably, impede necessary healthcare reforms envisaged under Sláintecare [the Government’s overall health reform plan] if not addressed”.

It calls for the HSE to adopt a different approach.

“In essence people with disabilities are living longer and healthier lives. Coupled with price increases as well as intensive regulatory implementation, urgent action is required in terms of taking a long-term investment approach as distinct to year-to-year budget allocations which only impedes the HSE’s capacity to plan and commission services to meet need.”

It said one “perverse outcome” as a result of this approach has been the phenomenal growth in high-cost “emergency residential placements” for people with complex needs.

“The net impact of not developing a multiannual investment approach means the HSE is faced with year-on-year financial challenges in terms of funding gaps.”

‘Opportunity cost’

It says, in 2019, the funding gap for disability provision alone, prior to mitigation, was €78.5 million “owing to unfunded costs in 2018 relating to high-cost emergency residential responses as well as cost growth associated with the application of [Hiqa] regulatory standards”.

“This is not just an unsustainable approach, it is also a significant opportunity cost issue for the State in terms of the foregoing investment in more appropriate services for the citizen, eg early-intervention clinical support services.”

The HSE report says the single most significant driver of costs in the disability sector has been the regulation of residential and respite centres. It says between 2016 and 2018 the HSE spent about €82 million on “Hiqa-related additional essential expenditure”.

It says regulations for disability centres are broadly identical to those in place for nursing homes within domestic dwellings in the community with four or five people living there. It says nursing homes could have up to 50 residents on a single site and therefore benefit from significant economies of scale.

The HSE report says disability facilities with four or five residents are required to meet the same standards as a larger nursing home “in such areas as health and safety/fire management, care planning, medication management, access to clinical supports and accessibility/building regulation requirements applicable to a clinical-type setting rather than a domestic dwelling”.

“The increased regulatory burden has led to significant increases in non-pay and capital outlay . . . but has also had the effect of requiring additional staffing to meet such needs as client-handling and transfer, safe evacuation procedures and managing behaviours of concern.”