Opinion: Residential care in the State has become increasing privatised without any public debate, writes Dr Shaun O'Keeffe
The clear, well-informed and powerful review by Prof Des O'Neill of the deaths in Leas Cross nursing home is an important wake-up call to the State to rethink its attitude towards its older citizens, and in particular those who require institutional care.
It is a stark and tragic counterpoint to the harrowing and moving images of neglect and cruelty to frail and vulnerable older people seen on the Prime Time documentary 18 months previously.
It must act as a tipping point towards redressing a cumulative neglect of this sector by the Department of Health and Children and the health boards and the Health Service Executive over many decades.
The Irish Society of Physicians in Geriatric Medicine (ISPGM) agrees with Prof O'Neill that it would be wrong to regard the events and the deficits in care in Leas Cross as the failings of a single unit.
Instead, we fear that the lack of clear standards and regulations, staffing levels that are not clearly linked to resident needs and the absence of a robust inspectorate for both public and private long-term units mean that sub-standard care is likely to occur throughout Ireland. The ISPGM, the Commission on Nursing, and the Human Rights Commission have drawn attention to these deficits over the last decade, but to little effect.
The ISPGM supports the need for explicit standards of care for long-term care. The revised guidelines for use by inspection teams for nursing homes do not provide such standards, and there are no grounds for using these minor changes to reassure the many residents and relatives of residents in long-term care who have been worried by the recent revelations.
We also support Prof O'Neill's recommendation that a defined data set, comprising medical, social and psychological details, must be maintained for all residents. Such data can serve as a tool for quality assurance and as a basis for determining staffing needs and provision of public funding.
There is a need for an independent inspectorate, covering both the public and private sector, with the resources to conduct regular random inspections at any time and the power to intervene in the event of shortcomings. The appointment of an ombudsman for long-term care would also be helpful.
The O'Neill report makes clear the high levels of disability, multiple illnesses and complexity of care required by many long-stay residents. Adequate numbers of well-trained staff can make a huge difference to the quality of life and care of such people, and recommended staffing levels should reflect the needs of residents on particular units. To these must be added the need for a range of therapy services and ready access to geriatricians and old-age psychiatrists.
An unplanned and growing trend towards privatisation of the residential-care sector has occurred in Ireland without any public debate.
The private sector, as structured and funded in Ireland, may not have access to essential disciplines such as occupational or speech and language therapy, and many private nursing homes are unable to manage all dependencies of care.
Many patients entering long-term care have extremely complex physical and mental health problems. The needs of most such patients will best be met by an expansion of the public long-stay sector rather than the contraction seen in recent years.
Lack of transparency and fairness in the funding of long-term care must also be addressed. Older people are entitled to free in-patient care, including long-term care, subject only to a maximum maintenance charge equal to 80 per cent of their Old Age Pension. Those who go to private nursing homes, with financial help from the State, often have to make up a considerable cost shortfall and they have no protection against rising costs.
Unfortunately, many other people opt for subvention and a private nursing home because of long waiting times for the public bed to which they are entitled. Others will have concluded that the only way of receiving the publicly-funded care they are entitled to is to get admitted to and to remain in the acute hospital until a publicly-funded long-term bed is provided.
Thus, one patient in a nursing home may, with difficulty, be paying the difference between subvention and nursing home costs, while in the next bed a patient with similar assets and needs has all costs paid by the State.
These problems identified in the O'Neill report are not unique to Ireland, and we should learn from the responses that have helped in other countries. We believe that legislation is required to strengthen the standards of care demanded of long-stay units and to provide a hierarchy of sanctions to deter breaches.
We, like other professional bodies, are keen to work with the Department of Health and Children and the HSE in developing such standards and improving the welfare and care of long-stay residents. Acceptance of the recommendations of the O'Neill report and a full apology to all affected by the deficits in our current system in Leas Cross and elsewhere would be a good starting point.
Dr Shaun O'Keeffe is chairman of the Irish Society of Physicians in Geriatric Medicine and is based at Merlin Park Regional Hospital, Galway