Almost the worst aspect of the heartbreaking and horrifying scenes from the nursing home RTÉ Investigates programme was the predictability that these should still occur 20 years after the Leas Cross scandal.
The Leas Cross report, which I authored, followed a similar exposé on shocking conditions and work practices in the private Leas Cross Nursing Home in Swords. It led to a range of recommendations and the institution of the Health Information and Quality Authority (Hiqa).
Last week’s documentary featured scenes of older people allegedly being manhandled, “forced” down into chairs or left in incontinence pads for so long their clothes were soaked.
The persistence of gross institutional abuse of vulnerable older people signals the lack of serious intent and will in the Department of Health and successive governments to address well-signposted problems and proposed solutions to a deeply flawed nursing home system.
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Not only are some of the recommendations from the Leas Cross report as yet unfulfilled, but none of those of significance from the ministerial panel on Irish nursing homes during the Covid-19 pandemic have been met, and others have been watered down. This is despite Irish nursing home residents experiencing very high death rates in comparison with the rest of the developed world and a torrid experience paralleling that of Amnesty UK’s report on nursing homes during the pandemic, As If Expendable.
At the heart of the problem is the shift from a largely public nursing home system to a private one without debate, foresight or learning from international experience and research. This occurred in a context of multiple failures by the professions, advocacy and the health system to develop a clear blueprint for the development of a high-quality framework for our future care in nursing homes.
Put simply, the health service has no control of care standards in the private sector, and in particular what is known as clinical governance, a clear framework for leadership, responsibility and accountability, both internally and externally, in a complex care environment with vulnerable older people.
Added to this is a profit-driven business with large chains, at least one of which, Emeis Ireland, has a deeply tarnished reputation outside this country – as detailed in Victor Castanet’s book Les Fossoyeurs: Révélations sur le système qui maltraite nos aînés (The Gravediggers: Revelations about the system that mistreats our elders). In some, profit trumps care and, as we saw with the documentary, cost-cutting erodes care. In addition, this is associated with the building of huge impersonal nursing homes distant from the communities where residents formerly lived. Despite Sláintecare pledging to reverse the ratio of private to public nursing home beds, the reverse has happened with an increase in the proportion of private nursing home beds.
[ What is Emeis and where are its Irish care homes located?Opens in new window ]
The framework is so rickety and uninformed that there is a misplaced belief in regulation and safeguarding. Standards in hotels, restaurants and hospitals are not high because of regulation or safeguarding, but rather because we, the public and professions, have set high expectations of what we should receive. This has long been accepted in healthcare. The author of the first major medical ethics scandal in the US, where African-Americans were left untreated with syphilis, wrote that regulation, while necessary, would never succeed on its own: what was required was a system that upheld virtuous thought and virtuous action.
As was obvious from the RTÉ documentary, and long clear to informed healthcare professionals, Hiqa cannot assure the public of appropriate and dignified care standards in Irish nursing homes, nor respond effectively and in a timely manner to grave concerns reported to it. Instead, we need a radical reset of prioritising informed support to residents in nursing homes and those working in them.
We can do this while recognising the many who strive to provide good care – they are not tarnished by critique of lack of policy or the inherent problems of an untrammelled private sector. If anything, all suffer if we do not address the glaring problems of the system.
There needs also to be soul-searching among the professions about supporting care in this sector. It would be helpful for the Nursing and Midwifery Board of Ireland to engage proactively on advising how nurses should engage with the challenges of providing high-quality care in a profit-driven nursing home system.
The public also need to start pushing their politicians to do better. As things stand – and hard as it is to accept – we have no assurance that the scenes played out in the RTÉ documentary are not occurring elsewhere in the Irish nursing home system. The Ombudsman has already pointed to the lack of dignity and choice in Irish nursing home systems.
It is not just a question of “it might be my mother” but actually “it might be me”: men have a one in four, and women a one in three, chance of spending time in a nursing home before we die. We need to clearly signal that we expect a setting where choice will be respected and that we can continue to flourish.
We must demand a lower tolerance for uninformed passivity from the Department of Health, HSE and other State bodies, and inclusion of stronger advocacy and gerontological voices (notably absent from the ministerial panel oversight implementation team) in responding to this lingering crisis. Politicians are adept at detecting the priorities of their constituents. If we do not push for a better present and future for those we care for and our future selves, nor will they.
Prof Des O’Neill is a consultant geriatrician and author of the Leas Cross report 2005-6
