Better care models for elderly must not be derailed by Covid-19

We must evolve from nursing homes to cost-effective, stay-at-home alternatives

Much has been written and spoken about residential care for older people in Ireland since the first outbreak of Covid-19 on February 29th. There has also been some public outcry about the excessive number of Covid-related deaths in nursing homes and calls for inquiries into such tragedies. Factors identified as responsible include: the Government’s initial, almost exclusive focus on hospitals and on the discharge from hospitals to nursing homes of frail, older people not tested for Covid-19; the asymptomatic spread of the infection within nursing homes; lack of personal protective equipment and oxygen supply; a recruitment drive by the Health Service Executive which probably caused staff shortages in the private and voluntary sector; and environmental factors like congregate living.

Repeatedly, in discussions about what went terribly wrong, experts have pointed to the need for a continuum of care and for new models of nursing home care to be introduced in Ireland, such as the Eden Alternative or the green house model. There is nothing that new about these models or indeed recommendations for their introduction. Several have been in existence across Europe since the late 1980s.

In 1987, Denmark passed new legislation suspending all institutional care for older people and in 1992, in Sweden, residential care was replaced with special housing in various forms. Since the 1990s, the Netherlands has also blazed a trail, providing its frail, older people, including those with dementia, with a suite of different accommodation options. In 2010, the Dutch government launched an ambitious programme for aged care facilities, worth €80 million, focusing on small-scale domestic dwellings, choice, autonomy, meaningful activities, preservation of personhood and facilitative relationships.

‘Home’ and nursing

Over the last decade, seminars have been hosted in Ireland where international experts have shared knowledge and expertise demonstrating how their countries have successfully reformed policy by re-engineering the organisational structure of care homes and by bringing “home” into nursing homes.


As far back as 2010, Athena McLean, author of the book A Study of Nursing Home Care in the US, gave a public seminar in TCD on the green house model, its philosophy of care, clinical leadership with multi-disciplinary input.

Sadly, over the years, much of this effort to recalibrate nursing home care in Ireland has failed, as investors continue to build large-scale facilities outside cities and towns, leaving many frail older people socially marooned and disconnected from friends, families and communities.

Investors continue to build facilities outside cities and towns, leaving frail older people socially marooned

But finally, politicians had begun to listen and acknowledge the need for change. The impetus for this change had already commenced before Covid-19. In early 2019, the government published an important policy statement addressing a range of housing options for older people and around the same time commissioned another report on the continuum of care for people with dementia. Reports are a useful way for politicians to demonstrate they are taking action but often nothing happens until a crisis occurs.

And now a crisis has occurred and the Government’s initial response has been to establish a nursing home panel to examine best-practice measures regarding Covid-19. Noteworthy here are the terms of reference for this inquiry and the focus on safeguarding older people. Noteworthy too is the panel composition, with no allied health service professional on board, no nursing home resident, representative or family caregiver. Also given that the side-effects of Covid-19 – like loneliness, isolation, anxiety and depression – may be as harmful as the infection itself, it is noteworthy that no clinical psychologist sits on this panel. And given that up to three-quarters of older people in long-term care probably have dementia, it is striking that that there is no dementia expert on the panel.

Aged-care landscape

A cynic might question the real purpose of this inquiry especially when experts have already identified those factors believed to have contributed to the crisis. A careful read of the lengthy transcript from the Oireachtas Special Committee on Covid-19 hearing of May 26th tells the whole albeit extremely tragic story.

These are extremely challenging times. While a nursing home review may be necessary, there is a danger now that its narrow and strongly bio-medical focus will take the spotlight off other broader unfinished initiatives, currently under way on the Irish aged-care landscape.

We have legislation entitling older people to live in nursing homes but none enabling them to live at home with homecare supports

For example we have a visionary piece of legislation, the Assisted Decision-Making Capacity Act, that has the potential to improve quality of life for many people whose capacity is compromised, as it enshrines a legal right to autonomy. Although first enacted five years ago, the legislation is still not widely implemented. We have a national dementia strategy about to expire, with no commitment made for its renewal and no ring-fenced funding allocated to progress the good work already under way. We have legislation entitling older people to live in nursing homes but no similar legislation enabling them to live at home with homecare supports. A new statutory homecare scheme was to be trialled this year but given the current pandemic this is unlikely to proceed.

The Covid-19 crisis has demonstrated that, more than ever before, there is an urgent need for good political leadership in older people’s services in Ireland and for a shift in the balance of care away from nursing home models towards alternate potentially cost-effective approaches. Greater emphasis must also be placed on home adaptation, universal design, and technological solutions to enable older people live well in their own homes. We cannot afford to let Covid-19 set the clock back.