It's time we asked the hard questions about care of the aged, writes Paul Murray
At long last: a prickly, public and political row on ageing. Senior politicians have entered the arena to chart how we should pay for the long-stay care of the elderly. The ducking and weaving is over; the age debate has moved on from the annual ritual dance over the extent of old age pension increases. Let's keep them engaged and ask for explanations of what they mean.
Fine Gael's Olivia Mitchell speaks of the need for shared responsibilities, Labour's Pat Rabbitte seemingly wants the State to pay a major whack, and the Tánaiste, Mary Harney, raises the hare on the obligations of adult children towards their parents.
Whatever the answer, Ms Harney's original comments, however short and off-the-cuff, angered a number of people with their seeming suggestion that the State is being left in the rough to care for older people because of a failure of duty by adult children. While in her January 29th article, the Tánaiste acknowledged that the vast majority of families do care for their older relatives, her comments came at a time when the astonishing heroism of families in caring for the elderly is becoming even more evident.
Telephone calls to Age Action Ireland highlight how adults can feel they are being left by the State to swing in the wind as they try to care for their parents. Continually we are being told that a carer who used to come twice a week now only comes once, that the public health nurse is making few visits, or that subsidies for nursing home care are piteously low. The most frantic calls are sometimes for older spouses caring for each other.
We listen, probe a little, gather our thoughts and give the best information we can. But the picture is dark. Despite huge expenditures, €115 million alone last year on nursing home subventions, for example, and increases in carers' payments and the use of home helps, the State is still floundering in its efforts to meet the requirements of older people.
And being older is not just a medical issue, as the Tánaiste makes clear. It's about rights to employment, services, study courses, to love and to be loved. Older people are not a health issue, but they can have health issues. Health, and their care when they become frail, is just one aspect of their lives which becomes more evident in later years. Good social policy would aim to ensure they have no undue worries about the ensuing costs.
It should also start from the basis that the elderly have a right to be looked after according to their needs. How this is done, and who pays, is a political issue which touches on the Coalition's health strategy, its "root and branch" review of the nursing home subvention scheme and commitments to provide additional assessment, rehabilitation day hospital and extended care beds.
For all these plans, however, there is a harsh wind out in the caring world and what emerges from a number of reports (Mercer on long-term financing, an Irish Nursing Homes Organisation report, and Eamon O'Shea's review of the subvention scheme, among others) is the confusion, lack of tranparency and of uniformity across the country on eligibility for long-stay care.
We can start with some questions. Why do health boards inspect private nursing homes twice yearly, when there is no independent scrutiny of health board units? Has it been definitively assessed how many beds are needed from both the public and private sectors? If more than 40 per cent of private nursing homes want to expand and are being encouraged to do so with capital allowances, do we need more public beds?
If one in six residents of private nursing homes are categorised "low dependency", should they not be cared for at home? What has gone wrong when 16 per cent of residents are in a nursing home bed for social reasons?
It can be asked, too, whether people are being placed in private nursing home beds when better resourced public ones would be more appropriate. How do assessment procedures for physical dependency vary around the State? It has also been questioned whether nursing home care can be regarded as an "in-patient service" and therefore a legally enforceable right.
However, the pivot of interventions by Ms Harney and others has been who shall pay for long-stay care. Prof O'Shea asked nursing home owners what happened to residents who could not keep up weekly payments. The most likely scenario was that families intervened, if they had not already been doing so. The next most likely outcome was that fees were reduced. What was least likely was that the residents would be returned to their communities.
This for many older people, and their families, is the great fear. What happens when the money runs out? It is a particularly poignant question if they could have stayed in the community, and at home, with decent community care services. These are a major part of the answer, as Prof O'Shea points out. Families care, but they need back-up to ensure their low and even medium dependency parents can be kept in the community.
But when older people need nursing home care, views differ on how this might be financed. "Ring-fenced" social insurance is one option. Private insurance and equity release have also been suggested.
One suggestion is that the State pays a hefty lump of the costs, with the rest being clawed back posthumously from the older person's estate, on the basis that the care of an older person is higher in the hierarchy of needs than the right of any children to inherit. Contentious, but practical?
Paul Murray is head of communications at Age Action Ireland, www.ageaction.ie