Older People in Nursing Homes - Vulnerable People in a Vulnerable Sector
Two weeks ago Sage Advocacy highlighted serious concerns about the developing situation in nursing homes. During last week we heard that more supports would be made available to private nursing homes including redeployment of healthcare assistants from the private homecare sector. Now there are to be payments and grants made available to individual nursing homes but some of them are dependent on business cases being prepared and considered by the National Treatment Purchase Fund which funds the Nursing Home Support Scheme (NHSS) on behalf of the state. There is much talk of further measures to tackle scores of coronavirus outbreaks in nursing homes, including the appointment of Covid-19 managers in affected homes, but it is urgent that we strengthen the level of nursing staff in nursing homes to address palliative care as well as infection control. Equally urgent is the need to strengthen the level of medical care available to the almost 30,000 people resident in all nursing homes; an issue which is of concern to many GPs. The truth is it is not just the residents of nursing homes that are vulnerable; it is the entire nursing home sector which is vulnerable in this crisis.
‘On call for Ireland’ must be on call for all of Ireland and it must be sector neutral. The closer support and oversight of the nursing home sector which is required in the current public health emergency must be accompanied by a determination to step in and adequately staff and manage when the public interest and the health and welfare of individuals demands. It must also mean that HIQA provide guidelines on the level of nursing staff and medical care required in nursing homes; some of whom are now as large as some of our smaller hospitals. Above all it must mean that in planning the six new health regions the need for community hospitals, nursing homes, high support housing, respite and hospice services are given as much consideration as the need for acute hospitals and the development of a decent system of home care supports. With proper design and integration into local authority development plans we might well be able to meet many of these needs on the one campus.
Care in congregated settings such as nursing homes has been privatised to a degree which is now worrying. This is not an ideological issue. It is a practical issue as we see where the weaknesses of the current system are starting to display themselves. We have created a system where one part of the state, the National Treatment Purchase Fund, tries to buy nursing home care as cheaply as possible from a highly diverse range of private providers who are not really operating within an effective framework of public health and social care provision. In some cases they are competing against each other for business; in all cases they are competing against the public healthcare system for staff. The minority of public nursing homes, some of which would have been closed by HIQA had government not twice provided a derogation from physical environment standards, are allowed to operate at ‘cost’. The private sector nursing homes resent this and their residents and their families pay in additional charges so that some can break even and others can make a return on their investment.
A new approach to care in congregated settings was proposed by a section of the HSE some years ago. This advocated developing residential care around a Teaghleach or Household model in which there could be shared resources across sites but in which small numbers of people would live in homelike settings supported by staff with the necessary range of skills but without demarcation as to who did the work that needs to be done in any household. It never went anywhere; fundamentally because it threatened traditional views among key professions and the service planners, like George Bush Senior, didn’t do ‘the vision thing’.
Much of this may seem irrelevant in the face of the pandemic storm but we will over time emerge after the storm. We owe it to all who will have sacrificed so much to ensure that we strengthen the moves towards Sláintecare and, in particular, that we develop an integrated model of long-term care; a term which in Ireland means only nursing home care but which in other European countries includes home care. The outgoing government was planning a new statutory scheme for home care to match the statutory nursing home support scheme. Any incoming government should look at the 35 years of policy consensus on services for older people and should develop a single integrated long-term care scheme covering homes and congregated care settings with an inbuilt bias towards care in the home. This is where the vast majority of older people want to be; providing they can get out fairly soon.
Executive Director. Sage Advocacy. 5th April 2020