Opinion Piece - Irish Mail on Sunday February 12th 2023
Arriving where we started.
Over 50 years ago 8 Health Boards were established under the Health Act of 1970. In 2005 the HSE was created and the, by then, 11 Health Boards were subsumed into one body which later created 7 hospital groups and 9 community health organisations. During 2023 we may see the emergence of 6 Regional Health Authorities as recommended in the all-party report Sláintecare. Well might T.S. Eliot have written:
“And the end of all our exploring,
Will be to arrive where we started
And know the place for the first time”.
The 1970 Health Act provided that in-patient services should be free for those with full eligibility for a medical card. However, from 1976 until 2005 charges were being imposed on long-stay residents in public care facilities despite the fact that these charges were known to be illegal. In 2004 the state tried to make these charges retrospectively legal but this was declared unconstitutional and so a limited Health Repayment Scheme was established in 2006 to repay charges for residents in public facilities from December 1988. Importantly, the scheme did not cover people who had to fund their own care because of a lack of a public provision. It was not so much that people chose to ‘go private’ as an initial lack of provision of quality public nursing home care (or care commensurate with need in their own homes) and a subsequent systemic bias towards private provision.
In 2009 the Nursing Homes Support Scheme (NHSS) was established to provide a legal basis for a system of co-payments towards care in both public and private nursing homes. In that same year HIQA began regulating and inspecting all nursing homes spurred on by the Leas Cross scandal of 2005.
In 1988 a major report ‘The Years Ahead: a policy for the elderly’ was produced by a Working Party led by Dr Joe Robins of the Dept of Health. The approach favoured supporting people to live in their homes and communities rather than in institutional or congregated care settings. In 1997, the Department of Finance designated nursing homes as industrial buildings enabling lucrative tax breaks for the building or refurbishment of nursing homes. The number of private nursing homes jumped from 408 in 2003 to 447 in 2010. Revenue data available for the years 2004 – 2011 indicate 4,796 claimants and a tax loss of €126M. Entry to the scheme ended in 2009 leaving an uneven pattern of provision across the country and claims that it was responsible for poor standards because it attracted investors who were purely in it for the money. There were also many well motivated people who opened small nursing homes, some of whom are now closing under the strain of regulation and increased costs.
In 2016, two years after it was established, Sage Advocacy published a report on charges in nursing homes. It stated “The fact that the care package provided for in the National Treatment Purchase Fund (NTPF) negotiated fee is frequently not adequate to meet the actual care needs of individuals is a matter of grave concern”. Setting out in detail a range of issues with charges, including inadequate access to therapies, equipment and aids required by individuals, the report bluntly stated “Given the number and type of issues outlined in this Discussion Paper relating to the role of the NTPF, and given its unique role and status, there is a strong prima facie case for the NTPF to appear before the Oireachtas Public Accounts Committee”. In a recent review of cases Sage Advocacy found evidence of growing levels of debt related to charges for services in private nursing homes with some residents being charged over long periods of time for use of items that could have been purchased for a fraction of the charges. One resident was charged for gloves to stop them removing their incontinence wear. In another case a resident was faced with notice to quit because their family was unable to pay increased charges.
In September 2020, informed by the experience of the pandemic, Sage Advocacy published ‘Choice Matters’ which examined how the “dangerous architecture” on which the current system of care in congregated settings for older people is built, presented major difficulties in responding to the challenges of Covid-19. ‘Choice Matters’ set out an implementation roadmap for the development of a single tier Sláintecare Social Care System which could be considered by a Commission on Care for Older People promised in the Programme for Government. The framework set out key underlying principles, important design features, a list of agencies that should be included in a multi-agency approach, the new legislation and regulation required, the need to develop an alternative and sustainable funding model and, finally, what is required in terms of implementing a new model. This government has less than 24 months to act on this promise. Meanwhile, Sage Advocacy is, once again, hearing reports that some nursing home residents are being charged for religious services.
CEO. Sage Advocacy.