SECOND OPINION:The health services see the elderly as a soft touch, writes DES O'NEILL
‘AS EASY as taking candy from a baby” always struck me as inapt, all the more so once I had children of my own. The attachment of a baby to its confectionery is legendary, and woe betide those who underestimate the protest if they try to remove it. In addition, moral opprobrium is heaped on those caught trying to take from children that which is rightfully theirs.
The experience of older people with the nursing home system over the past few decades provides a new idiom for an easy mark. “As easy as taking money from frail older people and their families” may not trip off the tongue as smoothly, but it neatly catches their experience at the hands of State agencies and the lack of public outrage.
Older people have been seen as a soft touch by the health services for many years. When the first Nursing Home subvention system was introduced in 1993, the health boards illegally assessed families as well as older people for a number of years until challenged.
In a pattern that was to become alarmingly familiar, enormous numbers of administrators, nurses and doctors colluded with this immoral manoeuvre. The reply to protesters was always verbal. Requests for clarification in writing were ignored, and it was made clear that such protests did not win friends for your service.
Even when this glitch was settled, many older people applying for nursing home care up to 2009 were wrongly told that subvention, covering only a fraction of the cost, was the only route available. In fact all those who needed nursing home care were eligible to have this provided at a cost of 80 per cent of the non-contributory old-age pension, either in a public facility or in a publicly funded bed in a private nursing home, as established in a 2005 Supreme Court ruling.
It is common knowledge that the Health Service Executive has been settling cases confidentially of those who apply for this to be rectified for those admitted to nursing homes up to 2009. The so-called Fair Deal extended the candy-snatching, exchanging an eligibility for nursing for a shabby scheme that could only be welcomed by those whose eligibility for publicly funded care had not been made clear to them.
The faults are legion: introducing a selective inheritance tax on stroke and dementia; miscalculating the amount needed (one of the unhelpful interjections in the recent debate was that population ageing had caught up with us in a matter of 18 months); limiting the amount (imagine if cancer services stopped after a certain amount had been spent?); failing to clarify who provides therapy services and equipment; and a contracting mechanism that does not recognise complexity of care.
In the background, there has been a horrifying failure to renew the public nursing home stock – 2,000 beds have been lost from the system – and a failure to engage with the disparities outlined in the unpublished Prospectus report on nursing homes, which showed major under-supply in urban areas and over-supply in some rural areas.
The Minister for Health has an opportunity to re-orient the moral compass, recalibrating the care of the most frail and complex group of older people with other illness groupings such as cancer and heart disease.
Starting a fruitless debate pitting an under-funded private sector against a neglected public system, which in the urban areas tends to deal with more dependent older people was not a good start, and hopefully the debate will evolve.
Significant opportunities exist for better assessment and care co-ordination in the community, wider use of social housing and geographical rebalancing of nursing home places. But many others must help in clarifying the complex needs, moral imperatives and also imaginative solutions that would create a climate whereby such systematic exploitation of older people would be unthinkable.
Given that nurses and family doctors are the largest group of healthcare professionals in the nursing home system, An Bord Altranais and the Irish College of General Practitioners need urgently to consider whether or not their collective attention, and advice to their professionals, has elevated debate and consciousness appropriately, and how history will judge their role in the great candy-snatch of the 21st century.
Dr Des O’Neill is a consultant in geriatric and stroke medicine
