IT ALL STARTED so well. Back in October 2009, when Mary Harney unveiled the Fair Deal scheme, aimed at sorting out the funding of long-term residential care for older people, she said it was “fair, equitable, transparent and progressive”. Less than two years on, few people would describe the scheme in such terms.
A cash crisis and a slowdown in the rate that applications are being processed by the Health Service Executive (HSE) has left many older people stressed about what the future might hold for them and what kind of care, if any, they will be able to afford.
In May the wheels seemed to come off the Fair Deal wagon entirely after it emerged that €1 billion set aside for it this year would only cover the 22,000 older people already in nursing homes and that new applicants would not be accommodated unless people already in the scheme died. When asked how the Government could have got its sums so wrong, Minister for Health James Reilly said that demand had “far outstripped what was anticipated”.
Once the scheme was declared full there were several weeks of crisis, during which the Minister expressed concern about the high cost, compared with private equivalents, of catering for older people in public facilities. Many people seeking care, he said, were left in acute hospital beds at considerable extra cost to the State. On the face of it, he was right.
It costs an average of €1,245 a week to fund a public long-stay bed, compared with €875 for a private one, though this comparison is somewhat misleading. Care in a public bed includes the input of specialists and therapists, and patients usually have the highest dependency levels, which is not frequently the case in private care facilities.
The Fair Deal scheme was revived in June, accompanied by dire warnings that there would still be “serious funding difficulties”. Reilly said he had been “left with a hell of a mess by the last government. I mean, there’s not just this issue, but right across all the departments , monies that were supposed to be provided for have transpired not to be there, so we’re going to have a serious challenge ahead and we’re working on that at the moment as well.” Reilly may have been left with a “hell of a mess”, but it is the older people who need care, and their families, who have been left to pick up the pieces.
Age Action Ireland’s Gerry Scully says the charity has been getting many calls from worried older people. Anecdotal evidence, he says, suggests that while the HSE and the Department of Health insist that the scheme is back up and running, “the reality is that there is a lot of foot-dragging, and the whole process has really slowed down and people are being left in a limbo”. He adds that this is “a very stressful time for a lot of people who simply do not know what to do. Nobody is quite sure if the Fair Deal is going to continue.”
It is not just older people who are facing an uncertain future; operators of nursing homes are also concerned that Fair Deal could fall apart. Their disquiet prompts them to press those coming into the system for upfront payments. “They used to say they were confident that someone would be admitted to the scheme, and they would hold off on demanding payments until the process was finalised, but now they are making people pay in advance, and that can put intolerable strain on them,” says Scully.
The problem is only going to get worse. The number of over-65s will rise by 44 per cent in the next 10 years and as life expectancy improves there will be increasingly intense pressure placed on a system that is already creaking under the strain.
Noel Mulvihill is an assistant national director at the HSE, with special responsibility for older people. He says that there has been a spike in Fair Deal applications since the beginning of the year and that there is a backlog to clear after the closing of the scheme in May.While he insists that the scheme is now open and processing applications as normal, he accepts that there are delays. He believes that things will improve as a new real-time processing system kicks in from this week.
“Already we can see the benefit of the new system, we can see movement happening, and over the coming weeks it will improve,” he says. He does have long-term questions, however, about the sustainability of Fair Deal. “Applications have been increasing fast, and the average length of time people are staying in long-term care has doubled to more than four years. As a society we need to look at the situation and work out how we are going to care for our older people. The HSE can only do so much. We need to go a different route and examine community-care options.”
Sean Moynihan, chief executive of Alone, agrees. He says the charity welcomed the Fair Deal scheme at first, although it had reservations, but “I think if you look at the way it has worked out, it is not sustainable. The future has to be in care in the community. It is what older people want, it is what their families want, it is what organisations like ours want. And it is cheaper.”
Moynihan says he can point to many examples of older people who, with the proper help, manage to live at home even when they have high support needs. He claims that care for older people in Ireland “has always been developed in a reactive way rather than according to a plan, and it is time for this to now change. The changing demographic in Ireland means that we will have more need to face, address and plan for these issues.”
He adds that the increased life expectancy of patients in nursing homes is an indication not of better care but of the fact that places are taken by people who do not have acute needs and could be less expensively catered for “where they want to be, in their own homes”.
He believes that the manner in which the Government handles this issue “will be indicative of its priorities in terms of wider social questions, and a test of the truth of Enda Kenny’s commitment, reiterated on his first day as Taoiseach, to make Ireland, ‘the best place on earth where people could age with dignity’.”
Case study: 'These delays seem calculated and are very cynical.'
Clive Johnston’s mother is 85 years old and until early this year was living independently in her home in Blackrock, Co Dublin. She had a serious stroke in January and has been in St Vincent’s Hospital ever since.
“We have submitted all the application forms and jumped through all the hoops, but we just can’t get it finalised,” he says. “She owns her own house, has a State pension and doesn’t have a lot of savings. We got a letter of assessment which said that, with all her assets, we would have to come up with around €550 of the €850 a week a nursing home in Greystones will cost. The letter stressed, however, that this was not an offer.”
Johnston says he was told that an offer of funding used to take between four and 10 days after the arrival of the letter of assessment, but his family have been waiting for four weeks. “We are certainly getting anxious at this stage. She is sitting in an acute hospital bed and they are not equipped to offer her the care she needs. We have been on to the hospital and have been told that they cannot do anything more for her. They say she would get a better standard of care in a nursing home. They have also said that there are at least 50 people in the same position as her, just sitting in beds waiting for funding to be approved. It [the HSE} says it is accepting and processing applications, but there seems to be a policy of foot-dragging, and the nursing home will not accept people unless they have the funding in place.
The situation is, Johnston says, “very stressful”. His family have “restricted access” because of hospital visiting hours. “I think she is getting depressed by the length of the delay, and we can see a decline in her mental capacity. I really think she would have had a better outcome if she had been admitted to a nursing home earlier. I know that the HSE is a monster, but these delays seem calculated and are very cynical.”
Case study: ‘Eight months ago he asked Alone to support his move into a nursing home after a bad fall’
Joe is 87 years old and lives on his own in Dublin after spending many years working in England. He has received the support of the charity Alone for many years and receives regular volunteer visits. Over the past few years his health has been declining and his ability to deal with day-to-day tasks and personal care has decreased.
Eight months ago he asked the charity to support his move into nursing-home care after a bad fall during the cold snap over the Christmas period. He had spent some time in respite care before returning home. He has no family in Dublin, which is why Alone is dealing with the Fair Deal application process on his behalf.
The completed application form for the Fair Deal scheme was sent in on May 2nd. A week later Joe received a letter acknowledging the application and looking for more details. These details were submitted on May 13th, after which he heard nothing.
On June 30th the charity made follow-up inquiries to the HSE in Naas. It was told that the application was being processed and that a request would be made to do an assessment by a public health nurse.
Three weeks later, Joe had still not been contacted.
On July 28th Alone contacted the public health nurse, who said she had not been made aware that the assessment had been requested. After an initial application, such an assessment is the first step in the Fair Deal process. While the public health nurse said she was more than happy to do the assessment and had been in touch with Joe, she had not received a request from the HSE three months after his initial application was submitted.
