The Prime Time report on nursing homes shows that fundamental reforms are badly needed, writes Ita Mangan.
Most older people live at home; only about 5 per cent go into long-stay care. However, those who do are among the most vulnerable and dependent people in society and are in need of a high level of care and protection.
Regrettably, we have failed to provide the appropriate level of care. The long-stay care sector has not been properly planned, funded or monitored. A number of reports and policy documents have been issued, but it seems to have taken the shocking images on Prime Time to get politicians and public exercised about the problems.
Long-stay care is provided in public, voluntary and private nursing homes. The Health Service Executive (HSE, formerly the health boards) has a statutory responsibility to provide long-stay care for everyone who needs it.
There are not nearly enough public places to cater for all who need them, so the HSE has some "contracted beds" in private nursing homes (this means the HSE pays the costs as if they were public beds).
The HSE also pays means-tested subventions in respect of some residents of private nursing homes. Other residents pay the full costs themselves. Fees paid to private nursing homes attract tax relief at the payer's marginal rate.
As well as paying for or subsiding beds in the private sector, the HSE is the regulator of the sector. It is obliged to ensure that private nursing homes meet certain standards before they are registered and then to ensure that those standards are monitored and inspected.
The current inspection system is flawed in many respects. There is no inspection system for the public nursing-home sector. The public providers are the inspectors of the private sector and they are dependent on that sector to carry out their own responsibilities. It seems that the nursing homes get notice of inspections - this contrasts sharply with the "dawn raids" and similar practices which regulators in the commercial world use.
Inspections do not seem to be conducted at night. It is at night that the worst abuses and bad practices, such as inappropriate medication and use of restraint, occur. Inspection reports are available under the freedom-of-information legislation, but there is no reason why they should not be posted on the HSE website.
The HSE cannot fulfil all of its roles in a satisfactory manner. It can exercise sanctions against nursing homes which fail to meet standards, but then it has to provide alternative accommodation for the residents affected.
The record suggests that the HSE is not prepared to exercise the sanctions available, possibly because of the resultant difficulties for itself.
It has long been recognised that an independent inspectorate is essential. The Health Strategy 2001 includes a specific commitment to put the Irish Social Services Inspectorate (which currently inspects children's homes) on to a statutory basis and extend its remit to nursing homes for older people. This has not happened.
In fact, virtually none of the commitments in the Health Strategy in relation to long-stay provision for older people have been implemented. Among these failed commitments are:
An integrated care subvention scheme
An integrated approach to care planning for older people
800 extra long-stay places
An action plan for dementia
An overall action plan to meet the needs of ageing and older people.
There is a simplistic notion that people who are in acute hospitals can be adequately provided for in private nursing homes and so take the pressure off acute hospitals. Some may be, but many private nursing homes are not equipped for, and do not take, highly-dependent residents. In general, people who need long-stay care are highly dependent and need appropriate facilities, not facilities which happen to be there.
Virtually no new public long-stay beds have been provided in recent years.
The development of the private nursing-home sector is largely tax-driven (capital allowances are available) so no consideration is given to whether or not they are in locations suitable for older people and their families.
While the physical standards of the newer nursing homes seem to be quite good, the standards in relation to staffing and training and monitoring of care workers are not nearly high enough.
People in care have the right to be treated with dignity and respect, to make decisions about their lives and to be involved in the life of what is now their home, and the staff need to understand and facilitate this.
Long-stay care is not just about providing somewhere to live for people who need care - it is about enabling them to live.
Ita Mangan is a barrister who specialises in welfare rights and is the author of Older People in Long-Stay Care, published by the Human Rights Commission 2003