Review of the Nursing Home Subvention Scheme
Professor Eamon O’Shea
National University of Ireland, Galway
With contributions by Janet Convery and Joe Larragy
1
Acknowledgements
The author wishes to acknowledge the significant contribution of Janet Convery and Joe
Larragy to this report. He also wishes to acknowledge the major contribution of the Steering
Committee to the work. During the course of the work we also had many discussions with
officials from the various health boards, all of whom were open and constructive in helping to
shape this report. Thanks is also due to the nursing home proprietors who responded to our
survey and especially to Joe Stanley of the Irish Nursing Homes Association who provided
valuable insight into the operation of the nursing home subvention scheme. Thanks also to
Aine Ni Leime and Larri Walker who helped in the coding and presentation of the data.
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2
Review of the Nursing Home Subvention Scheme
Table of Contents
Chapter 1
Chapter 2
Chapter 3
Chapter 4
Introduction
9
The Expenditure Review Programme
Background of this Review
Objectives of the Review
Methodology
Outline of the Report
10
10
11
11
11
Long-Stay Care for Older People in Ireland
13
Introduction
Long-Stay Beds in Ireland
Long-Stay Residents in Ireland
Dependency in the Long-Stay Sector
The Dementia Population
Conclusion
14
14
20
24
26
27
Private Nursing Homes in Ireland
29
Introduction
Methodology
The Subvention Population
Dependency in Nursing Homes
Staffing Levels and Costs
Services in Nursing Homes
Charges in Nursing Homes
Restrictions on Admission
Capital Tax Allowances
Policy Issues
Conclusion
30
30
32
34
35
39
40
42
43
43
45
The Nursing Home Subvention Scheme
46
Introduction
Evolution of the Nursing Home Subvention Scheme
Administration of the Nursing Homes Subvention Regulations
Mid-Western Health Board: Case Study
The Application Process
Public Versus Private Care
Older People’s Ability to Pay for Private Care
Reform of the Scheme
Private Sector Issues
Conclusion
48
48
51
54
54
55
56
56
57
58
3
Chapter 5
Chapter 6
Chapter 7
Chapter 8
4
The Effectiveness of the Nursing Home Subvention Scheme
59
Introduction
Policy Objectives and the Nursing Home Subvention Scheme
Equity
Access
Choice
Flexibility
Cost-Effectiveness
National Policy Objectives and the Care of Dependent Elderly People
Family Assessment
Adequacy of Subvention
Assessment of Means
Quality of Care
Conclusion
60
60
62
62
62
63
64
64
65
66
67
72
74
Nursing Home Care in the Future
75
Introduction
Long-Stay Residential Care Populations: 1996-2011
Policy Targets
Dependency in the Community
Needs and Community Care
Family Care and Admission to Long-Stay Care
Living Alone
Public Private Relationships
Conclusion
76
76
80
82
85
88
91
92
94
A New Model of Subvention for Long-Stay Care
96
Introduction
Principles for the Funding of Long-Term Care
The Current System of Funding
Choosing a Model for Ireland
Dependency and Placement
Adequacy of Subventions
Cost Sharing in Long-Term Care
Subventions for Community Care
The Social Economy and Older People
Care Management
Integrating Public Policy for Older People
Conclusion
98
98
100
101
102
103
104
107
108
110
111
113
Conclusions
114
Appendix 1
123
Appendix 2
132
References
137
Review of the Nursing Home Subvention Scheme
List of Tables
2.1
Non-Acute Care Beds for Older People by Type of Facility
in the Long-Stay Sector, 2000
15
2.2
Non-Acute Care Beds for Older People by Type of Facility
in the Long-Stay Sector by Health Board (HB) Region,
16
2.3
Non-Acute Care Beds for Older People by Type of Facility
in the Long-Stay Sector by Health Board (HB) Region Per
1,000 Elderly Population (NCE), 2000
17
2.4
Ranking (from Highest (1) to Lowest Provision (8)) of Beds
Per 1,000 Elderly Population by Type of Bed by Health Board
Region
19
2.5
Trends in Bed Numbers in Long-Stay Facilities Excluding Long-Stay
Beds in Psychiatric Units and Acute Care Hospitals (1994-2000)
20
2.6
Long-Stay Residents by Type of Facility by Age 1996 (%)
20
2.7
Occupancy Rates in Long-Stay Residential Care by Health
Board Region, 1996
21
2.8
Estimated Number and Percentage of Long-Stay Residents in all
Types of Long-Stay Facilities by Age Category By Health Board
Region, 2000
22
2.9
Estimated Long-Stay Residents in Public and Private Facilities
per 1,000 Elderly Population by Health Board, 2000
23
2.10
Estimated Long-Stay Residents per 1,000 Elderly Population
By Health Board Region by Age Category: Ratio of Highest to
Lowest Rates
23
2.11
Level of Dependency of Long-Stay Residents by Type of Long-Stay
Facility, 1996
25
2.12
Estimated Dependency of Residents in Long-Stay Units
(Public and Private) by Health Board Region, 2000
25
2.13
The Number of People with Dementia in Ireland, 1996
26
2.14
Estimated Number and Percentage of People with
Dementia by Health Board Region, 1996
27
3.1
Response Rates by Health Board Region
31
5
6
3.2
Number of Private Beds Currently Occupied by Health
Board Region
31
3.3
Numbers Receiving Subvention by Health Board Region
32
3.4
Type of Subvention by Health Board Region (%)
33
3.5
Enhanced Subvention by Health Board Region
33
3.6
Contract Beds by Health Board Region
34
3.7
Dependency of Residents by Health Board Region (%)
34
3.8
Residents in Private Nursing Homes Diagnosed with Alzheimer’s
Disease or Dementia by Health Board Region
35
3.9
Number of Full-Time Staff by Health Board Region
36
3.10
Number of Part-time Staff by Health Board Region
36
3.11
Hours Worked per Week (Full and Part-Time) by
Type of Staff by Health Board Region (%)
37
3.12
Distribution of Staffing Costs (full and part-time) by Grade
by Health Board Region (%)
38
3.13
Distribution of Total Costs in Nursing Homes by Source
by Health Board Region (%)
38
3.14
Number of Nursing Homes Providing Various Services by Health
Board Region
39
3.15
Number of Nursing Homes Providing Day Care Services By
Health Board Region (N)
40
3.16
Number and Percentage of Nursing Homes by Region Varying
Price by Dependency and Means of the Applicant
40
3.17
Average Weekly Charges in Private Nursing Homes by Region (£)
41
3.18
Number and Percentage of Residents by Region Unable to Keep
up Payments in the Past Year
42
3.19
Rank Consequences of Inability to Continue Payments in Private
Nursing Homes (N)
42
3.20
Restrictions on Admissions by Health Board Region
43
3.21
Impact of Capital Tax Allowances by Health Board Region
43
Review of the Nursing Home Subvention Scheme
3.22
Changes to the Subvention Scheme
44
3.23
Main Challenges in the Future
44
3.24
Role of Health Board in Reducing Challenges Faced by Nursing
Homes
45
6.1
Older People in Long-Stay Care: National Projections by Age
Category Based on CSO and NCE Population Projects, 2001, 2006
and 2011
77
6.2
Level of Dependency of Patients in all Long-Stay Units based on
CSO and NCE Population Projections, 2001, 2006, and 2011
77
6.3
Long-Stay Care Projections by Age Group by Health Board Based
on NCE Population Projections
78
6.4
Percentage Changes in Long-Stay Care Residents by Health
Board Region: 1996/2001, 2001/2006, 2006/2011
79
6.5
The Projected Growth in the Number of People with Dementia
in Ireland, 1996-2011
80
6.6
Number of People aged 75 years and over in Private Households
by Health Board Region, 1996
81
6.7
Chronic Physical or Mental Health Problems in Older People
by Age Group
83
6.8
Percentage and Number of Older People Requiring Physical Care
or Assistance by Age Group and Sex
83
6.9
Distribution of Dependency of Community–Based Older People
Living in Same Household as Carers: An ADL-Based Measure
84
6.10
Weekly Community Care Services for Dependent Elderly People
86
6.11
Public Health Nurses (PHN) by Health Board, 1996
86
6.12
Home Helps: Numbers and Beneficiaries, 2000
87
6.13
Respite Beds for Older People by Health Board, 2000
88
6.14
Average Number of Hours of Care Per Week Provided by Principal
Caregiver by Category of Dependency and Type of Care
89
6.15
Female Caretaker Potential in Ireland 1926-2031
90
6.16
Living alone in Private Households by Health Board, 65+, 75+,
1996
91
7
6.17
8
Public and Private Provision by Health Board Region:
Residential Long-Stay Beds and Community Services Per 1,000
Elderly Population
92
Introduction
chapter
1
chapter
1
Introduction
The Expenditure Review Programme
The government decided in 1997 to approve proposals from the Minister for Finance for a process of
expenditure reviews as a key part of the financial management systems that are central to the Strategic
Management Initiative and are intended to ensure greater predictability in resource planning. The aims
of the expenditure review process are as follows:
•
To provide a systematic analysis of what is actually being achieved by expenditure in each
programme;
•
To provide a basis on which more informed decisions could be made on priorities within and
between expenditure programmes.
The review process involves examining objectives, considering the extent to which these objectives
remain valid and warrant resource allocation on the current and planned scale, and checking how far
objectives have been achieved and how efficiently this has been done. Each review should consider
how a programme is likely to evolve, the context in which it operates, the future relevance and priority
of its objectives, and possible changes in its effectiveness and efficiency.
Background of this Review
As part of this process, The Department of Health and Children and the Department of Finance have
agreed to conduct an expenditure review of the Nursing Home Subvention Scheme.
This review is appropriate for a number of reasons:
•
The scheme, which was introduced in 1993 under the Health (Nursing Homes) Act, 1990, is a
discrete area of activity which can be readily isolated for review purposes from other health
services.
•
Expenditure on the scheme has increased from £12m in 1994 to an estimated £52.5m in 2001.
•
The scheme has a high public profile - 6,196 people are currently in receipt of a subvention.
•
There has been pressure from subvention recipients and nursing home owners for an increase in the
rate of subvention.
•
There has been concern on the part of health boards about the 'demand led' nature of the scheme
and their desire to maintain older people within the community, as far as possible.
Review of the Nursing Home Subvention Scheme
Objectives of the Review
The objectives of the review are:
•
To examine the objectives of the nursing home subvention scheme and the extent to which
they remain valid
•
To estimate the level of need in elderly populations, including inadequately met need
•
To assess the service delivered under the programme in terms of effectiveness, quality and
accountability
•
To consider the implications of demographic trends and other relevant changes in the
environment that may impact on the programme
•
To evaluate how far the programme objectives have been achieved and how efficiently and
effectively this has been done
•
To establish what scope, if any, exists for achieving the programme objectives by other more
efficient and effective means
•
To specify the performance indicators that could appropriately be put in place to facilitate
future reviews of this type.
Methodology
The Department of Health and Children contracted with Dr. Eamon O' Shea of the National
University of Ireland, Galway to undertake the review of the nursing home subvention scheme.
The study was overseen by a Steering Committee comprising officials of the Department of
Health and Children and the Department of Finance. The work began in March 2000 and was
completed in March 2001. Data on the nursing home sector was obtained from the Department
of Health and Children. A postal survey of nursing home proprietors was also undertaken for the
study. The Irish Nursing Homes Association were also consulted. A series of meetings with
relevant health board officials were held in each health board. These meetings brought together
all staff involved in the operation of the nursing home subvention scheme.
Outline of the Report
The report opens in Chapter 2 with a discussion on the number of beds and residents in the
long-stay sector in Ireland. The long-stay sector is comprised mainly of long-stay beds, but also
includes respite beds, assessment beds, convalescent beds and beds occupied by people under
65 years of age. A detailed inventory is provided on the number of long-stay residents in all
types of long-stay care in the country, including estimates of the number of people with
dementia in the long-stay sector. Differences in provision are explored across health boards and
comparisons are standardised in terms of beds and residents per 1,000 elderly population.
Chapter 3 provides detailed information on the private nursing home sector in Ireland. The data
is based on a postal survey of all known nursing home proprietors in the country. The survey
11
chapter
1
Introduction
covered both quantitative and qualitative issues, including data on beds, residents, levels of
dependency, costs and charges. Information on charges is important because it allows us, in later
chapters, to examine the hypothesis, now conventional wisdom, that subvention levels are low
relative to the fees paid by older people in private nursing homes.
Chapter 4 deals with the operation of the nursing home subvention scheme as provided for in
the Health (Nursing Homes) Act, 1990 (the 1990 Act). The 1990 Act set out the statutory
requirements for nursing homes regarding registration and standards, and outlined the
subvention process for certain categories of older people admitted to private long-stay care. The
subvention scheme requires health boards to pay a contribution towards the cost of nursing
home care for qualified older people living in registered homes. Eligibility for the scheme is
based on the dependency of the applicant and the means of the applicant.
Chapter 5 examines the effectiveness of the nursing home subvention scheme and provides a
detailed analysis of the problems associated with the scheme. Effectiveness is concerned with
the relationship between the aims of policy and policy outcomes at both macro and micro levels.
The macro questions deal with link between the objectives and the outcomes of the nursing
home subvention scheme and the relationship of the scheme to the general policy objectives for
dependent older people in the country. The micro questions relate to the internal effectiveness
of the scheme and focus on four key issues: family assessment, adequacy of subvention rates,
assessment of means and quality of care.
Chapter 6 considers the implications of demographic trends and other relevant changes in the
environment for the demand and supply of long-stay beds. While demographic trends and
changes in age distributions are very important they do not provide a complete account of likely
future trends in long-stay care usage. The level of dependency and disability in the community
and the number of older people on the boundary of community and residential care also matter.
So too does the adequacy of community care and the continued willingness of families to
provide care at current high levels to older people living at home.
A revised model for the funding of older people in public and private long-stay care and in
community care is proposed in Chapter 7. The aim is to recalibrate the current model to favour
home care over residential care, thereby improving the overall effectiveness of long-term care
financing for older people. The current system is biased towards residential care. Services and
facilities should, however, serve the needs and preferences of older people, not the other way
round, and financing systems should be designed to give maximum expression to those needs
and preferences, which, for most people, would mean more funding for home care. A number of
proposals are put forward to improve the nursing home subvention scheme including more
rigorous dependency assessment, an increased rate of subvention for nursing home residents
and the use of community-based subventions for people living in the community but on the
point of admission to residential care.
12
Long-Stay Care for Older
People in Ireland
chapter
2
chapter
2
Long-Stay Care for Older People
in Ireland
Introduction
This chapter provides information on the number of beds and residents in long-stay facilities for
older people in Ireland. The analysis is based on data supplied by the health boards to the
Department of Health and Children. The long-stay sector is comprised mainly of long-stay beds,
but also includes respite beds, assessment beds, convalescent beds and beds occupied by
people under 65 years of age. The private nursing home sector has become increasingly
important in the provision of long-stay care for older people, with the number of beds in the
private sector now accounting for more than 50 per cent of all long-stay beds in the country. A
detailed inventory is provided of the number of older people in all long-stay facilities in the
country, including estimates of the number of people with dementia in long-stay care.
Differences in provision are explored across health boards and comparisons are standardised in
terms of beds and residents per 1,000 elderly population. The analysis contained in this chapter
provides the context for the examination of the nursing home subvention scheme which follows
in later chapters.
Long-Stay Beds in Ireland
Table 2.1 shows the number of beds in the long-stay sector by type of facility in the year 2000 1.
This data has only recently become available from the health boards and is not yet as complete
as the latest published statistics for 1996 (Department of Health and Children, 1999a). However,
the new data provides important current information on bed numbers by type of facility in this
country. There are an estimated 24,052 beds for older people in long-stay facilities at the
moment. Of these beds, 11,415, or 47 per cent of the total, are located in health board facilities,
with the vast majority of these being extended care beds. The latter are located mainly in health
board geriatric homes but also include beds in health board welfare homes, health board district
hospitals and health board community nursing units. In addition, there are 551 long-stay beds for
the elderly mentally infirm. Just over 1,700 beds (7 per cent) in the long-stay sector comprise
assessment, respite and convalescent beds. Strictly speaking, these beds are not long-stay and
are left out of the estimation of long-stay residents later on, but they are included here because
they do impact on long-stay numbers by keeping people out of long-stay residential care.
1 Not all beds in the long-stay sector are long-stay since the sector also includes assessment, respite
and convalescent beds.
Review of the Nursing Home Subvention Scheme
Table 2.1: Non-Acute Care Beds for Older People by Type of Facility in the Long-Stay Sector, 2000
Type of Facility
Beds (N)
Beds (%)
Beds/1,000
Elderly Population
(CSO)
Beds/1,000
Elderly Population
(NCE)
9,045
37.7
21.1
20.9
HB Elderly Mentally Infirm
551
2.3
1.3
1.3
HB Assessment and
Rehabilitation
974
4.0
2.3
2.2
HB Respite
497
2.1
1.2
1.1
HB Convalescent
245
1.0
0.6
0.6
HB Other2
103
0.4
0.2
0.2
11,415
47.5
26.7
26.3
HB Subvented Beds
6,196
25.8
14.5
14.3
HB Contract Beds
1,281
5.3
3.0
3.0
385
1.6
0.9
0.9
7,862
32.7
18.4
18.2
Total HB Funded Beds
19,277
80.1
45.1
44.5
Private and Voluntary
Beds (Non-Subvented)
4,775
19.9
11.1
11.0
24,052
100.0
56.2
55.5
Health Board (HB)
Extended Care
Sub-Total: HB Provided
Winter Initiative Beds3
Sub-Total: HB Funded in
Private Facilities
Total Beds
There are 6,196 beds in private and voluntary4 homes that are occupied by older people in
receipt of public subvention from the health boards. In addition, there are 1,281 contract beds in
the system whereby the health board enters agreement with the private sector to provide
extended care in private nursing homes for eligible older people. As part of the 2000/2001
Winter Initiative a further 385 beds have recently been made available for older people in the
private sector, primarily for older people leaving acute care facilities. Adding these beds to the
publicly provided beds means that 80 per cent of all beds in the long-stay sector (19,277) receive
public funding of some sort from the exchequer. There are an estimated 4,775 beds in private
and voluntary homes that are purely private and the people occupying these beds do not
receive any financial support from the health board.
Combining the data on beds with population projections for 2001 from the Central Statistics
Office (CSO) and the National Council for the Elderly (NCE)5 yields an overall ratio of beds per
1,000 elderly population (65 years plus) in long-stay facilities of approximately 56 per 1,000.
2 Includes psycho-geriatric beds.
3 At the time of going to press this figure had risen to 592 beds.
4 Voluntary homes are non-profit making homes mainly run by religious orders (often for their own
members) and charitable organisations. Throughout the remainder of this report private/voluntary
will simply be referred to as private for ease of exposition.
5 Now called the National Council on Ageing and Older People
15
chapter
2
Lo n g - S t a y Ca r e f o r O l d e r Pe o p l e i n I r e l a n d
There are just over 14 beds per 1,000 elderly population allocated to people receiving
subvention from health boards under the Health (Nursing Homes) Act, 1990 (the 1990 Act), while
the national rate for contract beds is 3 per 1,000 population. The ratio of beds to elderly
population in the purely private (non-subvented) sector is 11 per 1,000, which accounts for 20 per
cent of all beds in the long-stay sector.
Table 2.2: Non-Acute Care Beds for Older People by Type of Facility in the Long-Stay Sector by Health
Board (HB) Region, 2000
Type of Facility
HB Extended Care
M
MW
NE
NW
SE
S
W
Total
2,349
671
744
686
639
1,234
1,560
1,162
9,045
65
123
38
61
115
114
0
35
551
HB Assessment/
Rehab Beds
417
39
96
70
103
108
42
99
974
HB Respite
145
48
45
105
54
13
76
11
497
HB Convalescent
114
6
4
0
35
0
0
86
245
0
14
63
0
0
26
0
0
103
Sub-Total: HB Provided
3,090
901
990
922
946
1,495
1,678
1,393
11,415
HB Subvented Beds
1,531
338
892
407
380
734
861
1,053
6,196
HB Contract Beds
733
5
0
80
189
0
274
0
1,281
Winter Initiative Beds
240
0
25
37
29
6
34
14
385
Sub-Total: HB Funded
in Private Facilities
2,504
343
917
524
598
740
1,169
1,067
7,862
Total HB Funded Beds
5,594
1,244
1,907
1,446
1,544
2,235
2,847
2,460
19,277
Private and Voluntary
Beds (Non-Subvented)
1,950
282
635
185
63
441
671
548
4,775
Total Long-Stay Beds
7,544
1,526
2,542
1,631
1,607
2,676
3,518
3,008
24,052
HB Elderly Mentally Infirm
HB Other
16
ERHA
Review of the Nursing Home Subvention Scheme
Table 2.3: Non-Acute Care Beds for Older People by Type of Facility in the Long-Stay Sector by Health
Board (HB) Region per 1,000 Elderly Population (NCE), 2000
Type of Facility
HB Extended Care
ERHA
M
MW
NE
NW
SE
S
W
Total
17.1
26.2
19.2
18.8
21.6
25.4
23.1
23.4
20.9
HB Elderly Mentally Infirm
0.5
4.8
1.0
1.7
3.9
2.4
0.0
0.7
1.3
HB Assessment/
Rehab Beds
3.0
1.5
2.5
1.9
3.5
2.2
0.6
2.0
2.2
HB Respite
1.1
1.9
1.2
2.9
1.8
0.3
1.1
0.2
1.1
HB Convalescent
0.8
0.2
0.1
0.0
1.2
0.0
0.0
1.7
0.6
HB Other
0.0
0.6
1.6
0.0
0.0
0.5
0.0
0.0
0.2
Sub-Total: HB Provided
22.5
35.2
25.6
25.3
32.0
30.8
24.8
28.0
26.3
HB Subvented Beds
11.2
13.2
23.1
11.1
12.8
15.1
12.7
21.2
14.3
HB Contract Beds
5.3
0.2
0.0
2.2
6.4
0.0
4.1
0.0
3.0
Winter Initiative Beds
1.8
0.0
0.6
1.0
1.0
0.1
0.5
0.3
0.9
Sub-Total: HB Funded
in Private Facilities
18.3
13.4
23.7
14.3
20.2
15.2
17.3
21.5
18.2
Total HB Funded Beds
40.8
48.6
49.3
39.6
52.2
46.0
42.1
49.5
44.5
Private and Voluntary
Beds (Non-Subvented)
14.2
11.0
16.4
5.1
2.1
9.1
9.9
11.0
11.0
Total Long-Stay Beds
55.0
59.6
65.7
44.7
54.3
55.1
52.0
60.5
55.5
The distribution of long-stay beds for older people by type of bed and health board region is
shown in Table 2.2, while the relationship between bed numbers and the number of older
people in each health board is examined in Table 2.3 using NCE population projections (Fahey,
1995). The CSO does not provide population projections by health board — hence the reliance
on NCE projections for the year 2001. There are 21 publicly provided extended care beds per
1,000 elderly population in the country. The range of provision of publicly provided extended
care beds lies between a minimum of 17 per 1,000 elderly population in the ERHA to a maximum
of 26 per 1,000 in the Midland Health Board. The national ratio of subvention beds per 1,000
elderly population is 14 per 1,000. The Mid-Western Health Board has the most subvention beds
per 1,000 elderly population at 23 per 1,000, with the North Eastern Health Board and the ERHA
having the least number of subvention beds per 1,000 elderly population at 11 per 1,000. The
North-Western Health Board has the highest ratio of contract beds per 1,000 elderly population
at 6 per 1,000, followed by the ERHA at 5 per 1,000. Three health boards do not have any
contract beds: the Mid-Western, the South-Eastern and the Western, while the Midland Health
Board has only five contract beds.
There are just over two assessment beds per 1,000 elderly population in the country, while the
national rate for respite beds is just over one per 1,000 elderly population. The North Western
Health Board has the highest ratio of assessment/rehabilitation beds per 1,000 elderly
17
chapter
2
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population at 3.5 per 1,000, with the North Eastern Health Board having the highest ratio of
respite beds in the country at 2.9 per 1,000 elderly population. The Western Health Board has
the highest rate of convalescent beds per 1,000 elderly population at 1.7 per 1,000, nearly three
times the national average. There are no reported convalescent beds in the North Eastern, South
Eastern and Southern health boards.
Combining beds directly provided by the health boards and long-stay beds subvented in some
way by the health boards yields an overall national ratio of publicly funded non-acute care beds
per 1,000 elderly population of just under 45 per 1,000. Overall, the North Western Health Board
has the highest ratio of publicly-funded beds at 52 per 1,000 elderly population, while the North
Eastern Health Board has the lowest ratio at 40 per 1,000. The Mid-Western Health Board has
the highest number of private (non-subvented) beds at 16 per 1,000 elderly population, while the
North Western Health Board has the lowest ratio of private beds at 2 per 1,000 elderly population.
Overall, the Mid-Western Health Board has the highest number of non-acute long-stay related
beds (public and private) per 1,000 elderly population at 66 per 1,000, while the North Eastern
Health Board has the lowest ratio at 45 per 1,000. The national ratio for all non-acute care beds
in the elderly long-stay sector, public and private, is 56 per 1,000 elderly population.
Table 2.4 shows the ratio ranking across health boards of various types of beds, with 1 signifying
the highest ratio of beds per 1,000 population and 8 signifying the lowest ratio of beds per 1,000
population. The most obvious contrast is between the Mid-Western Health Board and the North
Eastern Health Board. The former has high rates of bed provision, with the exception of
extended care beds, while the North East has consistently low rates of provision across all types
of long-stay beds. The obvious question is whether differences in overall rates of long-stay bed
provision between the two regions matter for the well-being of older people? Similarly, does it
matter that the North West has an additional 12 publicly funded beds per 1,000 elderly
population than the North East? These are both clearly empirical questions, the answer to which
require an audit of community care facilities (which is attempted later on in the report) in the
various regions and, ultimately, a longitudinal analysis of outcomes for older people (which is
beyond the scope of this report). Hence, it is not going to be possible to say with any certainty
whether older people in regions with more beds are better off than older people in regions with
fewer beds. Although, even at this early stage of the report, we have some sympathy with the
view expressed in The Years Ahead (Report of the Working Party on Services for the Elderly,
1988) that (in 1988) “ those regions with lower bed ratios seem to be coping as well, if not better,
than those boards with higher ratios”.
What is clear, however, is that differences in the public–private mix of beds provided within
regions will likely have different financial implications for older people. Those living in regions
with higher ratios of public beds to private beds will likely face lower out-of-pocket costs for
long-stay care than older people living in regions with low ratios of public beds to private beds.
For example, older people living in the ERHA are less likely to be admitted to public extended
care beds than older people living in the Midland Health Board region because of differences in
the availability and mix of such beds between the two regions. Consequently, older people in
the ERHA are likely to experience greater cost-sharing pressures than older people in the
Midlands. Therefore, what we can say at this early stage of the study is that where you live
matters in this country for access to public long-stay facilities and for your chances of admission
to public care over private care.
18
Review of the Nursing Home Subvention Scheme
Table 2.4: Ranking (from Highest (1) to Lowest Provision (8)) of Beds per 1,000 Elderly Population by
Type of Bed by Health Board Region
Type of Beds
ERHA
M
MW
NE
NW
SE
S
W
HB Extended Care Beds
8
1
6
7
5
2
4
3
HB Funded Beds
in Private Facilities
4
8
1
7
3
6
5
2
Total6 HB Funded Beds
7
4
3
8
1
5
6
2
Private (Non-Subvented)
Beds
2
3
1
7
8
6
5
3
Total Beds
5
3
1
8
6
4
7
2
Any attempt to explore trends in bed numbers is fraught with difficulty mainly because of
inconsistencies in the way data has been collected and presented in the official publication
Health Statistics. Prior to the introduction of the nursing home subvention scheme in 1993, nonpublic beds were divided into two categories: voluntary/approved nursing homes and other
private nursing homes. This distinction held no meaning after the 1990 Act, but it took until 1994
before the official data was reconciled with the changes in the way nursing homes were to be
funded from then on. Even though bed numbers are shown for the years 1991-1993 in Table 2.5,
the fact that no changes are recorded across the three years suggests that these figures are
unreliable and should be treated with caution. In addition, the long-stay care data shown in
Health Statistics cover all beds in long-stay facilities, including extended care beds, respite beds,
assessment beds and convalescent beds. The annual survey of long-stay units asks respondent
units to separate extended care beds and respite beds but does not ask for any other
distinctions to be made. Moreover, when it comes to presenting the data in Health Statistics the
respite beds are not separated out from the other beds; the data presented simply refers to
number of beds. Neither does the survey, explicitly at least, cover older people resident in
psychiatric units or acute hospitals which explains why these beds are excluded from the trend
analysis.
The data on the public sector presented in Table 2.5 are, therefore, more an indication of
general trends in overall bed provision for older people in long-stay facilities than an accurate
representation of changes in long-stay public bed provision in the period under review. During
the nineteen nineties, there was a small increase in the number of beds in long-stay public
facilities of approximately 5 per cent, but most of this was likely to be in assessment and respite
provision rather than long-stay provision. The figures are likely to be more reliable for the private
sector, where the data shows an increase of 3,237 long-stay beds in the period 1994 and 2000.
The number of beds in the private and voluntary sectors is now one third higher than in 1994,
the latest year for which comparative data is available. While a significant amount of this change
reflects an increase in publicly-funded subvention provision in private nursing homes, including
an increase in contract beds, the point is that the private sector now has a much more significant
role in the provision of long-stay care in this country. The ratio of publicly provided beds to
private/voluntary provided beds has reduced from 50:50 in 1994 to 44:56 in 2000.
6 Includes respite, assessment and convalescent beds as well as long-stay.
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Table 2.5: Trends in Bed Numbers in Long-Stay Facilities Excluding Long-Stay Beds in Psychiatric Units
and Acute Care Hospitals (1994-2000)
Facility
1991/92/
93
1994
1995
1996
2000
Change in
beds (N)
1994-00
% Change
1994-00
Public Long-Stay*
9,035
9,278
9,261
9,573
9,749
+471
+5
Private**/Voluntary
7,658
9,400
9,523
9,995
12,637
+3,237
+34
16,693
18,678
18,674
19,568
22,386
+3,708
+20
Total
* Includes respite beds, assessment beds and convalescent beds
** Includes publicly-funded subvention beds and contract beds
Long-Stay Residents in Ireland
Estimating the number of older people in long-stay care is more difficult than simply counting
the number of beds in the long-stay sector. First of all, as we have already observed in Table 2.1,
1,716 beds are designated for assessment/rehabilitation, respite and convalescent care for older
people. These beds are not part of the long-stay sector although they do impact on placement
decision-making for admission to long-stay care. This means that the actual number of long-stay
beds currently in the system is 22,3367. Not all of these beds will be full, however, as occupancy
rates are unlikely to be 100 per cent, making it necessary to make an adjustment to take account
of the actual number of patients in long-stay care at any given time. In addition, some of the
beds are likely to be occupied by people under 65 years of age. These people must, by
definition, be excluded from our calculations of elderly residents in long-stay care. Both the
occupancy issue and the under 65 question will now be briefly discussed, beginning with the
latter.
Table 2.6: Long-Stay Residents by Type of Facility by Age 1996 (%)
Age
Type of Facility
< 40
40-64
65-69
70-74
75-79
80-84
85+
Health Board Extended
Care Beds
0.4
5.7
6.7
12.6
18.8
24.9
30.9
Voluntary Nursing Homes
1.3
6.2
3.8
8.2
14.0
23.4
43.1
Private Nursing Homes
0.2
3.1
2.8
7.4
15.8
29.6
41.2
Total
0.5
4.9
4.9
10.0
16.9
26.1
36.6
Source: Department of Health (1999b): Long-Stay Activity Statistics, 1996
7 This figure should not be confused with the figure for total beds presented in Table 2.5 which was
calculated differently to allow comparison over time.
20
Review of the Nursing Home Subvention Scheme
The most recent year for which information on the age distribution of long-stay residents is
available is 1996 (Table 2.6). The age distribution is calculated on the basis of all older people in
long-stay facilities, not just those people in extended care beds. Just over 5 per cent of all
people in long-stay care are under 65 years of age. These people are, therefore, excluded from
our estimates of long-stay residents in the country. In general, residents in private nursing
homes, which comprise subvented and non-subvented patients, are older than patients in all
forms of public facilities. Over 70 per cent of residents in private nursing homes in 1996 are aged
80 or over, compared to a figure of 56 per cent in health board geriatric hospitals/homes. The
age profile of private nursing homes has increased during the nineteen nineties. In 1988, only 58
percent of long-stay residents in private nursing home were aged 80 or over (O’Shea et al, 1991).
The age distribution of long-stay residents has implications for resource use in residential care
settings, since the very old typically make greater demands on care services.
Table 2.7: Occupancy Rates in Long-Stay Residential Care by Health Board Region, 1996
Health Board
Region
Beds
Residents
Percentage Occupancy
ERHA
5,876
5,395
91.8
Midland
1,381
1,243
90.0
Mid-Western
2,019
1,848
91.5
North-Eastern
1,486
1,380
92.9
North-Western
1,364
1,289
94.5
South-Eastern
2,014
1,901
94.4
Southern
2,872
2,666
92.8
Western
2,556
2,390
93.5
19,568
18,112
92.6
Total
Source: Department of Health and Children (1999b): Long-Stay Activity Statistics 1996
The most recent year for which data on occupancy rates are available is also 1996 (Table 2.7).
Once again, the basis of the calculation for occupancy rates is all beds in long-stay units, not just
extended care beds. The national occupancy rate is 93 per cent with the rate varying between 90
per cent (Midlands) and 95 per cent (North West and South East) across the country. The rates
suggest that at the time the 1996 survey was undertaken nearly 1,500 long-stay beds were
empty. This is somewhat surprising, even allowing for cyclical effects on bed usage, given the
pressure that the long-stay sector is assumed to be under from increasing numbers of older
people seeking admission into long-stay care. While the occupancy data are not broken down
by type of facility, the high number of beds not occupied points to some combination of
inefficiency in bed management and variable levels of demand relative to the availability of
beds. Whatever the reason for the failure to fill existing beds, occupancy rates of just over 90 per
cent do undermine general claims of excess demand in the system as a whole, although real
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pressures on public beds continues to exist in some areas. Empty beds also point to the need
for more effective monitoring of bed management in the system than has been the case in
recent years. More immediately, for our purposes, the occupancy rate by health board must be
built in to our estimation of long-stay residents across the country.
Table 2.8: Estimated Number and Percentage of Long-Stay Residents in all Types of Long-Stay
Facilities by Age Category by Health Board Region, 2000
Health Board Region
ERHA
M
MW
NE
NW
SE
S
W
Total
Residents (N)
65-69
271
63
107
91
75
147
133
118
1,005
70-74
549
174
235
141
136
265
328
247
2,075
75-79
914
199
436
253
233
427
612
421
3,495
80+
4,168
772
1,310
782
812
1,472
1,928
1,729
12,973
65+
5,902
1,208
2,088
1,267
1,256
2,311
3,001
2,515
19,548
65-69
5
5
5
7
6
6
4
5
5
70-74
9
14
11
11
11
11
11
10
11
75-79
15
16
21
20
19
18
20
17
18
80+
71
64
63
62
65
64
64
69
66
65+
100
100
100
100
100
100
100
100
100
Residents (%)
Estimates of the number and percentage of long-stay residents by age category across health
boards is shown in Table 2.8 for the year 2000. The estimated number of long-stay residents
aged 65 years and over currently in long-stay care beds in Ireland is 19,548. This is 4,510 less than
the number of beds in the system reflecting occupancy rates of between 90 and 95 per cent
across the regions, the omission of people under 65 years of age in long-stay beds and the
omission of people in respite, assessment/rehabilitation and convalescent beds. The vast
majority of long-stay residents are aged 75 years and over, with only 16 percent of residents
aged between 65 and 75 years. The proportion of residents aged 75 years or over is greater or
equal than 80 per cent in each health board with the Eastern Regional Health Authority
recording the highest rate at 86 per cent. The Midland Health Board has the lowest percentage
of residents aged 75+ years at 80 per cent. Two in every three residents in long-stay care are
over 80 years of age with the Eastern Regional Health Authority having the highest percentage
at 71 per cent. Age is clearly an important factor in determining admission and residency in longstay care.
22
Review of the Nursing Home Subvention Scheme
Table 2.9: Estimated Long-Stay Residents in Public and Private Facilities per 1,000 Elderly Population
by Health Board, 2000
Age category
ERHA
M
MW
NE
NW
SE
S
W
Total
65-69
6
8
9
9
9
10
7
9
8
70-74
15
26
24
15
18
21
19
20
19
75-79
33
35
54
32
37
41
44
40
39
80+
138
135
145
91
104
134
119
132
128
65+
43
47
54
35
42
48
44
51
45
Estimates of the number of long-stay residents per 1,000 elderly population in each health board
is shown in Table 2.9. National residency rates per 1,000 elderly population vary from 8 per 1,000
in the 65-69 age category to 128 per 1,000 in the 80+ age category. There are, however,
significant differences across health boards in the number of residents per 1,000 elderly
population across all elderly age categories. The Mid-Western Health Board has the highest
ratio of long-stay residents aged 65 or over per 1,000 elderly population; the North Eastern
Health Board has the lowest ratio. The North Eastern Health Board has the lowest ratio of longstay residents per 1,000 elderly population in three of the four elderly age categories (Table
2.10). The Mid-Western Health Board has the highest ratio of residents to elderly population in
the age categories 75-79 and 80+. The largest absolute difference in the number of people in
long-stay care between health boards occurs in the 80+ age category where an additional 54
people per 1,000 elderly population are in long-term care in the Mid-Western Health Board than
in the North Eastern Health Board.
Table 2.10: Estimated Long-Stay Residents per 1,000 Elderly Population by Health Board Region by
Age Category: Ratio of Highest to Lowest Rates
Age Category
National Rate/1,000 Highest Rate (HB)
Lowest Rate (HB)
Ratio H/L
65-69
8
10 (SE)
6 (E)
1.7
70-74
19
26 (M)
15 (E,NE)
1.7
75-79
39
54 (MW)
32 (NE)
1.7
80+
128
145 (MW)
91 (NE)
1.6
65+
45
54 (MW)
35 (NE)
1.5
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Dependency in the Long-Stay Sector
The latest year for which information on the mix of dependency in long-stay units is available is
1996 (Table 2.11). Almost two thirds of residents8 in long-stay beds in 1996 can be characterised
as high or maximum dependency. The percentage of residents in these two categories in health
board extended care beds is 68 per cent; the corresponding proportion for private nursing
homes is 61 per cent. There remains a small but significant number of low dependency residents
in all types of long-stay units, ranging from 10 per cent in health board extended care beds to 17
per cent in voluntary geriatric homes. Almost one in six people in private nursing homes are
characterised as low dependency patients. The high number of people with low dependency in
long-stay units reflects the fact that 16 per cent of residents across all types of long-stay units are
there for social reasons (Department of Health and Children, 1999a).
It is difficult to explore trends in dependency in long-stay units, given the absence of
comparable data, when data is available at all, and any agreement about how dependency is
best assessed. Blackwell et al. (1992) suggest that just over one fifth of people in public long-stay
units in the early nineteen nineties were low dependency patients, which, if taken as
representative, would suggest that the number of low dependent people in public long-stay care
has fallen since then. Similarly, data from the mid-nineteen eighties (O’Connor and Thompstone,
1986) suggests that just over one quarter of nursing home residents were self-reliant, which, if
equated to low dependency categorisation, implies that the number of low dependency
residents has also fallen in private nursing homes in the ten years between 1986 and 1996.
The reasons for the apparent increase in dependency in private long stay units may have more to
do with the vagaries of the subvention scheme than any deliberate policy of keeping low
dependency people out of nursing homes through enhanced community care provision. There is
an incentive to promote dependency among subvention applicants to ensure qualification for
the maximum grant, thereby reducing the gap between the cost of nursing home care and the
financial resources of the applicant. In the case of public long-stay care, the reduction in welfare
beds means that less people are now admitted to long-stay care for purely social reasons which
means higher average dependency in that sector. In addition, continued restrictions on the
number of public beds, particularly in the Eastern Regional Health Authority, is, at the margin,
likely to have reduced the number of low dependency people admitted to available beds. It is
impossible to be more precise with respect to the dependency question, given the different
approach to measurement among the health boards and the different procedures in place for
deciding on admission to long-stay care across the country. While the regulations define specific
categories of dependency for the purpose of subvention, the health boards tend to use variants
of the measures specified therein for the assessment of dependency (see Chapter 4).
8 These residents will mainly be long-stay residents but also include people in respite beds, assessment
beds and convalescent beds.
24
Review of the Nursing Home Subvention Scheme
Table 2.11: Level of Dependency of Long-Stay Residents by Type of Long-Stay Facility, 1996
Category of Dependency
Type of Facility
Low
Medium
High
Max.
Total
Health Board Extended
Care Beds
10
21
30
38
100
Voluntary Geriatric Homes
17
21
28
33
100
Private Nursing Homes
15
24
30
31
100
Total
13
22
30
35
100
Source: Department of Health and Children (1999b), Long-Stay Activity Statistics
Table 2.12: Estimated Dependency of Residents in Long-Stay Units (Public and Private) by Health
Board Region, 2000
Category of Dependency
HB Region
Low
Medium
High
Max.
Total*
N
%
N
%
N
%
N
%
N
%
ERHA
868
15
1,251
21
1,558
26
2,154
37
5,902
100
Midland
152
13
239
20
371
31
446
37
1,208
100
Mid-West
313
15
574
28
616
30
580
28
2,088
100
North-East
81
6
257
20
342
27
588
46
1,267
100
North-West
107
9
256
20
519
41
373
30
1,256
100
South-East
386
17
515
22
582
25
827
36
2,311
100
South
384
13
726
24
900
30
990
33
3,001
100
West
246
10
490
20
946
38
832
33
2,515
100
Total
2,537
13
4,308
22
5,834
30
6,790
35
19,548
100
Ratio H/L
2.8
1.4
1.6
1.6
* Includes “not specified” category comprising 79 residents
The latest year for which information on the mix of dependency by health board region is
available is also 1996. Table 2.12 applies the 1996 mix of dependency across the regions,
expressed in percentage terms, to the estimates of total long-stay residents in each region taken
from Table 2.8 to derive the number of older people with various levels of dependency in each
health board in the current year. Long-stay units in the South-East contain the highest proportion
of low dependency patients at 17 per cent, while the North-East contains the lowest proportion
of low dependency patients at 6 per cent. Whilst the biggest difference in the mix of
dependency among health boards occurs in the low dependency category there are also
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differences across health boards in the three other dependency categories, as shown by the
relative ratios between the highest and lowest percentage in each dependency category. The
Mid-West contains the highest proportion of medium dependency patients at 28 per cent; the
North-West contains the highest proportion of high dependency patients at 41 per cent; and the
North-East contains the highest proportion of maximum dependency patients at 46 per cent.
Overall, approximately one in three people in long-stay care in Ireland are either low or medium
dependency. The Mid-West contains the highest proportion of residents in the low to medium
dependency categories at 43 per cent. The North-East contains the lowest proportion of people
in the low to medium dependency categories at 26 per cent.
The Dementia Population
The application of EURODEM prevalence rates to Ireland suggests that there are just over 31,000
people with dementia in the country, made up of 18,000 females and 13,000 males (Table 2.13).
The Western and North-Western Health Boards have the highest percentage of people with
dementia in their populations (Table 2.14). The Eastern Regional Health Authority has the lowest
proportion of people with dementia in the population. Differences in the prevalence of dementia
between the East and the West of the country reflects differences in the age distribution of the
population between the two regions, with the West of the country having relatively higher
proportions of people in the older age categories.
Table 2.13: The Number of People with Dementia in Ireland, 1996
Age Group
Males
All Persons
30-59
1321
663
1984
60-64
1099
346
1445
65-69
1326
732
2058
70-74
2306
2434
4740
75-79
1761
3274
5035
80-84
2550
4684
7234
85-89
1492
3873
5365
90-94
669
1852
2521
95-99
134
487
621
12,658
18,345
31,003
Total
Source: Census of Population, 1996 by EURODEM prevalence rates.
26
Females
Review of the Nursing Home Subvention Scheme
Table 2.14: Estimated Number and Percentage of People with Dementia by Health Board Region, 1996
Health Board
Region
Population (All Ages)
Persons with Dementia
As % of Health
Board Population
Western
352,353
3,800
1.08
North-Western
210,872
2,274
1.08
Southern
546,640
4,946
0.90
Mid-Western
317,069
2,801
0.88
Midland
205,542
1,800
0.88
South-Eastern
391,517
3,414
0.87
North-Eastern
306,155
2,567
0.84
ERHA
1,295,939
9,401
0.73
STATE
3,626,087
31,003
0.85
Source: Census of Population, 1996 by EURODEM prevalence rates.
Estimates by Lawlor et al. (1994) suggests that there are just over 22,000 people with dementia
living in the community in Ireland. This suggests that there are about 9,000 people with
dementia not living in the community. The most recent estimates of people with dementia in
long-stay care from the Department of Health and Children (1999a) suggest that 18 per cent of
long-stay residents have dementia. This would mean that just over 3,000 long-stay residents have
dementia. Browne (1996) estimated that the number of people with dementia in long-stay care
may be in the region of 7,000 people, which is double the official figure. The higher figure is
likely to be closer to the truth, given the finding by O’Neill et al. (1991) that more than 50 per
cent of nursing home residents had a cognitive impairment that could be indicative of dementia.
There is also likely to be a significant number of older people in acute care elderly populations
showing symptoms of dementia, around 20 per cent according to Hickey et al. (1997). This figure
is not surprising given that many older people with dementia only come to the attention of
health professionals after a fall, or following an episode of some sort. Dementia and other forms
of cognitive impairment are common enough in older people admitted to the general hospital
for other reasons. We do not have the data to allow us estimate the extent to which dementia
increases both resource use and waiting time for older patients in acute care awaiting transfer to
more appropriate forms of care but the costs are likely to be significant.
Conclusion
The number of beds in the long-stay sector in Ireland is just over 24,000. The estimated number
of older people in long-stay care in long-stay facilities is 19,548, or 4.6 per cent of the elderly
population. The gap between beds and residents is due to average occupancy rates of 93 per
cent, the omission of beds that are not long-stay and a small but significant number of people in
long-stay care who are less than 65 years of age. The percentage of older people in long-stay
care across the European Union averages between 5 and 6 percent of the total elderly
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population, ranging from a low of around 2 per cent in Spain, Greece and Portugal to a high of
10 per cent in the Netherlands. Ireland is, therefore, on the low side of average for Europe in
respect of the proportion of the elderly population in long-stay residential care.
The current publicly funded bed provision of 45 per 1,000 elderly population is below the norm
of 50 beds per 1,000 elderly population currently used by the Department of Health and
Children for medium-term planning purposes. The norm used by the Department is based
largely on the recommendations contained in The Years Ahead for publicly-funded beds for
older people in this country. Setting norms for bed provision is a complex task and,
consequently, it is difficult to be prescriptive about optimal rates or norms for various types of
residential care provision in this country, or any other. Bed provision depends on a number of
inter-related factors including the historical provision of long-stay facilities, the availability of
community care services, the willingness of families to care and the preferences of older people
themselves. What is clear from this chapter is that the current provision of publicly-funded beds
is variable across the country reflecting the range of factors that influence supply at any
particular time.
In Ireland, the number of long-stay public beds has increased only slightly in the nineteen
nineties, whereas the number of private beds increased significantly during the same period. In
1980, for every one bed in a voluntary or private nursing home there were nearly two in the
public sector; twenty years later, at the end of the nineteen nineties the ratio had fallen below
one. Currently, 47 per cent of long-stay beds are located in the public sector, 33 per cent of beds
are subvented beds in the private sector, while the remaining 20 per cent of beds are private
non-subvented beds. Given the strict controls on the supply of public beds and the inability of
community care services to keep pace with the needs of dependent elderly people living at
home, it is no surprise that private residential care facilities have expanded significantly in the
past decade. More flexible and more generous public subsidy arrangements have proven
attractive to new entrants, leading to an increase in the supply of private facilities. Barriers to
entry into the private nursing home sector are also low and recent tax changes have further
encouraged private provision.
Long-stay beds are mainly occupied by the very old, with almost two thirds of beds occupied by
people aged 80 years and over. Residents of private nursing homes are generally older than
elderly people in public long-stay institutions, but the latter cater for more dependent older
people. However, long-stay units in both the public and private sector also contain a significant
number of low dependency persons. Admissions procedures, particularly to public long-stay
care, have not been so finely tuned as to admit only high dependency people. For some older
people, the situation is complicated by the fact that they have nowhere else to go. These so
called ‘social cases’ often end up in care for the rest of their lives because of the absence of any
alternative community-based facilities.
28
Private Nursing Homes
in Ireland
chapter
3
chapter
3
Private Nursing Homes in Ireland
Introduction
This chapter provides detailed information on the private nursing home sector in Ireland. The
data is based on a postal survey of all known nursing home proprietors in the country. The survey
covered both quantitative and qualitative issues, including data on beds, residents and levels of
dependency in nursing homes. The main emphasis, however, is on the nature of costs and
charges in nursing homes across the country. Information on charges is important because it
allows us, in later chapters, to examine the hypothesis, now conventional wisdom, that
subvention levels are low relative to the fees paid by older people in private nursing homes. The
survey also elicited the views of nursing home proprietors with respect to the current and future
operation of the nursing home subvention scheme. This type of qualitative data is important, not
least because it provides important background information for the subsequent analysis of the
nursing home subvention scheme contained in this report. The survey also provides an
opportunity for nursing home proprietors to make recommendations for the future operation of
the scheme, thereby facilitating their involvement in the policy process.
Methodology
The postal survey was conducted in June and July 2000. A complete list of private and voluntary
nursing homes was obtained from the Department of Health and Children and a questionnaire
(Appendix 1) was sent to every nursing home on that list. The questionnaire was successfully
piloted on seven nursing home proprietors before being sent out to all nursing homes.
Proprietors who participated in the pilot study were selected with the help of the Irish Registered
Nursing Homes Association. For the main study, a letter of introduction accompanied the
questionnaire. The letter set out the context of the work and encouraged the proprietor to
return the questionnaire, thereby making a contribution to the ongoing policy debate in this
area. Nursing home proprietors were given three weeks to return the questionnaire. At the end
of the three weeks all nursing homes were written to again reminding them to return the form if
they had not already done so. They were given a new return date two weeks from the date of
the reminder letter.
The total number of questionnaires which were eventually returned was 151, out of a total
population frame of 380, giving an overall response rate of 40 per cent (Table 3.1). The highest
response rate was in the Midland Health Board region at 53 per cent, while the lowest response
was in the South-Eastern Health Board region at 20 per cent. The survey accounts for 43 per cent
of the private beds in the system, with the returns for the Mid-West and Midlands reaching 55
per cent and 64 per cent of total beds respectively. These returns are satisfactory, and are in line
Review of the Nursing Home Subvention Scheme
with expectations from a postal survey of this kind, although the poor return from the South-East
and, to a lesser extent the North-West, is a cause for concern.
Almost one third of nursing homes (48) in the survey are concentrated in the Eastern Regional
Health Authority region, while the North Western Health Board region, with five nursing homes,
has the lowest number of responses in the survey. The Eastern Regional Health Authority has by
far the highest number of beds in the survey at 1,887, or just over one third of the total, which is
the same as its share of the national total of private beds. The number of beds in the other
regions range from 854 (16 per cent) in the Mid-West down to 246 (5 per cent) in the South
Eastern region. The average number of beds in the nursing homes responding to the survey
ranges from 27 in the South Eastern Health Board region to 41 in the Mid-Western Health Board
region.
Table 3.1 Response Rates by Health Board Region
Nursing Homes
and Beds
ERHA
SouthEast
Total Nursing Homes in
Ireland (N)
115
46
54
44
25
19
16
61
380
Nursing Homes Responding
to Survey (N)
48
9
20
21
10
10
5
28
151
Nursing Homes Responding
to Survey (%)
42
20
37
48
40
53
31
46
40
Total Private Beds
In Ireland
4,454
1,181
1,615
1,552
709
625
661
1,840
12,637
Total
Beds in Survey (N)
1,887
246
620
854
290
400
279
801
5,377
42
21
38
55
41
64
42
44
43
Beds in Survey as %
of Actual Beds
West
MidWest
NorthEast
Midland NorthWest
South
Total
The total number of private beds accounted for by the survey is 5,377. The number of occupied
beds according to the survey is 4,991, giving an overall occupancy rate in nursing homes
responding to the questionnaire of 93 per cent (Table 3.2). This corresponds to the national
occupancy rate of 93 per cent calculated by the Department of Health and Children (1999a) in
their most recently published report on long-stay beds and residents in Ireland. The rate of
occupancy in the sample varies from 87 per cent in the North East to 99 per cent in the North
West.
Table 3.2: Number of Private Beds Currently Occupied by Health Board Region
Beds
ERHA
SouthEast
Number of Beds in Survey
1,887
246
620
854
290
400
279
801
5,377
Number of Beds Currently
Occupied
1,780
233
566
770
251
358
275
758
4,991
94
95
91
90
87
90
99
95
93
Occupancy Rate (%)
West
MidWest
NorthEast
Midland NorthWest
South
Total
31
chapter
3
Private Nursing Homes in Ireland
The Subvention Population
A total of 2,829 residents are reported in the survey as receiving subvention assistance (Table
3.3). This represents 57 per cent of all occupied beds. The percentage of nursing home residents
in receipt of subvention assistance varies from region to region, from a minimum of 39 per cent
in the Eastern region to a maximum of 90 per cent in the Midlands. The estimated percentage of
subvention residents to occupied beds in private nursing homes nationally is just over 50 per
cent. The estimated proportion nationally varies from a low of 41 per cent in the Eastern
Regional Health Authority to a high of 66 per cent in the Western Health Board. The survey
returns are likely to be biased by self-selection into the study, with a higher proportion of homes
with subvention residents, or with a high proportion of subvention residents in the home, more
likely to respond to the questionnaire. This is particularly the case in the Midland Health Board.
Table 3.3: Numbers Receiving Subvention by Health Board Region
Receiving
Subvention
ERHA
SouthEast
692
143
428
508
147
321
193
397
2,829
Number of Occupied Beds
1,780
233
566
770
251
358
275
758
4,991
Subvention Residents as %
of all Occupied Beds in the
Survey
39
61
76
66
59
90
70
52
57
Subvention Residents as %
of all Occupied Private Beds
Nationally (Own Est.)
41
60
66
61
59
55
54
44
51
Number Receiving
Subvention
West
MidWest
NorthEast
Midland NorthWest
South
Total
More than half (56 per cent) of nursing home residents receiving a conventional subvention
payment receive the maximum level of subvention (up to £120), 27 per cent are in receipt of high
subvention (up to £95), and 17 per cent are receiving medium level payments (up to £70). This
trend is reproduced in the various regions, with most residents in receipt of the maximum levels
of subvention (Table 3.4). In the Western region, 71 per cent of nursing home residents receive
maximum subvention, while only 7 per cent receive the medium subvention. In the NorthWestern Health Board region, only 10 per cent of residents in the survey receive a medium
subvention payment. The Mid-Western Health Board region and the Midland Health Board
region have the lowest proportion of residents receiving the maximum subvention at 46 per cent
each.
32
Review of the Nursing Home Subvention Scheme
Table 3.4: Type of Subvention by Health Board Region (%)
Type of
Subvention
ERHA
SouthEast
West
MidWest
North- Midland North- South
East
West
Total
N
Medium
20
14
7
23
18
23
10
21
17
433
High
21
28
22
31
21
31
36
30
27
669
Maximum
59
58
71
46
61
46
54
49
56
1,378
Total
100
100
100
100
100
100
100
100
100
N
526
137
421
471
120
251
193
361
2,480
The proportion of subvention residents in the survey in receipt of enhanced subventions (above
£120 but, normally, less than the full amount paid in fees to the nursing home) is 12 per cent
which is below the official national estimate of 20 per cent. The highest proportion of enhanced
subvention recipients are to be found in the Southern Health Board and the ERHA (Table 3.5). A
quarter of all subvention recipients in the ERHA and the South are receiving enhanced
subventions. On the basis of the survey, the practice of enhanced subvention payment is largely
absent in the Midland, Western and Mid-Western regions, although the Midland Health Board is
the only region showing zero returns for enhanced subvention recipients. Some people in
receipt of enhanced subventions in particular regions may be receiving funding from
neighbouring health boards, rather than the one where the nursing home is located.
Table 3.5: Enhanced Subvention by Health Board Region
Enhanced
Subvention
ERHA
SouthEast
173
19
4
12
15
1
8
94
326
As a Percentage of
All Residents
10
8
1
2
6
0
3
12
7
As a Percentage of those
Receiving Subventions
25
13
1
2
10
0
4
24
12
No. of Residents Receiving
Enhanced Subvention
West
MidWest
NorthEast
Midland NorthWest
South
Total
In all, 284 beds in nursing homes in the survey are contract beds reserved by the Health Boards1.
This constitutes 5 per cent of all beds in nursing homes and 10 per cent of all subvention beds
(Table 3.6). The corresponding national percentages for contract beds taken from Table 2.1 are 7
per cent and 13 per cent respectively. The majority of these contract beds (68 per cent) are
reserved by the Eastern Regional Health Authority. At the other end of the spectrum, neither the
Western nor the Mid-Western Health Board had any contract beds, while both the South Eastern
Health Board and the Southern Health Board had only 2 contract beds each. While the survey
1 The survey was undertaken before additional contract beds came on stream as a result of the Winter
Initiative 2000/2001.
33
chapter
3
Private Nursing Homes in Ireland
results for the West, Mid-West and South East are not surprising given the low level of contract
bed provision in these regions (see Table 2.2), the survey has not picked up many of the 178
actual contract beds in the Southern Health Board. On the other hand, the survey results indicate
more contract beds in the North East and Midlands than is suggested by the official figures
shown in Table 2.2. When contract beds are expressed as a percentage of all the beds in the
survey, the North Western region has the highest proportion, with one fifth of beds, followed by
the ERHA at 10 per cent. A similar pattern is observed if we examine the data for the number of
contract beds expressed as a proportion of subvention beds.
Table 3.6: Contract Beds by Health Board Region
Contract Beds
ERHA
SouthEast
West
MidWest
NorthEast
Midland NorthWest
South
Total
No. of Contract Beds
194
2
0
0
23
11
52
2
284
As Percentage of Total
Beds in System
10
1
0
0
8
3
19
0
5
As Percentage of
Subvention Beds
28
1
0
0
16
3
27
1
10
Total
%
Total
N
Table 3.7: Dependency of Residents by Health Board Region (%)
Dependency
ERHA
SouthEast
Low
20
9
6
12
10
6
1
10
13
599
Medium
25
12
10
21
14
19
12
28
21
975
High
32
25
22
35
24
29
42
31
28
1,264
Maximum
23
54
62
32
52
43
45
31
38
1,710
100
100
100
100
100
100
100
100
100
1,606
224
556
751
251
354
245
731
100
%
Total N
West
MidWest
North- Midland North- South
East
West
4,548
Dependency in Nursing Homes
Information on dependency was provided for 4,548 of the 4,991 older people in nursing homes
responding to the survey. Therefore, information on dependency was not available for 9 per cent
of the respondent population. The majority of nursing home residents in the survey appear to
have either high (28 per cent) or maximum (38 per cent) dependency levels (Table 3.7). In total,
two thirds of residents have either high or maximum dependency levels, one fifth have medium
dependency levels and approximately 13 per cent have low dependency. This pattern seems to
be broadly repeated throughout the regions apart from the Eastern region, which appears to
have a more even distribution of dependency in the nursing homes responding to the survey.
Very few (1 per cent) of the residents in the North-Western region have low dependency levels,
34
Review of the Nursing Home Subvention Scheme
while 87 per cent have either high or maximum dependency level. The data on dependency
levels in private nursing homes generated in the survey is in line with the most recently
published inventory of long-stay statistics (Department of Health and Children, 1999b), where it
is reported that 61 per cent of older people in private nursing homes have either high or
maximum dependency.
Table 3.8: Residents in Private Nursing Homes Diagnosed with Alzheimer’s Disease or Dementia by
Health Board Region
Diagnosed with
Dementia
ERHA
SouthEast
306
44
86
154
54
103
55
141
943
17
19
15
20
22
29
20
19
19
Number of Residents
Diagnosed with AD or
Dementia
Percentage of Residents
Diagnosed with AD or
Dementia
West
MidWest
NorthEast
Midland NorthWest
South
Total
In this survey, 943 nursing home residents are reported as having been diagnosed with
Alzheimer’s disease or dementia (Table 3.8). This suggests an in-patient prevalence rate of 19 per
cent expressed as a percentage of residents in occupied beds in nursing homes. In most
regions, the prevalence rate lies between 15 and 22 per cent. The Midlands region has the
highest prevalence rate of 29 per cent. These figures only relate to patients who have been
diagnosed with Alzheimer’s disease or dementia. Presumably, there are residents who exhibit
some or all of the symptoms of dementia but who have not been diagnosed with the illness. The
prevalence rate of 19 per cent can be used as a minimum figure for dementia in private nursing
homes. It is broadly similar to the national prevalence rates for long-stay care estimated by the
Department of Health and Children (1999a).
Staffing Levels and Costs
The total number of full-time staff in nursing homes responding to the survey is 1,980. Just over
two thirds of all staff are engaged in nursing and direct care duties (Table 3.9). One quarter of all
staff are nurses while 42 per cent are nurses aides. Domestic, catering and cooking personnel
account for one fifth of all full-time staff in nursing homes. Administrators account for 7 per cent
of all full-time staff. The total number of part-time staff employed in nursing homes responding
to the survey is 2,539 (Table 3.10). Of these, 24 per cent are nurses and 46 per cent are nurses
aides. One fifth of part-time staff are either cooks or domestic/catering staff. Only a small
number of staff in nursing homes are engaged in activity-related therapeutic activities (1 per cent
full-time and 3 per cent part-time), while there is no evidence of rehabilitation services for older
people in nursing homes. The absence of rehabilitation services in private nursing homes points
to the need for investment in this area, especially if nursing homes were to be used more, in the
future, as an intermediary location for older people, between acute care treatment and a return
to home care.
35
chapter
3
Private Nursing Homes in Ireland
Table 3.9: Number of Full-Time Staff by Health Board Region
Staff
ERHA
SouthEast
50
4
20
18
11
7
4
24
138
7
Nursing
154
37
57
82
43
25
5
80
483
25
Nursing aide
374
39
79
64
49
56
59
119
839
42
Domestic/Catering
119
12
14
31
26
19
5
23
249
13
Cook
58
6
22
20
15
11
4
20
156
8
Maintenance/Grounds
53
5
5
6
7
3
4
7
70
3
Activity Therapists
11
0
2
0
4
2
1
2
22
1
Other
27
2
3
3
0
2
8
6
23
1
Total
806
103
204
227
155
124
85
276
1,980
100
Admin/Man
West
MidWest
North- Midland North- South
East
West
Total
%
Table 3.10: Number of Part-Time Staff by Health Board Region
Staff
ERHA
SouthEast
14
4
3
3
3
6
3
4
40
2
Nursing
197
24
73
25
52
66
48
133
618
24
Nursing aide
338
50
129
144
71
115
98
211
1,156
46
Domestic/Catering
163
7
43
48
19
30
35
38
383
15
Cook
30
5
16
16
17
18
4
23
129
5
Maintenance/Grounds
22
2
9
9
8
6
2
12
70
3
Activity Therapists
53
1
11
11
3
3
1
10
88
3
Other
27
2
3
3
0
2
8
6
55
2
Total
844
95
287
258
173
246
199
437
2,539
100
Administrator/Manager
36
West
MidWest
North- Midland North- South
East
West
Total
%
Review of the Nursing Home Subvention Scheme
Table 3.11: Hours Worked Per Week (Full and Part-Time) by Type of Staff By Health Board Region (%)
Staff
ERHA
SouthEast
4
5
8
6
10
3
2
10
Nursing
20
27
28
33
22
20
34
29
23 24,742
Nursing aide
46
42
39
35
47
50
46
43
45 42,979
Domestic/Catering
20
14
11
15
7
13
9
7
15 14,127
Cook
6
8
8
6
10
9
2
7
7
6,379
Maintenance/Grounds
2
3
3
1
3
3
2
2
2
2,303
Activity Therapists
7
0
1
1
1
1
1
1
1
700
Other
1
1
2
2
0
1
4
1
1
1,367
100
100
100
100
100
100
100
100
100
35,606
5,201
10,075
10,637
3,843
9,551
9,224
14,105
Administrator/Manager
%
Hours
West
MidWest
North- Midland North- South
East
West
All
Hours
(National)
6
5,645
98,242
The total number of hours worked in the nursing homes responding to the survey is 98,242
(Table 3.11). Nearly half of these hours (45 per cent) are worked by nurses aides. Almost one
quarter of the recorded hours are spent in nursing. Just over one fifth of all hours (22 per cent) is
spent in cooking and catering activities. Administration/management accounts for 6 per cent of
hours. The remainder of the time (4 per cent) is spent in maintenance, activity therapy and other
work. In all, the time spent on actual caring tasks (nurses and nurses aides) represents just over
two thirds (68 per cent) of all hours worked in nursing homes. The proportion of all nursing home
hours accounted for by caring personnel is consistent across the country, with figures ranging
between 66 per cent and 72 per cent in seven of the eight boards. The exception is the North
West where 80 per cent of hours-worked in nursing homes is spent on caring tasks. This anomaly
may be due to the small number of returns from this region. The share of domestic/catering
hours varies significantly across regions from a high of 20 per cent in the ERHA to 7 per cent in
the North-East and South. The bulk of activity therapy seems to be concentrated in the Eastern
region.
The distribution of staffing costs in nursing homes is shown in Table 3.12 and reflects the hours
spent caring shown in the previous table. Care costs (that is nurses and nurses aides) are
generally in the region of 60-70 per cent of total staffing costs. The major exception to this trend
is the North Western region where care costs are 78 per cent of total staffing costs. Nationally,
just over one third of staffing costs (37 per cent) can be attributed to nurses with a further third
(32 per cent) attributed to nurses aides. In all, therefore, direct care provision costs are just under
70 per cent of total staffing costs in nursing homes. This is an important and consistent finding
which has implications for our discussion in later chapters of optimal public funding
arrangements for older people in private nursing homes. Administration/management accounts
for one tenth of staffing costs, while domestic and catering accounts for a further tenth of all
staffing costs. This pattern is followed in most regions. Overall staffing costs per hour work out at
£9 for staff in the nursing homes responding to the survey.
37
chapter
3
Private Nursing Homes in Ireland
Table 3.12: Distribution of Staffing Costs (full and part-time) by Grade by Health Board Region (%)
Grade
ERHA
SouthEast
7
7
18
7
15
7
2
8
11
Nursing
30
34
39
44
52
27
30
33
37
Nursing aide
38
36
23
30
20
40
48
41
32
Domestic/Catering
13
11
11
9
2
12
9
6
9
Cook
6
6
8
5
10
8
3
7
7
Maintenance/Grounds
4
5
1
2
1
4
4
3
2
Activity Therapists
1
0
0
1
0
1
0
1
1
Other
1
1
0
2
0
1
3
1
1
Total
100
100
100
100
100
100
100
100
100
Administrator/Manager
West
MidWest
NorthEast
Midland NorthWest
South
Total
The bulk of costs within nursing homes comprise of wages and salaries (75 per cent) reflecting
the labour intensive nature of care provision within the sector (Table 3.13). The next highest cost
is food at 6 per cent of the total costs. Cleaning accounts for 2 per cent of costs, as does
medical and pharmacy costs. Light and heat constitute 3 per cent of total costs with other
overheads accounting for 5 per cent of total costs. There is a similar pattern and structure of
costs in the majority of regions apart from the Western and Midland regions where salaries and
wages in the nursing homes responding to the survey only account for 58 per cent and 60 per
cent of the total costs of production, respectively. In general, there was reluctance among
proprietors responding to the survey to disclose very detailed information on costs with many
respondents returning incomplete accounts or refusing to answer the question on costs at all.
Table 3.13: Distribution of Total Costs in Nursing Homes by Source by Health Board Region (%)
Source of Costs
ERHA
SouthEast
76
73
58
81
73
60
78
88
75
Food
7
7
8
6
7
7
7
4
6
Cleaning
2
2
2
1
1
3
1
1
2
Medical and Pharmacy
2
1
8
2
1
2
1
1
2
Light and Heat
3
3
6
4
3
1
3
1
3
Other Overhead
5
6
11
2
7
3
2
2
5
Professional Fees/
Maintenance
2
2
2
1
1
2
1
0
1
Bank/Fin Charges
1
3
3
2
3
12
2
2
3
Other
2
3
2
2
4
10
4
1
3
Total
100
100
100
100
100
100
100
100
100
Wages and Salaries
38
West
MidWest
NorthEast
Midland NorthWest
South
Total
%
Review of the Nursing Home Subvention Scheme
Services in Nursing Homes
The most widely provided services in nursing homes are those of hairdresser and chiropodist,
which are provided in most nursing homes responding to the survey (Table 3.14). Almost two
thirds of nursing homes responding to the survey say that physiotherapy services are provided to
residents, while two-fifths of nursing homes report that residents receive occupational therapy
services on a regular basis. Both these estimates are surprising, in that they are at variance with
the data shown earlier on weekly hours worked by therapists and the associated weekly staffing
costs of therapists. One possibility is that respondents interpreted the question loosely, as asking
whether older people in the nursing home had ever received physiotherapy or occupational
therapy services, rather than were they regularly receiving such services. Alternatively, some
older people may be buying-in these services from the private sector as need arises and paying
for them from their own resources. Around one tenth of homes report that residents receive
psychologist services on a regular basis, while public health nurse and social work services are
available in just 7 per cent of nursing homes. One quarter of nursing homes provide a wide
range of other services, such as reflexology, speech therapy, music and aromatherapy. It should
be noted that self-selection was likely to have been a feature of the survey, with the more
progressive nursing homes more likely to have responded to the survey, thereby leading to an
upward bias in the results on services available to older people in private nursing homes.
Table 3.14: Number of Nursing Homes Providing Various Services by Health Board Region
Service
ERHA
SouthEast
5
0
1
0
2
0
0
2
11
7
Occupational Therapist
21
3
7
3
5
3
1
10
57
38
Physiotherapist
29
4
12
9
9
9
3
21
95
64
Social Worker
3
0
4
0
2
0
0
1
10
7
Psychologist
3
0
2
2
2
2
0
4
16
11
Chiropodist
43
8
20
20
10
20
4
26
141
94
Hairdresser
35
9
20
20
10
21
5
26
142
95
1
5
0
0
2
2
2
9
34
23
Public Health Nurse
Other
West
MidWest
North- Midland North- South
East
West
Total
% of
All
Homes
One fifth of nursing homes responding to the survey provide day care services (Table 3.15). The
total number of day care places provided is 280. Just over half of these places (54 per cent) are
paid for by the health board. Just over half of all day care places in private nursing homes are
located in the Eastern region. In the East, the health board pays for 57 per cent of people
attending day care in private nursing homes. The only other region where the private sector
provides a substantial number of day care places is the North West with 65 places. Funding for
the majority of people availing of day care facilities in private homes in this region is provided by
the Board.
39
chapter
3
Private Nursing Homes in Ireland
Table 3.15: Number of Nursing Homes Providing Day Care Services by Health Board Region (N)
Day Care
ERHA
SouthEast
10
2
5
2
0
3
3
6
31
149
5
36
3
-
5
65
17
280
85
0
3
0
-
3
60
0
151
Nursing Homes Providing
Day Care
Number of Day Care Places
Places Paid for by Health
Board
West
MidWest
NorthEast
Midland NorthWest
South
Total
Charges in Nursing Homes
Just over two fifths of nursing homes in this study vary their charges according to the level of
dependency of the applicant (Table 3.16). The proportion of nursing homes varying price by
dependency in the various regions varies from 10 per cent in the Midland Health Board to 55 per
cent in the Western Health Board. These findings raise an interesting issue about the current
system of deciding on the level of subvention for older people in long-stay care. If the majority
of nursing homes in the country do not vary charges by dependency then it may be necessary to
simplify the current approach to paying subvention on the basis of three levels of dependency.
This issue is taken up again in subsequent chapters of the report. One fifth of all nursing homes
responding to the survey vary their charges according to the means of the applicant. This varies
from 10 per cent in the North-Eastern and Midland regions to 40 per cent in the North-Western
region. More nursing homes vary charges by level of dependency than by the means of
applicants.
Table 3.16: Number and Percentage of Nursing Homes by Region Varying Price by Dependency and
Means of the Applicant
Charges
ERHA
SouthEast
Number which vary
Charges by Dependency
18
4
11
10
3
1
2
14
63
As Percentage of Nursing
Homes in Survey
38
44
55
48
30
10
40
50
42
9
3
3
6
1
0
2
5
29
19
33
15
15
10
10
40
18
20
Number which vary
Charges by Means
As Percentage of Nursing
Homes in Survey
West
MidWest
NorthEast
Midland NorthWest
South
Total
The mean weekly charge in the private nursing homes responding to the survey ranges from
£220 in the North Western Health Board region to £390 in the Eastern Regional Health Authority
region (Table 3.17). The mean weekly charge for all nursing homes in the survey is £306 with
differences across the country confirming a priori expectations with respect to demand pressures
40
Review of the Nursing Home Subvention Scheme
and overhead costs in the various regions. The maximum nursing home charge in the survey is
£600 per week, reported for a private nursing home in the Eastern region. Somewhat
surprisingly, the minimum charge also occurs in the Eastern region with one nursing home
reporting a charge of £195. The voluntary nursing home sector is excluded from the analysis
mainly because any charges levied in this sector are likely to be nominal and not reflect an
economic rate2. On the basis of an admittedly truncated set of returns for costs, the average gap
between weekly revenue from charges and the average weekly cost of care is approximately 18
per cent, excluding depreciation costs. The margin between reported average costs and
reported average revenue is highest in the Southern Health Board and lowest in the North
Western Health Board.
Table 3.17: Average Weekly Charges* in Private Nursing Homes by Region (£)
Charges
ERHA
SouthEast
390
256
247
270
323
280
220
297
306
96
31
23
34
52
61
8
42
81
Minimum
195
210
220
200
240
200
210
220
195
Maximum
600
300
300
320
400
380
230
400
600
Average (Mean)
Weekly Charge
Standard Deviation
West
MidWest
NorthEast
Midland NorthWest
South
Total
* Where more than one price is given, the highest figure is used.
A total of 341 residents receiving a subvention payment were reported as being unable to keep
up their payments in the past year (Table 3.18). This is equivalent to 12 per cent of all subvention
recipients in the nursing homes responding to this question. The proportion of residents
receiving a subvention who were unable to keep up payments is under 10 per cent in all regions,
except for the Southern Health Board where the proportion is 23 per cent. The total number of
residents not receiving a subvention who were unable to keep up payments in the past year is
93, which is equivalent to 7 per cent of all non-subvention residents in the nursing homes
responding to this question.
It is also of interest as to what typically happens to residents who are unable to keep up weekly
payments. The views of nursing proprietors on what is most likely to happen to people unable to
keep up payments are ranked and shown in Table 3.19. The most likely scenario is that families
intervene and pay for the care of their kin, if not already doing so. This scenario was ranked first
by 55 proprietors. The next most frequently chosen scenario, ranked number one by 26
proprietors, is that nursing homes reduce the fee charged to the person in financial difficulty.
The least likely scenario is for older people to return to the community, either to live alone or
with their families. However, the fact that 14 nursing home proprietors did mention a move to
the community alone as a likely outcome if an older person is unable to keep up weekly
payments is worrying, given the concerns expressed in this report about the adequacy of
community care.
2 Including the returns from the voluntary sector reduces the mean rate to £256 and the median rate
to £282.
41
chapter
3
Private Nursing Homes in Ireland
Table 3.18: Number and Percentage of Residents by Region Unable to Keep up Payments in the Past Year
Receiving
Subvention
ERHA
SouthEast
West
MidWest
NorthEast
Midland NorthWest
South
Total
Number Unable
to keep up Payment
64
9
9
9
7
13
6
53
341
% Unable
to keep up Payment
9
6
2
2
5
4
3
23
12
Number Unable
to keep up Payment
35
0
10
19
0
3
1
25
93
% Unable
to keep up Payment
3
0
7
7
0
1
8
7
7
Not Receiving
Subvention
Table 3.19: Rank Consequences of Inability to Continue Payments in Private Nursing Homes (N)
Rank
Families Move to Move to Move to Nursing Move to Health
pay community community cheaper home
public
Board
alone with family nursing charges long stay pays
home less than
care
difference
full fee
Other
1
55
4
1
2
26
2
7
1
2
11
4
8
8
22
12
9
1
3
7
6
7
13
9
15
8
1
Total
73
14
16
23
57
29
24
3
Restrictions on Admission
Restrictions on admissions apply in 36 per cent of the nursing homes that responded to the
survey (Table 3.20). The likelihood of restrictions is highest in the Eastern and Midland regions
with half of all homes operating some barriers to admission. Restrictions are least likely in the
South Eastern Health Board. The most common restriction, applying in about 40 per cent of
cases, is that people with dementia are not admitted to nursing homes. The two other most
common forms of restrictions relate to the admission of psychiatric and aggressive patients. In
addition, a few of the voluntary homes are for religious orders only and do not admit people
outside of the order.
42
Review of the Nursing Home Subvention Scheme
Table 3.20: Restrictions on Admissions by Health Board Region
Restriction
ERHA
SouthEast
West
MidWest
NorthEast
Midland NorthWest
South
Total
Number Operating
Restriction
24
1
4
5
4
5
1
10
54
Percentage
Operating Restriction
50
11
20
24
40
50
20
36
36
Capital Tax Allowances
In the survey, 33 nursing homes report having availed of Capital Tax Allowances to fund new
building and expansion (Table 3.21). The Tax Allowance led directly to the provision of 381 beds
in the nursing homes responding to the survey. This constitutes 7 per cent of all of the beds in
the survey, with the North East having the highest proportion of beds (19 per cent) linked to the
tax incentives. Not surprisingly, almost one third of the new “tax” beds are located in the
Eastern Regional Health Authority, while one fifth are in the Southern Health Board. The NorthWest has been least affected by the new tax incentives, though, once again, the small number of
returns from the region suggests caution in interpreting this result. The Capital Allowance
Scheme for nursing homes is a controversial scheme for some nursing home proprietors. In a
submission to this report the South Eastern branch of the Irish Nursing Homes Association
claimed that the scheme was being used by people outside the industry as an investment
opportunity to facilitate other (unspecified) ventures once the period of the tax break had
elapsed.
Table 3.21: Impact of Capital Tax Allowances by Health Board Region
Capital
Allowances
ERHA
SouthEast
9
1
5
5
3
3
0
7
33
Number of
“Tax Allowance” Beds
117
12
19
53
56
38
5
81
381
Percentage of
“Tax Allowance” Beds
6
5
3
6
19
10
2
10
7
Nursing Homes Availing
West
MidWest
NorthEast
Midland NorthWest
South
Total
Policy Issues
The majority of nursing home proprietors (81 per cent) want changes to the operation of the
Nursing Home Subvention Scheme (Table 3.22). More than two thirds of all proprietors who
answered this question want the subvention rates to be increased, with a further 17 per cent
wanting full subvention or the abolition of the means test, particularly for people with dementia,
or maximum dependency. The need for standardized dependency assessment across the
country was raised by 8 per cent of respondents, while a further 7 per cent of respondents want
applications to be processed more quickly than is currently the case.
43
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3
Private Nursing Homes in Ireland
Table 3.22: Changes to the Subvention Scheme
Changes to Subvention Scheme
No. of Nursing Homes
% of all Responses
Increased Levels of Subvention
83
68
Full Subvention/Abolition of Means Test
21
17
Standardized Dependency Assessment
10
8
8
7
122
100
Speedier Processing of Applications for Subventions
Total
Respondents were also asked to outline the main challenge, outside of subvention issues, facing
nursing homes in future (Table 3.23). Just over 90 per cent of respondents replied to this
question. Over one half of nursing home proprietors who responded identify staffing as the
major challenge facing them in the future. The main concern here is the shortage of nurses
which has led a small number of homes to hire nurses from outside of the country. The second
most commonly identified problem, which is linked to the issue of staffing, is the rising cost of
care. The third major challenge identified is the difficulty of meeting increasing demands and
regulations from the Health Board, particularly if subvention rates are not increased. Competition
from large-scale investors taking advantage of Capital Allowances was mentioned by 6 per cent
of respondents who answered this question.
Table 3.23: Main Challenges in the Future
Main Challenges in the Future
No. of Nursing Homes
% of all Nursing Homes
Staffing
70
51
Rising Costs of Care
35
25
Health Board Regulations
18
13
Competition from Investors
8
6
Other
7
5
Total
138
100
Finally, nursing home proprietors were asked what the health boards could do to deal with the
challenges outlined in the previous table. This question had a poor response rate with only 40
per cent of nursing home proprietors responding to the question (Table 3.24). Of those who did
respond, 22 per cent felt that the health board could supply more services and supplies to
people in nursing homes. The service mentioned most often was physiotherapy, while
incontinence wear was the primary supply mentioned by proprietors. Staff training was
considered important by 17 per cent of those who responded, while 13 per cent wanted health
boards to increase subvention payments. One in ten proprietors wanted improved
communication, while a similar fraction wanted some formal acknowledgement from the health
boards of the work they were doing. A further 10 per cent wanted private and public long-stay
44
Review of the Nursing Home Subvention Scheme
facilities to be treated in the same way by the health boards, meaning similar inspection
procedures in each sector. The category “other” included the request for more flexibility with
respect to nursing ratios and night-time cover. This reflects the staffing difficulties referred to
earlier in the report.
Table 3.24: Role of Health Board in Reducing Challenges Faced by Nursing Homes
Role of Health Board
No. of Nursing Homes
% of all Nursing Homes
Acknowledgement/Recognition
6
10
Improve Communication
6
10
13
22
6
10
10
17
8
13
Other
11
18
Total
60
100
More Free Services/Supplies for Residents
Treat Private/Public Homes the Same
Staff Training
Increase Subvention
Conclusion
There is a general consensus in the survey that the current subvention rates are inadequate,
given the increasing cost of private nursing home care throughout the country. Although the
average cost of care varies greatly between the Eastern Regional Health Authority and
elsewhere, the majority of respondents to the survey are concerned about the shortfall between
individual applicant’s income plus the subvention and the weekly cost of care in a private nursing
home. The maximum subvention is now around 40 per cent of the average charge in nursing
homes in Ireland. That percentage falls to 30 per cent in the Eastern Regional Health Authority.
When the legislation on subventions was introduced in the early nineteen nineties, the maximum
rate was approximately 60 per cent of the national average charge in nursing homes. In
recognition of the income adequacy problem, some health boards, notably the North Western
Health Board, the Southern Health Board and the Eastern Regional Health Authority, are now
paying applicants enhanced subventions above the maximum rate stipulated in the regulations.
One fifth of all subvention recipients nationally are currently in receipt of payments in excess of
£120 per week. In the ERHA enhanced payments average £70 per week; in the Southern Health
Board enhanced subventions average £45 per week3. Other health boards do not give enhanced
subventions at all, although all seem to be under some pressure to do so. Thus, applicants and
residents are being treated differently in different health boards. The issue now is whether the
problems raised in the survey and in our discussions with the health boards can be resolved by
simply raising subvention rates to more appropriate levels or whether a complete overhaul of the
system is required. Before considering this issue we need to consider the subvention system in
more detail, beginning with a formal analysis of the operation of the scheme. This is done in the
next chapter.
3 Personal Communication
45
The Nursing Home
Subvention Scheme
chapter
4
chapter
4
The Nursing Home Subvention Scheme
Introduction
This chapter deals with the operation of the nursing home subvention scheme as provided for in
the Health (Nursing Homes) Act, 1990 (the 1990 Act). The 1990 Act set out the statutory
requirements for nursing homes regarding registration and standards and outlined the
subvention process for certain categories of older people admitted to private long-stay care. The
subvention scheme requires health boards to pay a contribution towards the cost of nursing
home care for older people living in registered homes. Eligibility for the scheme is based on the
dependency of the applicant and an assessment of the means, including assets, of the older
person. Currently, there are 6,196 older people in receipt of subvention, almost twice the number
of people in receipt of subvention (3,271) in the first full year of the scheme in 1994. Expenditure
on the scheme has increased from £12 million in 1994 to an estimated £52.5 million in 2001, an
increase of 438 per cent in seven years of the scheme.
The chapter first of all provides a brief history of the nursing home subvention scheme. This is
followed by a review of the administration of the regulations based on our discussions with the
relevant personnel in the health boards who are dealing directly with the subvention issue. The
main operating issues which emerged from our contacts with health board staff are then
explored. We include a case study detailing the operation of the subvention scheme in one
health board — the Mid-Western Health Board. The difficulties in the operation of the scheme in
this health board are typical of the problems faced throughout the country, which are those of
dependency assessment, means testing and the level of current subventions.
Evolution of the Nursing Home Subvention Scheme
Acceptance of public responsibility for residential care of sick and poor older people in Ireland
dates back to the 18th century with the development of state aided welfare institutions including
hospitals, asylums, workhouses and houses of industry. Although The Years Ahead, published in
1988, states that there was a ‘long tradition’ of private and voluntary nursing home care in
Ireland, the first formal reference to state responsibility for care of older people in private
residential units was made only in recent times in the Health Act 1964 (Homes for Incapacitated
Persons). Under this Act, the Minister for Health could make regulations to govern the
registration and operation of for-profit nursing homes in Ireland. In 1966, regulations under the
1964 Act set minimum standards for accommodation, food and care in private nursing homes.
These health and safety regulations were updated in 1985 and the new regulations specified new
standards regarding patient records, staff qualifications, fire safety and equipment. Under the
new regulations, the health boards were given the power to inspect private nursing homes.
Review of the Nursing Home Subvention Scheme
The legal position for entitlement and eligibility to in-patient services for all persons in the
country was set out in Health Act, 1970 (as amended). Unfortunately, the legal position with
regard to an individual’s entitlement to in-patient services is not straight-forward and remains
contentious1. According to Cousins (1994) the 1990 Act “did not change the fact that people are
entitled to in-patient services under the Health Act 1970 and that nursing home care is generally
within the definition of in-patient services”. The point being that the 1990 Act did not undermine
the existing legal entitlements to care. The critical question, however, is whether the 1970 Act
confers a legally enforceable right or entitlement for all citizens to be provided with in-patient
services, where necessary, by the relevant health board? While Section 52 of the 1970 Act
requires the health boards to “make available” in-patient services to eligible persons, the
manner and extent to which in-patients services are to be made available is not specified in the
Act, thereby weakening the basis of the original entitlement. Section 72 of the Act does,
however, enable the Minister, by regulation, to determine the manner in which and the extent to
which health boards shall make services available. The question of whether the nature of the
obligation imposed on health boards to make available in-patient services is such as to confer an
entitlement on an individual, insofar as this can be taken to mean a legally enforceable right
capable of being enforced by mandatory order, is not one that can be answered in this report.
In-patient services are free of charge for medical cardholders, and subject to certain charges in
the case of non-medical cardholders. Currently, the charge for in-patient services is £25 per day
for a full day subject to a maximum of £250 in any period of 12 consecutive months. Separately
from these charges, income-related hospital charges may also be imposed on long-stay patients
who do not have a medical card and do not have dependants. Long-stay is defined as in-patient
services in geriatric hospitals and in long-stay geriatric beds in district hospitals for 30 days or
more in the course of the previous 12 months. Patients are allowed retain a prescribed amount
per week for their own purposes after the charge has been imposed. The stipulated retention
amount is currently £2.50 but, in practice, residents are allowed retain up to £15 per week.
Older people who are receiving institutional assistance as distinct from in-patient services have
to contribute to the cost of such assistance in so far as they are able under the Health Act 1953.
Insofar as residential care in health board hospitals and homes involves maintenance and shelter
only it falls within the definition of institutional assistance rather than in-patient services. The
charges in relation to institutional assistance may be payable by residents who are in receipt of
any income, including medical cardholders and people with dependants. In practice, the
problem has always been the distinction between in-patient services and institutional assistance.
That distinction was never clear within health board facilities but has become even more blurred
in recent years, with the gradual reduction in welfare beds in welfare homes which were
traditionally assistance type beds rather than in-patient beds. Part of the difficulty in separating
out in-patient services from assistance services relates to the policy and procedures for
admission to long-stay care, which have favoured institutionalization over community care, as
evident in the range of dependency within long-stay institutions. While there are now fewer
“social” cases within public long-stay institutions, there are still people in all types of long-stay
care who do not need or receive conventional in-patient services. On the other hand, the
majority of people in public long-stay care are highly dependent and therefore are likely to
require in-patient services, although this remains an empirical question that can only be
addressed on a case-by-case basis. Similarly, within nursing homes, there are likely to be
1 Complex legal questions are not explored to any great depth in this report and the views expressed
in this and subsequent sections reflect a non-legal interpretation of the relevant legislation.
49
chapter
4
The Nursing Home Subvention Scheme
different needs catered for, some of which are likely to be in-patient type needs but others of
which are likely to be shelter and maintenance type needs.
The Health Act (1970) introduced the concept of ministerial approval of institutions outside of
the statutory sector providing “in-patient services” defined as “institutional services provided for
a person while maintained in a hospital, convalescent home or home for persons suffering from
physical or mental disability or in accommodation ancillary thereto”. The principle of public
subsidisation of private nursing home care was officially recognised in Section 54 of the Health
Act 1970. The Act placed an obligation on health boards to give financial support to older
people who choose care in “any (private) hospital or home approved by the Minister for the
purposes of this section”. Approximately one third of all nursing homes at that time were
“approved” and, in theory, all persons were eligible for support regardless of income. A rate of
£6 per day was prescribed and health authorities had no discretion to give consideration to the
different needs of applicants. Section 26 of the Health Act (1970) also allowed health boards to
make arrangements with voluntary or private nursing homes to provide a service for eligible
persons. In recent years some health boards, particularly the Eastern Regional Health Authority,
have exercised the option to buy “contract beds” for public patients under Article 22.3 of the
Subvention Regulations.
In 1980, the Department of Health stopped approving private nursing homes for subvention due
primarily to the severe budget constraints and financial restrictions imposed on the health
services at that time. There were also difficulties with the funding mechanism which involved a
payment per day per occupied bed to nursing homes, taking no account of the dependency or
means of the resident. In addition, the Department were concerned about the possibility of a
disproportionate shift of resources from the public sector to the private sector, whereby
individuals could decline the offer of public care and instead enter a private nursing home
approved by the Minister and seek a subvention from the health board under Section 54 of the
Health Act, 1970. The existing approval rating for private nursing homes, totalling 87 homes in
1980, was not affected by the decision not to approve any new homes, mainly due to the upset
and disruption this would cause older people residing in these homes and the fact that the
public system would not have the capacity to take over their care.
However, with the cessation of Section 54 “approvals” an additional confusion or anomaly
emerged between “approved” and “non-approved” homes, since the approved rating did not
in any way guarantee a superior quality of care. The new policy was particularly unfair to nursing
home proprietors who ran perfectly good homes but who could not get approval from the
Minister for Health and, therefore, could not attract patients with a health board subsidy. The
failure to approve new homes was also unfair to older people who required a subsidy but who
were unable to find a place in an approved home. The curtailment of approval meant that in
areas where both public long-stay beds and approved private beds were scarce, older people
and their families had to pay the full cost of private nursing home or continue to live at home in
the community, without, it must be said, much by way of community support services. Not
surprisingly, therefore, the anomalies and inequities caused by the abrupt halt to nursing home
approvals were a cause of real concern for policy-makers at the end of the nineteen eighties.
The Years Ahead recommended changes to Section 54 of the Health Act 1970 to enable health
boards to subvent the care of eligible patients, after assessment, in nursing homes licensed by
the board and to enable health boards to vary the level of subvention according to patient’s
needs. There would still be an annual licensing system for private nursing homes but subvention
50
Review of the Nursing Home Subvention Scheme
payment would be based on the means and dependency of individual applicants. Removing the
link between eligibility and subsidy from nursing homes and targeting older people instead
would provide an important degree of horizontal equity to the system which was hitherto
lacking. In the context of increased demand for long-term care, another advantage of a more
developed nursing home subvention system was that it would likely prove less costly than
providing additional public beds financed by the Exchequer.
The 1990 Act was the result of many years experience of, and concern about, previous legislation
and arrangements for the regulation and subvention of nursing homes. The main features of the
new legislation were as follows:
• Subventions payable in all nursing homes and not just as previously in a small number of approved homes
• Subventions based on three levels of dependency — medium, high and maximum, with provision for additional payment
in some circumstances
• Payment of subvention subject to a means test, which included the financial circumstances of family members
• Subvention recipients able to retain pocket money for their personal needs
• Tighter quality controls on the operation of nursing homes.
Prior to the 1990 Act, residential care in private nursing homes was funded under the Health
(Institutional and Specialist Services) Regulations 1970. Under the latter, the payment of nursing
home care was based on the bed as opposed to the dependency level of the applicant. The 1990
Act and the Nursing Homes (Care and Welfare) Regulations 1993, drafted with the involvement of
representatives from private sector providers, accepted recommendations in The Years Ahead for
mandatory assessment of applicants’ level of physical dependency and financial means and for
variation in the level of subvention depending on need for services as measured by dependency.
Subvention levels were set at £70/week for Medium Dependency, £95/week for High
Dependency and £120/week for Maximum Dependency. Section 22.4 of the Nursing Homes
(Subvention) (Amendments) Regulations 1996 permits health boards to pay more than the
maximum subvention level, although to date, some health boards do not exercise this option.
Under the Nursing Homes ((Subvention)Amendment) Regulations, 1998, the provision allowing
for the assessment of sons and daughters ability to contribute towards the cost of nursing home
care of their parent was removed from January 1999. This followed ongoing concerns about the
legal validity of requesting family members to contribute to the cost of care for their elderly kin.
Administration of the Nursing Homes Subvention Regulations
Responsibility for private nursing home subventions at senior management level varies from
health board to health board but is often divided between administrative managers (General
Managers, Programme Managers, Regional Manager, etc.) and Directors or Co-ordinators of
Services for Older People, who are almost always from a nursing background. The Eastern
Regional Health Authority (ERHA) is the exception to this latter trend. New Director of Care of
Older Persons posts in two of the three newly created health boards in the region have recently
been filled by officials from within the health board. In the Mid-Western Health Board, an
Assistant CEO has overall responsibility for services for the elderly. In the South Eastern Health
51
chapter
4
The Nursing Home Subvention Scheme
Board, there is a Regional Manager for the Elderly, while in the Southern Health Board the
Programme Manager for Community Services has responsibility for non-hospital services for
older people.
The administration of applications for the private nursing home subvention varies among health
boards. In the ERHA, the biggest health authority, a central Nursing Homes Unit has processed
applications for the whole region up to now, although there are plans to devolve responsibility to
each of the three, newly created health boards. The Southern Health Board and the Mid-Western
Health Board also have centralised units that administer the means test. In the North-Western
Health Board, the Area Co-ordinators of Services for Older People (in Donegal and Sligo/Leitrim)
receive applications and process them.
In other health boards, once applications are received (at a health centre or head office), they are
usually sent to Community Welfare Officers who administer the means test and to Public Health
Nurses (sometimes called Liaison Public Health Nurses) and/or Area Medical Officers in the area
in which the applicant lives, to assess the physical dependency level. In some health boards,
most notably the Midland and the Western, there is a designated Community Welfare Officer
who deals with all applications for subvention received from within the county, for example in
Longford and Galway. Mainly, however, Community Welfare Officers do the means testing of
applicants for the subvention along with their other work.
There is also evidence of significant time costs associated with the operation of the nursing
home subvention scheme. It is the exception rather than the rule for a decision on subvention to
be made on the basis of the standard application form alone. Additional information is nearly
always required from the older person and/or the family. Typically, clerical/administrative staff in
the unit have to contact applicants requesting information about additional savings and/or
income (other than that stated on the application form), or transfers of money or property in the
last five years. If the applicant owns property, he/she is often asked to have the property valued
professionally. Information from local Community Welfare Officers might be sought if there is a
query and, if an applicant is on a reduced social welfare pension, the Department of Social,
Community and Family Affairs is contacted for information which they might have on file about
the applicant. Reviews are now requested much more often than previously, which adds to the
administrative burden.
While some people may see this level of administration as simply the inevitable consequences of
the regulations, there is a substantial administrative opportunity cost associated with this kind of
detailed intervention. Some health boards have claimed that even though the number of
applications for subvention have increased significantly, particularly in recent years, the number
of staff dealing with this issue has not changed, leading to inefficiencies and inevitable delays in
the system. This causes particular problems in the acute care sector where there may be delays
in moving older people to more appropriate forms of care due to the slow and cumbersome
nature of the assessment process. The administrative burden is exacerbated by the fact that
much of the intervention is invasive with older people having to demonstrate and validate their
claim for subvention at a time when they are at their most vulnerable in terms of uncertainty
about the future. There is an argument for bringing simplicity and consistency into the
application and review process. This argument will be taken up in the next chapter.
There is a variety of practice with respect to the assessment of dependency for people applying
for subvention, in respect of both the personnel carrying out the assessment and the criteria and
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Review of the Nursing Home Subvention Scheme
scales used to measure dependency. The assessment of physical dependency in the ERHA is
done by a Consultant Geriatrician, if there is one in the area in which the applicant resides, or by
a Public Health Nurse if there is no geriatrician service available. In the Southern Health Board,
decisions about the level of physical dependency are made by teams which include Senior Area
Medical Officers and Senior Public Health Nurses, following visits to applicants by Public Health
Nurses. In the Midland Health Board a specially assigned public health nurse carries out the
assessment. In the Mid-West the assessment of dependency is mainly done by the Senior Public
Health Nurse in the home of the older person seeking the subvention. In the North-West, both
co-ordinators are from a nursing background and they assess physical dependency levels
themselves.
The criteria used to assess dependency vary across the country. There are many measures of
functional ability. Some measures focus simply on basic activity of daily living (ADL) functionings,
such as mobility or dressing, but more commonly, they also include items of instrumental
activities of daily living (IADL) such as ability to do housework or prepare meals. From our
investigations, the assessment of functioning for the purposes of subvention includes both ADL
and IADL components, sometimes weighted, sometimes not. There is variation among health
boards in the scales used to assess the physical abilities of older people. The scale used to
assess physical functioning of older people applying for subvention in the Midland Health Board
is based on the detailed First Schedule in the Nursing Home (Subvention) Regulations, 1993,
Section 5-12. The Barthel scale is used to assess physical dependency in the North West, while a
modified Barthel is about to be introduced in the Mid-West, where a modified Winchester scale
has been used up to now. The Crichton Royal Behavioural Rating Scale (CRBRS) is used to assess
dependency in the South Eastern Health Board. In the Southern Health Board a modified CRBRS
is used alongside the Barthel index. In the ERHA the community-based measurement of
dependency by public health nurses is often linked to the Clifton Assessment Procedures for the
Elderly (CAPE).
Measures of physical functioning and activity limitations do not always provide assessments of
functioning in every day social roles, nor do they deal fully with the cognitive abilities of older
people. That is why all assessments tend to include a social variable which takes account of the
socio-demographic, spatial, housing and familial circumstances of the older person. There is a
strong subjective element in the consideration of social factors in placement decision-making.
The social circumstances of older people matters for some people more than others, and this is
reflected in the weighting applied to social factors both within and among health boards.
Similarly, the approach to cognitive assessment is uneven and, in the case of people with
dementia, unsatisfactory. The situation with respect to the latter has been well-documented
(O’Shea and O’Reilly, 1999) and will not be repeated here, except to say that staff do not have
the training or expertise which would allow them to properly diagnose dementia within older
people.
The situation with respect to dependency assessment for the purpose of awarding subventions
is, therefore, unsatisfactory. A strong subjective element in the assessment process, despite the
very detailed First Schedule in the Nursing Home (Subvention) Regulations, 1993, has led to
horizontal and vertical inequities in the treatment of older people applying for subvention, both
within and among health boards. People with the same dependency are not being treated the
same, nor are people of unequal dependency always being treated unequally. There is a wide
variation among health boards in the proportion of applicants being awarded subventions and
the dependency categories in which they are placed. While there have been attempts to
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standardise dependency criteria across the country, there remains unacceptable variation in the
assessment process. A common assessment procedure should be the cornerstone of any reform
of the subvention system. This issue will be raised again in the next chapter.
There is also some evidence of dependency creep occurring, meaning that some older people
are placed in the highest dependency category in order to qualify for the highest subvention
payment. This behaviour has been explained by one health board official as “the pragmatic
response of the assessors to the failure to increase subventions in line with nursing home
charges”. There is no doubt that the gap between the financial resources of older people and
nursing home charges leads to pressure for a higher dependency rating, in some cases. The
practice of bidding up dependency can, however, undermine the independence of the older
person by artificially creating a higher dependency than already exists. Even if this is done for an
understandable motive, that of securing a higher subvention for the older person, it reduces the
human potential and capacities of the older person even further. It can also reduce the potential
for a community care solution to the difficulties faced by some older people and their families. If
financial support for dependent older people is only available on the basis of institutionalization,
then it is little wonder that this is the preferred, though not necessarily optimal, option for many
families.
Mid-Western Health Board: Case Study
The Application Process
Everyone who is in need of long stay care in the Mid-Western Health Board is asked to fill out a
private nursing home subvention application form, regardless of whether they want a public
long-stay bed or a bed in a private nursing home, subject to differences in the means
assessment procedure, as per the relevant regulations. Similar treatment for both public and
private applicants facilitates consistency and continuity in the rationing of scarce resources. The
only exception is in cases where so-called Level 1 medical and nursing need (which can only be
met in hospital) has been identified. People in this category are allocated to public facilities with
high levels of nursing care.
Clerical/administrative staff (including a Community Welfare Officer) in the Nursing Home Unit,
located in Limerick, process the applications and write back out to applicants requesting
additional information or documentation where appropriate. The Community Welfare Officer
assigned to the unit administers the means test for the subvention. This may involve personal
interviews with the applicant or with a family member, calls to the Department of Social,
Community and Family Affairs where appropriate, or contact with other CWOs who may be
familiar with the circumstances of the applicant.
Senior public health nurses carry out the assessment of physical dependency of applicants
already residing in private nursing homes. Area public health nurses do the assessments of
applicants still living at home. At the moment, a modified version of the Winchester rating scale
is used to rate applicants’ level of physical dependency, although a new dependency assessment
tool, based on the Barthel scale, is currently being piloted. Senior public health nurses reported
that, under the present system, it is difficult to accurately assess social need and the mental
health of applicants.
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An Assessment Team Meeting is held in each of the three health board areas every two weeks,
attended by the administrator from the Nursing Home Unit, the CWO as appropriate, the Senior
Area Medical Officer for the area, a geriatrician where appropriate, and the Senior Public Health
Nurse. At that meeting, agreement is reached on each applicant’s level of dependency, both
physical and mental. This is critical to further decisions regarding eligibility for the subvention.
Means are only considered after functional dependency has been determined.
The Nursing Home Unit Administrator then puts the information regarding dependency level
and financial means together and decides whether or not the applicant will get a grant and, if
so, the amount as determined by the level of dependency. The applicant is then informed of the
decision. If approved, applicants receive the subvention, backdated to the date of receipt of
application or to the date of admission to the nursing home if they are already in nursing home
care. If they have been approved but have not taken up a place in a private nursing home within
six months, a review of means and dependency level may be undertaken to determine whether a
change in health or financial status has taken place within that period. If the applicant is not
offered the maximum subvention, an Appeal Form is included in the letter, informing applicants
of their right to appeal the decision of the Nursing Home Unit. If applicants appeal Nursing
Home Unit decisions, the Appeals Officer requests a report from the unit, considers any other
information available to him and makes a decision regarding the appeal. The decision is sent to
the unit and the nursing home proprietor is notified of any changes which are implemented by
the unit. Reviews of the circumstances of those in receipt of the subvention are undertaken on
request. These requests are usually made by the family, by the nursing home or by other
interested parties. Staff constraints make it impossible to review every person in receipt of a
subvention at regular intervals. If the person’s health has deteriorated or if their financial
situation has changed since the subvention was granted, the subvention rate may be increased if
it is not already being paid at the maximum level.
Public Versus Private Care
There is a perception that the majority of older people prefer public long-stay care to private
care and staff in the health board noted several possible reasons for this preference. The first is
that the quality of care is believed to be better in public care. There are more services available
in public care, not only nursing care, but also services like physiotherapy and occupational
therapy. Second, private care is considerably more expensive for older people and their families.
Third, there is no stigma attached to being in hospital, whereas for some older people private
nursing home placement signifies some degree of loss or abandonment, as though being inside
the public care system would somehow legitimise their condition and plight.
In some cases, individuals admitted to hospital either in a crisis or for acute care/treatment have
refused to leave hospital once admitted, even though hospital staff may feel that their care
needs could be met more appropriately outside the hospital, at less cost. Some of these people
cannot afford to pay for private care, even with a subvention. Others do not want to pay for
private care under any circumstances, so they remain in a public bed even though there are
more dependent people waiting for a public bed. Given the ambiguities surrounding eligibility
for public beds, it can sometimes be difficult to persuade some people to leave public care for
private care, particularly those people who know the system well and are aware of the fine
distinctions that characterise placement between the two sectors. One respondent observed
that people who “shout the loudest” are often the ones who get the limited public services that
are available. A strongly held view among the officials we spoke to was that public long-stay care
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should be confined to people who need it most, and not for people who refuse to pay for
nursing home care.
In a separate category are those people who have unsuitable home accommodation and/or no
family to care for them so that, when it comes time for them to leave hospital, they have
nowhere else to go and must be kept in hospital because of a lack of appropriate alternatives.
Although qualitatively different than the preceding case, the result is the same: public beds are
not available for older people whose needs can only be met in hospital. This is a serious
problem for the health board as well as for individuals on hospital waiting lists. Efficient
placement policy is being undermined by the absence of both appropriate and well-resourced
step-down facilities and suitable housing in the community for people living alone who continue
to need high level community support services.
Older People’s Ability to Pay for Private Care
The Mid-Western Health Board does not pay enhanced subventions nor does it buy contract
beds in private nursing homes for public patients in spite of growing pressure to do so. This is
because, up until recently, there were thought to be sufficient public beds to meet the needs of
older people in the region who could not afford private care. At present, however, there is
concern that in some areas, most notably in Limerick city, there is a serious shortage of public
beds (including respite beds) which is putting pressure on the whole system in the Mid-West.
The implications are serious, not only for those needing to enter hospital (see above) but also for
those individuals who do not need hospital care but who cannot afford private nursing home
care, even with the maximum subvention. There is considerable concern about these people in
the Board, particularly as subvention rates have remained static while private nursing home rates
continue to increase.
Reform of the Scheme
There was unanimous agreement amongst those interviewed from the MWHB that the
subvention rates are too low and should be raised to reflect current charges in nursing homes.
The view was that not only should payment levels be raised but that the present regulations
should be changed to allow for payment of the subvention for care in other types of residential
care settings (e.g. private rest homes). More formally, in a subsequent written submission, the
Standing Committee of the Mid-Western Health Board on Elderly and Community Services
argued that “subvention rates ought to be increased to reflect the present-day values of the
rates introduced several years ago”.
There was an equally strong view that subvention payments should be used flexibly to include
payment for care in community care settings as well as for care in the institutions. Applicants who
are approved for the subvention i.e. who meet the physical dependency and means test criteria
should have a choice about the way in which the subvention is spent. The health board should
be able to allocate the subvention money to pay for domiciliary or day care services, transport,
physiotherapy and other rehabilitation services and not just for private nursing home care.
The problem is, however, that community care services remain seriously under-developed
resulting in more pressure on the residential care sector. Respite care, which can be critical to
maintaining older people at home, was thought to be seriously underdeveloped in some parts of
the region. For example, when we visited the region, there were 92 people on a waiting list in
St.Ita’s for two respite beds. The average home help allocation for people receiving the service
in the Mid-West is only 5 hours per week; there are waiting lists for home physiotherapy and
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Review of the Nursing Home Subvention Scheme
occupational therapy; there are no home care attendants, community ward teams, or social
workers working with older people in the community; there are little/no twilight nursing services,
no week-end cover and a shortage of chiropody services. ‘Step-down’ anticipatory services are
badly needed to ease the transition from hospital to home to prevent hospital re-admission and
the need for long term care.
Staff shortages in the health board are a problem with regard to the implementation of the
Private Nursing Home Regulations. Assessments and inspections take time and appropriate
personnel but this has not always been recognised in the allocation of resources. In Limerick
alone, 391 assessments were undertaken last year and the numbers are similar in the other two
health board areas. There was also concern that staff shortages make it impossible for health
board staff to offer a whole range of necessary services to older people once they enter private
nursing home care, although the legislation states that residents are entitled to these services.
More contact between the health boards and private nursing home staff is recognised as
important, having the potential to improve nursing home standards and improve quality of care.
A pilot programme was recently developed in the MWHB to train private nursing home staff in
recognition of the need for better integration of services.
The lack of co-ordination between local authorities and the health boards was also seen as a
problem, particularly with regard to the need to focus more on the housing needs of older
people and the relationship between adequate accommodation and health. The contribution
that sheltered housing schemes which are linked to appropriate community care services can
make to the welfare of older people has been widely recognised. However, inappropriate
housing continues to be a contributory factor in the inappropriate placement of older people in
long-stay residential care. The problem is that housing policy has been formulated and
implemented in a piecemeal manner with too little emphasis on the integrative role of housing
in the community. Housing policy remains fragmented and, despite some improvements in
recent years, much more needs to be done to integrate the efforts of voluntary housing
organisations, local authorities and the health boards. For example, programmes like Special
Housing Aid for the Elderly and the Local Authorities Essential Repairs for Disability need to be
rationalised and put under one body responsible for all such schemes. Similarly, community care
services need to be formally linked to sheltered housing schemes for vulnerable older people,
providing appropriate on site services for older people on an on-going basis. The need for
improved integration of service provision was a constant theme in our discussions with staff in all
of the health boards. The desire for new integrative structures to, as one respondent put it,
“raise the profile and capabilities of community care” is strong in the Mid-West and throughout
the country.
Private Sector Issues
In the MWHB, a small number of private nursing homes have closed or are facing closure
because they are unable to meet the standards laid down in the Private Nursing Homes Act. The
implications for residents in these homes are a cause of concern for officers of the Board.
Although tax incentives have worked to increase the number of nursing home beds, there is no
development plan that includes the private sector and no control on the number of beds
coming on stream. There is concern about an over-supply of beds in some areas and a
diminution of the caring role of the private sector as new entrants to the market emphasise the
commercial aspect of provision over the care needs of residents. Staff shortages and the
competitive labour market in the region have also combined to push up labour costs in nursing
homes and raise questions about the quality of care in some nursing homes. At the same time,
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there is concern about the fact that the cost of private nursing home care is difficult to monitor
and control, and this was thought to be especially important if enhanced subventions were
introduced in the region.
Conclusion
The 1990 Act provided the catalyst for major changes in the funding of older people in private
nursing homes. Expenditure on the scheme has increased more than four-fold since 1994, with
6,196 older people now in receipt of subvention. The scheme facilitated the expansion of longstay facilities for older people in this country. Without the scheme there would have been a
major crisis in the provision of long-stay facilities for older people, given the shortage of public
beds in some areas of the country. The scheme is not without its critics, however, not least
because of the differential manner of its operation throughout the country. There are also various
pressures on the scheme mainly concerning the relationship between levels of subvention and
the cost of care in nursing homes. These issues will be considered in more detail in the next
chapter.
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The Effectiveness of
the Nursing Home
Subvention Scheme
chapter
5
chapter
5
The Effectiveness of the Nursing
Home Subvention Scheme
Introduction
There were not enough public beds in the system at the end of the nineteen eighties to cope
with existing demand and some older people were denied access to long-stay care, to which the
majority of them were eligible. During the nineteen eighties, there had been a dramatic
reduction in the number of acute and long-stay beds as a result of financial constraints on the
health services. Between 1980 and 1990, the total number of hospital beds fell from almost
15,000 to 12,000. The closure of district hospitals and voluntary hospitals which had traditionally
catered for older people had a serious impact on the availability of extended care places for
older people. The subvention system in place at that time was inefficient and unsustainable
given the pressures on the public system of care. The rigid control of new approvals in the
nursing home sector maintained control over public expenditure but at a cost in terms of the
ability of the public system to cope with prevailing levels of need among older people. A new
policy was needed to alleviate the supply-side difficulties caused by the constraints imposed on
the private sector in the provision of long-stay care for public patients. Faced with the choice
between an expansion of public beds and the development of an enhanced public subvention
system for private nursing home care, the latter was chosen, mainly for the considerable cost
advantages it held over the former.
The objective of this chapter is to examine the effectiveness of the nursing home subvention
scheme which was put in place at the beginning of the nineteen nineties and to provide a
systematic analysis of the problems associated with the scheme. Effectiveness is concerned with
the relationship between the objectives of policy and the outcomes of policy at both macro and
micro levels. There are two key macro issues with respect to the nursing home subvention
scheme. The first concerns the relationship between the objectives of the scheme and the
outcomes associated with the scheme. The second concerns the relationship between the
scheme and overall policy objectives for older people in the country. The chapter also examines
the internal effectiveness of the scheme by focusing on four key micro issues: family assessment,
adequacy of subvention rates, assessment of means and quality of care. These issues emerged
during extensive consultations with relevant personnel in the health boards and from the survey
of nursing home proprietors already reported in Chapter 2.
Policy Objectives and the Nursing Home Subvention Scheme
We have already made some comments on the evolution of the nursing home subvention
scheme in an earlier chapter. Now the issue is whether the objectives set for the scheme in the
1990 Act and in the Regulations were realised in the subsequent operation of the scheme. The
Review of the Nursing Home Subvention Scheme
origins of the nursing home subvention scheme can be traced to the Report of the Working
Party on Services for the Elderly (The Years Ahead Report, 1988). The Years Ahead considered
that there were four main advantages in having a mix of public, private and voluntary beds for
the care of dependent older people. These advantages can be summarised as follows:
•
A more equitable system of placement for older people
•
A fairer system of allocation for nursing home proprietors
•
More choice for older people
•
Savings to the Exchequer from not having to provide public long-stay facilities.
In terms of the system of subvention, The Years Ahead recommended that older people entering
nursing homes and wishing to avail of subventions should be subject to assessment of means
and that subvention payments should be varied to reflect the care needs of residents. These
recommendations, along with others signalling a more integrative model of financing and
production, had a major influence on the new legislation on nursing homes.
The Report of the Commission on Health Funding (1989) also supported the development of the
private nursing home sector. The Commission report outlined three major advantages associated
with an expansion of the private sector:
•
More choice for older people
•
Smaller, cheaper and more flexible units of production
•
Savings to the Exchequer from reduced capital expenditure
The Report went on to recommend that “in organising and co-ordinating services for the elderly
in each area, full account should be taken of the scope for cost effective utilisation of private
nursing homes”. For that reason the Commission recommended that all registered homes
should be approved for provision of services subject to regular inspection and monitoring of
standards.
In introducing the legislation on the nursing home subvention scheme to the Dail in 1989 (Dail
Debates, November, 1989), the Minister for Health was more cautious with respect to
expectations for the scheme and was content to outline the objectives of the scheme in the
following general terms:
•
To promote the highest standards of care
•
To change the arrangements for the subvention of persons in nursing homes
•
To ensure improved cost effectiveness in the care of dependent older people.
It would be difficult to make any judgement on the effectiveness of the scheme in terms of two
of these three goals. The promotion of the highest standard of care is a statement of general
intent that applies to all health care programmes and not just the nursing home subvention
scheme. It is impossible to measure progress in respect of this goal because it doesn’t say what
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the highest standards of care are, or how they might be interpreted differently under different
circumstances. Changing the arrangements for the subvention of persons in nursing homes is a
statement of fact rather than a measurable objective. It simply tells us what is going to happen.
Improved cost effectiveness is a measurable objective, albeit one that is difficult to quantify. For
the purposes of this evaluation we will focus on the implicit objectives of the scheme, as outlined
in the two major documents of the period, rather than these more general statements, with the
exception of the latter. These objectives can be summarised in terms of equity, access, choice,
flexibility, and cost effectiveness.
Equity
The nursing home subvention scheme did address the equity question. Older people were no
longer denied access to needed long-stay care simply because there was no approved nursing
home in their area. For example, there was no approved nursing home in the North Eastern
Health Board at the end of the nineteen eighties, which meant that older people in this region
did not have the same opportunities for long-stay care as people in other regions. There was not
equal access for equal need across the country for dependent older people because of supplyside constraints associated with the failure to approve any new nursing homes since 1980. That
situation changed because of the new legislation which subvented eligible older people rather
than nursing homes. Similarly, the new scheme resulted in the more equal treatment of nursing
homes. Prior to the new legislation, nursing homes were arbitrarily designated as approved or
non-approved on the basis of year of opening; those opened before 1980 were designated
approved, those opened after 1980 were designated non-approved. Following the legislation, all
nursing homes were equal and able to accept subvented patients, subject to meeting standard
regulatory and licensing requirements.
Access
There is no doubt that the nursing home subvention scheme succeeded in offering more places
for older people in long-stay care. In relation to the registration of private nursing homes and the
approval of subventions the main objective of the 1990 Act was quickly realised. Older people
were now able to access private care facilities in much greater numbers than had been the case
up to that point. There was latent demand for residential care, the origins of which was the
shortage of long-stay beds in the system. Community care services were not capable of
providing the safety valve required by the rigid control on the expansion of publicly-subvented
private nursing home beds. Very quickly the 1990 Act resulted in a large increase in spending on
private nursing homes. Over the period 1993-1997 over £65m was spent on the implementation
of the Act (Ruddle et al., 1997), a huge amount relative to new expenditure on community care
services. Three thousand additional privately provided beds came into the system in the 1990’s.
Not surprisingly, in view of the increase in the number of subventions and the registration of new
homes, there was a very positive response by nursing home proprietors to the Act as reported
by Ruddle et al. (1997). The Act succeeded in bringing more people into the residential care
system and made a significant contribution towards the cost of long-stay care for these people.
Choice
Whether the new scheme offered older people more choice is open to debate. If by choice is
meant that people were able to weigh up the relative costs and benefits of public and private
long-stay care and make a free and fully informed decision on which to choose, then the new
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Review of the Nursing Home Subvention Scheme
system did not lead to more choice. This was especially so as the gap between subvention and
the cost of private care widened over the years. On the basis of out-of-pocket expenses, it is
unlikely that any older person would choose private care over public care given the cost
implications of that decision, if given a real choice. People did not have to pay for public care
outside of the normal pension contribution, whereas private care, even with maximum
subvention, always required some out-of-pocket payment in addition to the normal pension
contribution. Moreover, the vast majority of private nursing homes were not equipped with the
same therapeutic and rehabilitation facilities as some residential care units in the public sector
so, once again, freely choosing private care over public care on this criteria would be unlikely to
happen where differences in facilities existed. Private facilities did carry spatial advantages for
some older people but these would have to be strong enough to outweigh cost and facility
advantages associated with public care. In some areas, the scarcity of public beds meant that
some people had no option but to accept subvented care in private long-stay facilities. There
was no choice in those circumstances.
Flexibility
Flexibility is a difficult concept to define and it has many layers of meaning when applied to the
nursing home sector. The critical flexibility provided by the nursing home subvention scheme is
that, in the absence of public beds, it provided an option that did not exist prior to the
legislation. This flexibility is particularly important in health boards that do not have an adequate
supply of public beds. For example, the care of older people in the Eastern Regional Health
Authority would have been in crisis without the facility to contract beds to the private sector.
Flexibility was further increased when the potential for enhanced payment was provided for in
the 1996 Regulations. Nursing homes have also been used in some areas to accommodate
inappropriately placed older people from acute care hospitals, thereby providing timely and
appropriate care in a flexible way. Without doubt, the nursing home sector has provided much
needed support to the public sector since the inception of the nursing home subvention scheme
ten years ago.
Flexibility is often linked to size of facility. Because barriers to entry are low in the nursing home
sector the expectation is that the sector can provide a faster response to the needs of older
people in a particular region. It is likely to take much longer for an investment in public facilities
to come on stream. This is certainly true and flexibility has been a major advantage for the
private sector over the public sector. The problem is that profit-seeking private nursing homes
are likely to cluster in areas of high population density and high income. Flexibility in provision is
market driven and, therefore, is unlikely to always correspond to the overall planning needs of
the health and social care system. This is not a criticism of the private nursing home sector,
rather it is to make the point that if flexibility is to have meaning it must, paradoxically, be
subject to planning controls outside of the market. The problem of over-supply of private beds
in some parts of the country has been exacerbated in recent years by new capital allowancebased tax-breaks for the nursing home sector which has succeeded in attracting additional
private beds into the system. Concern has been expressed about the need for these additional
beds in our discussions with personnel in the various health boards and in our discussions with
the Irish Nursing Homes Organisation.
The critical issue for the care of dependent older people is to ensure the correct mix of long-stay
beds in a region. What are needed most are beds (and the care that goes with them) that serve
to keep older people out of both acute care hospitals and out of long-stay institutions. This may
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mean an investment in assessment and rehabilitative public beds at the same time as placing
controls on the development of pure long-stay beds in both the private and public sectors. The
danger is that the availability of long-stay private beds creates pressure to fill these beds leading
to higher rates of institutionalization than are optimal. Consequently, the over-supply of nursing
home beds may be just as inefficient as the under-supply of beds and flexibility, if it is to retain
meaning, must allow for less, as well as more, in terms of the supply of beds. This has not been
the case in some health boards where there is an over-supply of private beds in some areas, at
the same time as an under-provision of public assessment and rehabilitation beds in the region.
Cost-Effectiveness
Nursing home beds are cheaper for the government than public-long-stay beds. This was an
important consideration at the beginning of the nineteen nineties, when the budgetary position
of the government was much less favourable than it is today. Private beds do not require any
capital investment on the part of the state and subvention patients must also pay a significant
proportion of the cost of private care from their own resources. While the introduction of the
capital tax allowance scheme for private nursing homes now allows 42 per cent reclaim over
seven years for nursing home proprietors, private beds remain an attractive option for the
government. But is the less costly alternative also the most cost-effective alternative? It is
impossible to answer that question on the basis of the information available to us. There have
been no attempts to measure the relative benefits of private care relative to public care for older
people in this country. The difficulty is the absence of suitable measures of effectiveness and
output in long-stay care. This has not prevented claim and counter-claim on the relative merits of
one form of care over another. Public care is, on average, more expensive than private care
because of higher staffing levels and a wider range of services and facilities. The assumption is
that benefits are also higher in the public sector but this is an empirical question on which there
is not enough information in this country. The less frequently asked question is, of course,
whether nursing home care is more cost-effective than community care. This too is an important
question given overall policy objectives for the care of dependent elderly people in the country.
National Policy Objectives and the Care of Dependent Elderly People
The effectiveness of the nursing home subvention scheme must also be considered in the
context of national policy objectives for the care of dependent elderly people in the country. The
Years Ahead set out four basic objectives concerning the health and social care of older people,
three of which relate to home care solutions to the problems of dependent elderly people:
•
To maintain older people in dignity and independence in their own home
•
To restore those elderly people who become ill or dependent to independence at home
•
To encourage and support the care of the elderly in their own community by family,
neighbours and voluntary bodies in every way possible
•
To provide a high quality of hospital and residential care for elderly people when they can no
longer be maintained in dignity and independence at home.
Of the 119 recommendations in The Years Ahead only five referred to the nursing home sector.
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Back then, it seemed that home care was as much principle as objective and that community
care was an idea whose time had come. The reality turned out to be quite different. Instead of
community care becoming the dominant force in care of the elderly, the implementation of the
1990 Act absorbed the bulk of available resources for dependent older people, drawing on
resources that might otherwise have been used to improve the community care system. Between
1993 and 1996 expenditure on the combined community care services of home nursing, home
help and meals-on-wheels increased by 8 per cent. In the same period, expenditure on the
nursing home subvention scheme increased by 422 per cent. This caused some commentators
like Ruddle et al. (1997) to lament the failure to implement the many excellent recommendations
on the extent and nature of home and community care.
The process of admission to private long-stay care was made more rational and efficient, but at
the expense of the development of the community care system. This resulted in an institutional
bias to the system in direct contravention of the principle of home care for dependent older
people outlined in The Years Ahead. The financing of nursing homes should not have occurred
at the expense of resources for community care given the stated policy objectives at the time
and since. What was even more perverse was that the absence of community care services led to
a higher demand for private nursing home care which in turn led to further “crowding out” of
much needed community-based facilities as more and more subventions were sought and
granted.
The vision outlined in The Years Ahead for the care of dependent elderly people was universally
acclaimed at the time as a model of public-policy making. A well-developed analytical and
planning framework was provided for the reorientation of resource allocation towards care in the
community rather than care in long-stay institutions. The plan was to enhance and develop
community care services for older people relative to residential care services. The opposite
happened. The nursing home sector grew very quickly and absorbed the major share of
increased funding for the sector. It is not that community care initiatives were not funded, the
problem was the scale of the funding could not deliver on the promises contained in The Years
Ahead. This has been the most damaging aspect of the scheme and would, on its own, justify
some reformulation and recalibration. That reformulation should have at its core the use of
subventions in community care and more rigorous assessment mechanisms for admission to
long-stay care. In that regard, a new model is proposed in the next chapter. First of all, however,
we must examine the internal effectiveness of the current scheme in more detail in order to gain
some insight into what changes may be necessary to improve current arrangements.
Family Assessment
The most controversial aspect of the nursing home subvention scheme in the 1990’s was the
provision in the Regulations that appeared to enable health boards to take account of the
income of sons and daughters of the applicant in deciding what level of subvention should be
paid. Eligibility criteria for a subvention first of all required a health board to examine the income
and assets of an old person applying for assistance, as well as that of their spouse. Once
entitlement was initially established the Health Board could then look at other ‘circumstances’ to
determine the precise monetary value of the subvention. ‘Circumstances’ in this context meant
that the income of sons and daughters living in Ireland were assessed to see if they were in a
position to contribute to the financing of long-stay care of their parents. There were specific
rules for determining how much, if anything, family members were expected to contribute.
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The problem was, however, that the liability on children to contribute to the cost of care for their
parents was not explicitly provided for in the 1990 Act, which immediately cast doubt on the
legality of the provisions on “circumstances” set out in the Article 4.5 of the Regulations. Any
pressure to encourage sons and daughters to pay for the long-term care of their parents could
only be moral, buttressed by whatever pressure the administrative bureaucracy can bring to bear
on reluctant family members. It was no surprise that the Ombudsman received a number of
complaints relating to family assessment and that the issue became a source of legal controversy
and complaint from the beginning of the new scheme. Ruddle et al. (1997) reported that the
“family circumstances” aspect of the new Regulations was the one that raised most objections
among nursing home proprietors. It came as no surprise, therefore, when the Minister for Health
first of all amended the Regulations in 1996 to provide for an easing of the assessment of family
members and then finally dropped the family assessment provisions altogether from the
Regulations in 1999.
There has been no debate in this country about the responsibility, or otherwise, of families to
support their elderly kin in the final stages of their life (O’Shea and Hughes, 1994). Not
surprisingly, therefore, the philosophical basis for the inclusion of family assessment in the
Regulations to the 1990 Act remained implicit. This was unfortunate because, in the absence of
philosophical arguments, the justification for placing financial responsibility on families for their
parents, even when the legality of the provisions was being questioned, then centred around the
potential for budgetary savings. Considerable savings to the Exchequer were likely to accrue
from asking family members to provide financial support for their parents in times of need. This
is a basic substitution argument and derives from the view that the Exchequer is over-burdened
enough without having to pay for the care of older people whose own family could well afford to
bear the cost of care without any undue hardship. Asking relatively well-off old people and their
families to contribute to the cost of long-term care was seen as a way of achieving government
savings in as painless a way as possible in the difficult budgetary environment for health care
expenditure in the early 1990’s. While it is easy to be critical of both the Department of Health
and Children and health board officials for continuing with family assessment when there were so
many ambiguities attached to the provisions in the Regulations, the financial imperative should
not be dismissed lightly. Resources were scarce and well-off families were seen as a legitimate
target for the support of older people in long-stay care.
Adequacy of Subvention
The second major issue which continues to cause controversy for the scheme is the value of the
subvention paid to eligible nursing home residents. The level of subvention payment is
universally considered to be inadequate, even with the recent increases, due to come into effect
in April 2001. Subvention rates, at the time of writing (March 2001), remain the same as in 1993
and rising costs of private nursing home care in the intervening period have resulted in a serious
financing problem for older people relying only on subvention and state pension. In the Eastern
Regional Health Authority, the gap (for those on standard pension and maximum subvention)
averages about £200 per week, assuming an average weekly charge of £400, making it difficult to
find affordable care. In the North West region, where private nursing home care is less costly,
applicants in receipt of the maximum subvention could still expect to be paying £30 or more per
week on top of their pension. When the present subvention system was introduced the
maximum payment covered 60 per cent of the average cost of care in the country. Nowadays,
the maximum payment covers 40 per cent of the average cost of care. These percentages will
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vary, of course, depending on what part of the country the nursing home is located. The most
expensive regions are likely to be the East, North-East and South. While the recent
announcement of an increase in subvention rates is welcome, with the maximum rate due to
increase to £150 in April 2001, this still only covers 50 per cent of the average cost of care across
the country and considerably less in high cost regions such as the ERHA.
Five health boards currently pay enhanced subventions for significant numbers of older people
in response to the adequacy problem outlined above. These health boards are as follows: ERHA,
Southern, North-Eastern, North-Western and South-Eastern. The issue of enhanced subventions
is, however, important in all health boards, particularly in the boards not paying enhanced
subventions or those providing enhanced subvention payments for only a small number of older
people. Staff in these boards are coming under strong pressure to provide the same concessions
as in other regions, particularly since the Regulations allow such support. While there is some
concern amongst health board staff in regions currently not paying enhanced subventions to
significant numbers of older people that any increase in the subvention will lead to a pro rata
increase in private nursing home rates, the prevailing view is that enhanced subvention payment
should be used more, given the inadequacy (even with the proposed increase) of current
subvention rates. Enhanced subvention payments provide important flexibility in the system by
allowing higher payments for people unable to afford private care even with the maximum
subvention. They are also an important equity-enhancing instrument in regions where nursing
home charges are higher than the average.
Some health boards, most notably the ERHA, have used the provisions of the Nursing Home
(Subvention) Regulations, as amended in 1996, to pay more than the maximum subvention
payable through the contracting out of care to the private sector. These health boards negotiate
a mutually acceptable price with the private nursing home for the “contract bed”, which is then
used for traditional long-stay care or as a “step down” facility from acute and psychiatric
hospitals. Health boards are interpreting the legislation in a pragmatic way depending on the
constraints facing them with respect to the availability of public beds. This is particularly the case
in the East where there are less public beds than elsewhere relative to the needs of older
people. Unfortunately, there is less evidence of the same level of innovation and creative
thinking associated with the development of new forms of community care to offset the bias
which already exists towards residential care. It seems that less public beds translates into more
private beds rather than more community-based responses to the problems facing vulnerable
older people.
Assessment of Means
The third major area of concern with respect to the operation of the nursing home subvention
scheme is the means testing of applicants for long-stay care in private nursing homes. The main
problem is that admissions to long-stay care in public long-stay care facilities are not subject to
the same assessment procedures as applicants for subvention. In particular, the value of housing
assets is not taken into account in the public sector. This can lead to injustice and inequity in the
placement of older people between public and private facilities. Take the following example of
two older people (A and B), identical in every way, both with houses worth £100,000. If individual
A is allocated a public long-stay bed the maximum he/she will pay in a year is around £3,500 in
pension-related contributions. Person B cannot qualify for subvention because of the value of
his/her house. This means that if person B cannot access a public bed then his/her long-stay costs
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per year in a private bed will, on average, be around £15,000. Given the considerable discretion
that exists in the allocation of older people between public and private beds there is no doubt that
an injustice is being perpetrated on some people in such circumstances.
Even if a person qualifies for subvention she will end up paying about £5,000 more for long-stay
care than an equivalent person in public long-stay care. The assignment of people between public
and private care has, therefore, serious financial implications for older people. There is no research
on how decisions are made in relation to the allocation of public beds in health board facilities but,
from our discussions with health board personnel, practices vary significantly from area to area.
People who understand how the system works can sometimes act strategically to ensure they get
access to a public bed. This may involve older people refusing to move from an acute bed to a
private long-stay bed, preferring instead to wait until a public bed becomes available. If people act
in this way it is impossible for the health board to do anything about it. What is needed is more
transparency in the allocation process between public and private long-stay care. This requires
explicit criteria for the assessment and placement of older people between different facilities,
standardised for use across the country. This would also include the common assessment of
financial means for people seeking admission to public and private long-stay care.
Current subvention regulations with respect to means assessment are being interpreted differently
by health board staff, including assessors from the same professional background, when
subvention applications are being processed. This is leading to glaring horizontal and vertical
inequities in the system of assessment. This problem is exacerbated when staff with different levels
of training and experience are used to carry out the means test for subvention applicants. The
result is that some applicants’ income and assets are scrutinized more thoroughly than others,
depending on who is doing the scrutiny, in which areas, and under what time pressures. The
assessment of property (including farm property) is one of several ‘grey areas’ in the current
subvention regulations where assessors can make different judgements regarding applicants’
means. Community Welfare Officers are not always utilised in the decision-making process, even
when it might be beneficial to do so, particularly in cases where more than one pension is being
received by the applicant. In one health board, there is no personal contact at all with families with
regard to financial information. The result is that applicants in similar financial circumstances are not
being treated equally across the country.
The importance of simplicity in means testing is under-valued in this country as witnessed by the
various arrangements in place for qualification for contingency-based support schemes from the
state. There is no justification for separate means testing arrangements for older people in respect
of nursing home subvention, medical card and social welfare schemes. As things stand, an older
person can qualify for one but not the other leading to anomalies and inconsistencies in accessing
state services. For example, there are differences among the various schemes in the way assets are
assessed, particularly in relation to the savings disregard and farm property. Under changes in the
Social Welfare Act, the savings disregard will increase from £6,000 to £10,000. This change should
also apply to applicants for subvention, but there is no guarantee that it will. The system of means
testing is demanding enough without subjecting older people to multiple examinations of income
and assets. It would be more efficient if eligibility, already established on the basis of social welfare
criteria, could be transferred among various schemes for older people, including long-stay care. To
do this, however, would require changes in the way housing assets are dealt with in the nursing
home subvention scheme. This would require some imagination but it could be done, as we will
see in later chapters.
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Linked to the issue of a single assessment system is the need for simplicity in assessing the
means of people applying for subvention. The nursing home subvention application form is a
formidable document which is quite daunting for applicants. It could be much more user-friendly
given that it must be completed by older people at a time of great stress and vulnerability in
their lives, when they are considering leaving their home and going into residential care. The
problem is that the relatively straight-forward questions relevant to most applicants are
embedded in a series of detailed questions necessary and relevant only for a minority. This can
result in applicants neglecting to submit documentation such as Bank/Credit Union statements
and payslips because they are not asked for them clearly enough and in plain language.1 The
Mid-Western Health Board lists incomplete application forms as the main problem in carrying
out means testing on subvention applicants. The absence of timely information undermines the
decision-making process leading to longer delays than are necessary in the system.
There is also a need for clarification of the Regulations (Second Schedule, Assets (9)) in respect
of the relationship between savings and spending on community care. If an individual has been
using his/her own resources to maintain himself/herself in the community it seems reasonable
that he/she be given some disregard with respect to this expenditure. For example, if an
applicant for subvention has total savings of £10,000, he/she would be considered ineligible for
subvention because he/she is £4,000 over the maximum currently allowed. The applicant would
be told to re-apply when savings dropped below the current limit of £6,000. However, this seems
unfair if the applicant had been using own savings to maintain himself/herself in the community
up to this point. If the person had spent £4,000 in the recent past on special aids and appliances
within the home to enable home living to continue, it seems harsh not to allow such capital
expenditure, properly regulated and audited, against the savings disregard. A fairer system
would take into consideration the amount of money spent on special aids and appliances within
the home in the past and subtract it from the applicant’s current savings. This means that the
applicant in the above example would now be eligible for subvention on the basis of previous
expenditure on community-based supports. This approach would be in keeping with the primary
objective of policy for older people which is to keep them living at home in the community for as
long as possible and practicable.
Article 8.2 of the 1993 Regulations allowed an income disregard against the means test
equivalent to one fifth of the weekly rate of Non-Contributory Old Age Pension (NCOAP). This
was to ensure that residents retain some “pocket money” for their own personal use. Even
allowing for some ambiguity in the wording of Article 8.2, the income disregard did seem to
apply to both the calculation of means and the subsequent payment of subvention. However,
this interpretation was followed in only two health boards — the Eastern Regional Health
Authority and the North-Eastern Health Board. What tended to happen in the other boards was
that the income disregard was applied in the former case i.e. when calculating means, but was
ignored when it came to paying the subvention, i.e. the income disregard was subtracted from
the appropriate subvention payment. This led to complaints to the Ombudsman and legal
challenges to the operation of the Regulation. The situation was resolved in an amendment to
Article 8.2 provided by SI No.498 of 1998 which sought to ensure that one fifth of the NCOAP
was always available to the resident for his/her personal use.
1 Personal communication from Colman Rutherford, SHB
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The “pocket money” issue has been investigated by the Ombudsman and will not be examined
in any more detail in this report. Except to say that from our discussions with health board
officers the “pocket money” regulation is now being interpreted much more uniformly across the
health boards than before the amendment in 1998. Moreover, the previous failure to apply the
income disregard may have had more to do with the prevailing budget constraints in the health
care system than any deliberate attempt to undermine the spirit of the original regulation. A
more general point made by some health board staff is that the whole idea of the 1/5 disregard
is problematic anyway, because the current reality is that most applicants have to use every
penny of their income to finance their care. Even if the maximum subvention is paid to residents
it will not cover the cost of care in most nursing homes in the country. While people in receipt of
an enhanced subvention are in a stronger financial position, the reality is that the majority of
residents have to use all of the resources at their disposal to bridge the gap between subvention
and the cost of care and this includes the “pocket money” disregard. The result is that residents
have nothing left for their own personal expenditure needs.
There are also technical issues relating to the assessment of income and assets. The first of these
concerns the assessment of the income of couples under the present Regulations (Second
Schedule, Income (2)). At present, the applicant’s income is calculated to be 50 per cent of total
income of the couple. Only rent or mortgage payments are deducted from income when
assessments are done. There is concern that this does not take into consideration the fact that
the needs of the person remaining in the household (often elderly themselves) are not accurately
represented or accounted for. The remaining person in the household will still have many of the
same overheads as when the applicant was living in the home e.g. electricity, heating, household
repairs, even basic food staples. Either more discretion should be given regarding the
assessment of income in such cases or more deductions should be allowed for general
household expenses/exceptional expenses including, perhaps, loan repayments.
The assessment of principal residence as set out in the Regulations is also a source of concern.
Currently, people who own a house worth more than £75,000 (and whose income is more than
£100/week) are automatically ineligible for the subvention. The limit of £75,000 on housing assets
is unrealistic, given the increases in house prices in recent years, especially in urban areas. In
Dublin, Galway and Cork, it would be hard to find a house selling for less than £75,000. There is
concern, therefore, that this section of the Regulations causes certain categories of applicants to
be excluded in a way the Regulations did not intend. There is evidence of different practices
across the country in the application of this regulation, largely in response to the increase in
house prices. The general view is that rising house prices should not disadvantage people in a
way unintended by the Regulations. Currently, if a person looks for a review of their subvention
they may lose out if they own a house, the value of which has increased since last application or
last review. A related issue concerns who should be asked to assess the value of any relevant
property? While sometimes the assessment of the applicant is accepted (if it seems reasonable
in a local context), most health boards routinely require an auctioneer’s estimate of value. One
health board retains an independent valuer to do the valuation at no cost to the applicant, while
in most other areas the applicant pays for the valuation. Regulations are required to stipulate
when a professional valuation is required and who should pay for it.
Problems have also arisen in the scheme in the calculation of the value of a home as an asset
versus the calculation of the value of savings derived from sale of house. If an applicant has a
house, its value as an asset is computed by taking 5 per cent of the value of the house and
dividing by 52 to get a weekly income value. Yet, if the house has been sold (to pay for a
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person’s care) the value of the property (i.e. the money derived from its sale) is assessed as
‘savings’ to the great disadvantage of the applicant because the value will be much higher. This
seems particularly unfair since applicants who have acted responsibly in disposing of property to
pay for their own care are penalised under the present system.
Farm property is a particularly problematic area and there is evidence of differences in the
application of the Regulations across health boards. Farm property can be considered as an
asset or as income. If considered an asset, application for the subvention would often be
refused, while if considered as income (either computed notional income or rental income), it is
much more advantageous to the applicant. Some people believe that there should be a
threshold limit put on farm values as there is with house properties. There are also sometimes
difficulties in ascertaining what property was transferred, when it was transferred, and under what
conditions. Sometimes farm property is sold but certain rights may be retained by the applicant
which, if considered, would alter income/assets calculations. Moreover an examination of income
before the transfer of property may be necessary to get a complete picture of the applicant’s
financial situation. There also needs to be some discretion allowed regarding situations where
property is tied up legally, i.e. in cases where the proceeds from the sale of property can’t be
accessed because of litigation. In such cases, health boards should formally be allowed to pay
the maximum subvention for as long as it takes to sort out the applicant’s financial affairs and
then adjust by claiming back money from the estate, reducing the subvention or discontinuing it
as appropriate.
Inequities may also arise in the way reviews are carried out on subvention decisions.
In most health boards, reviews of the subvention payments are carried out in response to
requests from the original applicant, a family member, the private nursing home and, in an
increasing number of cases, by health board Appeals Officers. Reviews are requested when the
recipient’s financial circumstances change (e.g. their savings have diminished), or when their level
of physical dependence has increased significantly (and thus the cost of their care increases).
Health boards are adjusting subventions upwards in many cases; in some instances payments are
being enhanced to above the maximum payment specified in the Regulations (currently £120 but
soon to increase to £150), as noted above. The problem is that subvention recipients who may
be similarly financially stretched, but who do not think to ask for a review, or do not appeal
decisions, do not have their subvention increased by right and so are at a disadvantage
compared to those who do challenge the status quo. This is essentially an information problem,
which can only be fully resolved by more consumer-friendly policies on the part of health boards.
Some health boards are more consumer-oriented than others, but the same opportunities for
review should be available to all, irrespective of location, even if this means positive
discrimination for some client groups.
Finally, there is the problem of the length of time taken to assess applications for subvention.
The processing of applications can take between four weeks and six weeks for non-complex
cases. If additional documentation is required or there are legal issues in relation to home
ownership an initial decision will take longer. Part of the reason for the delays in the assessment
process are related to staffing problems in the health boards. The main problem however, is the
number of processes an application must go through before a final decision can be taken. The
decision-making process varies across the country but the dependency assessment procedure
usually takes a significant length of time. Typically the process may take the following path: first
the application form is received in Continuing Care Services, where it is processed by an
administrator who contacts the relevant senior public health nurse, who assigns a public health
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nurse to do the dependency assessment, who afterwards files a report, which is then discussed
by the assessment committee where a final decision on dependency is made, following which
the application is returned to Continuing Care Services. A decision is then taken on the amount
of subvention to be granted taking into account the financial means of the applicant. If there is a
doubt about the value or ownership of a house the application may be referred to the local
Community Welfare Officer for an opinion. Additional documentation may also be sought from
applicants.
The time scale involved in processing applications is too long, particularly if an applicant is
already in an acute care bed. Given the demands on acute care beds it is unreasonable for
delays in the processing of subvention applications to be holding up the efficient placement of
people in acute care hospitals. The time frame should be in days rather than weeks for
applicants in acute care beds especially. For cases where it is not possible to make a quick
decision, provision should be made for a temporary subvention in order to facilitate admission of
the person to long-stay care facilities. The “designated officer” for acute care patients could be
the hospital social worker or the hospital liaison officer, both of whom have access to the medical
team and most likely will have already met the applicant and members of the family. They also
have an institutional interest in completing the process as efficiently as possible. The goal should
be that no patient remains in an acute hospital bed because a subvention application has taken
more than five working days to process. Reducing the time between application and decision
would also overcome current differences in the timing of payments once subvention applications
are approved. Some health boards are paying from the date of admission whereas other health
boards are paying from the date of dependency assessment leading to anomalies in the timing
of payments.
Quality of Care
Quality of care is inextricably linked to the assessment of dependency for older people seeking
admission to long-stay care. The lack of standardised tools to determine levels of dependency
means that there is a good deal of subjective decision-making involved in determining who is
admitted to different types of long-stay care. Different assessment instruments are being used to
examine the physical and mental dependency of applicants, leading to different measurements
of disability depending on the scale being used. The assessment of social circumstances is
arbitrary with considerable variation in the definition of social need, even within health board
regions. Dependency assessment is also being carried out by different groups of health
professionals leading to horizontal and vertical inequity in relation to admission to long-stay care.
A related problem, which was referred to earlier, is the lack of co-ordination between the system
of assessment for a public long-care bed and the assessment system for private nursing home
subvention. There is no justification for different forms of dependency assessment for the public
and private sector; there should only be one system of allocation to long-stay care for publicly
funded patients, whether full or partial funding is at issue.
This raises an unresolved issue with respect to long-stay care in this country which is the
distinction between public and long-stay facilities and the ability of both to meet the different
needs of patients in the system. At the moment there is an unacceptable arbitrariness in the
allocation of older people between public and private facilities, which depends on the
availability of public beds and the discretion of a few key providers. While, we were assured in
our discussions with health board personnel that only people with high level needs are allocated
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to public beds, the facts are that public facilities also contain low dependency patients, while the
private sector also contains a significant proportion of high and maximum dependency patients.
There is particular concern among health board personnel that public patients in private care,
who are there because of the scarcity of public beds, are not getting the same level of service
that they would get in public long-stay institutions. The argument from the health boards is that
quality of care for older people is higher in public facilities than in private facilities and this is
reflected in people’s preference for public care over private care. The counter-argument from the
private sector is that private nursing homes are providing high quality care at a lower cost than
the public sector. Unfortunately, until we begin to measure health and social gain in residential
care we have no way of verifying claim and counter-claim with respect to quality of care.
For the moment, we must rely on intermediate measures to provide some pointers with respect
to quality of care. The legislation allows health boards to offer public health and social care
services, including physiotherapy, occupational therapy, speech and language therapy and
public health nursing, to recipients of subvention in private care. However, these services are
rarely offered, partly because of a lack of resources, and partly because of a lack of interest on
the part of nursing home managers. The result is that the residents of nursing homes are largely
outside the public remit of the health board, coming into view, only fleetingly, at the beginning,
when a decision on subvention must be taken, and, later on, whenever nursing homes are
subject to periodic inspection by the board. They do not get the same services as older people
in long-stay facilities.
Some health board officials have also expressed concern about staffing issues in some private
nursing homes. They cited low staffing levels and the use of untrained staff as two factors that
contribute to below standard care. The view coming from the boards is that the current
inspection procedure is focused too much on technical and procedural issues and not enough
on the health and well-being of residents. The same thing could be said, of course, for older
people in public long-stay care where there needs to be a similar emphasis on quality of care
and the measurement of outcomes. If there is a quality difference between public and private
long-stay care, then a similar gap may also exist within the public sector in terms of the quality of
care provided to older people in residential care. There is not a homogenous public long-stay
sector with high standards of care throughout for public patients; instead, there are differences
in staffing, services and infrastructure within the public sector. This must inevitably lead to
differences in the quality of care provided to older people in that sector. There is an urgent need
to explore the issue of the quality of long-stay care in this country through a longitudinal study
focusing on both process and outcomes for older people.
In some health boards, very good relationships have been fostered between individual health
board staff and local private nursing home providers on an informal, ad hoc basis. In the NorthWestern Health Board, for example, health board staff are involved in developing training
programmes specially tailored to the needs of some private nursing homes. In some other health
boards, private nursing home staff are offered places on health board courses, but there appears
to be much scope for the expansion and formalisation of such arrangements. Partnership
between the public and private sector, where it does occur, is in its infancy and needs
considerable nurturing to overcome existing levels of distrust between the two sectors. What is
clear, however, is that if common assessment and evaluation procedures are put in place, there
needs to be much more interplay between the two sectors with clear and explicit criteria for the
allocation of patients according to need between the two sectors.
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The Effectiveness of the Nursing Home Subvention Scheme
Conclusion
The current legislation dealing with the private nursing home subvention system is unsatisfactory.
The scheme has biased resource allocation in the direction of residential care rather than
community care. Indeed, the absence of community support services for older people and their
carers forces people to opt for private nursing home care, thereby maintaining constant pressure
on the subvention system. With regard to the scheme itself, there is general consensus that
subvention rates should be increased to take account of rising costs and property values in the
nursing home sector. The absence of consistency and standardisation in the application of the
Regulations has also led to horizontal and vertical inequity in the operation of the nursing home
subvention scheme. Consequently, there is a need for clarification and modification with respect
to some of the Regulations, particularly in the areas of means testing and dependency, because
they are being interpreted differently across, and sometimes within, health boards. Finally, there
is ongoing concern about the lack of public long-stay beds in some areas of the country which
has resulted in inappropriate placement for some older people and severe financial hardship for
others forced to rely on expensive private care.
74
Nursing Home Care
in the Future
chapter
6
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6
Nursing Home Care in the Future
Introduction
This chapter considers the implications of demographic trends and other relevant changes in the
environment for the demand and supply of long-stay beds. Population changes and shifts in the older
age distribution are very important indicators of future residential care use. However, they do not
provide a complete account of likely future trends in long-stay care usage. Credible policy targets can
also influence the pattern of community and residential care in the country. The level of dependency
and disability in the community and the number of older people on the boundary of community and
residential care will also likely influence admissions to long-stay care. The adequacy of community care,
which is related to both the policy target issue and the dependency question, will similarly influence the
rate of admission to both public and private residential care.
The continuing propensity of families to provide care at current high levels to older people living at
home is also important and will continue to influence the number of people in residential care. Women
provide the great bulk of care in the community, sometimes at great personal cost in terms of time,
money and ill health. The ability of an older person to look after himself or herself is often an important
factor in the decision to admit, and subsequently maintain, an older person in long-stay care. For that
reason, the number of older people living alone in the population may be an important indicator of
general need requiring separate analysis, since living alone, if accompanied by social isolation, may
undermine the ability of the older person to live independently in the community. While there are
almost insurmountable data problems in assessing the importance of each of these factors and,
therefore, the precise level of demand for long-term care (Carr-Hill and Dalley, 1999), some progress can
be made in that direction.
Long-Stay Residential Care Populations: 1996-2011
Estimates of the number of older people in long-stay care in the future are calculated by applying
current residency rates per 1,000 elderly population to the most recently available population
projections from the CSO and the NCE for the years 2001, 2006 and 2011. On the basis of CSO (1999)
population projections, the estimated number of older people in long-stay care will increase from
16,522 in 1996 to 22,515 in 2011, an increase of 36 per cent in the fifteen year period (Table 6.1). The
increase is higher if National Council for the Elderly (NCE) population projections are used (Fahey, 1995),
with the estimated number of people in long-stay care increasing from 16,522 in 1996 to 23,986 in 2011,
an increase of 45 per cent in the period. The largest increase in the period has already taken place
between 1996 to 2000. From now until 2011, the long-stay residential population will increase by 15 per
cent on the basis of CSO projections and 23 per cent on the basis of NCE projections. It should be
borne in mind, of course, that the period 1996-2000 reflects real changes in long-stay numbers, based
Review of the Nursing Home Subvention Scheme
on a whole range of factors, while the estimates for the period 2000-2011 are based solely on projected
changes in the population.
Table 6.1: Older People in Long-Stay Care: National Projections by Age Category Based on CSO and NCE
Population Projections, 2001, 2006 and 2011
Year
1996*
2000
2006
2006
2011
2011
Age Category
Actual
Actual
Estimate
(CSO)
Estimate
(NCE)
Estimate
(CSO)
Estimate
(NCE)
65-69
859
1,005
1,096
1,091
1,321
1,305
70-74
1,758
2,075
2,140
2,136
2,346
2,335
75-79
2,953
3,495
3,495
3,560
3,651
3,719
80+
10,952
12,973
14,225
14,994
15,197
16,627
Total >65
16,522
19,548
20,956
21,781
22,515
23,986
* Includes assessment/rehab patients and convalescent patients but excludes respite patients and under 65’s.
Table 6.2: Level of Dependency of Patients in all Long-Stay Units based on CSO and NCE Population
Projections, 2001, 2006, and 2011
Level of
Dependency
1996
2000
Year
2006
CSO
2006
NCE
2011
CSO
2011
NCE
Low
2,131
2,522
2,703
2,810
2,905
3,095
Medium
3,635
4,301
4,610
4,792
4,953
5,277
High
4,973
5,884
6,308
6,556
6,777
7,220
Max
5,783
6,841
7,335
7,623
7,880
8,394
Total*
16,522
19,548
20,956
21,781
22,515
23,986
* “Not specified” residents are allocated equally across the four dependency categories.
The overall mix of dependency in the future has also been estimated based on both CSO and NCE
population projections (Table 6.2). In the year 2000 just under 7,000 people in long-stay care are either
low or medium dependency. The number of low and medium dependent people in long-stay care will
rise to 8,372 by 2011, on the basis of NCE population projections. It is likely that the vast majority of
these people could be looked after at home if community-based resources were put in place to
facilitate, encourage and support family care. This support would include the development of highintensive assessment and rehabilitation units for older people. It is also likely that some people in the
high dependency category could be looked after at home under certain favourable conditions,
especially if, as is likely, some people in this category have been placed in a higher dependency
category in order to avail of higher levels of subvention.
The number of people in long-stay care in each health board in the coming decade, up to the year
2011, is shown in Table 6.3. The Eastern Regional Health Authority (ERHA) will experience the largest
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absolute and percentage increase in the number of people age 65 and over in long-stay care in the
period up to 2011. The North Western Health Board region will experience the smallest absolute and
percentage increase in the number of older people in long-stay care up to 2011. Growth rates will be
highest in the 80+ age category in the period 2000 to 2006, while the highest growth rates between
2006 and 2011 will be in the 65-69 age category (Table 6.4). During the period 2000 to 2006 the Midland,
North-Eastern and North-Western health boards will experience a small decline in long stay residents in
the age category 75-79, with the North-West also experiencing a small decline in residents in the 70-74
age category.
Table 6.3: Long-Stay Care Projections by Age Group by Health Board Based on NCE Population Projections
Health Boards
Year/Age
ERHA
M
MW
NE
NW
SE
S
W
Total
1996
65-69
221
56
88
86
69
116
116
107
859
70-74
447
161
193
133
126
209
266
223
1,758
75-79
745
183
359
240
215
336
496
379
2,953
80+
3,396
711
1,076
740
750
1,157
1,562
1,560
10,952
65+
4,809
1,111
1,716
1,199
1,160
1,818
2,440
2,269
16,522
65-69
271
63
107
91
75
147
133
118
1,005
70-74
549
174
235
141
136
265
328
247
2,075
75-79
914
199
436
253
233
427
612
421
3,495
80+
4,168
772
1,310
782
812
1,472
1,928
1,729
12,973
65+
5,902
1,208
2,088
1,267
1,256
2,311
3,001
2,515
19,548
65-69
306
64
116
98
82
158
144
123
1,091
70-74
585
175
238
143
134
277
341
243
2,136
75-79
989
192
442
248
229
425
617
418
3,560
80+
4,999
917
1,506
921
879
1,743
2,148
1,881
14,994
65+
6,879
1,348
2,302
1,410
1,324
2,603
3,250
2,665
21,781
65-69
364
76
141
122
95
190
171
146
1,305
70-74
667
180
260
155
147
300
371
255
2,335
75-79
1,068
195
454
255
228
452
650
417
3,719
80+
5,788
994
1,656
1,004
928
1,919
2,326
2,012
16,627
65+
7,887
1,445
2,511
1,536
1,398
2,861
3,518
2,830
23,986
2000
2006
2011
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Review of the Nursing Home Subvention Scheme
Table 6.4: Percentage Changes in Long-Stay Care Residents by Health Board Region: 1996/2001, 2001/2006,
2006/2011
Health Boards
Year/Age
ERHA
M
MW
NE
NW
SE
S
W
Total
65+
1996
4,809
1,111
1,716
1,199
1,160
1,818
2,440
2,269
16,522
2000
5,902
1,208
2,088
1,267
1,256
2,311
3,001
2,515
19,548
∆N
1,093
97
372
68
96
493
561
246
3,026
23
9
22
6
8
27
23
11
18
65-69
13
2
8
8
9
7
8
4
9
70-74
7
1
1
1
-2
5
4
-2
3
75-79
8
-4
1
-2
-2
0
1
-1
2
80+
20
19
15
18
8
18
11
9
16
65+
17
12
10
11
5
13
8
6
11
65-69
19
19
22
24
16
20
19
19
20
70-74
14
3
9
8
10
8
9
5
9
75-79
8
2
3
3
0
6
5
0
4
80+
16
8
10
9
6
10
8
7
11
65+
15
7
9
9
6
10
8
6
10
∆ %
2000 to 2006
2006 to 2011
We do not know if the number of people with dementia is on the increase in Ireland. This is because we
do not have the data to allow us to compare rates over time. What is happening is that more cases are
now being detected at earlier stages. This is due, in part, to improvements in primary and community
care diagnostic and assessment services linked to increased public awareness about the disease.
Incidence rates are also rising because more and more people are living to the age when dementia
usually strikes. An extrapolation of the international incidence rates to the elderly population in Ireland
suggests that approximately 4,000 new cases arise in the general community population every year
(Keogh and Roche, 1996). This figure will increase in line with the ageing of the Irish population in the
coming decades. The projected growth in the number of people with dementia is shown in Table 6.5,
with the numbers increasing by 5,000 between 2001 and 2011, in line with the general increase in the
elderly population. Not all of these additional dementia cases will end up in long-stay care but it is likely
that more cases than at present will, given the increasing profile of the disease and the huge
psychological costs for carers identified by O’ Shea (2000).
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Table 6.5: The Projected Growth in the Number of People with Dementia in Ireland, 1996-2011
Age Group
1996
2001
2006
2011
30-59
1,984
2,067
2,269
2,447
60-64
1,445
1,513
1,792
2,139
65-69
2,058
2,010
2,169
2,587
70-74
4,740
4,465
4,532
4,923
75-79
5,035
5,354
5,131
5,263
80-84
7,234
7,637
8,165
8,021
85-89
5,365
6,308
6,916
7,604
90-94
2,521
2,874
3,452
3,928
95+
621
562
690
839
Total
31,003
32,790
35,116
37,751
Source: CSO population projections by EURODEM Prevalence Rates
Policy Targets
On the basis of year 2000 data there are currently 19,548 people in long-stay care aged 65 years and
over. This constitutes approximately 4.6 per cent of the total elderly population on the basis of CSO
population projections for the year 2001. At the moment there is one explicit policy target with respect
to the desired balance between community and long-stay care for older people. That policy target is
that 90 per cent of people over 75 years of age should reside in their own homes in the community
(Department of Health, 1994). Achieving that target now would mean an additional 6,446 people living
at home in private households in the community (Table 6.6). This would not necessarily mean an
equivalent reduction in long-stay care of over 6,000 beds. Not all people over 75 years who currently live
outside of private households are in long-stay care. Some of them are in acute hospitals, others in
psychiatric hospitals, while some live in other forms of communal accommodation outside of private
household arrangements.
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Review of the Nursing Home Subvention Scheme
Table 6.6: Number of People aged 75 years and over in Private Households by Health Board Region, 1996
Health Board
Total Population No. in Private
Aged 75 Years
Households
and Over
% in Private
Households
No. in Private
Households if
90% Target
was met
Distance from
Target N
ERHA
50,363
42,549
84
45,326
2,777
Midland
10,329
8,968
87
9,296
328
Mid-West
15,788
13,559
86
14,209
650
North-East
14,665
13,043
89
13,198
156
North-West
13,430
11,920
89
12,087
167
South-East
19,086
16,323
86
17,177
854
South
28,362
24,605
87
25,526
921
West
22,508
19,665
87
20,257
592
Total
174,531
150,632
86
157,078
6,446
The 90 per cent home living target for the over 75’s is, therefore, problematic as a policy objective,
because it does not specify from where the transfers to home living should occur. It is not at all clear
that increasing the number of older people aged 75 years and over at home will lead to a pro rata
reduction in the number of people in this age category in long-stay care. Neither is it a very useful
target when it comes to evaluating the likely influence of public policy on long-stay care need in the
future. The policy target can only be achieved in a prospective, preventive sense, because taking
existing 75+ residents out of long-stay care without significant expansion of community care resources
would likely affect the quality of care of vulnerable people in the 75+ age category. In addition, there
would be a sizeable number of people in long-stay care in this age category who would not be able to
leave long-stay care anyway because they would not be able to survive outside an institutional setting,
even if physically able and ambulatory.
A more effective policy target might be to focus on reducing the admission of publicly subsidised low
and medium dependency older people to public and private long-stay care settings. While this policy
target would also require investment in community care resources and possibly more innovative
approaches to supporting care in the home, it is a more measurable and therefore, more meaningful
target. Currently, 13 per cent of people in all forms of long-stay care are classified as low dependency
patients (Department of Health and Children, 2000b), with Blackwell et al. (1992) suggesting that as
many as one in five people in public long-stay care may be low dependency patients. A further 22 per
cent of residents in all forms of long-stay care are classified as medium dependency. The data also
shows that approximately 1,300 people (16 per cent) in public long-stay care are there for social reasons.
Setting a zero target for low dependency/social cases in public long-stay care settings, and a 50 per
cent reduction in publicly-funded medium dependency residents in public and private care would
provide a powerful impetus for an overall reduction in extended care beds. Clearly, it is on dependency
and its assessment that policy must focus, if the target is to reduce publicly funded admissions to longstay care. There is very little justification for the admission of low and medium dependency people into
long-stay care, except in the most difficult of family and social circumstances. The current practice
reflects a lack of both imagination and resources to solve the problem at a local community care level.
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The policy target for publicly-funded long-stay beds for older people currently used by the Department
of Health and Children is 50 per 1,000 elderly population. The actual publicly-funded rate of long-stay
bed provision in the country is 44.5 per 1,000 elderly population (Table 2.1), leaving a current shortfall of
approximately 2,400 beds for older people. This will rise to just under 3,000 beds by 2011 on the basis
of NCE population projections for people aged 65 years and over for that year. However, the 50 bed
norm is already being exceeded in some regions with the rate of publicly-funded beds per 1,000 elderly
population varying significantly across the country, from a high of 52 per 1,000 in the North West to a
low of 40 per 1,000 in the North East (Table 2.3). Clearly, the inadequacy of publicly-funded bed
provision is a problem for some regions more than others. Moreover, the problem may be one of a
shortage of a particular type of public bed rather than a general shortage of beds. In particular, the
major area of underprovision is in the assessment/rehabilitation sectors where close to 1,500 additional
beds may be required to meet the current planning norm of 5.5 per 1,000 elderly population taken from
The Years Ahead (1988) planning report. An investment of this magnitude in assessment and
rehabilitation services through the continued development of Community Nursing Units would serve
two purposes. It would address the current under-provision of assessment/rehabilitation beds, but it
would also be an important integrative force in linking community care, residential care and acute care
for older people in this country.
Dependency in the Community
Dependency is the consequence of the state of incapacity stemming from physical or mental illness or
disability (Carr-Hill and Dalley, 1999). Moving from the measurement of dependency, through assessing
the impact of that dependency on need, to predicting future levels of dependency is a complex and
inexact process. The first difficulty is the absence of any agreement for measuring dependency at the
individual level (Wilkin and Thompson, 1989; Dunn and Lewis, 1993). Most commonly used is the scale
of core tasks or Activities of Daily Living (ADL’s), performance of which are necessary for survival,
including walking, feeding, dressing, bathing, going to the toilet and so on. This approach has been
used by the author in previous research but is not without it’s critics who point to the restricted nature of
the scale and its obvious inappropriateness for some types of dependency (for a good discussion see
Bowling, 1997). Even if agreement is reached on the measurement tool to be used there remains the
difficulty of moving from the level of the individual to that of assessing levels of dependency within a
population. In the absence of individual records from general practitioners or public health nurses,
population surveys are the only potential source of information on dependency within the community.
The problem is that such surveys are expensive, and there has not been any official exploration of
community-based dependency in this country. What information there is comes from existing surveys of
older people, all of which were undertaken for purposes other than the measurement of dependency in
the community. Consequently, there is no consistency in the approach to the measurement of
dependency, but these surveys are the only information available to us.
The most recent source of information on the dependency of older people in the community comes
from survey work by Layte et al. (1999). The total number of older people who experience chronic
physical or mental problems is 186,000, or 44 per cent of the elderly population. Nearly three in ten (29
per cent) older people who experience chronic physical or mental health problems are severely
hampered as a result of these problems (Table 6.7). The percentage of older people who are severely
restricted as a result of chronic illness does not change much with increasing age from the age of 65
years upwards. Information on the number of people who are severely restricted as a result of chronic
illness is a good indicator of the level of serious need in the community. However, it is unlikely to tell the
full story with respect to overall need, since people who are not severely restricted may also need
support and care from family and friends.
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Review of the Nursing Home Subvention Scheme
Table 6.7: Chronic Physical or Mental Health Problems in Older People by Age Group
Age Group
% with chronic
physical or mental
problem
Number with
% Severely restricted Number severely
chronic physical or
as a result of
restricted as a result
mental problem
chronic illness
of chronic illness
65-69
34
44,166
30
13,250
70-79
48
96,192
28
26,934
80+
47
45,778
32
14,649
All 65+
44
186,136
29
54,833
Source: Adapted from Layte et al. (1999) and based on CSO 2001 population projections
Work by Fahey and Murray (1994) suggests that just under 90,000 older people in the community
require care and assistance from family and friends (Table 6.8). This data can be transformed into an
ADL-based measure to examine the degree and distribution of dependency in older people living at
home and receiving care from family and friends (Table 6.9). The basis of this transformation is a study
conducted in the early 1990’s which examined the dependency levels of community-based older
people requiring some (however small) level of care in order to continue to live at home (Blackwell et al.,
1992). The measure is based on a Guttman scaling of disability which reflects the view that if people
cannot perform a particular task, they will be unable to perform tasks rated as higher order. The scale
rests on the assumption that disability progresses in a cumulative loss of function, and that disability can
be represented in a hierarchy of severity. Provided that disability progresses steadily from one activity to
another (i.e. people first have difficulty with bathing, then in bathing and walking outside and so on until
they are disabled in respect of all activities contained in the scale), this method of scaling yields a single
rating of 1 (no disability) to 9 (disabled on all nine). The scale shows considerable range in dependency
amongst older people living at home. What is of major interest for our study is the significant number of
older people with high levels of dependency who might legitimately be deemed, under any measure of
dependency, to be on the margin between community and residential care.
Table 6.8: Percentage and Number of Older People Requiring Physical Care or Assistance by Age Group and
Sex
Age Group
Males
Requiring Care
%
Females
Requiring Care
%
Total People
Requiring Care
%
Total People
Requiring Care
N
65-69
10
12
11
14,289
70-79
13
23
18
36,072
80+
34
45
40
38,960
All >65s
16
24
21
89,321
Source: Adapted from Fahey and Murray, 1994
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It is difficult to compare data on dependency in the community with similar data in residential care since
there has not been any consistent or disaggregated measurement of dependency in either sector in this
country. Neither has there been any attempt made to harmonise the measurement of dependency
between the community and residential care. All we can do in the circumstances is to attempt to
reformulate existing community-based measures of dependency in line with official residential-based
measures. One possible approach in that regard is to redefine the various levels of Guttman disability
shown in Table 6.9 into broad categories of dependency as follows: low, medium1, medium2, maximum
and high. Using this admittedly subjective approach to defining dependency suggest that there are just
under 50,000 people living at home who are significantly dependent (medium1 or higher) and in need
of high levels of care and attention from family and friends. The broad estimate of 50,000 in need of
care is close to the estimate provided by Layte et al. (1999), shown in Table 6.7, of the number of older
people who are severely restricted as a result of chronic illness. Just over 13,000 of these people are
likely to be high to maximum dependency if one takes being unable to wash or feed unaided as a
signal of very heavy dependency. Thus, if one accepts these estimates, it appears that for the most
dependent elderly, family care has the same significance as formal institutional care in terms of the care
requirements for this group (see Table 6.2). The allocation of public resources between the two sectors
is, however, heavily biased in support of people in residential care. This points up a significant inequality
in public funding and resources for two similar groups of older people, which cannot be justified on
grounds of dependency or income.
Table 6.9: Distribution of Dependency of Community-Based Older People Living in Same Household as Carers:
An ADL-Based Measure
Guttman ADL-Based
Scale Point
Category of
Dependency (%)
Category of
Dependency (N)
Independent
Low
15
13,399
1.Unable to bathe unaided
Low
30
26,796
2.Unable to walk outdoors unaided
Medium1
14
12,505
3.Unable to walk indoors unaided
Medium1
6
5,359
4.Unable to dress unaided
Medium2
3
2,680
5.Unable to get in/out of bed unaided
Medium2
4
3,573
6.Unable to sit/stand unaided
Medium2
3
2,680
7.Unable to use toilet unaided
Medium2
4
3,573
8.Unable to wash unaided
High
9
8,039
9.Unable to feed unaided
Maximum
6
5,359
6
5,359
100
89,321
Non-scale
Total
Source: Blackwell et al., 1992
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Need and Community Care
Policy formulation and the setting of targets is a necessary but not sufficient condition for effecting
change in the balance between community care and residential care for dependent older people.
Setting more ambitious targets for the number of older people living at home is of little use without an
investment in community care resources designed to support more people remaining in their own
homes. However, translating dependency and disability levels in the community into accurate
assessments of need is a complex task. The term need is usually taken to mean some underlying
absolute requirement, but there is no agreement on the nature and characteristics of that absolute
requirement. Bradshaw (1972) outlined four categories of need, which have endured and have been
used to explore the concept of need in other countries. These categories of need are as follows:
•
normative need: as defined by the expert or professional working in the particular field
•
felt need: this refers to what people want if given the opportunity to express their own
preferences
•
expressed need: this is felt need turned into action i.e. demand.
•
comparative need: this measure is found by comparing people in receipt of a service with
those of similar characteristics who are not in receipt of the service.
Population-based measures of need derived by researchers are usually based on a combination of
normative need and felt need. Policy-makers, on the other hand, have tended to define need by
reference to eligibility or receipt of service which by definition becomes self-limiting depending on the
availability of resources. This is an understandable reaction to the resource constraint but it does lead to
undesirable outcomes. Services are denied to older people with lower levels of need in order to
concentrate on higher levels of need, thereby overlooking the preventive aspect of early intervention.
Similarly, resources are denied to older people who are looked after within families, so placing
considerable and sustained burdens upon families.
One of the key elements of public policy initiatives designed to keep people living at home is,
therefore, the development of a good community care system. The Years Ahead report described an
optimal model of best practice for dependent older people in terms of a continuum of service
provision, with increasing levels of support as the level of dependency increases. While some real
progress has been made in the provision of community care services, the reality is that, relative to the
residential care sector, community care remains variable and fragmented across the country. Generally,
dependent older people, including people with dementia, do not come into contact with the health
and social services until a crisis occurs, involving the dependent older person, their carer, or both
parties. Late intervention is, in turn, more likely to lead to residential care, as the carer may no longer
feel that he/she is able to cope. The result is a system geared to providing substitute care for
dependent older people rather than providing anticipatory and ongoing care in partnership with
patients and their family carers.
Table 6.10 shows the low level of core community care provision for even highly dependent older
people (Blackwell et al., 1992). It is true that where care is provided it is concentrated on the most
dependent older people, but this reflects a pragmatic response to the paucity of resources rather than
an optimal strategy. Although this data is now somewhat dated, there is no reason to believe that there
have been major improvements in community care services. Recent data on community care services
for people with dementia confirms the low level of current provision (O’Shea, 2000).
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Table 6.10: Weekly Community Care Services for Dependent Elderly People, Number of Visits per Week
Category
of Dependency
GP
Public Health Nurse
Home Help
Meals on Wheels
Low
0.12
0.10
0.00
0.00
Medium1
0.23
0.04
0.14
0.17
Medium2
0.24
0.11
0.53
0.00
High
0.28
0.27
0.00
0.00
Maximum
0.23
0.76
0.64
0.42
Total
0.17
0.17
0.16
0.05
Source: Blackwell et al., 1992
Although a large proportion of community care resources go towards the public health nursing services,
the evidence suggests that the public health nurse is not always in a position to give older people the
level of service that they require. While the public health nursing service is highly valued by people who
receive the service (Ruddle and O’ Connor, 1993), visits are not frequent enough, or long enough, and
too few people receive the service. The community-nursing problem for people with dementia is
exacerbated by the relative absence of community psychiatric nurses working in this area.
The number of public health nurses per 1,000 elderly population is shown in Table 6.11 for 1996. The
Midland Health Board contains the most nurses per 1,000 elderly population at 4.2, while the Southern
Health Board contains the least number of nurses at 2.8 per 1,000 elderly population. The national
average is 3.4 per 1,000 elderly population. Table 6.11 also provides an estimate of the ratio of nurses to
dependent older people across the country. The estimated community-based dependent elderly
population of 89,321 is distributed across the boards on the basis of actual population weights to give
the ratio of nurses to dependent elderly population. What this data shows is the public health nursing
service under considerable pressure with nurses facing very demanding case-loads. It is no surprise that
with ratios varying from 1:51 to 1:78 that nurses concentrate on the high risk cases.
Table 6.11: Public Health Nurses (PHN) by Health Board, 1996
Health Board
86
Public Health Nurses
PHN per 1,000
Elderly Population
Ratio of Nurses to
Dependent
Older People
ERHA
454
3.6
1:60
Midland
105
4.2
1:51
Mid-West
121
3.2
1:67
North-East
118
3.4
1:64
North-West
105
3.6
1:60
South-East
157
3.4
1:64
South
183
2.8
1:78
West
173
3.5
1:61
Total
1,416
3.4
1:63
Review of the Nursing Home Subvention Scheme
Table 6.12: Home Helps: Numbers and Beneficiaries, 2000
Health Board
Region
Total Home
Help Hours
per Annum
Average Weekly
Hours of Home
Help per 1,000
Elderly
Number
Receiving
Services
(65+)
1,298,978
182
3,183
25.4
11
Midland
371,323
279
1,143
45.7
22
Mid-West
566,310
281
1,678
44.8
21
North-East*
698,964
368
1,590
45.7
21
North-West
561,065
364
1,286
43.7
21
South-East
656,483
260
1,287
27.6
13
South
1,829,477
521
4,163
63.0
30
West
524,486
203
1,731
35.2
17
Total
6,507,086
289
16,061
38.8
18
ERHA
Number
Number
Receiving
Receiving
Services (65+) Services as %
per 1,000
of Estimated
elderly
Dep. Eld.
Population
* Includes home care assistants
Despite the importance of home support services for older people and their carers, very few people
have access to a comprehensive range of these services. This remains the case despite the recent
significant increases in resources for home help services. There is also evidence of considerable
variability in the levels of provision of home support services across the country. For example, home
help hours per week per 1,000 elderly population are unevenly distributed across the eight health
boards (Table 6.12). The Southern Health Board provides almost three times more home help hours per
1,000 elderly population than the ERHA. Overall provision is also low relative to the number of
dependent older people living at home. Less than one in five dependent older people living at home
receive home help services, with the figure in the ERHA closer to one in ten. What tends to happen is
that the health authorities treat home help and informal care by family members as substitute services
rather than complements. Rationing is taking place on the basis of age, dependency and household
composition in a pragmatic response to under-provision. Similarly, occupational therapists,
physiotherapists, social workers and chiropodists have an important role to play in the care of older
people in the community. However, public provision of these services is minimal with only a handful of
older people receiving services from these providers.
Respite care provided by hospitals and nursing homes provides short-term and emergency relief for
carers. Respite services are necessary to provide carers with time off from the continual demands of
caring. It is one of the services that carers consider to be necessary for them to continue caring, yet
there is a considerable amount of unmet need in relation to this service (Ruddle and O’Connor, 1993;
O’Shea, 2000). Moreover, like most other community care services, marked variations exist in terms of
respite care provision across the country (Table 6.13). The North Eastern Health Board is by far the
leading provider of respite beds with a rate of 2.9 per 1,000 elderly population. The South Eastern
Health Board and the Western Health Board are the lowest providers of respite beds with rates of 0.3
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and 0.2 per 1,000 elderly population, respectively. There is one respite bed for every 180 dependent
elderly people living at home in the community. There is one bed for every 72 dependent elderly
people living at home in the North East, while in the West, the ratio is one respite bed for every 931
people living at home.
Table 6.13: Respite Beds for Older People by Health Board, 2000
Health Board
ERHA
Respite Beds
Respite Beds per 1,000 Ratio of Respite Beds
Elderly Population
to Dependent Elderly
Population
145
1.1
1:195
Midland
48
1.9
1:110
Mid-West
45
1.2
1:177
North-East
105
2.9
1:72
North-West
54
1.8
1:113
South-East
13
0.3
1:770
South
76
1.1
1:183
West
11
0.2
1:931
Total
497
1.1
1:180
Respite care for people with dementia is even more problematic. The majority of existing respite
services are not dementia specific and are often not inclined to accept certain categories of dementia
patients whom they perceive to be troublesome (O’Shea and O’Reilly, 1999). Not surprisingly, given the
objectives of respite care programmes, the carers of people with dementia tend to report high
satisfaction levels with respite services, where they exist (Levin et al., 1994). That said, the evidence is
mixed on whether the overall burden of care for carers, including stress levels, is reduced by respite care
(Lawton et al., 1989). Sometimes, in-patient respite care can cause disorientation and restlessness in
older people with dementia leading to increased levels of anxiety for the older person and their
families.
Family Care and Admission to Long-Stay Care
The high level of dependency among older people living at home is confirmed by large scale surveys
on the level of care provided by family and friends. O’ Connor et al. (1988) suggest that carers devote
between four and seven hours per day to caring, with 20 per cent of carers providing 10 hours or more
care per day. Blackwell et al. (1992) confirm the major role played by carers in keeping people of high
dependency living at home (Table 6.14). Averaged across all dependency categories, from low to
maximum dependency, carers spend an average of 49 hours per week caring. Carers spend an average
of 7 hours per week helping with physical activities of daily living, 16 hours per week helping with
instrumental activities of daily living and an average of 26 hours on supervision. For people on
maximum dependency carers spend an average of 84 hours per week caring; 29 hours providing help
with physical activities of daily living, 26 hours on instrumental activities and 29 hours on supervision.
88
Review of the Nursing Home Subvention Scheme
What is interesting about family care is the existence of a floor or bottom line level of care that must be
provided even for those who are relatively physically independent. This care involves help with the daily
activities of shopping, preparing meals, housekeeping, and washing and ironing, activities which require
a considerable amount of time. Supervision includes more intangible caring activities such as
encouragement, persuasion, keeping company and monitoring, activities that take on a very important
and significant role for people with dementia. It is only in the move from medium2 dependency to high
dependency that weekly care hours increase to any great extent, with the most significant jump evident
in the move between high and maximum dependency.
Table 6.14: Average Number of Hours of Care per Week Provided by Principal Caregiver by Category of
Dependency and Type of Care
Dependency
Dep. Rank
Physical Care
Supervision
All
Low
1.4
17.1
23.0
41.5
Unable to
walk outdoors unaided
Unable to
walk indoors unaided
Med 1
6.4
11.2
27.9
45.5
Unable to dress unaided
Unable to get in/out bed
unaided
Unable to sit/stand unaided
Unable to use toilet unaided
Med 2
11.0
12.9
23.8
47.7
Unable to wash unaided
High
16.6
17.7
25.1
59.4
Unable to feed unaided
Max
29.1
26.2
29.3
84.6
Non-Scale
7.2
18.4
37.1
63.7
All
7.0
16.0
25.8
48.8
Independent
Unable to bathe unaided
Instrumental
Care
Any reduction or withdrawal of family care from people with high or maximum dependency would
mean additional demand for public and private residential care, up to a maximum of 13,000 places. This
is the doomsday scenario for governments and private insurers everywhere, given the additional
financial cost associated with formal as distinct from family care. There is no evidence, however, that
family care-giving is declining, or that families are becoming more selfish, despite anecdotal evidence
to the contrary (O’Shea and Hughes, 1994). While most of the concern about the future has focussed on
the impact of increased participation rates of women on the willingness of families to care, particularly
for people on the boundary of residential care, this may not be the biggest danger to the family care
system. Analyses from the UK suggests that rising women’s employment has so far not led to any
reduction in the supply of informal care (Parker, 1990; Joshi, 1995). Women combine both aspects of
their lives, but at a cost to themselves and their families.
The main problem is not families continued willingness to care, which remains intact, but the fact that
families are being asked to do too much without adequate support from the statutory sector. This is
where the attrition on families willingness to care is occurring. The enormous psychological stress on
family carers is a consistent finding in the literature on the willingness of families to care for their elderly
kin (O’Connor et al., 1988; Blackwell et al.,1992; Fahey and Murray, 1994; O’Shea, 2000). The latter study
shows extraordinarily high and unsustainable stress levels for carers looking after people with dementia.
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The current policy asks a lot of families without offering much in return at a time when traditional family
caring and sharing arrangements are likely to be under most pressure. While the Carer’s Allowance
provides valuable financial support for those who receive it, the rules for qualifying for the Allowance
remain restrictive, despite significant improvements in recent years1. The Scheme currently supports just
over 17,000 carers, at an estimated cost to the exchequer of £108 million in 2001. Three fifths of people
being looked after by carer’s in receipt of Carer’s Allowance are aged 65 years or over (Department of
Social, Community and Family Affairs, 1998). This means that of the 50,000 older people living at home
and in need of significant levels of care only 20 per cent are likely to be cared for by someone covered
by the Scheme. In contrast, existing policy offers significant support to residential care, without much
evaluation of the returns to that investment relative to the returns to be gained from a sustained
investment in families. The importance of family care as the critical bulwark in lowering demand for
nursing home care cannot be emphasised enough. Unfortunately, the continued willingness of families
to care is being put at risk by the failure to expand eligibility for Carer’s Allowance and to develop
community care services and rehabilitation services in this country.
Table 6.15: Female Caretaker Potential in Ireland, 1926-2031
Year
Women Aged 45-69/
Population aged 70+
Women Aged 45-69/
Population aged 75+
1926
1.9
3.6
1936
1.9
3.8
1946
1.7
3.4
1951
1.6
3.1
1961
1.6
2.9
1966
1.7
3.0
1971
1.6
3.0
1979
1.6
2.8
1981
1.6
2.7
1986
1.4
2.5
1991
1.4
2.4
1996
1.4
2.4
2001
1.6
2.5
2006
1.7
2.7
2011
1.8
2.8
2016
1.7
2.6
2021
1.5
2.6
2026
1.4
2.3
2031
1.2
2.0
1 Medical expenses relief is also available in appropriate circumstances, while Carer’s Benefit currently
covers about 1,000 carers at an annual cost to the Exchequer of £5 million.
90
Review of the Nursing Home Subvention Scheme
Three quarters of carers in Ireland are women and the vast majority of these are aged between 45 and
69 years of age (Blackwell et al., 1992). Considering that care for the elderly has traditionally been a
female task, the ratio of women aged 45-69 to all people aged 70+ and 75+ may be considered a
crude indicator of the caretaker potential within the family system. As Table 6.15 shows, both potential
caretaker ratios actually improve in Ireland up to 2011, with the ratios only falling below current levels
after the year 2026. While there will be continuing pressure on the family caring system due to the
increasing participation rates of women in the paid labour market, the increase in the caretaker
potential ratio may partly offset some of the negative impact of these labour market changes on
dependent elderly people in the community. The development of supportive and relevant community
care structures will, however, ultimately determine the willingness of families to continue providing the
high levels of care currently being provided to dependent older people.
Living Alone
The impact of living alone on the demand for institutional care depends on the willingness and ability of
family carers and friends to care when the older person lives on their own. Most caring is done within
households, but not exclusively so, and there is no evidence of widespread neglect by carers when an
elderly person lives alone. Fahey and Murray (1994) examined the family network of older people and
found them typically large and strong mainly due to demographic factors. As well as having large
extended families, the majority of older people have high levels of contact with these families. The
exception to this pattern of large extended families are the elderly who never married who not only lack
spouses and children, but also have smaller number of siblings than the average for older people in
Ireland. It is not that this group are without contacts, simply they have less contacts than ever-married
older people.
In assessing the significance of the extent and quality of family networks among older people it is
important not to lose sight of the primary importance of the spouse in the welfare of older people
(Fahey, 1997). Researchers have found that the best way to avoid going into residential care is for your
spouse to stay alive. Grundy (1995) found that, for otherwise comparable groups in the United
Kingdom, twice as many widows go into residential care as do married women. Single women who
have never married are four times more likely to go into residential care than ever-married women. For
Ireland, O’Shea and Corcoran (1989) identify living alone as one of the primary factors likely to influence
the placement of an elderly person into public long-stay institutional care.
Table 6.16: Living Alone in Private Households by Health Board, 65+, 75+, 1996
Health Board
ERHA
Living Alone:
Persons 65+
(N)
Living Alone:
Persons 75+
(N)
Living Alone:
Persons 65+
(%)
Living Alone:
Persons 75+
(%)
32,554
15,753
28.7
37.0
Midland
6,453
2,984
28.0
33.0
Mid-West
9,927
4,542
29.0
33.5
North-East
9,266
4,486
28.6
34.4
North-West
8,074
4,110
29.7
34.5
South-East
11,774
5,527
28.6
33.9
South
16,995
8,500
28.2
34.5
West
12,100
5,920
27.0
30.1
Total
106,943
51,822
28.3
34.4
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The number of people aged 65 years and over living alone as a percentage of all older people in
private households is 28 per cent (Table 6.16). Just over one in three people over 75 years of age living
in private households live alone. The percentage of people aged 75 and over living alone ranges from
30 per cent in the West to 37 per cent in the ERHA. In the remaining six health boards the proportion of
people aged 75 and over living alone does not vary much from the national average. Unfortunately, we
have no way of telling if people who live alone are more physically dependent than those who do not,
leading to a higher probability of institutionalisation. We do know, however, that a significant
percentage (16 per cent) of older people in long-stay care are classified as social cases, many of them
categorised as such because they are incapable of looking after themselves on their own.
Table 6.17: Public and Private Provision by Health Board Region: Residential Long-Stay Beds and Community
Care Services per 1,000 Elderly Population
Type of
Bed/Service
ERHA
M
MW
NE
NW
SE
S
W
Total
HB Provided
Extended Care Beds
17
26
19
19
22
25
23
23
21
HB Funded in
Private Facilities
18
12
23
11
19
14
15
20
17
Private and Voluntary Beds
(Non-Subvented)
14
12
17
8
4
10
13
13
12
Respite Beds
Per 1,000 Elderly
1.1
1.9
1.2
2.9
1.8
0.3
1.1
0.2
1.1
Weekly Home Help
Hours per 1,000 Elderly
182
279
281
368
364
260
521
203
289
PHN per 1,000 Elderly
3.6
4.2
3.2
3.4
3.6
3.4
2.8
3.5
3.4
The critical question is whether the number of people living alone is likely to increase in the future
thereby adding to the demand for residential care places. According to Fahey (1995), the number of
older people living alone as a percentage of all older people (not just people living in private
households) is expected to increase only modestly in the period up to 2011, from 24 per cent in 1991 to
26 per cent in 2011. This is because the increase in the number of widowed in the population and in the
likelihood that the widowed will live alone will be counterbalanced by an increase in the number of
couples and a decrease in the number of single persons. While the 26 per cent mark has already been
passed, it is unlikely that actual growth in the number of older people living alone in the next ten years
will place much additional pressure on the numbers seeking admission to long-stay care. Even so, there
remains a higher risk of institutionalisation associated with living alone than with living with other
people. The policy issue is, therefore, one of finding the optimal strategy to providing support and
resources for vulnerable older people living on their own in order to keep them living at home for as
long as possible and practicable.
Public Private Relationships
People generally prefer public beds to private beds because of the financial implications of ending up
in private care, even with the maximum subvention. People may also prefer public care to private care
on the basis of quality of care, particularly if assessment and rehabilitation services are available in the
92
Review of the Nursing Home Subvention Scheme
public facility. On the other hand, the “County Home” stigma still prevails in some places which
sometimes leads to a preference for private care over public care. Spatial considerations and
geography can also lead to a preference for locally-provided private care, particularly if the relevant
public facilities are located some distance away. Under the Nursing Homes Regulations the health
board can refuse subvention payment to applicants who have been offered, but have declined a public
bed. Because of the shortage of public beds in some health boards, as described above, such action
does not happen very often and, in any case, it is the intention of the Department of Health and
Children to revoke the relevant articles in the Regulations pertaining to this issue. In one particular
health board, applicants were refused the subvention in cases where they had been offered public
beds, but because of strong negative public reaction, this policy was abandoned. Conversely, in some
parts of the country, for example in the North Western Health Board, people identified as being in need
of long-term care are offered a choice of care settings where possible. If they choose private nursing
home care they will be granted a subvention if they are eligible, regardless of the availability of an
alternative public bed in the area.
Health board policy documents increasingly show an acceptance of private nursing home care as a
legitimate alternative in the continuum of care for older people in their areas, as well as a belief in older
people’s right to choose private care. Some health boards rely more heavily on the private nursing
homes for the long-term care of older people than others, but this has more to do with the shortage of
public long-stay beds in the region rather than ideology. There is little evidence of strategic planning in
relation to the mix of services between public residential care, private residential care and community
care (Table 6.17). Where public beds are scarce the needs of older people are met through the
development of the private residential sector and subvention beds rather than through the
development of community care services. The ERHA has a relatively low provision of health board
provided extended care beds but does not compensate for weak public bed provision with a strong
community care system. Instead, the private residential care sector is used to meet the long-stay care
needs of older people in the region. Similarly, the Mid-Western Health Board has the highest rate of
non-subvented private bed provision but a poorly developed community care system. On the other
hand, the North Western Health Board seem to be more public in orientation, with more public beds
than private beds and more highly resourced community care structures than the national average. The
North Eastern Health Board region has the most developed community care services in comparison to
other regions, at least in the areas of respite care, home help hours and, to a lesser extent, public health
nursing. This may partly explain the relatively low level of overall bed provision in the North-East.
The absence of public beds in a region has a direct impact on the operation of the subvention system.
When public beds are scarce and community care services are under-developed, some older people
may have no choice but to enter private nursing home care. In these circumstances, there is likely to be
strong pressure on the health board to give subventions for private nursing home care as an alternative
to public care. For people with low incomes, the maximum subvention may not cover the cost of care,
especially in areas where charges are high, leading to more pressure on health boards to grant
enhanced subvention payments. The situation is exacerbated by the small but significant number of
older people currently occupying high-cost beds in acute hospitals because there are no non-acute
public beds available. Priority is given to these cases for enhanced subventions or, where available, for
contract beds in private nursing homes.
The pressure, therefore, when it comes, is nearly always for increased spending on residential care
rather than on community care services. The option of developing ex-ante community oriented
intensive rehabilitation solutions for vulnerable older people seems too cumbersome and complex
when compared to the ease with which beds can be subvented or contracted to the private sector ex
post. Investment in rehabilitation-based responses to the needs of vulnerable older people may be the
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way forward, however, if we want to prevent unnecessary admissions into long-stay care. In that regard,
approximately £200 million will be available for the capital development of services for older people
over the period of the National Development Plan. This will allow for the provision of approximately 20
new Community Nursing Units (averaging 70 beds in each) and 20 Day Care Centres (averaging 20-25
places per day in each), and for the extension of some existing facilities.
Some older people are in private nursing home care because of the lack of community care services to
support them in their own homes or in the homes of their family. The relationship between the
community care provision and residential care provision should not be pushed too far, however, given
the different unit of measurement within each sector — i.e. people and beds. There is a big difference
between the role of the home help and that of the private nursing home in terms of their effect on the
quality of life and well-being of older people, depending on the particular circumstances of each case.
Moreover, the issue of the adequacy of community care resources remains an important one. Even if
some regions have higher ratios of community care resources to elderly populations than other regions,
this does not tell us anything about the adequacy of provision, which may still be poor, even though
better than elsewhere. Increased investment in community care linked to greater evaluation of new and
existing community-based facilities are needed in all regions if the current objectives of keeping older
people living at home are to be achieved.
Conclusion
Based on CSO population projections the number of older people in long-stay care will increase to
22,515 in 2011, an increase of 36 per cent from 1996. The increase is higher if NCE population
projections are used, with the number of people in long-stay care increasing to 23,986 in 2011, an
increase of 45 per cent in the period 1996 to 2011. Not surprisingly, given the regional imbalance in the
population structure in Ireland, the ERHA will experience the largest absolute and percentage increase
in the number of people aged 65 and over in long-stay care in the period up to 2011. The North
Western Health Board will experience the smallest absolute and percentage increase in the number of
older people in long-stay care up to 2011.
These estimates are based on projected population changes only and need to be interpreted with
caution for that reason. For example, older people in the North West and West are more likely to be
living in single person households and in spatially isolated circumstances thereby increasing their overall
risk to institutional care. This qualification highlights the need to explore the range of influences on the
growth of the residential care sector beyond population changes. On the other hand, the fact that we
know so little about the differential impact of the various factors that influence placement decisionmaking in this country means that planning for the future is far from an exact science. In such
circumstances, population projections may be a reasonable, if crude, proxy for estimates of future need
in the system.
When public beds are scarce and/or private beds are expensive, the availability and willingness of
families to care makes the major difference to keeping people at home, not the existing community
care system. Without families the community care system for older people would have collapsed a long
time ago. Families provide extremely high levels of care, even for relatively low dependent older
people. At the margin between community care and residential care, family care has the same
significance as nursing care within public and private institutions. The contribution of the community
care system to keeping people out of care is less than that of families, primarily because of the
94
Review of the Nursing Home Subvention Scheme
inadequacy of the system as currently resourced. The overall level of dependency in the community is
significant, but the community support mechanisms are not as well developed as in residential care.
There seems little justification for the continued public subvention of low and medium dependency
residents in either public or private long-stay care, without first of all attempting to care for these people
in the community. Medium dependency is defined in the Regulations more in terms of the absence of
community care rather than any intrinsic physical or mental deficiencies that require a person to be
cared for in residential care. The key element in the definition of medium dependency is the following
phrase: because the appropriate support and nursing care required cannot be provided in the
community. Even if one was to interpret “cannot” as meaning “cannot because of the dependency of
the older person” it is difficult to think of many situations where that interpretation might apply for older
people with medium dependency. Solving the community care problem would, by definition, address
the medium dependency problem in long-stay institutions. It wouldn’t exist if appropriate community
care services and facilities were available in the first place.
Policy implementation has been under-estimated in the debate about the appropriate mix of care for
dependent older people and the associated cost of subvention. The most important contribution to
reform of the residential care sector would be to implement current policy on care of the elderly. The
introduction of appropriate policy targets to discourage the admission of low and medium dependent
older people into residential care, including social cases, would be an important signal that current
policy will be implemented. The provision of more publicly-funded beds for older people through
Community Nursing Units, particularly for assessment and rehabilitation, should also serve to orient the
system to a more intensive form of long-stay care provision where the emphasis will be on returning
people to the community rather than simply providing a long-stay bed. Ultimately, however, the
development of community care services, including enhanced support structures for family carers, is the
key to reform of the public subvention system for private nursing homes. The best way to reduce public
expenditure on private nursing homes in the future is to ensure that fewer older people are forced to
leave their homes in the community. This point will be elaborated upon in the next chapter.
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Introduction
This chapter sets out a revised model for the funding of older people in public and private longstay care and in community care. The aim is to recalibrate the current model to favour home care
over residential care, thereby improving the overall efficiency and effectiveness of long-term care
financing for older people. The system is currently biased towards residential care and the
nursing home subvention scheme is a good example of the perverse incentives facing older
people and their families to choose in-patient care over home care. Services and facilities
should, generally, serve the needs and preferences of older people, not the other way round,
and financing systems should be designed so as to give maximum expression to those needs
and preferences, which for most people would mean more funding for home care. Similarly, the
organisation and delivery of care affects the choices older people make when they have care
needs. Therefore, if we want to influence the behaviour of older people and their families then
changes are required in the way long-stay care is currently funded. A number of ideas and
suggestions for improving the effectiveness of the current system are discussed in the chapter.
These include a common approach to dependency assessment and means testing between
public and private long-stay care, an increase in the subvention payment for people in private
care, a time limit on the public funding of people in both public and subvented private
residential care, a new way of dealing with assets and the introduction of community-based
subvention payments. First of all, however, it is important to outline the principles behind the
reformulation of the current subvention system.
Principles for the Funding of Long-Term Care
Before any discussion of new approaches to the financing and subvention of long-term care,
including marginal changes to current arrangements, it is helpful to place the discussion in the
context of what we hope to achieve under any future system. Above all else, the funding system
should support an organisational structure that will lead to the realisation of given social
objectives with respect to care of the elderly. The most basic objective is that the autonomy of
older people should be respected; that means they must be supported in their home for as long
as possible and practicable. Financing systems will also be governed by other concerns including
wider political choices, social values and economic constraints, but keeping older people living
in their own homes must be the guiding objective throughout any discussion in this area. The
most useful way to evaluate potential financing schemes is to elaborate a set of principles
against which progress can be measured (OECD, 1992). There is no scientific way of doing this.
Any set of principles will contain both normative and subjective elements. What follows are three
core principles which should underlie the new model for the funding and subvention of long-stay
care in the future.
Review of the Nursing Home Subvention Scheme
• Funding should not determine care requirements; rather care requirements should determine funding
A financing system should not determine how funds should be spent but should be structured in
such a way as to respond in a flexible manner to meet the individual needs of older people.
Care requirements should, therefore, determine the types of services and supports to be funded
(Merrill and Smith, 1985). This means that should people value home helps, day care centres or
emergency response systems more highly than institutional care then finance should be available
to provide these services. People should not have to wait until they become dependent or enter
an institution before they are covered by the financing system. The conditions governing any
financing arrangements should enhance rather than reduce the degree of real choice that older
people have over the conditions of their life. While trade-offs and contradictions are inevitable
between what an individual would freely choose and what can realistically be provided even in
the best of systems, supply should not be allowed to dominate or determine demand. By this we
mean that service providers of a certain type (e.g. custodial care institutions) should not, by their
current and historic dominance, be allowed to have a disproportionate influence over funding to
the disadvantage of other more appropriate, but as of yet under-developed, services. Ultimately,
this may require a clearer separation between the funding of care and the provision of care, than
we have at present.
• There should be a built-in bias towards home care solutions while retaining a capacity for financing care in
institutionalised settings.
Older people have, by and large, expressed a preference for care in the home rather than in
institutions. This should be reflected in the financing system, through a financial commitment to
support home care solutions. People should not be given a subsidy for residential care unless it
is clear that a similar allocation would not have succeeded in keeping them at home. This means
supporting informal carers in their work, as well as providing funds for the social infrastructure so
necessary to allow older people to continue living at home. Respite care, day care, day hospitals
and rehabilitation facilities are important elements of the social infrastructure, as are visiting
services such as public health nurses and home helps. The voluntary sector also plays a major
role in caring for older people and should be integrated with the statutory financing system.
Their role should be explicitly acknowledged through prospective and fully accountable
budgetary transfers.
• Access should be on the basis of need and should not be impeded by an inability to pay, or by geography.
Access in this context means access to basic long-term care services in both the community and
in institutions. All older people, irrespective of income or wealth, should be entitled, on the basis
of need assessment, to essential community care services, unimpeded by their ability to pay.
There is scope for disagreement with respect to the definition of essential services, but they
would surely include the right to the core community care services of home help, public health
nurse, paramedical care, day care, respite care and general rehabilitation support services. Older
people should also have the right of admission to a long-stay bed on the basis of need.
However, growing old involves meeting foreseeable risks which means that there is scope for
sharing the responsibility for funding long-stay care in institutions among individuals, families
and the state. The assessment services should bear most of the burden of controlling access to
long-stay institutions. Assessment facilities should be available on a comprehensive and national
basis in order to establish common eligibility criteria for determining needs and, therefore,
placement. Essential services should be available in all areas and regions to overcome current
geographical inequalities in provision.
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The Current System of Funding
The present system of financing long-term care fares badly on each of the three principles
outlined in the previous section. Currently, funding arrangements have the effect of skewing
demand for long-term care in the direction of the residential option — long the bedrock of
formal provision. The nursing home subvention scheme succeeded in drawing more people into
residential care in contravention of stated policy objectives and preferences for home care.
Demands on the Exchequer arising from the implementation of the 1990 Act made significant
calls on the available public resources for older people. The availability of funding for private
nursing home care has largely determined patterns of care for older people in recent years,
restricting both sustained investment and innovation in community care provision.
The absence of an in-built bias towards community care in the existing financing system serves
to perpetuate the status quo in favour of residential care. Instead of being the catalyst for the
redeployment of resources from institutional to home care, the financing system is lending
support to the current unsatisfactory balance of care. Current financing arrangements between
the Department of Health and the Health Boards are of a prospective type with cash limits
imposing constraints on the ability of the Health Boards to over-spend. What the Department of
Health has not been able to do is to effect a major redeployment of resources to community
care in line with stated policy objectives. This has made it difficult for older people to remain at
home given that the prevailing incentives are geared towards supporting residential care
options, both public and private. Even allowing for binding budget constraints, the health
boards have not shown enough by way of innovation and ingenuity in support of community
care. While there have been some positive developments, for example, the introduction of
Community Ward Teams and District Care Units in the ERHA, the balance of care has not been
significantly altered towards care in the community. The status quo remains, in spite of unease
among health board officers at the paucity of provision for community care (Ruddle et al., 1997).
This problem is exacerbated by the tendency in official circles to view family care as essentially a
“free resource”, which can be relied upon to provide the bulk of care in the community for
dependent older people. The reality is that family provision, already under pressure, will require
significantly more support in the future if it is to be maintained at anywhere near its present
level.
Access to public long-stay care for elderly people is based on need as ascertained by medical
providers, working closely with non-medical providers, very often within the framework of an
admissions committee set up to ensure that only those who need residential care actually end up
there. The problem is that public beds are not always available which immediately changes the
rules with respect to co-financing arrangements. The maximum public subvention payable for
private care, with the recently announced increase, covers at most 50 per cent of the average
cost of care (unless supplemented by an enhanced payment), leaving the older person to find
the remaining 50 per cent from their own resources. While acknowledging that the pension of
the resident would cover some of this payment, it still leaves us with the anomaly of differential
coverage for public and private facilities, one that reaches significant proportions if the weekly
cost of the private bed is above average. A person who cannot find accommodation in a public
bed is likely to be faced with a difficult decision as to whether they can afford to pay the residual
component of the private nursing home bill. And this is after having agreed to the potentially
invasive and lengthy means-tested eligibility enquiry that accompanies every application for
subvention payment. Given geographical differences in public bed provision the potential for
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this problem to arise may be higher in some regions than others. Some older people are
currently denied access to free public long-stay care simply because of where they live and when
they have applied.
A similar equity problem exists with respect to resources for community care in Ireland.
Differences exist across and even within regions in the availability of both statutory and nonstatutory services. The available evidence suggests that access to public health nursing, home
helps, paramedical services, day care, respite care and day hospitals is limited and variable
within and among health boards (O’Connor, 1987; Blackwell et al., 1992; O’Shea, 2000). This
means that the quality of care for older people is better in some areas than others. For instance,
if older people are fortunate enough to live in the hinterland of a day hospital the likelihood of
admission to a long-stay institution is relatively low. On the contrary, an older person living on
their own in an isolated area without much social contact, and relying on sparsely provided
statutory care services, is more likely to be admitted to long-term care should a problem arise.
The current system of financing long-term care continues to support an unbalanced provision of
services across the regions, thereby making location an important variable in determining the
quality of care available to older people.
Choosing a Model for Ireland
Finding a financing model that satisfies all of these principles is not an easy task. For many
people, the task is made more manageable by reducing the question to one of the respective
roles of the public and private sectors in the financing of long-term care. As Wiener and Hanley
(1991) report some groups believe that the primary responsibility for care of the elderly should
fall on individuals and their families, with the government only intervening to look after the
needs of those people unable to participate in the market. The opposing view is that the
government should provide comprehensive long-term care for all persons with no distinction
between the coverage of rich and poor. In this approach, there is no role for the private sector. In
between these two polar views there are many different combinations of public and private
responsibility for the coverage of long-term care. The range of options reflects the absence of
any clear agreement on the merits of any one model over another. Each carries advantages and
disadvantages, with the choice of model ultimately determined by a consideration of
coverage/affordability trade-offs and efficiency/equity trade-offs.
We do not intend to say very much in this report about the various options for the financing of
long-stay care in this country as a separate study on funding long-stay care is currently being
prepared for the Department of Social, Community and Family Affairs. In any case, given that the
current funding system is likely to remain in place in the medium-term, it is more relevant to
explore changes at the margin of that system than to speculate about the dismantling of the
entire system of funding1. Financing systems in all countries are a product of history, culture and
politics and only undergo radical change in exceptional circumstances. Those countries that are
in the process of reforming their health and social care systems are doing so in ways that accord
broadly with existing methods of financing health and social services. Germany and Austria have
introduced more comprehensive long-term care entitlements in recent years, so too have The
Netherlands, while Japan is attempting to rationalise its largely hospital-based system of care
1 The author of the report has argued elsewhere for the implementation, over the longer-term, of a
social insurance model for the funding of long-stay care in Ireland (O’Shea and Hughes, 1994)
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with a new insurance model for long-term care costs. Most countries prefer alterations at the
margin to the replacement of whole underlying structures. The emphasis in this report is also on
the transformation of the existing system of cover rather than its replacement with a new system
of funding.
Payment systems for long-stay care show great variation across countries, both within and
between tax-funded and social insurance based systems (Ribbe et al., 1997). Most European
countries continue to rely on the state for the funding of long-stay care, through general taxation
or social insurance, but the trend is towards more cost-sharing arrangements and increased
private participation. There is also a trend towards providing additional cover and choice with
respect to care in the community but concerns about the moral hazard implications of such
increased cover in the community has slowed down the pace of change in this area. Not
surprisingly, there are tensions in most countries concerning the optimal mix of responsibilities
for the funding of long-term care. For example, in Britain and New Zealand long-term care in
institutions is means-tested unlike health care in hospitals, which is covered by one universal
system. The Nordic countries have increased user charges for long-stay care over time mainly in
response to more binding budget constraints in recent years. Australia has moved away from a
standard fee to a means-tested hotel charge while in France the health insurance system only
covers nursing care costs in long-stay care.
There is no blueprint available for the funding of long-stay care from a comparison of
developments and trends in other countries. There are, however, general pointers from
developments in other countries which may be helpful in planning change in this country. The
first of these is that the state is usually involved in the funding of long-stay care, mostly within a
cost-sharing framework that encourages people to choose home care over residential care.
Second, the need to promote and encourage family responsibility for their dependent elderly kin
through increased spending on community care and more flexible support mechanisms for
carers is recognised in most countries. Third, the importance of controlling access to expensive
long-stay facilities is also accepted in all countries. For the OECD (1998), a basic element of any
reform proposals is that long-term care is seen as a normal circumstance of life, implying a
partnership model in respect of the funding of various types of long-stay services and facilities
which would involve individuals, families and the state. The changes to the nursing home
subvention scheme set out below are an attempt to strike the correct balance between the
needs and preferences of older people and the varied and inter-related responsibilities of
families and the state in this country for the care of vulnerable older people.
Dependency and Placement
The reform of current funding arrangements for public and private systems of long-stay care
requires action on a number of fronts. The first step in that reform is the establishment of a
common dependency assessment for all types of publicly-funded long-stay care, whether
publicly or privately provided, linked to more appropriate placement procedures for admission
to long-stay care. National guidelines for the measurement of dependency should be
established for use across the country. These guidelines should be drawn up by a national
committee of experts whose task it would be to provide a comprehensive and weighted scale of
assessment for physical, mental and social dependency. While final decisions on placement
would remain with providers at local level, a standardised assessment process would provide an
important benchmark for controlling admission to long-stay care. People with low or medium
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dependency would not be funded in long-stay care but instead would be cared for in an
expanded community care system. For high dependency older people there should be a
guarantee that all possible community care strategies will be explored before a decision on
admission to residential care is taken. There would only be one subvention payment for
dependency instead of the three-tiered payment mechanism currently in use, because only
seriously dependent older people should now be in care.
As part of the reform public hospital beds should be reserved for those in need of intensive
nursing care which includes services not available in other settings (like rehabilitation, special
therapies, specialist medical services). Ideally, level of need for nursing and medical services
would be the criterion by which older people are allocated to different long-stay facilities.
Currently, however, public long-stay settings vary greatly in the type and level of care offered and
may not all have the facilities required to support people in need of intensive rehabilitation
services. Moreover, older people remain in public beds for a number of reasons that have little
to do with their level of physical or mental dependency. A significant number of older people
remain in public hospital beds because they can’t access the type of care that they need outside
of hospital. There must be significant public investment in both rehabilitation and step-down
facilities for older people; the latter in partnership with the private nursing home sector as part
of formal arrangements with the health boards.
Placement decision-making needs to become much more explicit and visible in the new system.
Assessment and rehabilitation services should be mainly provided in public facilities; longer-term
need should be shared between the public and private sectors on the basis of formal contractual
arrangements. The private nursing home sector must be included as a social partner in the
planning and provision of long-stay care beds and services within health board regions. To
ensure equal provision across sectors, the same services, particularly in the area of rehabilitation,
must be available to older people in private long-stay beds as are available to older people in
public long-stay beds. This requires a much more integrated provision of long-stay care than
currently exists with much more public services offered to eligible older people in private nursing
homes. It will also require new and innovative approaches to staffing within long-stay units and,
more than likely, new regulations for the optimal mix of staff in different types of long-stay units.
The monitoring/policing role of the health boards with respect to the private sector should be
abolished and replaced by a much more supportive role based on trust and partnership. Issues
of quality of care in both the public and private sector should be subject to independent
external audit through an agency or unit whose task it would be to establish quality guidelines
for long-stay care provision and monitor bed rates, occupancy rates, facilities and health
outcomes in long-stay care.
Adequacy of Subventions
An important aspect of the reform process should be to eliminate the distinction between public
long-stay patients and publicly-subvented residents in private facilities with respect to the
assessment of means, or more particularly with respect to the treatment of housing assets in that
assessment. Once need for long-term care is established, access to public funding in either
public long-stay institutions or private nursing homes should be based on a common assessment
of income and wealth. This would end the current anomaly whereby a person applying for a
subvention to a private nursing home is subject to a more rigorous means assessment than a
person seeking admission to a public bed. The cut-off point for housing assets should be raised
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from the current level of £75,000 to a more flexible, regionally determined, rate (the average
market valuation of second-hand houses in a region) to reflect the huge variation in house prices
across the country. Once eligibility for public funding is established, the older person should be
placed in the most appropriate bed for his or her level of need. For some people this will be a
public bed, for others it will be a publicly-funded bed in a private nursing home. The rate of
public subvention for private nursing homes should be linked in a more direct way to the cost of
providing care in the sector and should be subject to biennial review by the Department of
Health and Children. Setting a rate for older people in public facilities is not an issue by
definition, given the non-market nature of provision but it too should be seen as covering care
costs mainly. The cost structure in public long-stay facilities should also be subject to biennial
review by the Department of Health and Children. Notwithstanding the placement of older
people, everyone should have access to public rehabilitation facilities, with a view to enabling
people to return to their own homes where circumstances allow.
The main short-term problem that must be addressed in the funding of long-term care is the
inadequate rate of subvention for older people admitted to private nursing homes, even
allowing for the recently announced increases up to a limit of £150 per week for people with
maximum dependency and the facility for enhanced payment available in some circumstances.
While the resource allocation problem in long-stay care will not be solved by simply increasing
the subvention rate further, an increase in the rate is a necessary condition for a more efficient
and equitable system. In the spirit of partnership and shared responsibility the state should
assume full responsibility for the care costs of all eligible older people in private long-stay care.
Currently, care costs in private nursing homes are, on average 70 per cent of total costs of care
(including profits). This means that the rate of subvention for eligible older people in private
nursing homes should be increased up to a maximum of £200 per week which is approximately
70 per cent of the average cost of care in nursing homes in this country. The provision for the
payment of enhanced subventions in health boards where average costs are higher for reasons
of labour market pressures or higher property values should be retained in any new
arrangements. Where private nursing home charges are lower than the average, the rate of
subvention can be less than £200 per week subject to the provision that residents do not have to
pay more than 90 per cent of the Non-Contributory Old Age Pension (NCOAP) from their own
resources. People in public long-stay care should continue to be covered for all care services but
should be subject to a co-financing rate, equivalent to 90 per cent of the Non-Contributory Old
Age Pension, to cover hotel costs.
Cost Sharing in Long-Term Care
The question of the optimal mix of financing for people in long-stay care is one that deserves
more attention than it has received in this country, notwithstanding the current review by the
Department of Social, Community and Family Affairs on funding options for long-stay care.
Currently the state provides public support for people in long-term care from the time of
admission until discharge or death, and if the recommendation on increased subventions
discussed above is accepted this cover will now be enhanced. There is a case, however, for some
examination of the merits of providing a cut-off point for state support of long-stay care beyond
which cost-sharing arrangements would be put in place. There are a number of good reasons
why the state should only provide financial support for residential care for a set period of time
rather than indefinitely, as is currently the case. First, putting a time-limit on public funding might
encourage more older people and their families to choose home care over in-patient care.
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People might delay unnecessary admission to residential long-stay care, particularly if community
care services were expanded and developed to make living at home a viable alternative to inpatient care. Second, if people had to fund their own long-term care after a certain period of
time there would be more pressure in the system for rehabilitation services to enable more
people to return to their own homes rather than remain in long-stay care. While it is
acknowledged that older people entering long-stay care are now more disabled than before,
there remains considerable scope to return some of them, after an appropriate programme of
rehabilitation, to the community. Third, asking people to contribute to the cost of long-term care
after a set period of time would acknowledge the partnership aspect of funding long-stay care.
The state should certainly be involved in funding long-stay care, but there is a strong argument
that growing old is an insurable risk and people should be asked to share the financial burden in
partnership with the state wherever possible and practicable. Fourth, even if it were decided to
put a time limit on public financial support for long-stay care, the majority of long-stay residents
would be fully covered by any new scheme, since most older people (77 per cent) remain in
institutions for less than three months (Department of Health and Children, 2000b).
For a front-end residential care protection system to work some mechanism would have to be
put in place to support people who needed long-term care beyond the time-period covered by
the state. The obvious market development would be the emergence of private insurance
products to cover length of stays greater than say three months, or whatever cut-off point for
unfettered state support is decided2, in a long-stay institution. The main reason why private
insurance markets in long-stay care have been slow to emerge world-wide is the inability of
insurers to deliver comprehensive coverage at affordable prices (O’Shea and Hughes, 1994).
Insurers worry about the potential for moral hazard and adverse selection in long-term care
insurance and this is reflected in the high premiums charged to consumers. Alternatively, too
many restrictions have had to be introduced in order to make premiums more affordable. This
reduces the benefits of being insured in the first place. The advantage of front-end coverage by
the state is that it provides an important element of certainty and co-financing in the market,
thereby reducing the premiums charged by private insurers. If a private insurance market was to
develop it would have to be made explicit ex ante who would and would not be eligible for
public assistance in the event of non-insurance, and the conditions attached to that assistance,
following the termination of public coverage. If there was any ambiguity about this most people
would not insure, even if insurance products were available, in the belief that the state would
continue to provide coverage beyond the three month period.
An alternative to private insurance would be to draw posthumously on the assets of older
people to help pay for long-term care after state coverage has been exhausted. In this model
the state would provide comprehensive residential care coverage for three months for eligible
(assessed on the basis of income only) older people. At the end of this period responsibility for
funding long-stay care would pass from the state to the individual, de jure but not necessarily de
facto. The state would continue to provide full public coverage after three months, but only on
the legislatively-based understanding that costs would be eventually recouped from the sale of
any available housing assets of the older person above a certain valuation (estimated, as
previously, as a percentage of trend (regional) market rates), following the death of the resident.
2 O’Shea and Hughes (1994) suggested a cut-off period of one year in the context of a social insurance
model for long-stay care.
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Of course, there would be some people who have no assets or property and these people would
have no liability for a “reverse deductible” charge, unless their assets or property had been
transferred five years prior to the admission to long-stay care. The timing of the “reverse
deductible” payment after the death of the resident would also depend on the housing and
other circumstances of surviving spouses and partners. In no circumstances would the housing
needs of spouses, partners, or other dependants be compromised by the new arrangements and
government sponsored home equity schemes could be introduced to ensure fairness and
compassion in this regard. There are some signs in the market of interest in developing home
equity schemes in this country, but there is no reason why the state should not also offer a
scheme linked directly to long-term care financing requirements. Indeed the involvement of the
state in home equity schemes would likely overcome many of the risks older people associate
with market-based provision of home equity schemes.
It is acknowledged that the use of the housing assets of older people to help fund long-stay care
is a controversial topic, thereby making it very difficult, if not impossible, to implement a model
of the type described above. Yet, the possibility of drawing on the assets of older people
themselves as a means of reducing the financial burden of long-term care on the state is worthy
of some consideration. The wealth holdings of older people are somewhat higher than the
whole adult population in this country due to the high incidence of mortgage-free home
ownership among them (Fahey, 1997). And the reality is that some older people in long-stay care
who are funded by the state, either partially or in full, leave substantial property bequests for
their next of kin after they die. Public financing models which have as their objective the
protection of individual assets for the purpose of bequests have rather odd welfare
connotations. After all, taxing non-elderly, non-rich people to preserve bequests for non-poor
children is hardly an equitable solution to the problem of market failure in long-term care
financing.
The advantage of the ‘reverse deductible’ mechanism is that it acknowledges the right of the
state to take account of asset holdings while at the same time leaving the asset in the hands of
the older person while they are alive. This approach would be more equitable, more efficient and
less worrisome to older people than any of the available alternatives. It seems inequitable that
the state should subvent the long-term care for older people if one effect of that subvention is
to preserve their assets so that they might be passed on as a bequest to offspring who might be
reasonably well-off in their own right. The scheme would also penalise unhelpful or uncaring
offspring who stood to gain from bequests but who did nothing to support the long-term care of
their benefactor either before admission to long-stay care or afterwards. The scheme also avoids
the possibility of older people having to prove impoverishment before they can qualify for public
assistance. Forcing people to run down their assets or to sell their house fits rather uneasily with
a policy of community care, with home living at the centre of that policy. The model also
provides an incentive to delay admission to residential care for as long as possible since there
would be no equivalent cost-sharing arrangements associated with care in the community. Of
course, for the model to work, there would have to be significant investment in community care
services to persuade older people, their families and health professionals that home care did not
lead to inferior care. This brings us to the next requirement for change in the system.
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Subventions for Community Care
One of the problems with the nursing home subvention scheme is, as mentioned previously, that
the implementation process draws on resources that might otherwise have been used to
improve the community care system. In the future, the public financing of nursing homes should
never occur at the expense of resources for community care. Accepting this principle means that
a subvention for nursing home care would never be granted unless it was clear that a
community-based subvention would not have succeeded in maintaining the elderly person in
their own home. The subvention, if applied to community care, could be used to fund an
increase in resources for community-based services such as home helps, community nursing,
home respite care, home sitting services, day care and paramedical services. These services are
important in slowing down or preventing entry into long-stay care. It is only after assessment has
been completed and a recommendation is in place to the effect that the elderly person cannot
be cared for at home that the subsidy should be transferred to institutional care. The community
care subvention could be set at some percentage of the residential care rate (up to a maximum
of 60 per cent, or £120 per week) and be targeted on people on the boundary of in-patient care,
i.e. those with maximum dependency. The 60 per cent maximum payment allows savings to be
realised in the community relative to residential care as well as guaranteeing much more support
for family carers than currently exists. Subventions for people living at home will, however,
require additional money for community care over and above current allocations, up to a
maximum of £80 million for the 13,000 older people currently living at home but potentially on
the margins of residential care. Some of this additional spending will be offset by the reduction
of admissions to long-stay care resulting from the investment and from revenues generated by
potential new arrangements for funding residential long-stay care. The important point is that
community-based resources are expanded and used more intensively to support older people
living at home.
If community-based services are to be expanded then older people and their families will have
to be given more of an opportunity to influence the type of care received while living in the
community. Currently, the supply of community-based services is determining demand and we
do not know for sure if older people living at home get the services they most value when and
where they need them. The system of allocation should take more account of the preferences of
older people and their families for different types of community care services. Packages of care,
funded by the new community care subvention scheme, should be negotiated between the
relevant health board personnel (optimally through a designated care manager) and older
people and their families. Service plans should be determined on a case by case basis to ensure
that the most vulnerable older people are supported in their own homes rather than admitted to
long-stay residential care. New services should be put in place and all services should be made
more flexible to support care in the evenings, at night and at the week-end. The community care
service must move beyond the current office-hours provision if it is to make a real difference to
the lives of older people living at home.
There should also be some pilot studies to evaluate the potential of using different funding
mechanisms to support older people living at home. For example, the potential of using
community-based demand-led vouchers instead of prescribed in-kind provision of services for
people living at home in the community should be examined. Subventions for community care
could be paid in the form of community care vouchers which could only be used on verifiable
services and facilities. Similarly, a pilot study in providing cash transfers, mediated through the
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care manager, for older people living at home might also be tried. Under this approach, people
would, once again, be free to allocate the money among competing community care services,
but they would now also have the opportunity of using the money to pay family carers. Cash
transfers have proven to be a very popular way of supporting home care in Germany. Six years
after the start of home care benefits in Germany more than two thirds of beneficiaries prefer the
lower cash benefit to the much higher non-cash benefits (Vollmer, 2000). Some innovation is
required in this country to allow older people living in the community to choose among suppliers
in accordance with their own unique preferences and circumstances. Giving older people this
power would quickly determine the nature and form of core provision. For far too long our
understanding of the latter has been dictated by the supply side of the market. If the financing
system is to be made more responsive to the real expressed needs of older people a more
consumer-oriented approach will be necessary. Some experimentation in this area would allow us
the opportunity to consider the merits of different ways of providing more choice to older
people and their families.
The Social Economy and Older People
The new system of subvention proposed in the previous section requires a significant expansion
of community care services if it is to meet its objectives. While the state will be centrally involved
in the expansion of community care services there is also considerable scope for local, social
economy, provision of social services and facilities. The practical objections to the application of
social economy concepts to the sphere of services for older people in the community might be
that these needs are already addressed adequately through other channels, either through state
provision or through existing voluntary efforts. However, the scope of statutory community care
services funded by health boards tends to be limited to community nursing and home help
services. Provision in other areas, whether statutory or voluntary or a mixture, is uneven,
particularly with respect to day care, transport, home respite, night sitting, home repair services
and sheltered housing. Some of these services are not deemed core areas of provision by health
boards while others pose problems of co-ordination among government departments or
between local authorities and health boards, or between the statutory and voluntary sectors.
More importantly, the continued involvement of the voluntary sector in social care provision
should not be taken for granted. The demographic profile of volunteers in this field is little
researched but anecdotal evidence suggests that there is considerable reliance on more mature
women who have tended, in the past, to be full-time homemakers. Change in labour force
participation rates implies that this form of service will, in the future, be open to competition from
paid employment. The increasing participation of older women in the paid labour force, as we are
witnessing at present, is to be anticipated in the future and will reduce the capacity of volunteers
and relatives to provide various types of support or informal care to the same extent as in the
past. Moreover, concerns about pay, for example in the case of home helps, may lead to reduced
labour supply in the area of social care, as people are attracted elsewhere by the prospect of
higher pay. This leads to new challenges which social entrepreneurship and the social economy
might be able to address through quasi-market solutions to social need. There are signs of the
development of the social economy in some areas of the country (see Appendix 2) and evidence
of the willingness of people to pay for local services that meet local needs (O’Shea et al., 1998).
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One of the difficulties with the social economy is that many of the agencies and associations
which have sought to utilise the social economy model are not directly involved with providing
social services, or services for older people, but are more concerned with tackling
unemployment. This emphasis is still dominant in the recently launched social economy
programme despite the inclusion of service provision objectives along with local regeneration
(Department of Enterprise, Trade and Employment, 2000). There is no target for service provision
or the achievement of social objectives under the social economy programme. However, for the
social economy in community care provision to develop it is necessary that the relevant statutory
bodies be convinced not only of its employment potential but that it is effective in terms of the
objectives of the national health strategy. The employment potential of the social economy in
care of the elderly pales in comparison to its potential to improve the lives of older people living
at home in the community. The social economy contains the potential to expand the choice sets
of older people living at home through the provision of new services in the areas mentioned
above. The issue for the health authorities is one of choice between traditional/conventional
ways of delivering somewhat predictable community care services (whether directly by the health
boards, or indirectly through the voluntary social services sector) and supporting the more novel
and innovative set of possibilities offered by the social economy towards meeting social
objectives.
The Department of Health and Children and the health boards should be doing more to foster
and direct resources in the direction of locally-based support services for older people to enable
them to live in the community for longer. The development of the social economy in community
care provision will likely depend on considerable subsidisation from the health boards or local
authorities through contracting out or some similar type measures. The justification for this might
be that without such subsidisation the health boards would be faced with rising costs of
subvention in nursing homes. If nursing home care is to be subvented to considerable levels,
why should there not be some provision for the subvention of the community care services
needed to prevent admissions? Part of the appeal and legitimacy of the social economy arises
from the fact that it meets social needs that are otherwise ignored by the market or the state,
thereby enabling older people to continue living in their own locality. If some of the problems of
older people are social in nature then these problems should be addressed in a more social way
utilising local knowledge and local social capital to support care in the community. Part of the
problem at the moment is the over-professionalisation of care structures whereby solutions to
the needs of older people are seen more in medical and nursing terms than in overall social care
terms.
The social economy might, by virtue of its entrepreneurial aspect, also contribute to raising the
quality of local services offered to older people leading to a widening of the customer base. For
example, meals, assistance in the home and transport services could be provided to a higher
standard, thereby attracting a “traded income” from some groups of older people while also
meeting contractual obligations of a health board under a subsidised scheme. The social
economy approach could also benefit from spillovers along the local continuum between purely
traded income activities and statutory service contracts. If, for example, a local co-operative is
involved in tourism and catering services, it is likely to generate resources, skills and services in a
commercial environment that could be shared with or transferred to the services for older
people. For example, during the off-peak tourist season, winter services could be provided for
older people using the infrastructure and human resources from local tourist activities. The
critical point is the need to support innovation and social entrepreneurship in local areas as a
means of enhancing both the quantity and quality of community care services.
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Care Management
The lack of an integrated approach to long-term care at policy level and at organisational level is
mirrored in local approaches to decision making in individual cases. Older people and their
carers wishing to find out what long-stay services are available to them are faced with a complex
system and there is no one person whose job it is to explain it to prospective service users. It is
not until a crisis develops in the community that attention is focused on making long-term care
plans and the urgency of the situation may lead to decisions that are not appropriate in the
long-term. Older people already in hospital are at an advantage (although by that time, it may
be too late to restore the person to community living) in that there is a form of care
management in operation via the interdisciplinary case conference usually held prior to hospital
discharge. Here an attempt is made to assess the patient’s health and social care needs at
discharge and to look at what services might be required to meet these needs. A social worker is
often (although not always, especially outside of Dublin) charged with assessing social
circumstances and social supports, information which will be critical to decisions about whether
or not the patient can go home or must be referred for residential care.
In the UK, Scandinavia and the US, care management is an accepted feature of health and
welfare care systems for older people. In the UK, social workers and sometimes nurses are
designated care managers for older people whose job it is to assess need and develop a
package of services from a variety of sources (informal, voluntary, statutory, private) to meet
assessed care needs. In Norway, community nurses, working for the municipality which is
responsible for both health and social services including housing, similarly manage the care of
individual older people, referring them for services as appropriate. In the USA, many states
require care management services to be involved when Medicare or Medicaid money is being
spent to provide long-term care for older people. These services are provided by local area
agencies, county agencies (in the statutory sector) or by private, non-profit organisations which
provide a single point of entry for persons considering long-term care options (Coleman, 1998).
Again the brief is to do a comprehensive assessment of need and to source the most
appropriate and cost-effective services to meet that need.
In Ireland, there is interest in the concept of care management and some health boards are
exploring care management models. The Alzheimer’s Society of Ireland have received finance to
pilot care management posts in the ERHA especially for people with dementia. The National
Council on Ageing and Older People have recently commissioned research on the subject of
care management. Care management is critical to the development of an integrated care
system. The assignment of a key worker or care manager to take control of both budgets and
care strategies for older people would facilitate a greater emphasis on home care solutions to
the problem of dependency in older age. The new community-based subvention system
described earlier requires the introduction of care management into community care structures
in this country. The care manager would administer the community-based subvention system on
behalf of the older person. Pilot studies in cash transfer or community-specific vouchers for older
people could be accommodated within this framework without much difficulty, thereby allowing
older people an even stronger voice in the type of care that they receive.
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Integrating Public Policy for Older People
In the Irish context, three main factors have worked against the development of an integrated
approach to policy-making for older people. First, responsibility for support services for older
people has been divided among government departments (Health and Children, Social,
Community and Family Affairs, Environment and Local Government) and between health board
programmes (Community Care and Hospital). Although some progress has been made in
integrating the various responsibilities for older people within existing structures, there is a need
for more formalised communication links to further improve integration. In particular, there
needs to be improved mechanisms for the joint assessment of need and for the planning of
services between Departments, particularly in the area of housing for older people. Second, a
medical model of care has predominated which defines the needs of older people primarily in
terms of physical and medical need. While the latter are very important they are not the only
needs that older people are likely to have. People also have emotional, psychological and social
needs to live in normal housing close to their family and communities. Unfortunately, the medical
and hospital services continue to dominate care of the elderly and absorb the majority share of
public resources, leading to the removal of too many older people from normal home living
arrangements. Third, social care services have been developed mainly by the voluntary sector in
Ireland. The voluntary sector has, however, only recently begun to feature in state policy
development and planning which has meant that social services provision has never been central
to the care of older people in this country. The goal should be a partnership model of
production involving the various agencies of the state, such as the private sector, the voluntary
sector, families and older people themselves. Such a partnership would bring real rewards in
terms of an increase in the well-being of older people.
Housing is a critical issue for older people, particularly in allowing them to remain in the
community, or allowing them return to the community after a spell in hospital. There is evidence
of poor quality housing for older people, especially in the private rented sector. In general, older
people have poorer quality housing than the general population, particularly with respect to
dampness, rotting windows and floors and leaking roofs (Layte et al., 1999). The official response
to the various housing needs of older people has not always been satisfactory and does not
reflect the importance of good quality housing in keeping older people healthy, independent
and out of long-stay care. At an organisational level, the various departments and agencies
responsible for the housing needs of older people must develop better mechanisms whereby
they could work together to assess needs and jointly plan services. The National Council on
Ageing and Older People (1997) have commented unfavourably on the absence of co-ordination
between health boards and local authorities in relation to the provision of sheltered and semisheltered accommodation for older people. Schemes for the repair and upgrading of older
people’s homes have been, “reactive and fragmented” according to the National Council for
Ageing and Older People, with poor co-ordination between the health boards and the local
authorities. Recent attempts to come up with joint decisions and shared responsibilities for
Travellers and for the Homeless demonstrate the difficulties involved in various agencies working
well together to solve a common but multi-faceted problem. Solving the housing needs of older
people would reduce admissions to long-stay care. Before this can happen there needs to be
improved co-ordination between the local authorities and the health boards.
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There is also a noticeable absence of trust between the private nursing home sector and the
health boards. Private nursing home services have developed largely without reference to the
statutory sector. Development appears to have been market led. Interviews with health board
staff suggest that they are suspicious of services developed for profit. They note that, in spite of
rising nursing home costs — to extremely high levels in the Dublin area — nursing home
managers are demanding payment from either residents or the health board for basic ancillary
care in some cases. They observe that some nursing home managers are ‘cherry picking’
residents by refusing to accept high dependency applicants (including those with dementia) in
the first place. There were also reports that occasionally nursing home staff bring residents,
whose level of dependency has increased while in private care, to casualty departments as a way
of getting them into a public bed. There are quite serious concerns about the quality of private
nursing home care due to staff shortages and lack of staff training. When health boards have
offered places to private nursing home staff on health board training courses, they have not
always been taken up. Health board personnel are also concerned about what they see as the
uncontrolled development of nursing home beds while standards in the nursing home
regulations are inadequate to cover all the aspects of quality associated with providing care to
dependent older people.
On the private sector side, there is also distrust and suspicion of the health boards. Although the
regulations state that the health boards are obliged to offer the same level of community
services to nursing home residents after they go into care, staffing shortages have meant that
the health boards have been unable to do so. The only contact that nursing home staff typically
have with health board staff is during inspection twice/year as mandated by the legislation.
Health board staff are seen to be carrying out a monitoring/policing role rather than a supportive
role. Health board staff themselves reported that this situation does not foster a sense of cooperation or partnership between the two sectors. There is no inspection of public long-term
care facilities (although this is due to change shortly) and private sector managers feel aggrieved
about the unequal treatment between the two sectors. Clarification of the different roles
expected from each type of care setting, from acute hospital to low support facilities to day care
services would help to reduce mistrust between the sectors. Joint planning according to clearly
stated aims and objectives would also be welcome as would formal partnership arrangements
whereby nursing home representatives would be involved at a local and national level when
policy was being formulated.
There is also a need to develop closer links among the various agencies charged with
responsibility for the formulation of public policy at national level, particularly between the
Department of Finance and the Department of Health and Children. The recent introduction of a
capital allowance scheme for nursing homes is a good example of the need for more
consultation with respect to policy for older people. The new scheme has provided a strong
incentive for additional private beds in the system. For example, data from the Irish Nursing
Homes Organisation suggests that recent planning permissions for new private facilities, if all
were approved, which, of course, will not happen, would lead to an additional 4,000 private beds
in the system. The expansion of the private sector is fine provided that the problem in the
residential long-stay sector is an under-supply of private beds. This is not the case. Our
discussions with health board personnel suggest that occupancy rates in some private nursing
homes in some regions are now running below the official figures. The problem in the residential
care sector is an under-supply of public beds, particularly assessment and rehabilitation beds,
not a general shortage of private beds. The Irish Nursing Homes Organisation (Stanley, 1999)
claims that investors are now entering the private nursing home sector for tax avoidance
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purposes without due regard to the caring aspects of the business. It is hard to see the gains
from the capital allowance legislation from the perspective of current policy objectives for older
people in the country. More would have been achieved by a direct investment in public beds
and the development of community care services for older people.
Conclusion
The stated objective of public policy with respect to the long-term care of older dependent
people is to keep them in their own homes for as long as is possible and practicable. In recent
years there has been a rapid expansion of private nursing home beds, but there has not been a
similar increase in the level of resources for rehabilitation beds in the public sector or for
community care services. This is at variance with stated policy for dependent older people in the
country. The current system of subvention for long-stay care needs reform. That reform should
concentrate on keeping people out of long-stay care. There should be community-based
subvention payment structure targeted on vulnerable older people living at home. These
payments should be substantial and should reflect additional investment in community care
services but payments can be less than those paid to nursing home residents. The social
economy can also play an important supporting role in developing the community care sector.
Care management structures should be put in place in the community to co-ordinate the various
services and facilitate a more intensive provision of care for people on the margins of residential
care.
Access to residential care should be curtailed by more stringent dependency assessment.
People seeking public funding for long-stay care should be subject to the same dependency
assessment process and the same means test on assets whether seeking admission to a public
bed or a publicly subvented private bed. Subvention payments should be linked to care costs
within nursing homes and increased to a maximum of £200 per week, subject to local charges.
The facility to pay enhanced payments should remain in place. Consideration should also be
given to a front-end public funding system for long-term care where the funding responsibility of
the state would be for a fixed period only. Such a model would allow for the development of
private insurance markets in long-term care provision. Alternatively, new mechanisms might be
considered to draw on elderly assets as a source of finance for long-term care. One such
mechanism put forward for discussion in this chapter was a ‘reverse deductible’ measure, by
which the amount to be deducted from the older person’s assets as a contribution to the cost of
care would be calculated and collected posthumously.
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The estimated number of older people in long-stay care in long-stay facilities in this country is
19,548, which is equivalent to 4.6 per cent of the elderly population. The percentage of older
people in long-stay care across the European Union averages between 5 and 6 percent of the
total elderly population, ranging from a low of around 2 per cent in Spain, Greece and Portugal
to a high of 10 per cent in the Netherlands. Ireland is, therefore, on the low side of average for
Europe in respect of long-stay residential care. The current publicly funded bed provision of 44.5
per 1,000 elderly population is below the 50 beds per 1,000 elderly population norm currently
being used by the Department of Health and Children for planning purposes. The latter norm is
based, for the most part, on the recommendations of The Years Ahead planning report. There is,
however, considerable variation in publicly-funded beds across the country with some regions
better endowed than others.
The number of long-stay public beds increased only slightly in the nineteen nineties, whereas
the number of private beds increased significantly during the same period. More flexible and
more generous public subsidy arrangements have proven attractive to new entrants, leading to
an increase in the supply of private facilities. Barriers to entry into the private nursing home
sector are also low and recent tax changes have further encouraged private provision. Currently,
47 per cent of long-stay beds are located in the public sector, 33 per cent of beds are subvented
beds in the private sector, while the remaining 20 per cent of beds are private non-subvented
beds.
Long-stay beds are mainly occupied by the very old, with almost two thirds of beds occupied by
people aged 80 years and over. Residents of private nursing homes are generally older than
elderly people in public long-stay institutions, but the latter cater for more dependent older
people. However, long-stay units in both the public and private sector also contain a significant
number of low dependency persons. Admissions procedures, particularly to public long-stay
care, have not been so finely tuned as to admit only high dependency people. For some older
people, the situation is complicated by the fact that they have nowhere else to go. These so
called ‘social cases’ often end up in care for the rest of their lives because of the absence of any
alternative community-based facilities.
The purpose of this report was to examine the effectiveness of the nursing home subvention
scheme and to make recommendations for the future. The origins of the nursing home
subvention scheme can be traced to the Report of the Working Party on Services for the Elderly
(The Years Ahead Report, 1988). The Years Ahead considered that there were four main
advantages in having a mix of public, private and voluntary beds for the care of dependent older
people. These advantages can be stated as follows:
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•
A more equitable system of placement for older people
•
A fairer system of allocation for nursing home proprietors
•
More choice for older people
•
Savings to the Exchequer from not having to provide public long-stay facilities.
These objectives can be summarised in terms of equity, access, choice, flexibility, and cost
effectiveness. The extent to which the scheme met these objectives was considered at length in
the report. The nursing home subvention scheme did address the equity question. Older people
were no longer denied access to needed long-stay care simply because there was no approved
nursing home in their area. Before the new scheme there was not equal access for equal need
across the country for dependent older people because of supply-side constraints associated
with the failure to approve any new nursing homes since 1980. That situation changed as a direct
result of the new legislation which subvented eligible older people rather than nursing homes.
Similarly, the new scheme resulted in the more equal treatment of nursing homes. Prior to the
new legislation, nursing homes were arbitrarily designated as approved or non-approved on the
basis of year of opening; those opened before 1980 were designated approved, those opened
after 1980 were designated non-approved. Following the legislation, all nursing homes were
equal and able to accept subvented patients, subject to meeting standard regulatory and
licensing requirements.
The nursing home subvention scheme also succeeded in offering and providing more places for
older people in long-stay care. Older people were now able to access private care facilities in
much greater numbers than had been the case prior to the 1990 Act. There was latent demand
for residential care, the origins of which was the shortage of long-stay publicly funded beds in
the system. Community care services were not capable of providing the safety valve required by
the rigid control on the expansion of publicly-subvented private nursing home beds prior to the
new legislation. Three thousand additional private beds came into the system in the 1990’s. Not
surprisingly, in view of the increase in the number of older people covered by subventions and in
the registration of new homes, there was a very positive response from nursing home proprietors
to the new arrangements. The Act succeeded in bringing more older people into the residential
care system and made a significant contribution towards the cost of long-stay care for these
people.
The impact of the new scheme on the choices available to older people is more problematic. On
the basis of out-of-pocket expenses only, it is unlikely that any older person would freely choose
private care over public care given the cost implications of that decision, if given a real choice.
People do not have to pay for public care outside of the normal pension contribution, whereas
private care, even with maximum subvention, always required some out-of-pocket payment in
addition to the normal pension contribution. Moreover, in the assessment of eligibility for private
nursing home subvention the housing assets of the applicant are explicitly considered if the
value of the house is over £75,000. Housing assets are not taken into account in deciding on
admission to publicly-provided beds. Finally, most private facilities are not equipped with the
same facilities as the public sector so, once again, freely choosing private over public on this
criteria would be illogical. Private facilities do carry spatial advantages for some older people but
these would have to be strong enough to outweigh cost and facility advantages associated with
public care. There are some areas, of course, where the scarcity of public beds means that some
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older people have no option but to accept subvented care in private long-stay facilities. There is
no choice in those circumstances.
Flexibility is a difficult concept to define and it has many layers of meaning when applied to the
nursing home sector. The critical flexibility provided by the nursing home subvention scheme is
that, in the absence of public beds, it has provided an option for older people that did not exist
prior to the legislation. This flexibility is particularly important in health boards that do not have
an adequate supply of public beds. For example, the care of older people in the Eastern
Regional Health Authority would have been in crisis without the facility to contract beds to the
private sector. Flexibility was further increased when the potential for enhanced payment was
provided for in the 1996 legislation. Nursing homes have also been used in some areas to
accommodate inappropriately placed older people in acute care hospitals, thereby providing
timely and appropriate care in a flexible way. Without doubt, the nursing home sector has
provided much needed support to the public sector since the inception of the nursing home
subvention scheme eight years ago. Whether more appropriate kinds of support and flexibility
might have yielded higher returns is a separate issue and should not detract from the conclusion
that the private nursing home sector is an important provider of long-stay care in this country.
Comparisons between public and private long-stay care are difficult given the differences
between the two sectors in relation to scale, capital investment, co-payments and service
provision. In financial terms, nursing home beds are cheaper for the government than publiclong-stay beds. Private units are smaller; the beds do not require a capital investment on the
part of the state apart from some tax allowances; recipients pay a significant proportion of the
cost of private care from their own resources; and fewer services are provided than in public
facilities. But, the more interesting question is whether the less costly alternative is also the most
cost-effective alternative? It is impossible to answer that question on the basis of the information
available to us. There have been no attempts to measure the relative benefits of private and
public care for older people through a longitudinal study of health and social outcomes in both
sectors. This has not prevented claim and counter-claim on the relative merits of one form of
care over another. Public care is, on average, more expensive than private care because of
higher staffing levels and a wider range of services and facilities. The assumption is that benefits
are also higher in the public sector, but this is an empirical question on which there is not
enough information in this country. The less frequently asked question is, of course, whether
nursing home care, or public residential care for that matter, is more cost-effective than
community care. This too is an important question given overall policy objectives for the care of
dependent elderly people in the country.
Of the 119 recommendations in The Years Ahead only five referred to the nursing home sector.
Back then, it seemed that home care was as much principle as objective and that community
care was an idea whose time had come. The reality turned out to be quite different. Instead of
community care becoming the dominant force in care of the elderly, the implementation of the
1990 Act absorbed the bulk of available resources for dependent older people, drawing on
resources that might otherwise have been used to improve the community care system. Between
1993 and 1996 expenditure on the combined community care services of home nursing, home
help and meals-on-wheels increased by 8 per cent. In the same period, expenditure on the
nursing home subvention scheme increased by 422 per cent. The process of admission to private
long-stay care was made more rational and efficient, but at the expense of the development of
the community care system. This resulted in an institutional bias to the system in direct
contravention of the principle of home care for dependent older people outlined in The Years
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Ahead. The financing of nursing homes should not have occurred at the expense of resources
for community care given the stated policy objectives at the time and since. The irony is that the
absence of community care services has led to a higher demand for private nursing home care
which, in turn, has led to further “crowding out” of much needed community-based facilities as
more and more subventions were sought and granted.
In terms of the internal dynamics of the scheme itself, there is general consensus in the survey of
nursing home proprietors undertaken for this report that the major problem with the scheme is
that current subvention rates are inadequate, notwithstanding the recent approval for an
increase in rates up to a maximum rate of £150 per week, given the rising cost of private nursing
home care throughout the country. This concern is echoed in the health boards where officials
pointed to the need to increase the rate of subvention paid to people in private nursing homes.
Although the average cost of care across the country varies greatly between the Eastern
Regional Health Authority and elsewhere, there was universal concern about the shortfall
between individual applicant’s income plus the subvention and the weekly cost of care in a
private nursing home. The maximum subvention at the time of writing (March 2001) is around 40
per cent of the average charge in nursing homes in Ireland. That percentage falls to 30 per cent
in the Eastern Regional Health Authority. When the legislation on subventions was introduced in
the early nineteen nineties, the maximum rate was approximately 60 per cent of the national
average charge in nursing homes. In recognition of the income adequacy problem, some health
boards, notably the North Western Health Board and the Eastern Regional Health Authority, are
now paying applicants enhanced subventions above the maximum rate stipulated in the
regulations. Some health boards do not give enhanced subventions at all, although all seem to
be under some pressure to do so. Thus, applicants and residents with the same level of need
and resources are being treated differently in different health boards. On basic equity grounds
this situation is unacceptable.
More generally, the absence of consistency and standardisation in the application of the
regulations has also led to horizontal and vertical inequity in the operation of the nursing home
subvention scheme across the country. For example, dependency is assessed differently in
different regions with different scales used in the admissions process to long-stay care. The
social circumstances of older people are also given different weightings in placement decisionmaking across the regions. Means testing is another area where differences exist, with varying
degrees of discretion being used in the application of the regulations. Consequently, there is a
need for clarification and modification with respect to some of the regulations, particularly in the
areas of means testing and dependency, because they are being interpreted differently across,
and sometimes within, health boards.
Without families the community care system for older people would have collapsed a long time
ago. Families provide extremely high levels of care, even for relatively low dependent older
people. On the margin between community care and residential care, family care has the same
significance as nursing care within public and private institutions, with approximately 13,000 high
to maximum dependency older people living at home. Families incur significant opportunity
costs and health costs in caring for older people but, in general, the commitment to caring is still
strong in this country. The contribution of the community care system to keeping older people
out of residential care is less than that of families, primarily because of the inadequacy of the
system as currently resourced. The Carer’s Allowance provides significant support for those who
receive it, but not enough people meet the eligibility criteria for the Allowance relative to the
numbers providing care in the community. The key to maintaining the commitment of families in
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8
Conclusions
the face of changing economic and social circumstances is to further ease restrictions on
eligibility for the Carer’s Allowance and increase resources for community care.
While there is no doubt that the current system of subvention for long-stay care in private
nursing homes needs reform, that reform should be part of a wider strategy of keeping older
people out of all types of long-stay care. An essential part of any new strategy should be a
community-based subvention scheme for the most vulnerable older people living at home. For
that reason, there is a need to develop a pilot scheme for community-based subventions
immediately to evaluate the optimal approach to planning and developing such a scheme on a
national basis. The scheme should be administered and controlled by a key worker in the
community through the development of new care management structures. The weekly per capita
allocation should be substantial, but it can be less than that paid to nursing home residents to
take account of the different mix of care between the community and the nursing home. Up to a
maximum of £120 per week should be available to support older people living at home but at
risk of admission to long-stay care. The community-based subvention scheme should not take
money from existing community care allocations but should be an addition to existing funds.
Access to residential care should be also curtailed by more stringent and consistent dependency
assessment across the country. There should be a common assessment process for determining
need for long-stay care, developed through extensive consultation with the relevant professional
groups in the country. More resources for assessment and rehabilitation are also important, not
only to control admission to long-stay care, but to change the ethos of the care system away
from institutionalisation to one of renewal and restoration. There seems little justification for the
continued public subvention of low and medium dependency residents in either public or
private long-stay care, without first of all attempting to care for these people in the community.
Rehabilitation has a critical role to play in preventing unnecessary admissions to long-stay care,
particularly if linked to an expansion of community care facilities. Medium dependency is defined
in the regulations more in terms of the absence of community care rather than any intrinsic
physical or mental deficiencies that require a person to be cared for in residential care. Solving
the community care problem through a significant investment in services and facilities would
help address the medium dependency problem in long-stay institutions. It wouldn’t exist if
appropriate community care services and facilities were available in the first place to keep
people out of long-stay care.
Once need for long-term care is established, access to public funding in either public long-stay
institutions or private nursing homes should be based on a common assessment of means and
assets. This would end the current anomaly whereby a person applying for a subvention to a
private nursing home is subject to a more rigorous means assessment than a person seeking
admission to a public bed. The cut-off point for housing assets should be raised from the current
level of £75,000 to a flexible, regionally specific, rate equivalent to the average price of secondhand houses in a region. People in public long-stay care should continue to be covered for all
care services but should be subject to a co-financing rate, equivalent to 90 per cent of the NonContributory Old Age Pension, to cover hotel costs. For people in private nursing homes
subvention payments should be linked to care costs and, therefore, increased to a maximum
£200 per week. The latter figure approximates average care costs in nursing homes across the
country. The provision should continue to exist whereby health boards can pay higher than this
amount through enhanced payments in regions where care costs are higher than the average.
Where private nursing home charges are lower than the average health boards can provide less
than £200 per week subject to the provision that residents do not have to pay more than 90 per
cent of the Non-Contributory Old Age Pension from their own resources.
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Review of the Nursing Home Subvention Scheme
There should also be some consideration given to optimal cost-sharing arrangements for longstay care. The most obvious question is whether the state should provide funding for long-stay
care from the time of admission to discharge or death? While the model proposed in the
previous paragraph assumes that long-term care funding means just that, there are good
reasons for considering the introduction of co-financing arrangements, not least because of the
cost to the state of sole responsibility for funding, but also because of the contingency nature of
the need for long-stay care which makes it, in part at least, an insurable risk. Private insurance
markets have the potential to deal with the contingency issue but they are unreliable and the
market has been very slow to develop worldwide due to moral hazard and adverse selection
problems. One possibility would be to place a limit of three months on public responsibility for
all long stay care costs in both public facilities and in subvented private long-stay care and
require private insurance for stays longer than this. Private insurance would become more
accessible and affordable under such an arrangement and the state could pay the premiums for
people still unable to afford to take out insurance.
Alternatively, after three months, any expenditure by the state in relation to the care of older
people in either public or private residential facilities might be partly recouped by means of a
legislatively-based ‘reverse deductible’ on assets posthumously collected. There is a strong
argument, within this context, for the involvement of the state in offering home equity schemes
to eligible older people in competition to the emerging private market in this area. Older
people with no assets or with house valuations below a specified cut-off valuation would not be
subject to the deductible and would continue to receive unfettered support from the state. The
desire here is to protect the assets of the older person to facilitate their return to the community
if at all possible while, at the same time, penalising unhelpful or uncaring relatives and providing
some revenue to the exchequer for providing very long-term care for older people. The policy
context is the desire to recalibrate the current funding of long-term care away from residential
care towards care in the community by providing both financial incentives and posthumously
collected penalties to encourage people to choose care at home over residential care, whenever
possible and practicable. All of this pre-supposes a significant investment in community care by
the state if the new system is to work properly.
The social economy can play an important supporting role in developing a new and vibrant
community care sector. There are limitations on how far the state can directly provide the
services that are required at local level. There are also signs that traditional voluntary sector
approaches to meeting social care needs are not adequate and may be threatened by changing
economic circumstances. There has been some experimentation with social economy
approaches to the problem of community care provision. As yet, however, the concept of the
social economy remains foreign to the health and social services tradition in Ireland. Statutory
provision, which is geared to the individual who presents for care, is not sufficiently integrated
with local social networks or with local communities. Consequently, important elements of
reciprocity, social capital and inter-generational solidarity are neither being nurtured or utilised
for the support of older people in the community. The importance of the local community
cannot be emphasised enough since it is here that the full human needs of the older person can
be given maximum expression.
The emphasis on community care in this report does not mean that the residential care sector
can be ignored. There is a need for significant investment in public beds for older people,
particularly in the areas of assessment and rehabilitation. Current bed allocations for assessment
and rehabilitation are significantly less than the norms recommended in The Years Ahead. The
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8
Conclusions
development of intensive rehabilitation services for older people in public residential care is an
important pre-requisite for the new community-based model of care for older people.
Rehabilitation provides the critical interface between community care and residential care for
many dependent older people. An expansion of dedicated beds and services for people with
dementia is also required in line with the recent recommendations of the Action Plan for
Dementia published by the National Council for Ageing and Older People (O’Shea and O’Reilly,
1999). People with dementia sometimes need specialised care in appropriate residential care
environments. There are not enough of these dedicated beds available in the system at the
moment.
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appendices
1& 2
appendix
1
Nursing Home Questionnaire
The Department of Economics at the National University of Ireland, Galway is carrying out an
Expenditure Review on the Nursing Homes Subvention Scheme commissioned by the
Department of Health and Children and the Department of Finance.
As part of this study it is important that we collect information on the operation of the
Subvention Scheme from the perspective of the nursing home sector. In particular, it is important
that we have good information on dependency, costs and charges in the nursing home sector to
inform public policy-making in this area.
This questionnaire is designed to elicit information on the subvention population in your nursing
home, and to allow you the opportunity to give your view on the priorities for public policy
action in the nursing home sector. I can assure you of absolute confidentiality in all the
information you provide. Under no circumstances could any of your views or other details be
associated with your nursing home. Only a generalised report will be prepared on the
information which we collect. This report will contain only information on averages, percentages
etc. and it will not be possible to identify any individual or nursing home from it.
Review of the Nursing Home Subvention Scheme
1.
How many beds are in your nursing home?
2.
How many of these beds are currently occupied?
3.
Are any residents in the nursing home currently receiving any form of
subvention assistance (partial or full) from the Health Board? Please tick.
YES
1
NO
2
IF NO GO TO Q. 12
4.
How many residents are currently receiving any form of subvention?
5.
How many of these subvention residents are receiving a medium dependency
subvention of up to £70 per week?
6.
How many of these subvention residents are receiving high dependency subvention
of up to £95 per week?
7.
How many of these subvention residents are receiving maximum dependency
payment of up to £120 per week?
8.
Are any residents in your nursing home receiving an enhanced subvention
(above the maximum payment of £120 but less than the full fee paid by the
resident) from the Health Board? Please tick.
YES
1
NO
2
IF NO GO TO Q. 12
8a.
How many residents in your nursing home are receiving an enhanced subvention
payment?
9a.
Are any residents in your nursing home currently occupying beds that
are paid for, in full (after patient's own pension-related contribution), by the
Health Board? Please tick.
YES
1
NO
2
IF NO GO TO Q. 12
9b. If YES, how many beds in your nursing home are paid for, in full (after patient's
own pension-related contribution), by the Health Board?
125
appendix
1
10a. Are any of these beds which are paid for, in full (after patient's own pensionrelated contribution), by the Health Board contract beds, set aside by formal
arrangement with the Board? Please tick.
YES
1
NO
2
10b. If Yes, how many beds in your nursing home are contract beds?
11.
What is the average weekly payment (outside of patients own contribution) received
for beds paid for, in full, by the Health Board?
12.
What was the Total Amount of subvention income received by your nursing home
from the health board in the most recent financial year? If zero please state clearly.
13.
Can you indicate the dependency profile of the residents in your nursing home by
stating the number of people in each of the following dependency categories:
Low dependency
1
Medium dependency
2
High dependency
3
£
Maximum dependency 4
14a. Have any residents in your nursing home been diagnosed as having
Alzheimer’s Disease or dementia? Please tick.
14b. If Yes how many residents have been diagnosed as having Alzheimer’s disease or
dementia?
126
YES
1
NO
2
Review of the Nursing Home Subvention Scheme
15. Can you provide information on staffing levels (both full-time and part-time) in your home
under the following headings:
Staffing
Number of
Staff
A
Hours per
Week
B
Rate per
Hour (£)
C
1.
Administrator/manager
1
1
1 £
2.
Nursing
2
2
2 £
3.
Nursing aide
3
3
3 £
4.
Domestic/Catering
4
4
4 £
5.
Cook
5
5
5 £
6.
Maintenance/
Groundsman
6
6
6 £
7.
Activity Therapists
7
7
7 £
6.
Other (please specify)
8
8
8 £
16.
Can you provide information on Total costs per week/year (whichever is more appropriate)
in your home under the following headings:
Total Costs per Week/Year £
1.
2.
3.
4.
5.
6.
£
1
2
3
4
5
6
7.
8.
9.
Wages and salaries (including PRSI)
Food
Cleaning
Medical
Light and Heat
Other Overheads
(rates, insurance, telephone, repairs)
Professional Fees/Maintenance
Bank/Finance Charges
Other
10.
TOTAL COST
10
£
£
£
£
£
7£
8£
9£
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appendix
17.
1
Do residents in your nursing home receive any of the following services on a regular
basis? Please tick.
Receiving Service
SERVICE
1.
YES
1
2.
Occupational therapist
3.
Physiotherapist
YES
1
1
6.
2
Chiropodist
1
7.
YES
Other (specify)_______
1
YES
1
NO
2
YES
1
NO
2
NO
2
YES
NO
2
NO
2
1
NO
YES
NO
2
YES
NO
YES
Psychologist
YES
1
2
NO
2
1
NO
YES
1
5.
NO
2
NO
YES
1
2
YES
Social worker
YES
NO
2
1
4.
NO
YES
Public health nurse
Paid for by the Health Board
NO
2
YES
1
NO
2
18a. Does your nursing home offer day care services to older people living in the
community? Please tick.
YES
NO
1
2
IF NO GO TO Q. 19
Places
18b. If Yes how many day care places do you provide?
18c. How many of these day care places are paid for by the Health Board?
19.
20.
21.
When setting weekly charges for residents in your nursing home do you vary
the price charged by the level of dependency of the applicant? Please tick.
1
When setting weekly charges for residents in your nursing home do you
vary the price charged according to the means of the applicant? Please tick.
1
YES
YES
NO
2
£
22. What percentage of the weekly charge for residents relates to pure caring costs, as
distinct from hotel costs? Express care costs as a percentage of the weekly charge.
128
2
What is the average weekly charge, or payment rate, for people resident in
your nursing home?
23. Do you impose any additional charges on subvention residents for items like
dressings, laundry etc? Please tick.
NO
%
YES
1
NO
2
Review of the Nursing Home Subvention Scheme
24.
Have any of your current and most recent (within the past year) residents been
unable to keep up weekly payments for care? Please tick.
YES
1
NO
2
IF NO GO TO Q. 27a.
25a. How many subvention residents have been unable to keep up weekly payments in the
past year?
25b. How many non-subvention residents have been unable to keep up weekly payments
in the past year?
26.
In the event of residents not being able to keep up weekly payments from their own
resources what typically happens to the resident? Rank the following options from the
most likely scenario to the least likely scenario. Rank the most likely scenario as 1.
•
Families make up the difference
•
Health Board makes up the difference
•
Residents leave the nursing home and enter
public long-stay care
•
Residents return to live alone in the community
•
Residents return to live with their families in the
community
•
Residents move to a cheaper nursing home
•
Nursing home charge less than the full economic fee
Other (specify)
27a. Do you operate any restrictions on the type of resident admitted to your nursing
home? Please tick.
YES
1
NO
2
27b. If Yes please state the precise nature of the restrictions that apply.
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appendix
1
28a. Have you availed of the provisions of the 1998 legislation on capital allowances
against taxation to build or extend the nursing home? Please tick.
YES
1
NO
2
28b. If Yes, how many beds in your nursing home can be directly attributed to the new tax
incentives?
29.
How long have you been involved in the nursing home business?
30.
What changes, if any, would you like to see in the operation of the Subvention
Scheme for residents admitted to private nursing homes? List these changes in order
of importance.
1
2
3
31.
What do you see as the main challenges in the future to your continued involvement
in the nursing home business? List in order of importance.
1
2
3
32.
What can the Health Board do to reduce the challenges that you face now and in the
future to your continued involvement in the nursing home business? List in order of
importance.
1
2
3
33.
130
Have you any additional comments to make on the operation of the Nursing Home
Subvention scheme
Years
Review of the Nursing Home Subvention Scheme
Thank you for completing the pilot questionnaire.
Please return the questionnaire in the stamped-addressed envelope provided for that purpose.
All questionnaires must be returned before the 30th June 2000.
131
appendix
2
The Social Economy in Practice:
Illustrative Cases
The dynamics of social enterprise are better understood if seen in action, in case studies. It is
difficult to find more than a few case studies in this area but three are flagged below. We
provide thumbnail accounts only, but longer accounts can be found elsewhere. The first example
is the Tulsk Parish Services Ltd. Fuller accounts are to be found in Braithwaite (1997) and O’Shea
et al. (1998). The second case is the Roscommon Home Care Services Agency, established in
1997 and funded under the Employment Initiative of the European Union. This is described more
fully by WRC Social and Economic Consultants Ltd (1999). The third case is the Duhallow Rural
Community Care Network. This is described more fully, along with three related cases in
O’Shaughnessy (1999). While they are too limited a basis on which to form strong conclusions
they do offer suggestions as to the problems that need to be confronted and possibly some
questions as to practicability.
Tulsk Parish Services Ltd (TPSL)
TPSL was a response to need in the parish of Tulsk in Co. Roscommon, which comprises 570
households. As described by O’Shea et al. (1998: pp. 71-75) an agency was formed in 1995 to
provide home care, catering and laundry services for older people and young families in the
locality. The enterprise was created out of a traditional social services model of provision, but
people receiving services were charged for the services provided. Its set up phase involved
addressing issues of training and business management, premises and equipment, a
commitment to professionalism and a legal structure. The project has received assistance from
the EU and from the state in establishing itself and meeting employment costs, under the
LEADER II Initiative and from FÁS. Additional assistance was reportedly to be sought by bidding
for statutory service provision contracts. It is a limited company employing around 15 people,
mainly women aged 40 or over, most of whom were unemployed or long-term unemployed
previously. The project assessment by Braithwaite (1997) on behalf of the EU emphasised that
active support by statutory agencies, in particular the Health Board, would be significant. She
also recommended that policies be developed nationally to bring about and support local
delivery services arranged through the social economy.
Roscommon Home Care Services Agency
Another example is provided by the Roscommon Home Care Services Agency, reported in detail
by WRC Social and Economic Consultants Ltd (1999). The Agency was formed by a consortium
of organisations operating in Mid-South Roscommon, comprising the ICA, Teagasc, the MidSouth Roscommon Rural Development Company, and the Farm Relief Services Co-operative.
The Co-operative provided a model of the new organisation’s modus operandi. The Agency has
two main aims, first to provide high quality services in the area of home management, child care
and social care (care of the elderly) and second to provide accredited training and employment
Review of the Nursing Home Subvention Scheme
to a number of women, for whom it acts as agent. The operators who deliver the services are
technically self-employed. Most of the customers pay the full cost of the service but sometimes
the Health Board contacts the Agency to provide social care services on its behalf, paying a
subsidy along the same lines as to the existing home help service. The EU’s Third System and
Employment Programmes provide funding towards administration while the local Area Based
Partnership Company funds the training of new operators. The new Agency recognised that as
well as attempting to establish a market for services that often were previously not purchased, it
would be in competition with the black economy on one side and the Home Help service on the
other. At the time WRC reported, progress was mainly in the home management field, with less
success in the home care and child care areas. It was suggested that greater market penetration
and improved statutory support, particularly through contracts, could ensure future success.
Other possibilities under consideration were expansion into other geographic areas and
diversification of activities, such as garden maintenance, possibly creating employment for men.
Rural Community Care Network
O’Shaughnessy (1999) has outlined some perspectives on the social economy in relation to
services for older people in Irish rural areas based on a study of the Rural Community Care
Network (RCCN). The Network, established in 1997 with European Regional Fund assistance
(Article 10), is one of three Irish projects selected among 41 across the EU, all of which have
three goals of job creation, partnership in action and experimentation/innovation. The more
specific objectives of the RCCN were to create a “Community Caring Network” and in the
process generate employment in the delivery of new and existing care services targeted at
elderly people, people with special needs and children. There were four pilot projects within the
network, as set out below.
Pilot A –
Rural Community Care Network West
Limerick Ltd.
Pilot B –
Duhallow Rural Community Care
Network Ltd.
Pilot C Rural Community Care Network
Ballyhoura Ltd.
Pilot D –
Blackwater Rural Community Care
Network Ltd.
to improve housing conditions and, in turn,
offset demand for residential care
“meals on wheels” service
visiting service and the formation
of two carers groups
Respite care, day care and home care
Each project adopted a partnership (cross-sectoral) model of management, forming a limited
company and the network as a whole was organised on similar lines. Here a short description of
one of the four component pilot projects is provided.
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appendix
2
Duhallow Rural Community Care Network: This region, like the other areas under the RCCN,
exhibits an imbalanced demographic structure. An estimated 16 per cent of the population are
over 65 years compared with a national average of 11.5 per cent. This sub-population is the
pilot’s target group, in particular those with a higher income derived from contributory pensions
and thus not solely dependent on non-contributory state provision. The pilot focuses on
providing a “meals on wheels” service to elderly bachelors (an estimated 65 per cent of the
clientele) and other isolated residents of the region. A service co-ordinator was recruited and
existing kitchen facilities, already in place as a result of the efforts of the local LEADER company,
were upgraded. A central element of the programme is the voluntary input from the community
in delivering these meals to a dispersed rural population. There are eight people employed in
the programme, four of these under a FÁS Community Employment Scheme with the remaining
employees paid from the trading income generated through the project. O’Shaughnessy
reported that the group was delivering over three hundred hot plates for the elderly. It had also
started to diversify activities and prepare food for confirmations, communions and wedding
receptions.
A significant feature of this initiative has been its provision of training under terms of the EU
funding. A ten weeks “Women’s Development & Enterprise” programme was delivered to
twenty-three trainees and concentrated on a range of subjects, including basic business skills,
food and nutrition, and food hygiene. The focus on women stems from an analysis of female
participation in paid employment within the region. Like the other projects under the RCCN, this
particular initiative experienced difficulty in employing local women given the restrictive entry
condition onto the FÁS CE programme, which only permitted the employment of women in
receipt of social welfare payments. This links back to the role of social economy initiatives
discussed earlier and the concentration on employment objectives. According to O’Shaughnessy
(1999), “The RCCN has highlighted some of the limitations associated with the most recent Irish
proposals to develop the social economy sector. To successfully ensure that local interests would
drive the development of the social economy requires real commitment at a number of different
levels. Pursuing the social economy primarily through labour market mechanisms must be
questioned and challenged”.
Lessons from the Case Studies
These case studies have some similarities and differences. All are based in rural areas where the
demographic structure includes a higher than average proportion of older people. They are also
areas in which non-agricultural employment opportunities are below the national average. In
each case there has been some support from the EU, whether through the LEADER II initiative,
Area Based Partnership Companies or other EU initiatives or programmes. Another common
feature is that each of the projects has emerged largely from outside the traditional statutory
source of funding for social services for older people, namely the health boards. Where the
health boards have been involved this has come about through approaches made by the
projects or through contacts initiated after they were established.
The fact that these cases are all in rural areas may not be coincidental and possibly suggests that
rural areas might provide the best terrain for experimentation in serving older people through
the social economy. This would need to be carefully explored before drawing conclusions.
However, it is certainly true that rural areas exhibit higher old age dependency ratios and this
could be associated with other factors such as limited investment, population dispersion that
necessitate an area based approach to the continued maintenance of services and consolidation
of existing resources. Rural areas, with strong local identity too, may offer the basis for mobilising
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Review of the Nursing Home Subvention Scheme
the factor of reciprocity, which is a key ingredient in the success of the social economy.
Some differences between the projects are the status of the staff, who are self-employed in the
Roscommon project and employed under the FAS CE scheme in Duhallow RCCN and in Tulsk.
There are also differences in the precise EU lines under which support is provided and there are
further differences in the purpose for which funding is provided by EU and Irish statutory
agencies. In all cases the projects rely on funding that is not guaranteed in the long run.
However, in the case of Roscommon Home Care Services Agency, no subsidy on employment is
provided, implying that the Agency is partly dependent on the traded income for the brokerage
service it provides while the operators are entirely dependent on traded income. This places the
operators in a more precarious position and implies that the service is mainly provided for
households with reasonable incomes.
This may also be related to the Roscommon project’s focus on home management as distinct
from domiciliary care and childminding tasks. Of the three examples described this one is least
targeted towards vulnerable elderly people. There is an element of competition with the Home
Help service provided or subsidised by the Health Board and, evidently, the new agency has not
been able to expand the market in that direction. In contrast, the Duhallow RCCN has achieved
some success in a field of activity - meals on wheels - that is intrinsic to the health board
provision, but often provided through arrangements with local volunteers or voluntary
organisation. It may be that a superior form of provision has emerged in this case, related to
intrinsic qualities of the social economy model.
More investigation of each case would be required to establish whether the social economy
models described are potentially superior to the services already provided along more
conventional lines. It does seem that the three projects described are principally oriented
towards the creation of employment locally. However, that does not vitiate their potential in
improving services and there are certainly lessons to be learned. The first lesson is that each of
the projects appears to have a form of ownership that keeps the gains of the venture in the
community, whether as a company limited by guarantee or a co-operative structure. These
structures are very suitable to fostering the social economy. Moreover, some of the partners to
these initiatives are structured as partnership and co-operatives. This provides a further
possibility of strengthening the community ownership of new services and resources by
increasing networking. Second, the entrepreneurship function has been instigated not only by
development organisations or existing partnership bodies but has also come from communitybased social service organisations, as illustrated by Tulsk. The influence of LEADER companies
has proven considerable and area based partnership companies too have been critical, as would
be expected. However, the fact that social service councils too may be turning to the social
economy model suggests that there could be an important bridge here between the more
typical labour market focus and a social service perspective. Noteworthy too is the emphasis on
developing the entrepreneurial skills of project participants through training courses.
Third, social capital is in evidence in that the projects, in addition to employing people through
FÁS schemes or direct employment and self-employment, utilise volunteers. These volunteers
are part of the local community and have a stake in ensuring the development of appropriate
social services for older people as part of solidarity across the generations. The focus on older
people is present in all of the projects and the services offered are clearly of potential
importance in facilitating older people in maintaining a satisfactory lifestyle in the open
community environment. Resources and infrastructure previously established in the community,
as seen in the provision of premises and kitchen facilities by the LEADER Company in the case of
Duhallow, are also sometimes seen as a shared resource. This is a good example of the attempt
135
appendix
2
to gain economies of scope from resources that cannot gain from large scale specialised
activities due to small market size. However, the development of trust and co-operation has not
overcome traditional barriers between the formal and informal sectors. There is not a great deal
of partnership with health boards in any of the projects. There may be other statutory authorities
too with which relations could be further developed, particularly the local housing authorities, in
developing the social economy further. The reasons for the weakness of this link have been
referred to already, such as the labour market focus of much social economy discourse.
Nevertheless, it is sobering that in three projects that are specifically aimed at providing critical
services for older people, the role of health boards and local housing authorities has been
minimal. This point was the focus of comment and recommendation in the evaluations of the
various projects.
136
Review of the Nursing Home Subvention Scheme
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