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Finding sustainable funding for homecare is in all our best interests


Fashion designer and TV presenter Brendan Courtney. Photo: Andres Poveda

Fashion designer and TV presenter Brendan Courtney. Photo: Andres Poveda

Andres Poveda

Fashion designer and TV presenter Brendan Courtney. Photo: Andres Poveda

'There's no place like home," said Dorothy, clicking her heels. It's a sentiment we can all relate to but older people struggle to achieve, as Brendan Courtney showed earlier this week.

The TV presenter and his family documented the aftermath of their father's devastating stroke in 'We Need to Talk About Dad', which rendered him reliant on others to do daily basic tasks. There were medical tasks too, but the Courtneys hoped they could spend money under the Fair Deal scheme to buy the supports required to bring their father home.

Unfortunately, a complex system of services and grants with complicated and often incomprehensible rules, significant waiting times and perverse incentives, meant their father remained in hospital. Understandably, Courtney ended the programme on RTÉ in a blaze of anger demanding action.

This week, the Government launched a consultation process on the establishment of a new statutory homecare scheme. But what exactly will it take to provide the scheme?

First we have to decide how to fund such a scheme.

An extension of the Fair Deal scheme has been ruled out. This seems sensible, given that a large contribution from an older household's income would leave little to pay for other household and disability-related costs. Additionally, it's unlikely older people would take too kindly to another charge on their assets.

Even if they did, it wouldn't be the answer, as the review of the Fair Deal by Deloitte showed that contributions to the cost of nursing home care from older people accounted for less than a third of the total cost of care in 2014.

Admittedly, homecare is a cheaper service to run, but it cannot be financed through a narrow base of service users, as the ability to pay simply isn't there. Rather, a broad base of finance through long-term care insurance or taxation seems more sustainable. The forthcoming Health Research Board (HRB) report, which considers homecare arrangements in four countries, will likely guide the options available.

The Fair Deal scheme does, however, have the benefit of being a ring-fenced system. The same cannot be said for community services such as home help, public health nursing and respite care, to name but a few.

These services are subject to an annual dog-fight over the HSE budget, competing with the more powerful hospital services. A protected budget to pay for services which support older people to remain at home needs to be prioritised. Additionally, a personal budget structure (currently being considered for people with a disability) would facilitate the activation of the right services quickly, rather than depending on what's available in each individual service budget.

The second thing is to determine who is entitled to the scheme.

The Government aims to make homecare available to one-in-five of the older population, when currently every one-in-10 accesses the service.

To realise this target, there seems to be two options. One is to pursue the long-held policy goal to shift resources in the HSE budget from hospital to homecare.

However, doing so in the context of increasing demand from demographic ageing, the emergency department crisis and long waiting times for hospital appointments seems unrealistic at best, and dangerous at worst. Recent research by Professor Stephen Thomas in Trinity College Dublin found that the Irish health service is not in a position to withstand further budget cuts, after the 'crash diet' it has already endured.

The other more likely option is to embark on cash-raising processes alongside rules to ration the service. Rationing by need is plausible; the minimum level of need required to gain entitlement to the service could be increased, limiting the numbers eligible.

There are arguments for this, such as better targeting of limited public resources.

However, setting the level too high based on what budget is available rather than what is required runs the risk of denying the service to older people who need such support.

Finally, there is an option of further rationing the amount of homecare offered per client, though it seems unlikely to go below the maximum hours currently offered.

Ultimately, the Department of Health has the unenviable task of trying to get Irish political parties to agree on how to pay for homecare going forward, not easy when these parties have widely different views on how to fund public services.

Whatever does happen will need to be supported by hard evidence and good decision-making processes, as laying the foundations for a good service now will reap rewards later.

Ultimately, this reform is in all of our interests, as we are likely to know someone who needs ongoing care and dearly wishes to receive it at home.

Dr Lorna Roe is a research fellow in the Centre for Health Policy and Management in Trinity College Dublin, the vice chairperson of the Irish Social Policy Association and a committee member of the Irish Gerontological Society

Irish Independent