We need a Fair Deal for elderly at home - but it won't be cheap
The vast majority of older people in Ireland are active, healthy and live independently in their own homes. However, approximately one-fifth of older people living at home have one or more disabilities and need the help and support of others at various times and to varying degrees. A further 5pc of the older adult population live in long-stay residential care.
While Ireland currently has a relatively young population in comparison to other European countries, demographic trends suggest that the country will experience serious ageing of the population in the coming decades. Life expectancy for men and women has increased significantly in Ireland in recent decades. A male aged 65 years in Ireland can expect to live, on average, for another 18 years, while a female of the same age can expect to live for an additional 21 years. These gains are a cause for celebration and reflect the economic and health benefits of living in Ireland now in comparison to previous periods of our history.
Recent controversies have, however, highlighted serious imbalances in the care of dependent older people in Ireland. Although public policy purports to favour community-based care, the opposite is the case. The vast majority of government spending goes on supporting older people in residential care through the Fair Deal scheme. Close to €1bn was spent on the scheme in 2016, almost three times more than was spent on community-based care for older people. While there are some problems with Fair Deal, most people agree that it is an improvement on previous arrangements and it does allow people to access a very expensive resource on a statutory basis, albeit with some cost-sharing.
The situation is different in relation to community-based care. There is no right to community-based care in Ireland. The current provision is weak relative to need and distributed unevenly across the country. The result is that family carers bear most of the care burden and financial cost of looking after older people living at home.
For example, of the €2bn costs associated with dementia in the country, almost half is borne directly by informal carers. If families stopped caring, the care system would collapse. While there is no evidence to suggest that families will stop caring, increasing numbers of older people, a reduction in the number of potential carers due to lower birth rates and the increased labour force participation of women will necessitate a greater involvement of the State in the care of older people in the future.
Community care services for older people in Ireland are currently concentrated on public health nursing and home help provision. Public health nurses provide front-line support for dependent older people living at home, but they cannot meet all needs in the community given their considerable workload.
Home help is critical in allowing older people to remain in their own homes for as long as possible and practicable. However, financial constraints mean that the HSE has had to cut back spending on home support services, despite an increase in the number of people aged 85 and over and people living with complex conditions such as dementia. Not surprisingly, private expenditure on home care has grown in recent years as public spending has come under pressure.
Recent innovations in community care in Ireland have focused on the introduction of designated home care packages for older people living at home. These are additional support measures over and above existing community-based services and are designed to maintain very dependent older people at home, who might otherwise be in hospital or in residential care, through intensive home supports and rehabilitation services.
However, notwithstanding such innovation, not enough resources are currently being allocated to community-based care, including flexible, supported housing solutions for community-based living. This is long recognised and acknowledged by those at the front line of care in the HSE, but it seems to be impossible to change, even though it has been a consistent mantra of successive governments that change is necessary.
Thirty years ago 'The Years Ahead: A Policy for the Elderly' report highlighted the need for the development and practice of home-based care for older people and recommended greater state involvement to support community-based care. The report called for the development of a social model that maintained older people in their own homes rather than be admitted to long-stay residential care.
Back in 2005, the National Economic and Social Forum called on the then-government to spend an additional €500m to bring long-term care expenditure up to the OECD average. Nothing of the sort happened, even when we had the money to spend. It remains the official policy of the current Government to prioritise and support community-based care. But it is not doing so sufficiently.
So what needs to change to deliver the community-based system of care that all of us say we want? The first thing to acknowledge is that expanding community-based care is not going to be cheap. Providing good quality care that is individualised and tailored to the social needs of older people is expensive and sometimes requires complex supervision and co-ordination, especially when there is multi-morbidity involved. So solving the problem is going to cost money.
Some people are now talking about a Fair Deal-type of scheme for community-based care, but, even with cost-sharing, that will require additional resources, particularly if we include innovative housing solutions, which we must.
Funding long-term care through general taxation has not delivered the funds necessary to support an optimal community-based response for dependent older people. The latter seem to continually lose out in the allocation of scarce public resources collected through general taxation. So calling community care something different is not the solution, unless it is supported by additional money and a specific plan for policy implementation.
It is time, therefore, to think about a new social insurance model for financing long-term care that will generate earmarked funds to support care for dependent older people in Ireland living at home and in long-stay care facilities.
Additional money can be raised through social insurance contributions in a transparent and equitable manner over the lifecycle, in return for automatic entitlement should contributors need care and support at some time in the future. For those unable to make a contribution to the scheme, the Government could provide coverage. Social insurance would provide a public system of funding for the long-term built on reciprocity and solidarity across the generations, reflecting caring interdependencies and obligations that people in this country still value.
We need to act now to address the needs of dependent older people, particularly those living at home. We know the extent of the problem. We know the preferences of older people and their families. We have the policy tools to solve the problem. So let's address the issue through action rather than any further procrastination. Provide additional resources to older people living in the community now and initiate the process of developing a social insurance model to pay for these resources. This is prudent and rational public policy that will benefit dependent older people and their carers now and in the future. All of us have an interest and stake in getting this right.
Professor Eamon O'Shea is director of the newly established Centre for Economic and Social Research on Dementia at NUI Galway