Professor Eamon O'Shea:

I will focus primarily on the economics and financing of long-term care. The key point I want to make is that regulation and legislation are not enough unless they are accompanied by adequate resources. In recent years, adequate resources have not been provided in support of the long-term care we need. This is particularly true in the case of home care. If we are serious about changing the structure and the system of care, we have to find some way to provide the resources to do that. We have been really good at policy and the rhetoric of policy. Our vision for what we want, as set out in reports like the Care of the Aged report from 1966 and the The Years Ahead report from 1977 and in various strategies, including the recent dementia strategy, could not be faulted. The implementation aspect relating to that could be faulted, however. I think that is the key to change in the coming years. The key pressure among the numerous pressures that are coming on the system is demography, which will change the landscape over the next ten or 20 years. We have been seeing it coming, but it is arriving now. It will be a key game-changer in the context of the resource question. This is the fundamental area I want to talk about today.

Various countries take differing approaches to the key question of where the locus of responsibility with respect to care should lie. The Nordic countries, for example, tend to favour large Government spending on the welfare state. Countries in southern Europe tend to rely on family care. Where do we lie? Where is the locus of responsibility in Ireland in the context of care provision? De facto, it is with families. Families provide the main bulk of care. When a monetary value is put on the care that is provided in the area of dementia, in which I work, it is found that almost half of the cost of care is borne by families. De facto, care is borne by families. We do not have much data on preferences. Some 60% of the 100 members of the Citizens' Assembly recommended that families should have primary responsibility in this regard and the State should provide strong supports. One third of members of the Citizens' Assembly said that the State should bear the primary responsibility for care, with family support. Interestingly, 87% of members of the Citizens' Assembly agreed that more spending is needed. Regardless of whether one thinks the State should provide more or families should provide more, there is agreement that not enough is being provided. De facto, carers provide care.

I would like to speak about one of the things that have been happening in the home care area in recent years. This has been going on for a while. We have not managed to get sufficient resources. When we have had financial difficulties, the first thing we have done is cut back on community care services. One of the reasons for this is that community services are easier than other services to cut back, or not increase. That is what has happened in recent years. If one divides total expenditure by this country's total population of older people - I am talking about the number of people over the age of 65, rather than the total number of dependent older people - one will find that spending has decreased by approximately €1,000 per capitaover the past eight years. I am not saying that all of those over the age of 65 are depending on the State because of course they are not. The broad figure I have mentioned gives an indication that it is easier to decide not to fund community care services - we sometimes do this unwittingly - than it is to cut back on residential care services because there is a statutory element to services in the latter category. It is also difficult to cut back in the areas of pay and so on. We tend not to support fragmented community care services for these reasons. We need a statutory home care system because it will give people certainty in these respects.

One of the enduring criticisms of Government policy in respect of dependent older people is the imbalance between residential care and community-based care. I am not arguing that we should cut back on residential care, which is needed for some older people. There is no question of this being a case of one or the other. We need to give more support to people in community-based care. At the moment, the balance of care is fragmented and unequal. I would say there is inequality of home care provision across the country. One can be lucky or unlucky, depending on where one lives. It is sometimes more difficult in rural areas. Similarly, there can be difficulties in the community care systems in urban areas. The community care systems we have are very narrow. They tend to focus on home help, which is important and critical, but there are many other things that older people want, which is a question I want to focus on. At present, we tend to determine community-based care on the basis of what suppliers and health care and social care providers think older people want. I suggest we need to move towards a personalised care system that responds to the expressed needs and preferences of older people. Older people and people with dementia have a voice. They know their own care needs and preferences. We should be able to respond to them in a very personalised way. This is not just a question of rights. The emphasis should not be on home care only. We need personalised home care. We need a variety of responses. The focus should not be solely on the provision of more home help hours, although that is important. We need to think about psychosocial responses. We need to think about connecting dependent older people in the communities where they live. It is not good enough just to provide care. We must connect. We make people who are invisible visible in their own communities so that they can live good lives. This is a critical point in any discussion on the development of home care services. While expanding rights to community-based care is a necessary condition, it is not a sufficient one.

We need to think about what kind of services we have.

That brings me to the final point I want to talk about, which is funding. Funding for long-term care here in Ireland has typically come from general taxation. There are good reasons we use general taxation to fund care. General taxation is universal. It is democratically accountable. It yields a large amount of money and it tends to be progressive. However, dependent older people have lost out. General taxation does not trickle down to where we want those resources for older people. In particular, it does not trickle down to flexible, responsive, personalised community-based care. If we simply legislate for more home care and rights, unless we address the funding issue we will not change very much. That means we could opt to allocate more resources. I do not mean allocate willy-nilly as one has to evaluate what is good and what is bad in care. This is not simply a case of allocation for the sack of it. There are alternatives. An alternative option which I spoke about probably 20 years ago was discussed ten or 15 years ago. Some countries, such as Japan and German, use designated social insurance funding for long-term care. Under a social insurance system, people would pay into a fund and in return would get an automatic entitlement. I will not go into how one would create that system, but it is a social insurance system. Such a system would allow for a more protected, and, if we want, designated, visible transparent community-based care system where we could say what we have, what we allocate and what is the impact of that.

When we last discussed this, for example, in the four years between 2002 and 2006 when we were coming up to the fair deal legislation, we as a society felt it would be too costly, it might impact on competitiveness and it might impact on labour markets. We wondered would it be seen as an additional form of taxation. I believe there are significant advantages to a social insurance system and it, along with rights-based community-based care, needs to be part of the debate over the coming years. It works well in Germany and Japan. If we do not think about changing the structure of funding, we need to ensure that taxation gets allocated and trickles down to where we want it.

I would again say that rights without resources for community-based care will not achieve what we want it to achieve. Therefore, if we want to develop high-quality services, if we want to shift the balance where the onus of care is primarily on families, we need to think about what we are thinking about now, which is rights, but we need to do more. We need to think about rights for a rich variety of services for older people. We need to think about rights for a visible equitable system of care for older people. We need to shift the balance from residential to community, although keeping strong residential care services, and we need to think about having the older person, the person with dementia, right at the centre of that decision-making process. Then we would have a credible home care system for an increasing demography that will put considerable pressure over the next ten years on this society.