Peter Fitzpatrick (Louth, Independent) | Oireachtas source

Ireland has an ageing population. Life expectancy in this country has risen by two years for women and 2.5 years for men since 2008. With an average life expectancy of 84.1 for women and 80.5 for men, Ireland is now above the European average. Central Statistics Office, CSO, projections indicate that by 2030, there will be more than 1 million people aged 65 and over in Ireland. It requires planning and allocation of resources to meet the increased demand for both home-based and nursing home care.

At present, 80% of nursing home beds are in the private and voluntary sectors. Demand for home support continues to increase. According to age and population statistics, we will need an additional 1,500 beds annually for the next ten years. Instead, there has been a loss of 500 beds in the past year alone. The disruption to families and the heartbreak caused to older residents forced to leave the place they call home are immeasurable. Waiting lists for home support have become a feature of the service and are now primarily associated with an increasing capacity issue related to the availability of care staff.

The difficulty in accessing home support for older people is, after housing, one of the biggest issues raised by people in my constituency office every week. In County Louth, there are significant difficulties getting full home care packages for those who need them. They may get partial packages. People I have spoken to in CHO 8 say it is difficult to get home care assistants to travel to north Louth. The eircode lottery not only affects initial home care waiting lists but also how many hours of care are delivered to a client. As a rule of thumb, areas in Dublin have shorter waiting lists than rural areas, and areas with a high proportion of directly delivered HSE care have longer waiting lists than areas with greater involvement of the independent sector.

A significant issue at present is that smaller nursing homes located in rural Ireland face closure as the fair deal subsidy is failing to match rising costs. Each individual nursing home must negotiate its own fair deal arrangements. Currently, public nursing homes run and staffed by the HSE receive 62% more per person per week than is given to private nursing homes. Some public nursing homes receive substantially more under the fair deal scheme, even though the public home may have fewer services for those living there.

Ireland lacks an equivalent statutory scheme for the home care sector. While the programme for Government commits to introduce a statutory scheme to support people to live in their own homes, there has been little to no headway in delivering it. The statutory home support scheme, which aims to introduce a regulated home support service with a new model of funding and service delivery for adults over the age of 18, has been in development since 2018. The delivery of the scheme is pivotal to the growth and sustainability of the home care sector. Delays are preventing strategic planning. In June 2020, the then departing Minister for Health and current Taoiseach told the Dáil the scheme was nearly ready. In December 2020, the Minister of State, Deputy Butler, targeted quarter 1 of 2021 for the introduction of legislation and 2022 for the implementation of the scheme. Legislation to regulate home support providers has yet to be published and other aspects of the scheme have also been delayed or are stalled. Putting the scheme in place requires regulation, funding and reform of service delivery.

It is hoped to ultimately integrate the home care system with the nursing home care system in order that individuals can transition from home care to nursing home care much more easily, if the need arises. Referring to a potential funding model, the Minister suggested at the Home and Community Care Ireland conference in October 2023 that co-payments would be necessary. Others favour a social insurance model similar to that used by several of our European peers. Implementing the scheme raises challenging political questions. It will require significant political capital, as well as human resources, to drive through its implementation. The marginal increases in funding in the past two budgets are concerning. By the HSE's own admission, demand for home support increases by 4% each year. By that reasoning, anything less than a 4% increase in funding represents a cut to home support in real terms. That is evidenced in the HSE's national service plan for 2024, which shows a cut in the number of clients and targeted hours of home support delivery compared with 2023. Funding will likely be the most contentious issue but setting out a clear funding model is critical for the future sustainability of the sector.

A statutory home care scheme is a vital development for the future of care for older people and adults with disabilities. The current misalignment in funding between disability and older person services is creating a two-tiered home care sector that risks seeing disability home support provision being left behind.

Repeated delays to the scheme do a disservice to clients, home care workers and providers and have added instability and uncertainty to the sector. Furthermore, other reforms are dependent on the development of this scheme and the home care sector remains hamstrung until it is placed on a statutory footing.

The Sláintecare report recognises that, in the absence of an entitlement to home care services, many people pay out of pocket for private home care services, and that this should be addressed by ending the over-reliance on market mechanisms to deliver new health care services with the expansion of public nursing homes and home care. Yet the home care Bill 2024 relates entirely to the regulation of providers of home care services, which of course is required, but it does not address access to services or affordability. The Department of Health's home support reform team should be equipped with more resources so that the five different work streams of this scheme can be developed in parallel, instead of in tandem, one at a time.

Rather than restoring balance within a truly public health system that is universally accessible and free at the point of use, this Bill would actually reinforce privatisation by structuring the home care regulatory framework around the private market. The expectation within the sector was an improved version of the nursing home support scheme that delivered equitable access to home care. The reality is that seven years later we have produced a licensing scheme.

Access, staff recruitment and retention do, however, remain an ongoing problem not only in the home care sector, but across the health system as a whole. To get a sense of the scale of recruitment that Ireland needs, the European Centre for the Development of Vocational Training forecasts there will be an additional 119,000 personal care worker job openings in Ireland in 2030 compared to 2018. The goal in all of this is to streamline the process for the individual and their families and to ensure continuity of care. Yet, on any given day, approximately 100 people - plus or minus 25 - experience delayed transfer of care due to the unavailability of a home care worker to deliver a home care package. While the well-documented recruitment crisis contributes to this issue, the method of commissioning home care exacerbates it. When a patient is deemed fit for discharge, the hospital discharge team must wait and hope that one of the home care providers has a worker available to support the patient’s transition from the hospital. This approach highlights a strategic failure in hospital discharge planning. Considering the cost of keeping a patient in the hospital, which is €7,203 per week, the risk of hospital-acquired illnesses, and the impact on accident and emergency department overcrowding, it is crucial to view home care providers as partners in the discharge process and to provide them with the frameworks necessary for strategic discharge planning.

While the Government deserves credit for substantially increasing home support funding and establishing the Commission on Care for Older People, reform is essential if Ireland is to develop an aged care sector suitable to meet our changing demographics. Home care in Ireland has evolved without being supported by a comprehensive strategy for home care for older persons. Similarly, the Government’s commitment to a home first model of care lacks strategic backing. The commission requires sufficient resources to complete its work on schedule. In order to implement these reforms and to create effective home care policies, we need a data-driven strategic approach to develop solutions that could modernise the sector. Wholesale reforms are also needed in home care workers’ pay, benefits, training and career progression among other things. As demand for home care is set to grow substantially over the next number of years, it is essential that we put in place the appropriate systems for home care. The present system is letting down both the patient and the carer. We should strive towards a sector that has equal access to care and where waiting lists are kept to a minimum.

See this speech in context