What Next for Irish Healthcare Providers?

What Next for Irish Healthcare Providers?




  • The government’s Fair Deal Nursing Homes Support Scheme has divided opinion since it was introduced in 2009
  • To qualify you must contribute 80% of your income, and 7.5% of the value of your assets for three years
  • Farmers are at particular risk when using this current scheme, as the family home is treated like a business, which doesn’t benefit from this three-year cap

What impact will the Health Service Executive-managed Fair Deal scheme have on nursing homes and the primary care sector?

The government’s Nursing Homes Support Scheme – known as Fair Deal – has divided opinion since it was introduced in 2009 to financially support elderly people needing long-term nursing care.

“It works well for some,” says Gerard Scully, senior information officer at Age Action Ireland. “The less money you have, the better it is for you. If you only get the state pension, it’s ideal – but for those with other income or assets, it’s more complicated.”

Many charities believe the contribution required to qualify for support – 80% of your income, plus 7.5% of the value of your assets for three years – is too high. Critics say claimants face a stark choice of giving up their home, savings or both, to pay for their care – leaving nothing to pass down to their children.

An ageing population means the scheme’s current business model could be hard to maintain.

A 2015 report into the scheme by economists DKM warned that the current system of individual negotiations for each nursing home means Fair Deal “operates in an ad hoc manner, lacks rationale, consistency and fairness, only applies to the private sector and in the long run is unsustainable”.

More money has helped – a €44m government top-up for the scheme in 2015 halved waiting lists for nursing homes from eight to four weeks, followed by a further €22m investment last year. But this appears to confirm the need to look at long-term sustainability.

However, the report was critical that fee agreements don’t accurately reflect dependency levels or nursing home costs, which it said is a barrier to investment by the private sector.

The right structure

Tadhg Daly, CEO of Nursing Homes Ireland, says the lack of what he calls ‘proper structuring’ of the scheme means the current funding model is “not fit for purpose”. He adds: “This is threatening the sustainability of providers and stifling their ability to meet the rapid growth in requirement for nursing home care.”

And such sustainability would need to be addressed if Fair Deal were extended to home care – an issue highlighted in January in Brendan Courtney’s moving RTÉ documentary We Need To Talk About Dad.

“Fair Deal gets you money for nursing home care but not care in your own home,” said the celebrity fashion designer, who was shocked at the lack of options when he sought a care plan for his father Frank, left paralysed following a stroke. “You can get a loan from the Credit Union to spend on what you want,” he added, “so how come the HSE loans you money on your asset and then tells you what to spend it on?”

A compromise in standards

Daly is concerned that Fair Deal’s current format risks compromising care standards in nursing homes – and even the homes’ existence. “What the money provides at the moment is a basic essential nursing care – it excludes social programmes, therapies, all the things that add to quality of life.

“Because the state is a monopoly purchaser, there is a focus on driving down costs. This threatens the quality of care but ultimately the low payments will make the homes unsustainable and in danger of closing altogether.” 

“The less money you have, the better it is for you. If you only get the state pension, it’s ideal – but for those with other income or assets, it’s more complicated” 

Gerard Scully, senior information officer, Age Action Ireland

Another concern is that while offsetting assets to pay for nursing home care may hit homeowners hard enough, for families operating farms, it’s potentially disastrous.

“The 7.5% a year is capped at 22.5% after three years for family homes – but because farms are a business, there is no limit,” says Eddie Punch, general secretary of the Irish Cattle and Sheep Farmers’ Association.

“And with a slow, degenerative disease like Alzheimer’s, you can have good physical health but need nursing home care for years. The annual demand for 7.5% means farms have to be sold, or broken up. Non-farmers may have to sell their home to fund care – but their children may have their own homes and don’t need to inherit one. However, farming is a legacy. If a farmer has to sell, there’s nothing for the next generation – no home, no job, no way of life.

“And it’s not just that family affected. It’s all the other rural businesses relying on that farm.”

Plans for change

So how can Fair Deal better pay its way? Taoiseach Leo Varadkar, then Minister for Social Protection, urged the government to remove the cap on funding. DKM’s report suggests a more structured assessment process would enable it to access equity via the Employment and Investment Incentive Scheme or a state investment lending fund. Another option is compulsory long-term insurance, as happens in Germany and Holland.

There are signs of change. Two days after Courtney’s documentary aired, the then Minister of State for Older People, Helen McEntee, announced a public consultation, saying: “I am determined to change this and establish a new statutory home-care scheme.”

But, says Daly, the urgent need is to find a solution for everyone. “This debate is sometimes presented in the media and public as a ‘nursing homes versus home care’ battle but it is absolutely not the case – we need to find a system that acknowledges our ageing population and caters for every single person.

“Fair Deal does improve what it replaced, providing clarity for residents and families over care and finance. But we need a more transparent commissioning model, a dependency-led model, a right for operators to appeal over the level of funding they get – and it must be index linked to recognise costs are increasing.”

Whatever happens, the system needs to cater for an elderly population predicted to rise to 1.4 million over the next 30 years. “Current average life expectancy in Irish nursing homes is 82.9 years,” says Daly. “But 60% of our residents are over 85. Inaction is not an option.”



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