Covid-19 deaths in care homes are a wake-up call to us all
The C&AG’s report into nursing homes contained no real insight into the problems affecting the sector; we need to ask ourselves what we want from a nursing home, writes Des O’Neill (originally published in the Business Post) .
The coronavirus-related deaths of almost 1,000 people in Irish nursing homes reflected an abject failure of policy and oversight by successive health ministers and the agencies they oversee, allied to untrammelled privatisation of a highly vulnerable sector. Onto that deep, glaring wound was poured a hefty bucketful of salt by the Comptroller & Auditor General last week in a report on the Fair Deal scheme. It reinforced the sense that, like the Bourbons, the political class have learned nothing and forgotten nothing about our care in nursing homes.
The report’s key findings focused on opaque mechanisms and variability of funding. It is, of course, right and proper that government spending should be appropriately monitored. But this monitoring should keep some perspective on what, why, how and for what purpose the money is being spent.
In that context, the C&AG report was jaw-dropping in its complete lack of insight into the complexities involved in the care of frail older people, appropriate expectations of modern care, and adequate supports and oversights.
It was agnostic on issues like the failure of successive health ministers to implement appropriate needs assessments of potential and existing nursing home residents, a decade after the selection of the international standard, known as interRAI, as the Irish standard instrument.
It said nothing about the neglectful policy of separating the largely private sector from the structures and services of the health service, nor about the clear absence of expertise on the care of older people in the National Treatment Purchase Fund (NTPF).
Also missing was any discussion of the failure of Hiqa, the regulatory body, to develop appropriately sophisticated oversight of the sector, or the lack of focus and leadership from the nursing and medical professions.
Only days prior to the release of the C&AG study, the Oireachtas committee on Covid-19 had alerted us to many of these systematic and catastrophic failures in its own report on nursing homes, although it singularly failed to mention the moral and actual responsibility of the corporate and individual owners of privately-owned nursing homes.
In the C&AG report, the Department of Health is reported as expressing concern for potential and existing investors in private nursing homes. Yet not a word is mentioned on the maintenance of high standards, reserve and resilience. This is truly troubling.
The C&AG also blithely noted without further comment the fact that many services which would be considered to be integral to care in nursing homes in the international context, from therapies to social activities and continence wear, were not included in the Fair Deal scheme.
The resultant media discussion of the report yet again brought up the claim from Nursing Homes Ireland, the body representing the owners of private nursing homes, of an unfairness in funding of the private sector relative to the public sector.
In fact, much of this difference is explained by the public sector offering pay and conditions that are standard in the health service (and are far from princely), and its costs including aids, equipment and often therapies and other supports.
Given the concerns of the Oireachtas committee over staffing, pay and conditions in the private sector, the reality is that both sectors are under-funded.
I have a vivid memory of a minister visiting our voluntary sector nursing home, which provides therapists, diversion activities and regular consultant oversight. Their only comment was: “You’re very expensive.”
At the time, our funding was equivalent to bed and breakfast in a three-star Dublin hotel, so my response was: “No, not for what you’re getting.” It was an insight into the dismal ministerial mindset that can often be associated with the sector.
While we will all work towards maximising support in the community and at home so that we can stay as long as we can in our homes, congregated living is, and will continue to be, an important element of the care spectrum. As such, it should be a welcoming space with an appropriate combination of domestic feel and sophisticated care.
What we have learned from the coronavirus pandemic has shaken our belief and faith in the integrity of the current system, and we need to use this time to ask ourselves what we want from a nursing home. Do we want it to be welcoming and supportive, a place where entry is not associated with stigma or fear?
Politicians respond to popular sentiment in their direction of leadership, funding and attention, as pointed out by Susan Sontag in her book Illness As Metaphor. Therefore, a first step is for us all is to embrace not only the likelihood that time in a nursing home may be an element of our life narrative, but also the belief that it can be done in such a way as to support and sustain us in individualised, comfortable and even liberating ways.
The solutions require imaginative thinking, but can also draw on many positive examples, from design in small domestic-scaled units embedded in local communities, to better measurement of care needs by implementation and use of interRAI, as well as integration of support therapies and services, flexibility of care routines, and widespread training and standards for all professions engaged in nursing home care.
We cannot do this without a clear understanding of the tragedy of the last six months. The forthcoming report of the ministerial panel on the issue will be an important interim step in moving forward. But we also need a detailed review of the care circumstances of all those who died in nursing homes during the pandemic through a public inquiry.
This should set a baseline on creating a system that will be one we enter without fear or shame, but rather reassured of high standards, flexibility and possibilities for continuing to flourish.
Des O‘Neill is a consultant physician in geriatric and stroke medicine, and a professor in medical gerontology, at Tallaght University Hospital and Trinity College Dublin