Nursing home care is an essential part of a well functioning health and social care service in Ireland. Within communities across the country, home-from-home, dedicated healthcare settings provide long-stay care for people with high-dependency, specialised and complex care needs. Nursing homes also specialise in providing short-stay care services such as rehabilitative and respite care. They support people to move from hospitals back into their local communities and avail of care in non-acute hospital settings not far removed from their home to support care recovery.
Nursing home care encompasses:
- Nurses being available to provide clinical care to residents on a 24/7 basis;
- Carers being in situ to support day-to-day living needs;
- Catering teams meeting residents’ nutrition and dietary needs and wishes;
- Tailored activities to bring enjoyment, happiness and support residents physical and cognitive needs.
567 nursing homes were operating within Irish communities year-end 2021, with capacity to provide care to approximately 32,000 people. Approximately 80% of nursing home care is provided by private and voluntary operated providers. Private and voluntary nursing homes provide care to around 26,000 people. Private and voluntary nursing home care leads in the provision of nursing home care in Ireland.
The Nursing Home Support Scheme, commonly known as Fair Deal, is the scheme operated by the State to fund nursing home resident care. Around nine-in-ten residents in nursing homes are supported by Fair Deal.
Under the scheme, the private and voluntary nursing home is paid a defined fee for resident care. The set fee is payable on behalf of every resident entrusted in the nursing home’s care. The fee paid to private and voluntary nursing homes is set by the National Treatment Purchase Fund (NTPF), acting on behalf of the State.
Fair Deal covers basic services, encompassing nursing and personal care for residents, bed and board, bedding, laundry, and basic aids and appliances.
The most recently published listing of fees payable for resident care under Fair Deal for HSE nursing homes, for January 2022, informs the average payable was €1,674 per resident. For private and voluntary nursing homes the average payable was €1,047. Therefore, a 60% funding differential was being applied by the State in the funding of nursing home resident care.
A Department of Health commissioned analysis, A Value for Money review on nursing home care costs, published December 2021, stated: “If the full cost of the eligible cost components had been charged to the NHSS [Fair Deal], the cost differential would have been 73%”, adding: “The average additional actual cost of an occupied public bed was €692 per week compared to a bed in a private setting.”
In 2020, the Office of the Comptroller and Auditor General, the State spending watchdog, reported within its Special Report: The Nursing Homes Support Scheme (Fair Deal): “Between 2010 and 2018, the average weekly rate for public nursing homes increased by 26% to €1,564. Over the same period, the agreed maximum price for private or voluntary homes increased by 11% to €968.”
HSE Fair Deal fees are not subject to negotiation and are set by the HSE. The gross distortion in fees payable under Fair Deal represents gross discrimination against residents in private and voluntary nursing home care.
Successive independent and Government commissioned reports have stated fees payable under the Fair Deal do not encompass the reality of nursing home resident care costs.
Analyses have included:
- Department of Health, Review of the Nursing Homes Support Scheme, A Fair Deal, July 2015: “The cost of public long-term residential care should be based on a pricing model that is objectively and consistently formulated, and which takes account of, and accurately quantifies, unavoidable cost distorting factors.”
- Department of Health, Department of Public Expenditure and Reform (DPER), National Treatment Purchase Fund (NTPF), Health Service Executive (HSE), Economic and Social Research Institute (ESRI) Steering Committee, A Value for Money Review of Nursing Home Care Costs, December 2021: “A programme of work should be established to examine and develop, as appropriate, a model for the allocation of resources through the use of Resource Utilisation Groups to align resources/payments to care needs.”
- Department of Health commissioned analysis, DKM Economic Consultants, Potential Measures to Encourage the Provision of Nursing Home and Community Nursing Unit Facilities, December 2015: “It is untenable that the State quality regulator can assess differentiated dependency levels and in doing so impose costs on nursing homes, while the State price regulator (NTPF) claims it is unable to reflect the same factor in its pricing decisions.”
- Office of the Ombudsman, Who Cares? An Investigation into the Right to Nursing Home Care in Ireland, 2010: “The Ombudsman was concerned that, in many individual cases, the NTPF agreed care packages were not adequate to meet the actual care needs of that individual and that, in this event, the agreements made by the NTPF were falling short of the level of care apparently envisaged under the NHSS Act…While the NHSS [Nursing Home Support Scheme] Act appears to provide for the “maintenance, health or personal care” needs of older people, in reality, it need only meet some of these needs rather than all of them.”
- Office of the Comptroller and Auditor General, Special Report: The Nursing Homes Support Scheme (Fair Deal), August 2020: “The NTPF has not provided a model explaining how the various criteria [to assess dependency levels of residents] are weighed and combined, stating that all the criteria are considered in the aggregate. Consequently, it is unclear how these criteria influence the negotiation of the price that is agreed with the nursing home.”
A crisis and emergency presents for nursing home care in Ireland. As of November 2022, 17 nursing homes have been forced to close their doors. Over the past five years, 44 private and voluntary nursing homes have closed their doors, with 1,248 beds lost within nursing home care.
Years of reports have informed the State’s Fair Deal scheme does not pay fees that recognise the reality of resident care costs. This is now compounded by nursing homes operating within an exceptional and unprecedented cost environment. Fair Deal fees now in effect were set years previously.
The Temporary Inflation Payment Scheme, introduced by Government, falls well short of what is required to support nursing homes in addressing the cost of care crisis. Without serious intervention, more nursing homes are expected to close in the weeks and months ahead.
Every nursing home closure represents heartbreak for residents, families, staff and providers. Each has implications for healthcare and society. Every nursing home fulfils an essential role at local level in providing long and short-stay care for older people and in facilitating discharges from hospitals. The regulator HIQA has publicly expressed concern regarding the levels of closure. It has pointed to knock-on effects of closures for residents, moving them away from family and friends, the social setting that is their local community, and removing established links to local services such as residents general practitioner (GP) or pharmacy.
Our asks are reasonable, fair and imperative to ensure nursing home resident care is appropriately recognised and supported.
- Immediate ask: Introduction of a fit for purpose stabilisation fund. An immediate increase in funding support to meet the very significant escalation in resident care costs is necessary to stem the tide of nursing home closures on a short-term basis. This will secure the homes of nursing home residents and inject badly needed confidence in our sector.
- Medium–term ask: Fair Deal has been in effect 13 years; the requirement to address the fundamental failings in its pricing mechanism are long overdue. Government must grasp the imperative need to reform the mechanism to stem the closure of nursing homes against the backdrop of a rapidly increasing ageing population. An evidence-based, fit-for-purpose pricing mechanism that encompasses the reality of resident care costs requires urgent prioritisation. It represents a fair, appropriate and reasonable ask.