Home care in Ireland is being privatised without debate

One of the most troubling advertisements on the radio recently was from a private home care agency. A woman actor speaks of how caring for her parents was relieved by carers from the agency, particularly after one of her parents had a stroke.

No mention was made of the public health nurse, of Home Care Packages, or of the discharge arrangements of the stroke team under whose care the parent had been discharged. Our practice in Tallaght Hospital, and I am sure in most other stroke services, will only discharge patients requiring Home Care Packages when they have been agreed by the HSE.

Nor was there any mention of the considerable costs and challenges of trying to manage a private care package without the public supports available.

Privatisation of community care

Allied to the unannounced obstruction to access to Home Care Packages other than from hospital discharge since March 2016, this disconnect from the public system amounts to an increasingly overt privatisation of community care. This is akin to the rapid privatisation, without debate, of the nursing home sector (where a healthy system mandates a mixture of public, voluntary and private nursing homes), or outsourcing of mental health care to private agencies.

As discussed in previous columns, the problem is not the private or public route per se but a failure to openly discuss the ethical, social and practical problems arising from working with both systems.

Privatisation of community care has been underway for some time with the contracting out of Home Care Packages to private agencies. It has been promoted by a trinity of politicians, elements of the HSE and private sector (which retains a large proportion of the €22 an hour for home care, further subsidised by tax breaks to these fees).

Healthcare should be a right

Unwitting support for taking even more money from disabled older people arises from advocacy and the public by those who perceive an injustice between the so-called Fair Deal – which itself removed eligibility to State-funded nursing home care – and current Home Care Package provision, which is not means-tested but maxes out at four calls a day for the most disabled people.

In fact, there are multiple layers of problems with this reasoning, which received fresh oxygen from a recent documentary on the effect on a family of discharge of a person after stroke.

Without in any way negating the important role of family in providing support to us all, community services are for the person rather than for the family, and such healthcare support should be seen as a right on the same basis as cancer or cardiac care. It also enables people to depend less on care from family and other informal supports

A second issue is that the gap between the payment for a maximum Home Care Package and the average for a so-called Fair Deal would still leave over 100 hours in a week uncovered, and in particular it would not cover nights which is very often a deal-breaker.

In addition, more intense rosters inevitably mean a wide variety of people with variable training and approaches coming into the home, which can be very stressful and destabilising for not only the older person but for those living with them, as eloquently described by Ruth Fitzmaurice in this newspaper on January 4th last year : "Our house is filled with nurses and carers and they are hurting me. It's not their fault."

Trumpian alternative truth

A third issue is that the so-called Fair Deal is based on the fact that you are paying for board and lodging in your nursing home (even if you don’t have residency rights!). With community care, not only do you need resources to live in your own home but the first Irish longitudinal study on ageing (Health and Social Services for Older People II ) showed that older people already pay for part of their care.

If we later need nursing home care (as can often happen), are we likely to be further double-charged on our homes, assets and income with this selective inheritance tax on dementia and stroke – something that would be inconceivable for cancer care?

We, the present, future and increasingly healthy older people of Ireland, need to recognise our own stake in this sinister development. Rather than settling for a Trumpian alternative truth, we must demand a system that provides community and institutional care for age-related disability and disease on the same basis as that for cancer and cardiac disease.