The lack of public nursing home care in urban areas is both a source of suffering and a key factor in the A&E crisis, write Desmond O'Neill and Cillian Twomey.
Older people are one of the groups most affected by the crisis in access to emergency services in the health services. Not only do they represent about 40 per cent of such admissions, but they also have complex care needs and are particularly ill-equipped for care in settings such as trolleys in corridors.
The reduction in acute beds - removing almost 5,000 beds since the 1980s with a 15 per cent growth in population since then - is one of the main factors in this crisis.
The need to increase these bed numbers has been recognised by successive governments, although the official response so far has been slow and inefficient.
There is also a welcome emphasis on more efficient uses of existing facilities by way of innovations such as acute medical admission units: Comhairle na nOspidéal is shortly to publish a report on the benefits of acute medical units and their essential contribution as one component to ensuring high quality patient care.
However, these developments will not work if our society does not simultaneously address one other area of capital development in the health services which has also been underdeveloped, the provision of public nursing home beds.
Older people consistently state a preference to live their lives in their own homes. Should they develop a disability, they still wish to be supported at home. This has also been the stated aim of Government policy since 1993. However, for a significant minority of older people, about 5 per cent of the total, care in the community is no longer possible despite family and State support. At this stage nursing home care is required.
The 5 per cent figure conceals the fact that a much higher figure of older people will spend some time in nursing home care before they die. Even if improved community services should develop, evidence from Scandinavia suggests that this proportion will remain at this level or even increase.
Although private nursing homes can manage care for some of this group, there is a clear need to provide a significant proportion of this care in public nursing homes. Private nursing homes have no obligation to take all who present to them, and in one study in 2001 they refused up to three-quarters of dependent older people who were referred to them.
Current subvention rates will not meet the cost of many nursing homes in Dublin (even with enhanced subvention, think how much full board you will get in a three-star hotel for €690 a week, without nursing and other costs included). Geographical location is another factor: relocation to what is a new home that is distant from friends and family is not appropriate. In terms of planning the relatively sophisticated services which this most vulnerable population will require, public oversight and input will be required. Sadly, our health service has neglected to match public nursing home care beds with the growth of the population in our large cities. In the 1980s, the bed complement per 1,000 older people in Dublin was only half that available in the rest of the country.
This trend has been aggravated by the relentless urbanisation of Irish society. For example, in 1961-96, the population of the Dublin region increased from 719,000 to 1,056,700, or by 47 per cent. This has compounded the situation. A significant number of beds has been taken out of the system, and only a small number of community units has been built.
The collision of urban growth, reduction in existing bed stock, and a failure to develop at an appropriate rate causes great distress and suffering to many older people and their families. The situation is similar in Cork and is becoming apparent in Galway and other growing urban centres.
The failure to develop public nursing home services is also one of the root causes of the current A&E crisis. If an illness such as a stroke, fractured hip or delirium finally undermines the ability to remain at home, the only route to extended care is through the general hospital, which is increasingly the final common pathway to extended care.
At any one time the number of people awaiting extended care in the Dublin hospitals greatly exceeds the number of those waiting on trolleys, and timely access to augmented community services, specific rehabilitation facilities, and increased numbers of public and private nursing home beds would provide a major easing of the problem.
In Titanic terms, this is the iceberg. Without such access, innovations like acute medical admission units represent yet more shifting of deck-chairs. The presence of older people awaiting nursing home care in general hospital beds is a system failure. It is totally inappropriate, not to say pejorative, to use terms such as "bed-blockers" for them. Not only have they not caused this situation, but they and their families have often made Herculean efforts to stay at home for many years.
Looking forward, an accelerated programme of building and staffing public nursing homes is a key element of catching up on years of neglect. Better community and rehabilitation services are also vital, but they are complementary to, and will never eliminate the need for, an adequate range of public nursing home beds, appropriately resourced and geographically distributed to ensure equity.
The promise in 2002 (if realised) of a Public Private Initiative of 850 public nursing home beds in Dublin (450) and Cork (400) represents a start but no more than this.
To truly match need, policy-makers need to plan for a programme that recognises that up to half of us may experience nursing home care before we die, and that to plan for this in an organised way will lead to a win-win situation.
It will be cheaper to maximise general hospital use by freeing up beds used by those awaiting long-term care than by increasing numbers of more expensive hospital beds alone.
More importantly, it will begin to allow older people (us as we age) to enter nursing home care in a more organised and dignified manner than at present, without spending up to a year in a general hospital bed first.
• Prof Desmond O'Neill and Dr Cillian Twomey are secretary and president respectively of the Irish Gerontological Society