OPINION:Blaming Hiqa for facility closures or delayed openings ignores the State's failures to invest, writes DESMOND O'NEILL
A MAJOR part of the sense of security when flying, even with the ever-increasing economies of budget airlines, is the reassurance of a robust regulatory framework. So, can you imagine the reaction if the safety guidelines and regulations for the maintenance for jet aircraft were relaxed due to the recession?
This might seem far-fetched, yet in another complex area of life, there are disturbing signs of pressure to dilute the regulatory framework for care standards in Irish nursing homes. Whether by misattributing blame for the delay in opening the new public nursing home in Dingle or the closure of Loughloe public nursing home in Athlone, or by the recent statement of the nursing homes representative organisation about the standards of the Health Information and Quality Authority (Hiqa), it is troubling that we might miss the point of, and need for, these standards.
It is barely a year since the second review of Leas Cross by senior counsel Diarmuid O’Donovan confirmed that the State had failed to provide an adequate regulatory framework of regulation and inspection for nursing homes up until 2009. Our most frail and disabled older people, with the most complex care, support and rehabilitative needs, live in these homes. That these needs should be met adequately, no less than aircraft engines should run safely, should not be a matter of discretion.
The care standards and independent inspectorate are not only an enormous advance, but the process of their development represented a degree of buy-in from all interests unparalleled in the history of Irish health care. Building on a briefing document originating from within the Department of Health, Hiqa immediately involved representatives from all interested parties, including older people, advocacy organisations, health professionals and senior representation from the Health Service Executive (HSE), and achieved a level of consensus that few would have imagined possible. The balance between the need to retain a sense of home, while maintaining sophisticated nursing, medical and therapist care, seems reasonable.
Implicit in these guidelines was an inevitable need for redevelopment of facilities (many public nursing homes in particular have multi-occupancy rooms, and often out-dated facilities) and investment in staff and training. Indeed, older people in nursing homes are paying €190 a year themselves for the inspection framework.
The negativity now being shown to Hiqa actually has its roots in two areas: the first being the failure of the Department of Health and Children and the HSE to invest, maintain and develop public nursing homes; the second arises from concerns as to whether the process of contracting with nursing homes by the National Treatment Purchase Fund is sufficiently attuned to the complex needs of this group of Irish citizens.
The investment in public nursing homes has been nugatory in comparison with the hundreds of millions we have poured into new buildings for acute hospitals, and it is deeply troubling that there does not seem to have been an impetus to anticipate this need. In addition, there are deep concerns about the impact of the moratorium on staffing and morale in public units.
The result is that increasing numbers of public nursing homes will run into difficulties as seen with Dingle and Loughloe: the concerns are not the fault of Hiqa, but lie rather with planning, execution and oversight of these services, and the political will of the Department of Health and HSE to make the necessary development to protect and nurture these services.
For the private nursing homes, the question is whether the National Treatment Purchase Fund has adequate gerontological expertise embedded in its contracting process (the exclusion of incontinence wear, therapies and specialist equipment from the contracts must raise concerns), and whether the rates of reimbursement are sufficient to provide the complexity of care required. Consideration of the calculations by the Joseph Rowntree Foundation as to what is realistic funding for nursing home care is not reassuring.
So, where next? The changes in the HSE, and of their senior personnel, allow for a fresh start.
First, a re-think of the public nursing home programme: it would be helpful to make public the Prospectus report of nursing home provision, which shows gross under-provision of public places in urban areas, yet over-supply in some rural areas, suggesting room for rebalancing.
Second, a crash programme of redevelopment: just as Franklin D Roosevelt engaged in major public works such as the Tennessee Valley Authority during the Great Depression, could we not engage in a similar programme for redeveloping our stock of mostly outdated public accommodation?
Third, protect public and voluntary nursing homes from the moratorium, and clarify therapist and equipment support.
Fourth, a more open and gerontologically informed contracting process for private nursing homes which recognises the real cost of providing complex care.
But most importantly, stop blaming Hiqa and the regulatory standards! We need to honour not only the memory of those who suffered in Leas Cross, and their families, but also to understand that it is not only the issue of care for our families and us as we age that is at stake, but also a wider sense of trust in our care system: in terms of life, death and public confidence, surely of at least as much importance as aircraft maintenance?
Prof Desmond O’Neill undertook the first review of Leas Cross Nursing Home, published by the HSE in November 2006