Nursing home residents denied essential services
Poor access to essential care services for nursing home residents exemplifies the inequalities of our system. See below column from 5 December 2013. An unpublished HSE audit of access to four therapies for older people in nursing home care – physiotherapy, speech and language therapy, occupational therapy and dietetics – reveals that the vast majority of nursing home residents do not have access to these essential public health services.
It exposes huge geographical inequalities in access, inequalities between residents in public and private nursing homes as well as discrimination based on medical card status.
More than one-quarter of all private/voluntary and public nursing homes were surveyed alongside HSE primary care teams and advocates of older people resident in nursing homes. Currently more than three-quarters of all Nursing Home Support Scheme (NHSS) funded beds are in the private/voluntary sector while less than one-quarter in the public sector.
A hierarchy of access emerges from this survey. If one is a medical card holder resident in a public nursing home, one is most likely to access HSE-provided therapies at no additional cost. If one is a medical card holder in a private nursing home, one may or may not access HSE provided services. If one does not have a medical card in a private nursing home, then the resident or their family will have to pay the full cost of these services privately.
Access to HSE allied health professionals through the primary care teams (which is free) varies hugely across the country depending on levels of staffing of these professionals in HSE primary care teams. At best, on average, just more than half (52 per cent) have access. Some public nursing homes have such professionals on staff or direct access to them. The majority of private nursing homes buy these services for residents privately, either through paying the staff themselves or through private contractors.
Public nursing homes in the HSE South region have the best access to all four therapies from the HSE (68 per cent). Sixty per cent of public nursing homes in Dublin North East have access, while 43 per cent of residents in public nursing homes in Dublin Mid Leinster and 41 per cent in HSE West have access to these services through local primary care teams.
Access to these therapies through primary care teams is worst for residents in private or voluntary nursing homes in the West, at just 20 per cent. Dublin Mid Leinster is the second worst region in terms of access at 25 per cent, whereas 45 per cent of private nursing homes in HSE South and 50 per cent in Dublin North East access therapies through local HSE primary care teams. Some regions and therapies fare particularly badly; just 12 per cent of residents in private nursing homes and 28 per cent of residents in public nursing homes in HSE West have access to HSE physiotherapy.
Although the majority of nursing home residents have medical cards, those who do not have to pay privately for all of these services. In this survey, 80 per cent of residents had medical cards. That means that one in five older people resident in nursing homes have to pay for such essential services and many others with medical cards either do without or pay too due to the absence of HSE provided services.
At the crux of all this is that the cost of essential services is, incredulously, not included in the NHSS. The National Treatment Purchase Fund (NTPF) negotiates the price of care paid by the State to all nursing homes under the NHSS. The NTPF contract states explicitly: “for the avoidance of doubt, long-term residential care services shall not include: all therapies; incontinence wear; chiropody; specialised wheelchairs; and ophthalmic and dental services’. How such essential health and social care services and appliances are not included in the cost of nursing home care is beyond belief, unless its authors, former health minister Mary Harney and her advisor Mr Oliver O’Connor, wanted to incentivise the private provision of such care. The NTPF contract also specifies the exclusion of hairdressing, newspapers, dry cleaning, transport and social programmes, which can be justified as additional rather than essential services.
One can only speculate that the reason why this HSE audit, dated 13 January 2013, is not in the public domain, is that is findings are too controversial. This is especially so in the context of Government and HSE measures which are reducing community staffing and withdrawing medical cards from older people.
This audit highlights the complete under provision of primary care, in this instance the allied health professions, as well as the complete absence of clarity on who is entitled to what. It exemplifies the inequalities of the Irish health system – denying a majority of older people in residential homes access to these therapies and forcing many older people and their families to pay for what is crucial care.