There will be 16 less nursing homes in Ireland by the end of December. Most of those have closed already and the rest have notified the Health Information and Quality Authority (HIQA) that they will soon be de-registering. Most were family-run, rural businesses.

The CEO of Nursing Homes Ireland, Tadgh Daly, is calling for government action to prevent more closures. It needs to be more than “sticking plaster” action, he insists.

“This is a crisis and if something isn’t done there will be more closures,” he says.

Those who are closing their doors are not exclusively small, he states.

“There is a narrative out there sometimes that it’s the small ones that are closing, but the one in Athenry [Castleturvin House] had 42 beds and the two in Waterford [Maypark and Rockshire Care Centre] were both 38 beds. That’s not small.”

The problem that is leading to these closures relates to nursing home owners not being paid enough under the “Fair Deal” aka The Nursing Homes Support Scheme (NHSS).

“We have spoken a long number of years about the Fair Deal and what we are seeing now is years of the ignoring of the fundamental issue,” Tadgh Daly says.

“We are not being paid enough. Bills are eye-watering as the cost of care continues to rise – there’s the age profile, the dependency, the complexity of care and staffing requirements. What you have through the Fair Deal is a 1.5-2% increase per year. That wasn’t sufficient to begin with and now what we are seeing is these annual increases are way, way behind in terms of meeting the true costs of care.”

The problems haven’t all been triggered by the war on Ukraine and the consequent economic factors.

“Twenty nine nursing homes closed between 2018 and 2021, many before the COVID period and the current inflation, so the underlying issue has been there for a number of years and it isn’t going away,” he adds.

But has the pandemic forced a lot of nursing homes out of business?

“It’s probably more complex than that,” he says. “Yes, COVID had a huge impact but of the people who have sold recently – for example in Kiltormer [Galway] and in Athlone [Stella Maris], they are second generation [owners].

“They are people who are in the business of care for a long, long time so making the decision to close isn’t something that they’d make lightly. COVID no doubt would have had an impact but the other thing with the pandemic is that whatever financial reserves nursing home owners would have had have all been exhausted now also.”

Huge heating costs

Right now, energy is a huge cost for nursing homes.

“It’s 24/7. We don’t have the ability in this sector to close on a Monday or close early or reduce hours. The economic situation is having an impact on indirect costs for us as well – the cost of food, laundry, clinical waste disposal, staff looking for increases because their costs have gone up - there is a myriad of inflationary pressures now which are being exacerbated or illuminated further by current inflation.”

But are nursing homes closing in order to be repurposed for refugee accommodation because that is an easier option?

“Only two across the country have been repurposed as far as I know. Some might think they are doing this because it is easier for owners but my reply to that is that if you have a viable nursing home business that has a viable future you wouldn’t be closing on the basis of a short-term business [option].”

Causes rather than symptoms

The causes rather than the symptoms need to be examined, he says.

“The cause is that the nursing home is no longer viable and they just can’t make it work any longer in the current funding environment.”

He doubts that nursing homes that have repurposed will come back into the system in the future.

“They would have to re-register with HIQA and they mightn’t meet the standards so I’m not sure they will re-register. I think they’ll be lost in perpetuity, to be honest.”

Tadgh Daly’s particular concern is that it is predominantly rural nursing homes that are closing.

“Brideswell in Roscommon, the Moyne [Enniscorthy], Kiltormer in Galway… People will probably never build a nursing home in those areas again.”

A St James’s Hospital report has shown that the HSE is more selective than the private sector

He mentions how visitors will be disinclined to travel to see their friends or relatives.

“This will be a loss to residents who are less likely to have visitors if visitors have further to travel. If you have a 90-year-old person in a nursing home with siblings and friends of the same vintage they would be unlikely to travel 20 or 30 miles further to visit, so it will have a consequence. When people are in a nursing home in their own community, they are more likely to know staff too. Staff bring in news from the community – who won what match and so on. Some of that would be lost in community settings when a nursing home closes too. There will also be the disruption to residents of having to resettle somewhere else.”

While no research has been done in Ireland on the impact of elderly residents having to move care homes, there are genuine concerns about how this could impact on the health of residents.

Funding needs reassessment

The average cost of a private nursing home, per week, is €1,047. The cost, per week, of a HSE run nursing home is €1,650.

Nursing Homes Ireland is not happy about the discrepancy. While the original stance was that HSE nursing home places were for the more medically complicated cases which require a higher nurse/resident ratio, Tadgh Daly says this isn’t the case.

“HSE-run nursing homes are not just for complex cases. Maybe they were 20 years ago but it’s a different model now and the government’s own Value For Money report said there was no differentiation between dependency levels between public and private nursing homes. In fact, a St James’s Hospital report has shown that the HSE is more selective than the private sector particularly in relation to dementia care. The private sector is now the main provider of dementia care. Also if a person is applying for the Fair Deal they can choose where they want to go, so the notion of [HSE-run nursing homes] being for high dependency cases only is gone really.”

Tadgh Daly says government reports have shown, three times, that nursing homes are not being funded adequately.

“Three reviews of the Fair Deal mechanism have shown this to be the case and another one is due. We are saying expedite this review and introduce a funding mechanism that ultimately recognises what the true costs are. If this doesn’t happen there will be more closures. Today you have 612 people on hospital trolleys so what’s happening is having a huge impact on the health service as well as on the nursing home sector and rural communities.”

Nursing Homes Ireland is surprised that more isn’t being done by government.

“There is an almost simplistic response of government saying ‘oh yeah there’s a few closing all right’. The fear is that in three or four years’ time when we’re looking back we’ll be saying why didn’t we do something about it when we should have?”

There is an opportunity to stabilise the sector now and even give owners who are considering closing some hope, he believes.

“If they thought there was some change imminent they might decide to hold on for a period thinking this might improve, but at the moment they’re saying ‘we’ve had three Fair Deal reviews, there is no appetite from government to do anything so I might as well just close’.

That’s going to be damaging for the nursing home sector, for rural communities and for the wider health service because at the moment we don’t have enough nursing home beds. With an ageing population we need to be putting more beds and a whole range of care plans in place to meet that care need, not seeing nursing homes close.”

Review of Nursing Home Care Cost

Some detail from the Value for Money and Policy Review of Nursing Home Care Costs undertaken between March 2018 and March 2021 by the Departments of Health and Public Expenditure and Reform, the National Treatment Purchase Fund (NTPF), the HSE and the Economic and Social Research Institute (ESRI):

The purpose of this review was to identify, quantify and analyse the reasons for any cost differential between private/voluntary and public nursing homes and following analysis, to make recommendations for improving the value for money obtained by the health sector.

In 2019 the NHSS budget for private/voluntary nursing homes was €992 per resident per week and €1,616 per resident per week for public nursing homes (62% more on average).

(As stated above, the average cost of a private nursing home now, November 2022, per week, is €1,047. The cost, per week, of a HSE run nursing home is €1,650.

The steering committee made nine recommendations with the first one being the establishment of an inter-agency project team to drive the delivery of the other recommendations.

  • The report shows that the pay cost differential is largely due to variances in nursing-to-resident ratios and skill mix.
  • Basic salary for nurses is broadly similar.
  • Health care assistants receive almost a third more in basic pay in public nursing homes.
  • There are two and a half times as many nurses to residents in public nursing homes compared to private nursing homes.
  • Private nursing homes have more than twice as many healthcare assistants than nurses than their public sector counterparts. Having more healthcare assistants and fewer nurses in private nursing homes results in lower overall costs in the private sector, the report states.
  • The study found that there was little difference in the levels of dependency between the mix of public and private nursing homes that participated in the study.
  • Energy costs are €13 higher per resident per week in the public sector, which is likely due to the older stock of nursing homes in the public sector.
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