Ireland needs a paradigm shift in health and social care

Ireland needed a new type of social care system and a recalibration of care to primary and community-based care, Prof. Eamon O’Shea, Director, Centre for Economic and Social Research on Dementia, NUI, Galway, told the conference.

Prof. Eamon O'Shea
Prof. Eamon O’Shea

“Marginal changes will not work. We need a radical shift in how we integrate home care into health production models, “he said.

This would also involve an emphasis on productivity, pay and training for the workforce and an examination of the economics of new care pathways.

He said that Currently, there are about 35,000 people with dementia living at home in the community, many of whom are not receiving any type of public support.

Now we have more people willing to pay out-of-pocket for social care, leading to the possibility of having a two-tier social care system in the future. Currently, there are about 35,000 people with dementia living at home in the community, many of whom are not receiving any type of public support.

Prof. O’Shea was speaking on “Economic Imperatives for Healthcare in Ireland.”

He said that in 2014, Ireland was spending 11.6 per cent of Gross National Income (GNI) on health. This compared with the Netherlands, 11 per cent, Sweden 10.9 per cent, Germany, 10.8 per cent, Denmark,10.2 per cent, Finland, 9.4 per cent and the UK 10 per cent. The U.SA was spending 16.1 per cent.

Expenditure did not always correlate with outcomes such as increased life expectancy and reduced infant mortality – for example, the US was not top of the rankings for life expectancy and infant mortality despite spending the most money.

Ireland’s expenditure on health had increased over the last ten years. A disproportionate amount – 34% – went on acute hospitals, compared to 27 per cent on primary and community care, 12 per cent on disability, 11 per cent on ageing, six per cent on mental health and one per cent on health and well-being. Healthcare spending on hospitals would not solve all our problems. You could not discuss the allocation mechanisms or pathways to care without understanding the social care system.

Currently, there are about 35,000 people with dementia living at home in the community, many of whom are not receiving any type of public support.

Prof. O’Shea said that our population was increasing and was forecast to increase by 11.8 per cent between 2016 and 2031. However, in the same period, the population of those aged between 75 and 84 was forecast to increase by 75.9 per cent and those aged 85 and over by 95.5 per cent.

“This is good news. We are living longer but we need to change our healthcare to care for those over 85 (where the numbers are set to increase by almost 100 per cent) and how we integrate this through primary, social and acute care. The numbers are compelling in terms of how we organise future health and social care services.
Life expectancy for males had increased by 36.3 per cent and for females had increased by 22.1 per cent between 1995 and 2015. By 2031, there would be 100,000 people with dementia in Ireland.

By 2031, people over the age of 65 would generate almost half of all healthcare activity. There would be an estimated 46 per cent increase in demand for primary care, an estimated 39 per cent increase in demand for residential care beds, an estimated 70 per cent increase in demand for homecare and an estimated 24 per cent increase in demand for non-elective in-patient episodes in public hospitals.

“There wasn’t and hasn’t been much action on how we organise a system of care that recognises the new demography of care, how we care and who cares, including family responsibilities.”

Prof. O’Shea said that even where there were intensive home care packages, families were participating significantly in care and people were increasingly paying for care themselves.
”We need to move away from the idea that care for older people is either about care at home or care in a residential or nursing home bed. We need to think about how we innovate in terms of a new models of care, including sheltered housing with care supports. However, we will still need residential type beds, but we need to think about the kind of beds we will need.

“The Department of Health capacity report proposed health and well-being, recalibration towards community-based care, especially for older people, as well as productivity improvements.

“It estimated that we will need an extra 2,590 public beds by 2013, or 5,360 if the system is not reformed, an extra 13,000 residential care beds a 48 per cent increase in the primary care workforce and a 120 per cent increase in home care (home help hours and home care packages.)

“But even the capacity targets following reforms do not tell the full story. When you talk to people about home care packages people worry about integrated care. The complexity of carers and therapists coming into the home is sometimes too much for people – the organisation of care can become very complex. We need to integrate different carers into the everyday life of families, while respecting people’s preferences and delivering it in a way that is as simple as possible.

“In 2017, Ireland had a per capita spend of €2,648 on people aged over 65, compared to €3,514 in 2009. This indicates that as the population increased, and overall spending was divided by the number of people over the age of 65, the per capita spending went down over those years. The implications are straightforward – as population increases, so too must expenditure.

“In 2017, there was €940 million for the NHSS Fair Deal scheme providing financial support to 23,000 people and €373 million to provide 16,750 Home Care Packages, 11 million Home Help Hours and 190 Intensive Home Care Packages.

“We don’t know a lot abut home care and our data is not good enough to allow people to make good decisions within the HSE.

“We are now spending a lot on the Fair Deal, which, to be fair, is acknowledged by most people as a good scheme. However, we are spending much less on home care compared to the Fair Deal. There will have to be increased spending on home care, while protecting and indeed increasing spending on the Fair Deal scheme.

Currently, there are about 35,000 people with dementia living at home in the community, many of whom are not receiving any type of public support.

“Statutory cover is confined to residential care. Meanwhile, there is uncertainty around community-based funding, a significant unmet need in the community, a reliance on family care, a supply-driven model, an absence of integrated care, a formal carer shortage (and pay issues around that) an absence of personalised care and a weak social model.

“In terms of outcomes, we really don’t know the outcomes we want. Home care can keep people out of residential care and acute beds, but we don’t know enough about the process of care within the home. Sometimes residential care may be the best placement for dependent older people and indeed the preference of the person themselves.

“We don’t recognise the caring function in families in terms of education and training, nor do we pay formal home carers enough to make the job attractive and sustainable.
“What are our expectations of staff who go into homes and what are our expectations of training.

“I think about home care in terms of connectivity – connectivity to families, connectivity to self, communities and the formal community services.
“Often what older people want is good and reliable information. They should have choice, there should be individualisation of care, integrated care, family involvement and the opportunity to live well at home.

“If we want to revise how we think about social care, we must think about re-enabling people right up to the end of life, if we want a co-production model that makes sense. Support for community-based care is fragmented and inadequate. This is not fair, and it is not ethical.”

Prof. O’Shea said there should be a continuum of care that reflected a real array of choices. This included people living in their own homes, which might be modified and adapted, home sharing where people received companionship in return for low rent, split housing with relatives /friends, retirement villages, which provided private living in a community setting, communal resident controlled, co-housing in the community, supportive/sheltered housing for independent living, housing with social care and technological supports, residential nursing home care plus housing with care and supports on site and residential nursing care units.

“We need to think differently too about residential care. For example, small is beautiful. So too is good design. An emphasis on personhood for people with dementia is absolutely essential. This requires new ways of thinking, including integrating residential care with various types of community-based supports.

“Economic evaluation offers the opportunity for ‘better’ decisions to be made in relation to resource allocation. Its real value is not simply changing which decisions are made, but how various choices are made.

“We need to think about the economic evaluation of integrated care. This will involve a paradigm shift; it is not just about increasing hours, but the development of a new type of social care system. Workforce economics, including pay, must be part of any new thinking. So too must be the economics of new care pathways.

“It is a big challenge but the returns in terms of the potential for new ways to think about health and social care production are huge.”