Comment: Home is the safest place for many vulnerable people

Covid-19 is redefining how we think about caring for vulnerable people. It will have as far-reaching an effect on our care models as the 2008 financial crash had on banking practices.

The latest figures recorded by Home and Community Care Ireland (HCCI), which represents organisations providing home care to older and vulnerable people, show 45 active Covid-19 infections among our members’ 20,000 clients. Home really is the safest place to be.

The limited impact of Covid-19 in the home stands in stark and depressing contrast to the devastation the virus has wrought in congregated settings such as nursing homes. One of the main problems is the nature of congregated settings; with so many vulnerable people in a confined space, it is fertile ground for infectious disease to spread.

HCCI strongly supports legislating for a statutory home care scheme as soon as possible. The current target date is 2021. In designing the scheme, we can learn from some of our European neighbours, including Finland and Germany.

In Finland, with a population of 5.5 million, 74,000 people receive home care services and a similar number live in supported housing developments. Only 7,400 Finns are in nursing homes. Finland has recorded just 328 deaths from the virus and a total of 7,209 cases. This is down to a variety of factors, but it is notable that the country has avoided widespread deaths in congregated settings mainly because Finns do not use them very much.

Ireland, with a similar population but with 30,000 people in nursing homes, has had five times Finland’s deaths (1,735) and three times as many cases (25,462).

If the Finns can teach us about how more widespread home care provision provides greater protection in a pandemic, the German model is more useful to learn from in designing a new system.

In Germany, people in need of care are assessed and assigned to one of four care grades. This national care assessment is transparent and holistic. Once assigned to one of these grades, the client is offered cash or in-kind benefits, depending on their care level, along with a priced list of services (public and private) to choose from in their local area. A person can also choose to spend some of this on informal care. The Dutch use a similar system. I hope we adopt these principles in our own home care scheme.

Healthy competition between providers – private, public and non-profit – within a regulated environment is seen as a benefit of the Dutch, German and Finnish systems rather than a disadvantage. The person receiving care is empowered to make meaningful choices and has access to a range of services that include home care but also physiotherapy supports and home visits by a GP.

Technological innovation is especially encouraged in the German system. Our Sláintecare Integration Fund is €20 million and open only to public sector and voluntary organisations. Germany takes a broader approach, funding a €300 million annual health innovation fund that encourages new models of care and more effective ways to deliver care across a range of healthcare settings, with the private sector closely involved. While we cannot replicate the size of this funding, we can design a national framework for healthcare innovation that carries with it an annual budget.

Finland is similarly keen to integrate technology into its healthcare services and helps people receiving home care to participate in virtual meet-ups. As people get frailer, this type of support becomes more important. In Ireland, people of all ages have quickly learned to rely on video calls to stay connected. Technology – from wearables to tablets – is something we should incorporate into the new statutory scheme, helping people to thrive at home, not just survive in place.

In Ireland, home care has historically been the poor sibling to nursing homes. The Fair Deal scheme, which was introduced in 2009, provides funding support to those needing nursing home care. It has a budget of over €1 billion in 2020 and a waiting period of four to six weeks. By contrast, home care does not operate on a statutory basis and thus the budget must be fought for annually in a sort of perverse guerrilla warfare. There is a waiting list of 8,000 with no timeframe for when someone can expect their home care package to begin.

In fairness to this government, the home care budget for older people has reached historic highs each year, starting in 2017. Budget 2020 allocated €490 million to the service with the aim of providing 19.2 million hours to 53,700 people. Pressures on the acute hospital system and the difficulties in implementing community healthcare as proposed by Sláintecare, however, are the root issues that have kept attention away from home care. So long as hospital waiting lists and trolleys consume our national collective attention, we will struggle to effect meaningful change in health policy.

As able as the Sláintecare team is, things have moved too slowly. A cabinet minister needs to take charge of the process, and the first thing on their to-do list should be launching a broad and imaginative pilot for the statutory home care scheme within the next three months to precede the scheme coming into force in 2021. Alongside this, they should explore how we can improve conditions and career options for carers as well as develop a “home first” policy in tandem with the HSE and the wider sector to see how, starting from day one of the new government, we can care for more people at home.

Joseph Musgrave is chief executive of Home and Community Care Ireland, the representative organisation for 80 companies that provide home care to 20,000 older and vulnerable people in Ireland