Problems in delivery of 'Fair Deal' on nursing home care

Just six months ago, the 'Fair Deal' scheme was introduced, changing the way nursing home care is funded and paid for. So how is it faring and has it achieved what it set out to? By Sara Burke.

Up to last October, there were huge disparities in how nursing home care was paid for; if you were in a public bed all your care was paid for out of public money and you contributed 80% of your income.

If you were in a private nursing home bed, some or all of the costs of your care was paid for by the State but it was a matter of pot luck as to how much of it was subvented by the State.

(Picture: Gormanston Wood Nursing Home, Co. Meath)

Under 'Fair Deal', everybody in care contributes 80% of income towards that care. Also, if you have assets, up to 5% of those assets for three years are paid towards your care.

So what's the difference between now and before Fair Deal?

On one hand it creates an even playing field no matter who you are or what type of nursing home you are in. On the other it means that everyone has to contribute towards your care including some of your assets after death. Also, the budget is limited. Previously under the 1970 Health Act, every one was entitled to free public nursing home care. The Fair Deal removes that entitlement.

There been a large uptake on the 'Fair Deal' with about 9,000 applications, of which 5,000 have been processed. It takes between four weeks and four months to process applications.

The average cost of care is between €800 and €1,000 a week. The budget for 'Fail Deal' is €152m per year. But comparing the number of applicants with how much the State contributes on average per applicant, the budget for 2010 is
significantly short of what should be allocated to it (about €80m short by conservative estimates).

And if the money runs out, according to the HSE “a national waiting list will apply”. Now this has not happened yet but given the sums it seems inevitable.

What is really important is that the 'Fair Deal' covers just bed and board and nursing care. Previously in public nursing homes other care like chiropodists, physiotherapists, occupational therapists and speech and language were all included in the cost. Now they are additional. Technically, people with medical cards are entitled to these under primary care services but in many places these services just do not exist. And it remains a grey area for those without medical cards.

One of the key principles of the 'Fair Deal' was that no one would be worse off and people are entitled to hang on to what they had before it was introduced. If you are a new resident under the 'Fair Deal' it is still unclear who is entitled to what support care.

One of the main rationales for the 'Fair Deal' was to get people out of hospital who were in need of nursing home care. However the figures available show no impact yet. Admittedly, it is hard to tell at present as the HSE cannot gather information due to continued work to rule by unions.

There were more delayed discharges in December (783) after the 'Fair Deal' was introduced than in September (742). And it seems there is a particular problem with under 65 year olds who are in hospital in need of nursing home care getting stuck there because the costs of their care is more expensive than what is being paid for under the 'Fair Deal'. So generally care is paid at a rate between €500 and up to €2,000 depending on the level of dependency, however some people would need care costing far in excess of this.

I have spoken to nursing homes who estimate care for some of these people would cost between €2-4,000 but no nursing home will take them under 'Fair Deal' as the pay is capped at the rate agreed between the nursing home and the National Treatment Purchase Fund (NTPF). I am aware of cases where people are stuck in hospital as their care costs are considered too high.  It is very unclear what happens in these cases.

So, in effect, it is 'Fair Deal' or no deal. It seems that in these cases there are no options for these people – people with extreme brain injury who cannot live in other assisted living places, people with early dementia, young people with degenerative conditions such as multiple sclerosis that require high levels of nursing.

There seems some confusion about this group as I saw an internal HSE memo dated 16 April saying under 65 were no longer to be dealt with under 'Fair Deal'. However, I have been reassured by the HSE and the Department of Health that this decision has been reversed.

But, clearly, the Fair Deal is not working for this population. Especially not for the 120 under 65 year olds currently stuck in hospital, not due to shortage of places, but due to high cost of their care elsewhere.