Dr Kevin McCarroll
Medical Matters
The Fair Deal Scheme has once again come under increasing pressure and scrutiny this year as costs rise and concerns loom that delays will ensue for older adults waiting to access nursing home care. Introduced in 2009 as a new way to help finance long term care, it replaced a wholly inadequate and hotch potch system based on means testing and subventions with regional variations that failed to cover costs.
The Nursing Home Support scheme, as it’s properly called, was to provide universal access to funding for longterm care on the basis of making a contribution based on what you could afford. Its proponents argue that it has made easier access to nursing homes and in most cases the majority of costs is borne by the state.
However, it has been plagued by several issues over the years not least the criticism that it is financially inequitable and places undue burden on older adults and their families.
Sight shouldn’t be lost of the fact that about 50% of older adults going to longterm care are aged over 85+, about 20% have a history of stroke and a much larger proportion have dementia. They are a group who often have multiple medical ailments, are frail and need specialist nursing care and ongoing medical input. Indeed, many are in the end stages of their life with overall average mortality as high as 30% in the first year and 70% at 5 years.
If one is unfortunate enough to be struck by a stroke or dementia is it fair that part of their family home should be used to pay for their care in the last few years of their life?
Even in a healthcare system under pressure, understandably substantial budgets are spent on very expensive drugs that may marginally prolong life but not cure disease. However, medical conditions that impact frail elderly who go to nursing homes seem to be considered in a different light. Indeed, not surprisingly the scheme has been dubbed by some as a “tax on dementia” or as a “selective inheritance tax”.
The individual contribution can be very substantial and in about 60% of cases the family home becomes part of the calculation.”
So how does the scheme operate? If one avails of Fair Deal, 80% of income is taken to help pay costs as well as 7.5% of all personal assets (per year) above €36,000. Where the asset is a family home this is capped at three years meaning that approximately a quarter (22.5%) of the value of your share in your house can be used. However, up until this year an indefinite contribution was applied to family businesses or farms sometimes having a crippling impact on their future viability. Due to signficiant lobbying on the government new draft leglisation has been approved, which places a three year cap on business assets provided a family member continues to operate it for a specified number of years.
Overall about 70% of the cost of private nursing homes is covered by Fair Deal, though this does not factor in additional costs which can amount to up to €400 per month. In addition, for those on small pensions little is left over for personal use.
The individual contribution can be very substantial and in about 60% of cases the family home becomes part of the calculation. Sometimes families opt out of Fail Deal and pay privately or find themselves in the difficult position of wondering how long their loved relative might live for in assessing future costs.
The decision to go into a nursing home can sometimes also be a bit of a false dichotomy as sufficient care packages to provide for support in their home are not always available making longterm care a ‘forced inevitability’.
The state has also divested hugely from providing nursing home care in recent decades and failed to invest in public units, many of which do not meet HIQA regulations and are now undergoing improvements. In fact, about 25% of nursing home places are now public compared to 75% in the past.
Public nursing homes though costing up to 60% more to fund have to some extent taken more heavily dependent and frail elderly, particuarly those with complex medical problems. In particular, this may offset what is considered to be cherry picking by some private providers who are essentially profit-making institutions.
No one doubts that providing nursing care is costly and indeed now amounts to about one billion annually.”
Recently and also over the years, delays in accessing funding from Fair Deal has also had a major impact on the acute hospital system accounting for up to 60% of all delayed disharges.
No one doubts that providing nursing care is costly and indeed now amounts to about one billion annually. However, the vast majority of older adults live at home and want to stay at home. Disability is also reducing at any given age though an ageing demographic simply means that a bigger number of our elderly will need nursing home care.
It is now time that both at a government and societal level, we seriously decide how we value such a frail, vulnerable and elderly group and fund their care in a equitable and fair way providing where possible too the necessary home care they need.
Dr Kevin McCarroll is a Consultant Physician in Geriatric Medicine, St James’s Hospital, Dublin.