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Wednesday 4 October 2023 Dublin: 12°C
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# fair deal scheme
Nursing home staff question ethics of relying on large nutrition firms to assess residents
Nursing home staff said that elderly residents are being transferred to hospital to get catheters changed because it is so hard to access primary care.

STAFF IN SOME Irish nursing homes are having to rely on large, private nutrition firms to provide specialist care to residents and there are concerns that the practice is “not ethically sound”, a new Nursing Homes Ireland report has revealed. 

Nursing Homes Ireland (NHI) is the national representative body for the private and voluntary nursing home sector. According to the 2016 Census over 22,000 people are living in over 530 nursing homes in Ireland, the majority of which are not run by the HSE. 

Having carried out a focus group in 2022 with directors of nursing from 10 different nursing homes across the country, NHI has stated the Fair Deal Scheme is no longer “fit for purpose”, as staff have serious concerns about residents under the scheme accessing essential primary care, and the effect this is having on their quality of life. 

The Fair Deal Scheme (FDS) was introduced in 2009. At the time, as one of the NHI survey responders puts it, the scheme went a long way to solving the “inequity” in the long term residential care system in Ireland. 

“Years ago, when there wasn’t a fair deal, families were trying to pay the difference. Like it would be six sons and daughters all trying to make up the money,” the staff member added. 

The FDS which is also known as the Nursing Home Support scheme is the State’s statutory funding model to support people to access nursing home care. Through the scheme, older adults pay a portion of the fees for their care (up to 80% of their disposable income), and the HSE pays the rest. 

What the Fair Deal Scheme covers

Residents are entitled to bed and board, personal care appropriate to their needs, bedding, a laundry service, and basic aids and appliances necessary for their day-to-day lives. 

They are not entitled to social activities, newspapers, therapies, incontinence wear, dry eye and dental services, transport – including care assistant costs, specialised wheelchairs, hairdressing or similar services. 

Through the contract of care, residents and their families in many cases end up footing the bill for these activities, services and therapies, even in cases where the resident is also a medical card holder. 

Though residents are entitled to several primary care services, NHI says they are aware that many are experiencing real difficulties accessing them due to community services being overstretched. This is leading to nursing home staff calling in private service providers and either passing on the bill to residents and their families or, for some services, seeking free care from large corporate providers.

This free care comes by accessing the services privately, specifically when it comes to securing visits with dieticians, speech and language therapists, and tissue viability nurses. Those providers include large nutrition firms that will see residents free of charge.

The Journal understands that reputable companies are increasingly providing these services and that there is no requirement for nursing home staff to then purchase products from them.

One nursing home staff member did raise concerns about the ethics of this practice, and about the reliance of private and voluntary nursing homes on companies that provide these services, because they are having such difficulty securing them through the HSE, according to the NHI report. 

“Access to Physiotherapy, [Occupational therapy, speech and language therapy, and Dietetics] from primary care is almost non-existent,

“We rely on nutritional companies to provide a dietician, a speech and language therapist, and a tissue viability nurse, there is no charge to the resident.

“However, for Physio and occupational therapy services, we have to pass on the charge to the residents as we source them privately,” they said. 

The senior nursing home staff member added that it is “impossible” to get tissue viability assessments if a resident is “immobile” and bed bound unless staff enlist private services. 

‘Totally discriminatory’ 

“It’s the same for clinical nutrition unless you use a reputable nutrition supply company.  Which really is not ethically sound but people need to access the services.” 

“Private nursing home residents are not able to access [these services in the way people are able to in] public nursing homes. This is totally discriminatory as these people did not choose to go into a private facility, they chose whatever bed was available at the time,” the staff member explained. 

Another key issue that the NHI report raises is the difficulties nursing homes are experiencing in getting access to GPs for patients. 

“Overwhelmingly, the biggest issue identified by respondents was the requirement to pay GPs a retainer fee to provide care to nursing home residents,” the report stated. 

“GPs asking for retainer fees, GPs asking nursing homes to transfer residents to another GP as they are too busy to look after residents in nursing homes. It could be days before you hear back from a GP and this is after many follow-up emails and phone calls-sometimes we have to ask families to call also to try to get the GP to respond,” one respondent told NHI. 

“GPs are under extreme pressure. Many of them do not have the comfort of having enough time to see referred residents. Very often they are not able to call in if a resident is sick or needs assessment in person. Receiving prescriptions is a long and painful process of sending emails and calling, often, a number of times,” another said. 

One senior staff member said that some GPs are reluctant to call out to residents when requested and that some have refused to do three monthly reviews as they are “not governed by HIQA”. 

Out of 53 respondents who work in nursing homes across the country, 31 told NHI that they have had to access primary care services on behalf of nursing home residents. 

“In addition, some services are provided by medical nutrition companies and in some areas access to therapies is available and within other areas, it isn’t,” the report notes. 

A staff member reflecting on the issue which is causing real problems for residents and their families said that at the root of the issue “private homes are being left completely on their own”, and suggested that some may be under the misapprehension that they have “loads of funds”. 

Staff members also made suggestions on what should be done to try and remove the obstacles that entitled residents are coming up against when trying to access primary care. 

“GPs need to be incentivised to take on Nursing Home Residents. Those in nursing homes will have more complex medical needs, so I feel GPs should have increased compensation to look after these residents” one said. 

Another said that residents in private homes are being brought to hospital emergency departments for minor procedures such as having a catheter change. 

“Patients in nursing homes are valuable members of our ageing community. If some were at home they would have immediate access to occupational therapy and physio from [community healthcare organisations].

The community does not in practice cover nursing homes. This is an area that should be developed. A Community Liaison team should be in place to prevent as many hospital transfers for minor procedures,” they said. 

NHI is calling for a comprehensive overhaul of the FDS. It has also called for GP’s general medical services contracts to be reviewed to take into account the requirements and resourcing of nursing home residents. 

Ultimately, it stated that their focus group and survey of NHI members have shown that the majority have had poor experiences of accessing primary care on behalf of residents. 

“We live in a society that is ageing but is in denial about all aspects of ageing,” the report concluded, adding “a society that has a poor history of caring for older people, and we are struggling to shake that history”. 

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