El “Emmanuel” en la “ausencia” de Dios

The interaction between the public and private sectors in care of people with dementia is mainly confined to the nursing home sector. The Health (Nursing

Homes) Act, 1990 and the Nursing Homes Regulations which came into effect

on the 1st September, 1993 govern the regulation and public subsidisation of long-stay care in private nursing homes. In particular, new criteria, based on an examination of the means and dependency of old people, are now used to

determine the extent of public funding for the private long-stay sector. This has resulted in a large increase in spending on nursing homes, at least compared to spending in other areas, of approximately £65 million between 1993 and 1997. The integration of the private sector into public systems of delivery is more pronounced in some boards than in others, with the sector playing a major role in long-stay provision in the Eastern Health Board.

The most recent survey of long-stay units estimates that 23 per cent of

admissions to nursing homes are due to dementia, amounting to approximately 1,500 people. However, the total number of people with dementia in private nursing homes is likely to be closer to 4,000 people, if estimates by O'Neill et al (1991) are correct. There has been little if any public policy acknowledgement of the implications of such a large dementia population in private care, either in terms of necessary care supports, or with respect to financing arrangements. Current subvention arrangements are a cause of concern to nursing home proprietors, as the maximum public subsidy for a person entering a private nursing home is £120 per week, which is equivalent, at the very most, to 50 per cent of the cost of care. This leaves a significant gap, for a large number of people, between what they are asked to pay and what they can afford to pay, even with a public subsidy. This causes financial worries for both patients and nursing home proprietors, and ultimately becomes a problem for the public sector. We have already highlighted the accommodation and design needs of people with dementia in private nursing homes. We are not likely to see much progress in this area, given existing public subsidy arrangements and the

prohibitive cost of investment in new facilities.

The potential for co-operation between the public and private sectors with respect to placement procedures has not been exploited fully under the new legislation. There is a strong argument for a more uniform and standardised approach to assessment and admission in both the public and private sectors. Otherwise, differences will continue to exist in the ways, and the circumstances in which, decisions are taken to admit older people with dementia into long- term care, both between and within each sector. An elderly person seeking a subvention to enter a private nursing home should be subject to the same assessment procedures as a person entering a public long-stay institution. One possibility in this regard would be to use the resources of existing public long- stay hospitals to make decisions of this kind, based on uniformly applied dependency criteria. Indeed one might go further and make the case for a common assessment procedure for all nursing home admissions, whether an application for a statutory subvention is received or not (National Council for the Elderly, 1991). An assessment of this type would determine whether an older person was seeking care in a private home voluntarily, or whether the decision was forced on the individual and family because of the limitations of the available community care services. This, in turn, might focus attention on the need to stimulate the development of the community care option across the whole social spectrum.

One of the unwelcome by-products of the new legislation on private nursing homes is that the implementation process has drawn down resources that might

otherwise have been used to improve the community care system. In general, the financing of nursing homes should not occur at the expense of resources for community care. Accepting this principle means that subvention for nursing home care should never be granted unless it is clear that a similar subsidy would not have succeeded in maintaining the elderly person with dementia in their own home. The subsidy, if applied to community care, could be used to fund additional services in the areas of community nursing, home helps, day care and so on, as well as perhaps making some financial contribution to family carers. These services are vital in slowing down or preventing entry into long-stay care. It is only after assessment has been completed and a recommendation is in place to the effect that the elderly person should be moved out of his or her own home that the subsidy should be transferred to residential care.

30. We recommend an audit of the number of people with different types and severity of dementia in private nursing homes; an evaluation of the public subsidy arrangements for these patients; and greater integration of public and private production in the care of people with dementia.