The demographic demands outlined in this Chapter are likely to generate additional cost pressures for services. The Fair Deal scheme is resource capped with applicants placed on a waiting list once the spending limit is reached. It is hoped that some provision for additional placements can be made in each of the next three years to take account of demographic pressures. Staffing, skill mix and other efficiencies in public nursing homes should contribute to financing further placements which will be required in each year.
14.9 CONCLUSIONS, SAVINGS AND REFORM
Demand for the various sub-programmes of the Services for Older People programme will increase significantly in the years to come as a result of the country’s ageing population.
The programme provides a cost effective service which helps to alleviate pressure on acute hospitals by caring for clients in more appropriate settings.
While there is scope to introduce efficiencies in some services (e.g. home help guidelines/legislation; reconfiguration of residential care etc.), any savings will be required within the programme to support the additional demands.
The Programme for Government commits to increased funding for both residential and community services.
Key Savings:
• Payments to Private Nursing Homes: Negotiations on the level of payments to private nursing homes will take place aimed at improving value for money for the Exchequer.
• Long Stay Charges: The level of long stay charges will be increased for clients who were in public beds prior to the introduction of the Nursing Home Support Scheme.
• Non-Service Area Savings: Savings will be driven in non-service areas across the HSE.
• Total savings from the above initiatives: €30m (it should be noted that these savings are once-off and ring-fenced for Fair Deal and therefore cannot be counted against the Department’s CRE target).
Key Reforms:
• Supply of Medical Care and Pharmacy Services to People in Long-Stay Residential Accommodation: Currently, GPs receive a special higher capitation fee for GMS patients who are admitted to private nursing homes. It is proposed to develop and tender for an alternative model of care which would apply to all residents of a long-stay institution based on an appropriate combination of publicly employed doctors and GPs.
In the case of medicines, dispensing fees, wholesale and retail mark-ups apply to drugs and medicines dispensed in community pharmacies for persons in long-stay residential accommodation. It has been suggested that savings would accrue if medicines were supplied instead by hospital pharmacists in the nearest acute hospital, even allowing for the cost of appointing additional hospital pharmacists. Further work is required to evaluate these two possible measures.
• Alternative Model for Service Delivery of Public “Fair Deal” Beds: The average cost of public (HSE and Section 38 agencies) long term residential care facilities is some 50% higher than the average cost of private facilities. The HSE is about to enter into a contract with a private operator to manage a 100 bed public residential care unit in Ballincollig which it estimates will save €1.8m a year. The Department of Health is currently reviewing the provision of public residential care in the light of the need to meet national standards and regulations, local demographic pressures and public/private provision. Options being considered include a central Care Commissioning body which, as well as procuring long term care from public and private facilities, would also
procure community services focused around a single assessment tool, structured around the patient. The review will reflect the wider health reform programme to which the Government is committed and, in particular, the positioning of social care services with the post-HSE health service. Accordingly, it is proposed to accelerate the engagement with the public service unions under the Croke Park Agreement to bring the cost of providing long-term care in HSE and Section 38 nursing homes into line with that of such private nursing homes, where there is evidence that best practice care is delivered to patients at an equivalent level of acuity of need at lower cost.
• Short Term Residential Care and Community Based Services: It will not be possible to increase the number of home help hours to meet the projected growth in need over the next three years. In the circumstances, consideration could be given to introducing a different skill mix which differentiates between the two main types of home help provided, i.e. personal social care (washing, hygiene, incontinence etc.) and instrumental activities of daily living (light household duties, dusting, shopping etc.).
This would allow available home help staff to focus on essential personal care to clients and involve a new, lower paid, grade of home help to take on the instrumental activities of daily living.
• Other reforms:
o Standardisation of Needs Assessment: The further roll out of a standard needs assessments and monitoring across the country for older peoples’ services.
o Supporting Older People in the Most Appropriate Setting: Closer integration between assessment and entitlement for community support and nursing home care to ensure that individuals are supported in the most appropriate setting.
o ICT: The use of technology will be maximised across all community supports in line with the HSE Report on the use of Assistive Technology for Older People. This may involve partnership arrangements with the private sector.
o Elder Abuse Case Management: The Department will seek to ensure that case management and workloads related to tackling elder abuse will be distributed in the most efficient manner as opposed to being entirely determined by geographic considerations.
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