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JOINT COMMITTEE ON SOCIAL AND FAMILY AFFAIRS debate -
Tuesday, 21 Feb 2006

NESF Report on Care for Older People: Presentation.

On behalf of the joint committee, I welcome Dr. Maureen Gaffney, chairperson of the National Economic and Social Forum, and Mr. Seán Ó hÉigeartaigh, director of the forum. The purpose of the meeting is to discuss the forum's recent report, Care for Older People, copies of which have been circulated to members. Unfortunately, we will be unable to devote as much time as we would like to this because, unexpectedly, the Social Welfare Law Reform and Pensions Bill 2006 will be introduced in the House later, which means there is a clash, a matter outside our control.

Before the presentation begins, I remind committee members of the long-standing parliamentary practice that they should not comment on, criticise or make charges against a person outside the House or an official by name or in such a way as to make him or her identifiable. Members who wish to make a declaration regarding a matter under discussion may do so now or at the beginning of his or her contribution. Members are also reminded that if there is a possibility of a conflict of interest, they should make a declaration now or at the start of their contributions. I draw the attention of witnesses to the fact that committee members have absolute privilege but the same privilege does not apply to witnesses who appear before the committee. While it is generally accepted witnesses have qualified privilege, the committee cannot guarantee any level of privilege. I call Dr. Gaffney to make her presentation.

Dr. Maureen Gaffney

I am delighted to avail of this opportunity. I must also apologise because this was the earliest I could attend because of a prior commitment but I would be happy to appear before the committee again if further clarification or time is needed.

That would be appreciated.

Dr. Gaffney

I pay tribute to the Chairman and three other committee members — Deputy Cowley and Senators Kate Walsh and Feeney — who served on the project team. In some respects, I am addressing the initiated.

The context of the report is that we are trying to change the paradigm on ageing. People traditionally think of ageing in the context of frailty, weakness, ill-health and so on and, therefore, it tends to be associated in the public mind with many problems. A cohort of people is entering what is increasingly defined as the third age, post-65, which Ireland has not experienced previously. They are much better educated and are in much better physical and psychological health and they have high expectations of that period in their lives. We are not only addressing the current cohort of older people but we are also putting down a marker regarding the need for a radical reform of services for older people and our attitude to them. It is people such as ourselves who are entering that age group and we will have different expectations.

This report is only the beginning of the work that needs to be done. It signals that the paradigm needs to be changed and many practical suggestions are made to streamline services. A national strategy on ageing is needed to examine not only the question of how to provide services, which is still about thinking of older people as having problems, but thinking about how we will recreate society to make it much more amenable to the expectations, talents and capabilities of older people. We have not even begun to examine some of the more radical changes that need to be in place in society. I know from working in other countries that when one asks older people, or people who are approaching that age bracket, what their expectations are, they have a very definite agenda about the issues they want resolved. Information from other countries indicates they want society to have a far more flexible, malleable and innovative way of balancing up in an individual way work life, leisure life, community contribution and so on. Older people want to shape life around their own needs.

Having said that, there is another fundamental issue. Not only is our view of old age increasingly out of synch with the capabilities of older people, but we now know from psychological literature that, in research parlance, age is what is called an empty variable. In other words, one can predict almost nothing about people on the basis of their age. In a much more stable and slow-changing society, with less opportunity, one could have predicted beforehand what one's life would be like at 50, and what they were capable of at 50. One cannot do so anymore, because there is significant individual variability. This means there are 75 year olds who are capable of holding down a full-time job, and want to hold down a full-time job, and have a very busy social and leisure life, while others in the 75 year old age group will need a lot of care at the other end of the continuum, and there will be everything in between. Increasingly, older people will be looking for services that take this aspect into account, in the same way as individualism has become the dominant motif of modern society. What this means for older people is that they are also individuals.

I say all of this to put down a marker that it is just the beginning of this thought process. However, I would not like the report to be regarded as anything like the last word; it is just trying to put right some of the things we need to put right. However, it does not tackle the much more fundamental agenda. Politicians should be intensely interested in this agenda because not only does their profile suggest that they are heading in that direction, and there is a certain amount of self-interest in the issue, but because older people are politicians' most consistent supporters. Older people are the people who vote. They vote generally, not just on small issues, but they have a much more philosophical sense of what is required. They vote on values and so on. As they are very consistent and loyal supporters of the body politic, it amazes me that politicians do not pay them much more attention.

In terms of Irish expenditure on elder care, I am sure what I will say will come as no surprise to the members. Ireland is a very low spender on social protection compared to our EU partners. Our spending is approximately 60% of the EU average, with just Spain and Portugal spending less. While that might have been excusable at one point when we were a poorly performing economy, we cannot use that excuse any longer. This is now a very rich and prosperous economy, and older people are the ones who made that happen. They have a limited time to enjoy it and, by any standards, they deserve to have their needs catered for. Our overall spending on care services equates to approximately 6.7% of 1%, and we need to increase this to at least 1%, which is the average.

The whole orientation of the report is to move away from our current situation where lip service is paid to community care. While approximately €1 billion is spent on older people — it may sound like a lot, but it is not because it includes pensions and so on — it is disproportionately spent on residential care, even though just 5% of older people use residential care. The most radical shift must be to put our money where our mouth is. The money must follow the defined economic and political goal, which is to shift towards community care.

What is meant by community care? There is no legal definition of it in Ireland, therefore it is no wonder that hardly any money follows it. It is a very loosely defined concept. Normally what it means is that services that are provided in a hospital, for example, are provided in a local clinic. This the most minimalist definition of community care. We are suggesting a much different definition of community care such as a radical overall of the service. We should wrap the services of the State around the person, which should not include just chiropody and meals-on-wheels. I am talking about people in high dependency situations, not all older people, just a small proportion of older people. We are not just talking about shifting medical services out into a parish hall, but about radically examining transport services. It should be possible for people to live as long as possible the way they want to live, which is in their own homes, independently, with dignity, and surrounded by the social capital which they have accumulated all their lives. They will have their neighbours and friends, and the lucky ones will have their families. They must be kept networked in that sense.

The psychology aspect is an interesting finding. The self-esteem and longevity of older people depends very much on their sense of self-sameness, which changes. When one is younger, different things count in terms of one's mental health. When one is older, just having a sense of oneself as one always was, and having around one all the things that remind one of this, is a crucial part of remaining physically healthy and living as long as one can. The more we disrupt that sense of self-sameness by transplanting people into residential centres, where they are removed and dislocated from everything they know and everything that reminds them of their past successes, past achievements and past relationships, we are putting them at risk. Any kind of move puts older people at risk. Even if one is moving them to better services, they are better staying where they always were once the services are around them. We are not just talking about medical services, but social services, transport, street lighting, security and so on. The report recommends a whole raft of low level services that would make it possible for people to remain in their own homes for as long as possible.

One aspect we must distinguish in our own minds is the idea of dependency. We must separate that out from situations of dependency. Sometimes people become dependent because they are in a situation where they must be dependent. We associate older people with becoming dependent because we must collect them to bring them to clinics. This makes them feel dependent, whereas if there was a proper rural transport service, many people would not be dependent. The report refers to the success of the rural transport initiative.

Small things can tip an older person into dependency. One may be able to manage in one's house with meals-on-wheels and so on, but one cannot manage one's fear of being broken into. Proper security and alarm systems are required, such as the Summerhill project. I visited Intel today and reference was made to the fact that we have not even begun to explore the use of technology as a way of assisting people to live in their own homes. There is even more sophisticated technology around the corner if we are prepared to invest in it. For example, rather than older people having an alarm to hang around their necks, there is now the capacity to tell those monitoring them if they have fallen over. Many otherwise healthy older people are pitched into long-term institutional dependency when they fall. They may break a hip and not recover, their self-esteem goes down and their house falls into disrepair. People then give up the ghost and suggest they go into a nursing home. This could be prevented by having this kind of electronic surveillance — those involved in the team know about this technology. It could tell us, for example, whether somebody accessed a cupboard for food in 24 hours. Therefore, we would not need to break down the door and people would not have to wait three weeks to be found if they had an accident. We could electronically monitor people in an unobtrusive way that does not invade their privacy.

A recent campaign in the UK, called Sloppy Slippers, discovered that a significant number of falls of older people are precipitated by unsuitable footwear, particularly old slippers. People in one catchment area were supplied with proper, safe, comfortable slippers and the number of accidents was reduced significantly. These are small initiatives we could take, but they are powerful once they are motivated and dictated by the new paradigm, namely that we keep people in their own place as long as possible. Very frail or very old people are often pitched into dependency by just one accident which is often followed by a set of unfortunate events. I will not go through all the recommendations in detail, but there are simple practices we could put in place. Community care is not just about moving out the chiropodist, but about rethinking the services in a more innovative way in terms of how they are delivered.

I will outline an approach described in this report and I would like the committee to imagine the response it would get if this was possible here. It relates to a small, rural area in the Netherlands which had become depopulated, a bit like parts of the west of Ireland. The area has a population of approximately 9,000 older people spread across seven villages. Many of the younger people have left and those left are high risk — a "despair" situation. In the mid-1990s those involved in services to the area decided they would have to take a radical approach to keeping people independent in such a dispersed area. They developed a new approach to integrating housing, welfare, social services and care. The initiative was part of an overall strategy to ensure more people did not leave and that the whole area did not become depopulated. Basically, it was about integrating people and reversing rural decline.

All those involved in services for the area pooled their budgets, some money was provided from central government and personalised service brokers were appointed — what most adult children here have now become for their elderly parents. They were employed to work as advocates for the elderly. They went to the services and pointed out what people needed — the equivalent of what adult children do — and inquired about getting the service delivered on time. They filled out the forms for people and informed the services of what was being provided by each one, social welfare, housing etc.

This is the same kind of personal broker services adult children here must provide, sometimes from a great distance when they live in Dublin and their parents live in the country. However, in the Netherlands people are employed as personalised brokers. The community in the Netherlands worked outside of the existing bureaucracy to provide the most suitable services. Within that internal economy vouchers were provided to people from the funding available to pay for various services. The new service also included an ombudsman-type role. Therefore, there was someone to complain and advocate on behalf of older people.

The service had five multidisciplinary teams which went around the seven villages. These included general practitioners, home helps, home carers, nurses, social workers, physiotherapists, etc. A care home in the area was replaced by apartments equipped with the type of technology I mentioned and people also had a place to meet and talk to each other in an intergenerational network. A care hotel was set up where people who were discharged from hospital after a fall or whatever could spend time in care before being returned to their homes.

That type of service is a deluxe one. People here might say it would cost too much. However, the committee should understand that the residents of that community consumed up to one third less care compared to the Dutch national average, leading to significant savings. We should post that fact up somewhere because it is a counter argument to the usual response that we would love that system, but it costs too much. We need to be bold and innovative and put it in place. We should not be like the last of the small spenders and assume that such a service would bankrupt the country. While this community in the Netherlands benefited from all these services, the members of the community consumed one third less care than the average Dutch citizen of the same age, a revealing statistic.

We included many recommendations in the report with regard to co-ordination of services in terms of bureaucracies coming together to deliver a more personalised service. Where people have problems with elderly parents it can be a nightmare trying to communicate what the health services have suggested to the social welfare services and on to the housing service etc. We should develop a way to share non-sensitive data, but if there are problems related to data sharing, why do we not give the older person a master file, stored electronically, that they can take with them to the doctor, housing or social welfare officer? He or she could then find out what they need. Such a system is not beyond our ingenuity or capability. I will not go through the raft of recommendations that we could accomplish.

We are now on the 34th or 35th NESF report. A key theme of the reports has been the need for co-ordination. We try to work across the services, but we are not good at it at departmental or local level. We will not be good until we reward and incentivise it. Co-ordination is a big job for people doing their normal work such as the housing end of the service. The attitude of most people is that they have enough on their plate without getting involved in another area such as the medical area. However, we will achieve better co-ordination if we reinforce and incentivise it by providing a larger budget or promoting people who put extra effort into it. I will not go through everything we said should be done as the recommendations are in every report.

We suggest there should be inspection of all care services. Currently we only have inspection of nursing homes, but there should be an inspection service for all facilities. If someone lives at home, the inspectorate should be able to check whether it is safe and adequate for them. The situation should be similar in the case of assisted housing etc. We need proper criteria for all facilities.

We did not cover the subject of carers in depth in the report. The issue of carers would need a report in its own right. We need to look at how this business will grow, particularly in a society which has increasing migration to large cities. Older people can no longer rely on their children, mainly their oldest daughter, to look after them because these children may be married and working full-time. There is a crisis looming in the area of care. We need a policy on carers but we only address the issue in a cursory fashion as it is a topic in its own right.

This has been a gallop through a long report, but I know the committee is pressed for time. I will leave it at that, unless the committee wants me to elaborate on any particular area.

We are quite pressed for time. The report highlights important issues and we would like Dr. Gaffney to return another day. The committee intends to review the presentation and invite the delegation back for some elaboration by means of questions and answers. The Dáil is in session and is dealing with the Social Welfare Law Reform and Pensions Bill. I am my party's spokesperson. Other members of the committee have responsibilities also such as Deputy Stanton who is the Fine Gael spokesperson.

Dr. Gaffney

I am happy to return as it is a topic that merits further discussion.

We did not envisage dealing with a Bill when we arranged to hold a meeting today. I hope the delegation will not regard this deferral as a sign of disrespect.

Dr. Gaffney

I understand.

I was a member of a committee with members of the delegation. This is one of the most important reports produced by the National Economic and Social Forum. We are all moving into that stage in life and we should be paying more attention to some of the issues raised. We have been a little cavalier in our approach and we may pay the price. The Dutch model, across seven villages, could be applied to any part of rural Ireland and it would save expenditure by one third. There is a lot to learn.

The committee prepared a detailed report on carers and there may be some shared information, some crossover, on the reports. The report is being updated on a continuing basis. The NESF has submitted a report and we will seek further elaboration from the delegation. We will arrange a mutually convenient time and date in a number of weeks. The committee will have an opportunity to review the delegation's submission and this may allow for a more comprehensive discussion on the matter.

I thank the delegation for its attendance.

The joint committee went into private session at 4.13 p.m. and adjourned at 4.15 p.m. sine die.

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