Brid Smith on private care homes and COVID-19

Half of all COVID-19 deaths so far in Ireland were residents in nursing homes. North and South, a reliance on private nursing homes & the deprioritisation of elderly care have worsened the impact of COVID-19 for the elderly.

At the time of writing there were 119 reported clusters in nursing homes in the South. In one case it is reported that four residents have died with over 70 staff members and 19 other residents also testing positive.

In the North, numbers of cases in care homes are clearly on the rise, with 12 more homes affected in the space of a week. Just today, however, the Chief Medical Officer (CMO) made the unsettling claim that the total number of deaths was ‘unclear’, leading the Commissioner for Older People to demand greater testing in care homes. Worse, a story in today’s Irish News tells of heartache for one family whose relative in a private care home in Belfast have no idea whether their loved ones is alive or dead. 

The concentration of deaths from COVID-19 in elderly care centres isn’t confined to Ireland, however. Last week the Guardian reported:

“In Spain, the army has reported finding dead and abandoned people in their beds after it was drafted in to help disinfect care centers. Care homes in the Madrid region alone have reported the deaths of 4,260 residents who were diagnosed with coronavirus …In France almost a third of all coronavirus deaths have been of residents in care homes…In Germany there have been reports of deaths in homes totaling hundreds across the country. In the worst case so far, 29 out of 160 residents at a care home in the northern city of Wolfsburg…. Prosecutors are now investigating the home on charges of death through negligence.”

COVID in care homes

There are a number of reasons for the high death tolls in nursing homes. The virus affects over 70s and over 80s disproportionately. Also, the nature of elderly care means an asymptomatic worker or visitor in a home can quickly infect vulnerable residents who are likely to spread it among themselves as they socialise at meal times and at social events.

All of this has been known since early February and the experience in other states meant Ireland’s authorities were well warned by the time the first clusters were reported, and despite massive and largely successful efforts to spin both the HSE and Irish Government’s handling of the crisis, the catastrophe in nursing homes is pointing to a colossal failure.

And given the all too recent history of scandal and neglect in care homes in the North, this issue is one which called for urgency from the Stormont Executive, which we are yet to see.

The key “technical” failure was refusing to test staff and residents at nursing homes from early in the crisis, despite knowing how vulnerable the residents would be, and despite warnings internationally since early March when a similar tragedy unfolded in Seattle. 

Particularly in the North, where little to no testing in the community has taken place, it is incredibly difficult to trace and prevent spread in care homes – particularly where senile residents with alzheimers may not be able to communicate that they are feeling unwell. 

When asked by myself at a briefing in early March about prioritising testing for care workers of the elderly, the state’s CMO simply dismissed the idea replying “we are not doing that”. The largely fawning press coverage of Holohan’s performance meant there was little scrutiny of the HSEs actual actions on the ground.

When asked a similar question in Stormont, CMO McBride responded to my colleague MLA Gerry Carroll to say simply that ‘testing is not a silver bullet.’

From early on  in the crisis, the Irish association that represents private and voluntary nursing homes were warning of what lay ahead and requesting greater support, in terms of finances, equipment, and staff from the state. Their appeals were largely ignored until the last week when the scale of the tragedy was becoming difficult to mask. Harris announced a 78 million euro package to bail out private nursing homes, with a promise of PPE and staff. 

Clearly, the demands of the private nursing homes around COVID-19 are actually an admission that for-profit provision of elderly care cannot provide the kind of services needed in a crisis.

Political privisation

Ireland’s shift to privatised care was dramatic and accelerated under the Fianna Fail McGreevy /Ahern Governments, when huge tax breaks were heaped upon the builders of private nursing homes. Mary Harney would later introduce the so-called “Fair Deal” which now finances the increasing numbers needing residential care. That sees the homes of elderly as well as any pensions they have part fund the costs of care. Harney herself is now on the board of one group, Brindley, which has over 10 nursing homes across the country.

Later, in 2002, Fianna Fail championed the Finance Act, whereby Finance Minister McCreevy put generous tax breaks in place for the developers of private nursing homes and private hospitals. This represented a huge State subsidy, estimated at around €10 million between 2004 and 2014 for the new investors.

The so called “grey entrepreneurs” could now borrow money (at historically low interest rates) and then write the capital costs off against their tax liability over seven years.

Bertra Capital, owned by former head of Treasury Holdings Richard Barrett, has plans to build or buy up to 2000 beds in nursing homes. Barrett, along with Johnny Rohan, had accumulated debts of 2.7 billion with the Treasury by 2012 when it folded. Like others, Barrett sees the lack of state provision of nursing homes as a great opportunity. He is not the only ex-property tycoon to eye up elderly care as a new profit opportunity. Builder Joe Kenny of the Healthcare Group  has seven nursing homes.

Many homes are largely funded via the Fair Deal scheme and through top up fees charged on top of the state subsidy. Residents are often charged for having access to services such as a doctor, even when they don’t avail of them. Direct state subsidies last year to the Fair Deal scheme across all providers was 980 million euro.

Major funds like AXA Investment Managers are also investing.

The impact of for-profit care

A direct side effect of this privatisation and corporatisation has been greater pressure to cut costs, produce profits, pass on charges to families and employ a workforce on low pay, with long working hours and under ever increasing pressure. Private nursing homes do not provide much nursing, with actual medically qualified staff a rare presence. Any potential resident with high medical needs requiring intensive care is usually left to the public system.

In 2010, an ombudsman’s report warned of the “creeping privatisation” of the service, involving a virtual trebling in the number of private home places since 1997 and a significant decline in public beds. Since then the creep became a gallop with one study commenting;

The same study also quoted a host of international reports that found that:

“ private for-profit health systems tend to be less efficient, more costly, less egalitarian, and provide lower quality of care”

Lower standards and poorer care are a consistent finding in private nursing homes across the world. In Australia one study found that the quality of care was worse in private nursing homes. Studies in Britain showed drug therapies are used more in private homes while a US study showed patients in private care homes have a higher risk of infection. Overall, it seems staffing levels in for profit care are about 20% less than not for profit.

The pressures to prioritise profits over care lay behind a number of scandals such as at Leas Cross, where an investigation into the deaths of 105 residents over several years eventually led to the setting up of HIQA to enforce some regulations on providers. The scandal fitted a picture where cost cutting and increased pressure on staff resulted in often dehumanising and abusive treatment of the elderly.

Similarly, the North has been rocked by scandal after scandal in the private care home sector, with neglect and abuse exposed at various facilities. Now infamous, the private Muckamore abbey saw around 1,500 cases of abuse, and abuses at Owen Mor in Derry were described as ‘depressingly similar’ to those in Belfast’s Dunmurry Manor, where an investigation found a ‘horrific catalogue of inhuman and degrading treatment’. 

The majority of care homes are private in the North. Even when public homes have been closed – despite local protest – because of a ‘lack of demand’, private care homes spring up in their place with full beds. Staff at public residentials homes closed in 2015 in Belfast claimed that beds were not being refilled when residents passed away, faking the ‘lack of demand’.

And indeed the NHS in the North is rife with Private Finance Initiatives which see Stormont Departments pay out to private firms every month for building health infrastructure.

Health before profit

The COVID-19 pandemic has revealed the underlying weaknesses of Ireland’s two tier health system in the South, and poor cross border bed and ICU capacity, and reliance on private, for-profit, elderly care.

Over recent weeks, People Before Profit elected representatives across the country have been contacted by workers in residential homes, speaking of horrendous pressure and conditions. 

The lack of PPE, the use of agency staff on long hours and poor contracts, and the general level of care are their main concerns. One worker told us “Care workers in Private Nursing Homes are overworked, underpaid and undervalued. At a very minimum in this crisis we need regular testing of staff and access to PPE’s at all times and this is obvious from the growing number of clusters in private nursing homes”

While the elderly in residential care would always be susceptible and more vulnerable to a virus like Covid 19, Ireland’s reliance on private homes has left our elderly even more exposed.

Just as we should not accept a return to a two-tier health system, we should insist that when this tragedy is over, we see an end to the privatised care for the elderly. No one who is familiar with the care of the elderly in the public system would claim it is perfect, but the drive to privatise and corporatise the care sector has exposed how a for-profit system can wreak havoc on the most vulnerable. 

We need a properly funded public system where the importance of elderly care is understood and those that work in it are treated as vital workers not just opportunities to generate profits for the already wealthy.