Ireland – A great place to grow old?

As at Census 2016, there were a reported 635,567 over 65s in Ireland [1]. This is projected to have increased to over 740,000 by 2021 [2], or almost 15 per cent of the population. Planning sufficient housing, healthcare and income supports now will ensure that our growing, ageing population will be provided for in to the future.

Housing and Older People

Ageing at Home

For older people who own their own home, continuing to age at home presents it own challenges. 

Housing Adaptation Grants is the collective term given to the three grants:  Housing Aid for Older People, Housing Aid for People with a Disability and Mobility Aid Grant.  These grants are provided to eligible people to modify their own homes, allowing them to live at home, within their communities, for longer. Given the large proportion of older people and people living with a disability who own their own homes, the Housing Adaptation Grants are especially important.  In 2010, a total of €77.3 million was paid in respect of 13,588 grants.  These grants were subject to cuts during the austerity years, and in 2013 reached their lowest point in the decade, with €37.7 million paid in respect of 7,011 grants, less than half 2010 levels.  Building on moderate increases since 2015, the total amount paid in respect of these grants in 2018 was €51.2 million in respect of 9,413 grants. An improvement on 2013, but still just two-thirds of 2010 levels.

In addition, delays in accessing the necessary Occupational Therapists to certify a need for home modifications means that people living with disabilities may be at risk in their homes due to lack of necessary works.

Ageing Tenants

Between 1991 and 2016, there was a 12% increase in the number of over people aged  80+ renting, and a 49% increase in people aged 85+ renting [3].  While the number of people in these age groups renting in the private sector is relatively small, there is a concern that this will increase in the coming years. According to Census 2016, 2.4% of people aged 65 and over, and almost 10% of people aged between 50 and 54 are renting from a private landlord [4]. The number of renters aged 55 – 64 has also increased in recent years, from 37,263 in 2011 to 44,440 in 2016, an increase of nearly 20% [5].

Ageing in Social Housing

The Housing Agency, in its ‘Summary of Social Housing Assessments 2020’, reports that 61,880 households were on the waiting list for social housing as at the November 2020.6,704 (10.8%) of these households are 60 years and over, representing a 2.9% increase compared to 2019. [6]

Ageing in Homelessness

Since the publication of Rebuilding Ireland, the Government's previous housing strategy with a commitment to eliminate homelessness, in July 2016, the number of over people aged 65+ experiencing homelessness in Ireland has increased by 44%.

Social Justice Ireland has long called on Government to provide a spectrum of housing suited to older people. The issue of renting into older age, and income adequacy to do so, requires urgent attention, and ageing in homelessness demands an emergency response.

Healthcare and Older People

A well-developed, co-ordinated and integrated approach to the management of older people’s needs reduces referrals to long-term residential care [7]. A report from the ESRI suggests that people stay a shorter period in hospital in Irish counties with better supply of home care and long-term residential care services [8]. Thus, better home care and long-term residential care supply can help reduce older patients’ length of stay in acute hospitals [9].

The ostensible Government policy commitment to support people to remain in their own homes (which coincides with the wishes of most older people) was not evidenced by the significant decrease in the provision of Home Help hours [10] following 2008 at a time of population ageing. As previous iterations of this review have evidenced, numbers of people receiving home help and the hours allocated reduced from 2008 and especially from 2010, and there were still fewer people in receipt of Home Help support in 2017 than there had been in 2008 [11]. Numbers of people in receipt of Home Care Packages (HCPs) grew after 2008 but the funding for that scheme was largely static for many years and the average value of each package fell [12].

In 2018, two home care schemes were amalgamated by the HSE making comparison of their delivery with earlier years difficult. The HSE Annual Report for 2019 suggests that 17.48 million hours of home support (combining home care packages and home help but not intensive home care packages) were delivered to some 51,300 people. As compared with 2018, this represented an increase in the number of hours (+2 per cent) but a decrease in the  numbers of people in receipt of these services (-3.1 per cent). In addition, 376,665 hours of intensive home care packages were delivered to 188 people, which represent decreases on the figures for 2018 [13].

Ireland provides relatively low levels of formal home care by comparison with several other countries and research suggests that 38 per cent of older people who need home care do not have their needs met; they were also the group with the highest level of unmet need [14]. Indeed, the HSE itself suggests that home care has not kept pace with population growth or population ageing and that demand for home support continues to exceed the level of service that is funded [15]. The HSE performance report (to June 2020) suggests that 5,689 people were waiting on funding for home support [16]. This had decreased from the earlier months of the year, when the number had well-exceeded 7,000; it also represents a decrease on the numbers of people waiting in June 2019 (7,219 people) [17]. The Department of Health told the Oireachtas Committee on the COVID-19 response (2020:35) that it hopes to reduce the list of those waiting for home support to a very small number, or to get rid of it entirely, by October 2020, as it recognises this is a method of keeping people safe and out of hospital. Amongst the issues that the pandemic has highlighted is fragmentation in how we provide long-term care for older people and the relative detachment from the health service of private nursing homes. It is to be hoped that the shortcomings in the response to COVID-19 within nursing homes in the first half of 2020 and the high levels of deaths of residents might lead to a more community focused approach to long-term care of older people in the future as well as better linkages and oversight between public and private sectors.

Over 60 per cent of the older people’s budget goes towards long-term residential care while only approximately 4 per cent of the over 65 population live in residential care settings [18]. The number of people supported by the NHSS (Fair Deal) scheme in 2019 was approximately 23,600 or approximately 3.3 per cent of those aged 65+, a proportion that has been static or falling over recent years. 

In November 2019, the Joint Oireachtas Committee on Health published its report on the Provision of Homecare Services [19]. Among its key recommendations were:

1. the enactment of legislation underpinning the provision of homecare. This legislation must set out to provide a definition of homecare, the eligibility of homecare and the statutory obligations on the HSE to provide homecare. The Committee strongly recommends that appropriate resources are provided to enable the enactment of legislation by 2021, as set out in Sláintecare’s strategic plan.
2. that homecare services are regulated by HIQA or another independent body which should be responsible for regulating the standard of care provided by professional carers, the commissioning of service by the HSE to voluntary organisations and the provision of homecare services.
3. that family carers are provided adequate support to incentivise informal homecare support. Such support includes:
   1. simplifying access to carer allowances and grants
   2. widening eligibility to accessing carer allowance and grants
   3. removing irregularities within the tax system which have a punitive effect on those providing informal homecare
   4. providing respite hours to those who supply home care hours.

A statutory basis for home care has been called for by Social Justice Ireland and initiatives taken in this direction in recent years are welcome. However, while a consultation process was commenced to consider establishing a statutory homecare scheme, recent media reports suggest that  its implementation has now been deferred until 2022, which is unfortunate. Supporting people to live at home requires an integrated approach that ensures access to a range of supports in the home as well as transitional facilities. To achieve this, deficits in infrastructure need to be addressed urgently with an emphasis on replacement and/or refurbishment of facilities. If this is not done, the inappropriate admission of older people to acute care facilities will continue with consequent negative effects on acute services and unnecessary stress on people and their families. A related issue is the shortage of short-stay community beds intended to enable people to return to their own homes after a period of intervention and support (including step-up, step-down, convalescence, assessment and review, respite and rehabilitation services).

The National Clinical Programme for Older People (2012) recommendations have not been implemented requiring that hospitals have a dedicated specialist geriatric ward and a multi-disciplinary team and access to structured rehabilitation [20]. Thus, the fundamental right of an older person to receive an adequate period of rehabilitation before a decision with regard to long-term care is made is not upheld.

Planning and investment are required to meet the challenges presented by population ageing, and also to address the infrastructural deficits created by underinvestment. Health-promotion measures and action to facilitate the full participation of older people with disabilities in social life are also required, as well as a comprehensive approach to care services that would include integrated services across the areas of GP care, public health nursing, home care supports, acute hospital care, rehabilitation, short-term and long-term care.

Social Justice Ireland believes that on the capital side, an investment in the order of a total of €500 million over five years (€100 million each year), is required to meet growing need.  This would enable some 12 to 15 community nursing facilities with about 50 beds each to be replaced or refurbished each year. In addition to supporting the needs of older people, this proposal would also stimulate economic activity and increase employment in many local communities during the construction periods.

Substantial commitments on healthcare expenditure were made  in Budget 2021 including €425m for enhanced community and Social Care Services. This is very welcome. There is unmet demand for home care for older people and an allocation in the region of €500m is required to go some distance towards meeting this demand.

Poverty and Older People

The latest SILC data indicates that 10.5 per cent of the population aged 65+ were living at risk of poverty. This equates to 74,542 people living on or below the poverty line [21]. This represents a decrease on 2018, when 78,547 people aged 65+ were at risk of poverty, but remains a substantial increase on 2017 when this number stood at 57,191.

The number of people aged 65+ experiencing enforced deprivation in 2019 was 78,852, or 11.2 per cent of this age group. Enforced deprivation means that they are unable, due to financial constraints, afford two or more basic items from a list of 11. These include basic items such as a warm waterproof coat or heat for their home [22]. This represents an increase of 40 per cent (23,116 people) on 2018, when the number was 55,736.

Consistent poverty is a measure of the proportion of the population who are both living at risk of poverty and in enforced deprivation. The consistent poverty rate of people aged 65+ in 2019 was 2.4 per cent, or 16,669 people. This represents an increase from 1.7 per cent, or 11,851 people in 2018.  . The consistent poverty rate is higher again for over 65s who live alone, at 4.1% [23].

Time for a Universal State Social Welfare Pension

In 2018, Social Justice Ireland published A Universal State Social Welfare Pension, an analysis of Ireland’s pension system and a fully costed proposal for the introduction of a Universal Pension in Ireland based on residency, not social insurance contributions. In it, Social Justice Ireland proposes three key adjustments to the present system:

• On equity: ensure every older person who has been resident in Ireland will receive a full pension payment (unlike the current system or the Government’s proposed new system, both of which leave large numbers of older people with only partial or no pension.
• On sustainability: make the system more sustainable by standard rating employee contributions to private pensions (unlike the current system which gives tax relief at the marginal rate which results in the major benefits going to the higher paid).
• On bureaucracy: dramatically reduce the bureaucracy by having only one test for accessing the payment and eliminating the myriad of conditions that are part of the current or the Government’s proposed systems.

With an ageing population and the number of people in defined benefit schemes falling, it is clear that the shortcomings in Ireland’s pension system need to be addressed urgently. Outside the scope of the Pensions Commission's remit, is the Government's policy a new automatic enrolment savings scheme. This, apparently, is not for moving. The proposed scheme is intended to bolster the contribution private pension savings plans make to retirement adequacy. This will result in an estimated cost to Government of €650m-€700m per annum, on top of the billions of euros in income already being foregone by the Exchequer on an annual basis to subsidise the private pension industry.

The prevalence and adequacy of private pensions will obviously have an impact on discussions of the level at which public pensions should be set (as it has informed policy in other OECD countries), and so it is bizarre that this has been omitted from the Pensions Commission brief.

One of the ways in which a lack of fairness has long permeated the Irish pension system is the manner in which entitlement to a pension from the State has been based on social insurance contributions. This ties pension entitlements to an individual's labour market participation history and has historically resulted in lower pensions (and sometimes no pensions at all) for people (mainly women) who have spent long periods away from the labour force raising families or caring for elderly family members. While some improvements have been made in this area in recent years, we still have a very long way to go. 

Social Justice Ireland’s proposal shows how to fund a Universal Pension System based on residency. This would replace all other social welfare pension payments and would be funded by a restructuring of the tax relief system on private pensions and a modest increase in Employer PRSI. This is the best way to achieve a fairer and more equal Ireland. It is proposed that the Universal Pension would start at €243.30 a week, the same as the current State Pension (contributory). It would be residency based, meaning that the more working-age years a person is resident in Ireland, the higher the percentage of the full pension they receive. 40 years of residency between the age of 16 and the State Pension Age would entitle a person to the full amount.

There would be two primary mechanisms to fund the cost of this provision. First, reducing the rate of tax relief on private pensions from 40 per cent to 20 per cent and second increasing employers PRSI by 0.5 per cent. These, along with some other smaller measures, would raise in the region of €949m, which is €200m+ more than the additional cost of the Universal Pension in 2019.  The study goes on to argue that the social welfare pension should rise to 35 per cent of average earnings and be maintained at that level in the decades ahead. The study projects the numbers forward to 2046.

 

 

---

[1] Central Statistics Office, 2017. Census of Population 2016 - Profile 3 An Age Profile of Ireland. [online] Central Statistics Office. Available at: https://www.cso.ie/en/releasesandpublications/ep/p-cp3oy/cp3/agr/

[2] Central Statistics Office, 2018, Population and Labour Fore Projections.[online] Central Statistics Office. Available at Population and Labour Force Projections 2017 - 2051 - CSO - Central Statistics Office

[3] Central Statistics Office, n.d. Census of Population 2016 - Profile 1 Housing in Ireland. [online] Central Statistics Office. Available at: https://www.cso.ie/en/releasesandpublications/ep/p-cp1hii/cp1hii/tr/ [Accessed 10 May 2021].

[4] ALONE, 2018. Housing Choices for Older People in Ireland. [online] ALONE, p.8. Available at: https://alone.ie/wp-content/uploads/2018/07/Housing-Choices-for-Older-People-in-Ireland-Time-for-Action-1.pdf [Accessed 29 April 2021].

[5] Central Statistics Office, 2020. Private Households in Permanent Housing Units 2011 to 2016. Central Statistics Office.

[6] gov.ie - Summary of Social Housing Assessments 2020 – Key Findings (www.gov.ie)

[7] Department of Health (2015). Review of the Nursing Homes Support Scheme, A Fair Deal. Dublin: Department of Health

[8] Walsh, B., Wren, M-A, Smith, S., Lyons, S., Eighan, J. and Morgenroth, E. (2019) An Analysis of the Effects on Irish Hospital Care of the Supply of Care Inside and Outside the Hospital. Dublin: Economic and Social Research Institute

[9] ibid

[10] HSE reports make it clear that older people are the main beneficiaries of Home Help services and Home Care Packages.

[11] Healy, S, Bennett, C., Leahy, A., Murphy, E., Murphy, M. and Reynolds, B (2019) Socio-Economic Review 2019: Social Justice Matters 2019 Guide to a Fairer Irish Society. Dublin: Social Justice Ireland

[12] Walsh, B., Wren, M-A, Smith, S., Lyons, S., Eighan, J. and Morgenroth, E. (2019) An Analysis of the Effects on Irish Hospital Care of the Supply of Care Inside and Outside the Hospital. Dublin: Economic and Social Research Institute

[13] Health Service Executive (HSE) (2020). Annual Report and Financial Statements 2019: Building a Better Health Service Dublin: Health Service Executive

[14] Privalko. I., Maître, B., Watson, and D., Grotti, R. (2019)  Access to Care Services Across Europe. Dublin: Department of Employment Affairs and Social Protection and Economic and Social Research Institute

[15] Health Service Executive (HSE) (2020). Annual Report and Financial Statements 2019: Building a Better Health Service Dublin: Health Service Executive; and Health Service Executive (HSE) (2019). Performance Profile: July – September 2019 Quarterly Report. Dublin: Health Service Executive

[16] Health Service Executive (HSE) (2020). Performance Profile: April-June 2020 Quarterly Report. Dublin: Health Service Executive

[17] Ibid

[18] Department of Health (2015). Review of the Nursing Homes Support Scheme, A Fair Deal. Dublin: Department of Health

[19] 2019-11-21_report-on-the-provision-of-homecare-services_en.pdf (oireachtas.ie)

[20] Performance Profile July September 2020 (hse.ie)

[21] Survey on Income and Living Conditions (SILC) 2019 - CSO - Central Statistics Office

[22] Central Statistics Office, 2020. Survey on Income and Living Conditions (SILC) 2019. [online] Central Statistics Office. Available at: https://www.cso.ie/en/releasesandpublications/ep/p-silc/surveyonincomeandlivingconditionssilc2019/povertyanddeprivation/

[23] Ibid