From both a medical and societal perspective, the COVID-19 pandemic has reinforced that private and public nursing homes alike cannot and should not operate in isolation. Rather they should be seen as part of our shared community, linked with local Primary Care Centres, physiotherapists, occupational therapists, and speech and language therapists plus of course, hospitals. NHQI concurs with the Nursing Home Expert Panel Report that adequate and robust clinical oversight, monitoring with appropriate enforcement capability and clear governance structures are required across the nursing home sector.
We welcome the recommendations from the Nursing Home Expert Panel, especially those relating to the continuation and formalisation of contingency measures, already introduced for the clinical support of nursing homes by the wider health networks and community services. Enhancing working relationships between community healthcare specialists and nursing homes and introducing greater integration would ensure residents have their specialised care needs met through timely access to medical, clinical and community healthcare specialists. We agree that there is an urgent need to establish a Clinical Leadership/Medical Director that would link up all of the services and provide specialist advice for defined areas. However, NHQI differs with the Expert Panel recommendation that an identified GP lead should be contracted to engage with individual nursing homes, Our collective experience is that when this happens, the primary contact becomes the nursing home and the resident loses the individual GP-patient relationship.
For years, private nursing home residents have struggled to enjoy access to routine health services available to others in the community. Perhaps this viewpoint is best illustrated by stories of my own mother’s personal experiences as I am sure these stories mirror the common experience of many. For example, when my mother lived at home, she enjoyed occasional visits by a community physiotherapist and occupational therapist. When she had to enter a nursing home due to issues with her mobility, I naively assumed that this service would continue. When I contacted the physiotherapist, the attitude was polite but along the lines of, “We provide community services only.” My question – is the nursing home not part of the community or had my mother gone to live in a parallel universe, where despite being a citizen, she was no longer entitled to the same services as those in the community? Due to Parkinson’s, at that point in her life, my mother was wheelchair bound and in even greater need of physiotherapy and occupational therapy support. The assumption was that the private nursing home would provide physiotherapy services. In my experience, many private nursing homes did not and still do not routinely provide those services.
In our view, this idea of “other” contributed in no small part to COVID-19 deaths taking place predominantly in nursing homes, where it appears to us that the HSE did not view nursing homes as being part of the healthcare system. This was further exacerbated by the general lack of medical equipment in nursing homes, particularly private ones. Earlier this year during the pandemic crisis, I read an article in one of the Sunday newspapers, which talked about nursing homes not having ventilators. From my experience, it is sadly a great deal more basic than that. We often read that it is not desirable to admit older people to hospital through Emergency Departments, where they can encounter long delays and where the experience can be traumatic. I agree with that view in principle. However, and this is the important caveat, many older people when they become ill with a UTI or chest infection need IV therapy. In my experience, the majority of private nursing homes are unable to administer IV. This renders a stay in hospital inevitable with all the resulting delays, traumas and hospital beds unnecessarily occupied. We hear a great deal about the division between private and public healthcare – ironically in terms of older person care, the situation is reversed. Private patients generally have access to poorer level of services in the nursing home environment. Public nursing homes generally have routine access to such services and many if not all are equipped to administer IV.
Additionally, there is currently no system in place that provides a proper assessment tool for nursing home residents and none that allows for the transfer of consistent information between nursing homes and other care facilities such as hospitals. Citing again from personal experiences, on one occasion, I was told by the hospital consultant that my mother had a serious condition and would likely die later that day. It later turned out that this was based on erroneous information provided about the onset of illness from the nursing home. There was no bad intent but there appeared to be no set process or questions to complete – hence the information was not fully recorded and had been misinterpreted. NHQI welcomes the fact that HSE staff have been seconded to nursing homes during the COVID-19 crisis. We believe that over the longer-term, some kind of cross-training programme could be beneficial for both parties in terms of increasing knowledge, expertise and understanding of each other’s work. Nurses working in a hospital setting would gain important insights into the care of older people in a nursing home environment. Likewise, nursing home staff would have a better understanding of how an acute hospital operates.
Let me cite one final example that illustrates the lack of linkage between nursing homes and community services and supports. My mother was wheelchair bound and found standing difficult. This meant it was difficult to bring her out for stimulation and to attend family events such as her grandchildren’s Holy Communions. I decided to apply for the wheelchair accessible grant scheme, which provided VRT and VAT relief. To do so, I needed to acquire a Primary Medical Certificate. It took a whole year to get this signed by the Medical Officer. During the course of the application. I was asked several times why my mother needed access to a car if she was living in a nursing home. My response was that when she moved into the nursing home due to poor health, I did not see a sign over the door that said “Abandon Hope all you who enter here. Your life is over.” The reality is that eighty percent of long-term residential care provision is delivered within the private sector. The residents of private nursing homes are citizens of Ireland. Due to limited spaces, they are unable to avail of public nursing home care. However, these citizens are entitled to the same services as everyone else.
Sadly, despite all the negative outcomes earlier this year and the promises of lessons learned, there still appears to be disconnects. In early November 2020, letters from HIQA and the HSE show concerns that private nursing homes are still not receiving good support from the HSE during the Covid-19 pandemic. Phelim Quinn, chief executive of HIQA told HSE chief executive Paul Reid in a letter on October 6th, 2020 that nursing homes were experiencing “significant challenges in securing infection and prevention control expertise and sourcing experienced nurses to staff their nursing homes”. Perhaps, it might be an idea for the HSE to consider providing nurses to all nursing homes as a proactive measure during this pandemic rather than waiting for an outbreak to occur before deployment?