This review is taking place at a time of unprecedented pressure on health funding, at a time when the structures for delivering health care are in the process of being dismantled and replaced, and at a time when a new and radically different model of health provision (Universal Health Insurance) is proposed to be put in place over a period of years. Much of the detail of the proposed new structures and of the model itself remains to be provided.
The Nursing Home Support Scheme (NHSS) was introduced in 2009 in response to a decades old gap in provisions to meet the needs of elderly people requiring long-term residential care. The NHSS was introduced into a health system characterised by a lack of overall coherence and clarity and by the absence of a clear model. The Ombudsman has in the past characterised our health services as being half-in and half-out of a statutory framework; certain services are required by law to be provided, while other services lack any specific legal basis.
The role of the State in healthcare has not, in recent times, been articulated in an unequivocal way. What we have for the most part is a fused public/private system with the private, commercial element enjoying very considerable support and subsidisation – in the form of tax concessions, training of medical personnel, use of facilities and other public infrastructure – from the public purse.
Healthcare remains one of the key ideological battle grounds of our time and it is arguable that an ideology of private, market-based provision has been promoted almost by stealth. In the meantime, many fundamental aspects of our healthcare arrangements remain uncertain and, perhaps, deliberately so.
For example, what responsibility (if any) has the State either to provide healthcare or, alternatively, to ensure its provision? Are our arrangements intended to be rights-based (reflected in legislation), or entirely discretionary, or a mix of the two? Are our services intended to be delivered within a public service ethos (by public bodies and/or publicly–funded bodies), or within a private market ethos, or some mixture of the two?
The Ombudsman has in the past drawn attention to the fact that, in an area as important as healthcare, the manner and extent of the State’s involvement is both a reflection, and a determinant, of the kind of society we are and want to be:
"It seems to me that a state's public health service should amount to far more than arrangements to ensure services are provided. Though of course it is essential that services are provided - after the first five hours waiting on a trolley in A&E one rapidly looses interest in the philosophy underlying the public health service! The context in which services are provided, the institutions providing them, the financing of the services, the governance arrangements for those services, the extent to which one is entitled to services - these are all factors which both reflect and support the maintenance of the kind of society we want to be. Health services made available on the basis of the exercise of consumer choice within a purely commercial private market do nothing to promote social solidarity or good citizenship. On the other hand, services provided through state agencies which are dysfunctional are not the answer either." (Health Care in Ireland - An Ombudsman Perspective - Doolin Memorial Lecture 2011)
In summary, therefore, the NHSS is a stand-alone set of arrangements for a particular (and very pressing) area of need. The NHSS was not developed as the expression, in a particular area, of an existing model of public healthcare which has been well articulated and widely understood and accepted. In fact, as described below, the NHSS reflects a model which is at odds with what appeared to be the model hitherto (in so far as one can discern) of the State’s involvement in healthcare.
Presumably, the shape of the State’s future involvement in the area of long-term residential care for the elderly will be determined ultimately within the context of the new healthcare model and structures proposed by the Government. Thus, conducting a meaningful review of the NHSS at this particular point, when the details of the proposed new healthcare model and related structures are not fully available, is problematic.