In this case the HSE sought to argue that Mrs. Coffey’s bed at the Roscommon nursing home was not a contract bed; however, the evidence in the case, as presented above, pointed to a different conclusion. It was not disputed that the NAHB entered into an arrangement with the Roscommon nursing home, which offered to make 20 beds available to it at a preferential rate (€312 as against €480 for other residents). The NAHB agreed this rate and approached people in need of long-term care and/or their families, through its staff (Hospital Consultants and Public Health Nurses), and suggested that they consider taking up places at the home. The NAHB then paid the nursing home in full (including negotiating and agreeing increases in fees as they occurred over a number of years) without the knowledge or involvement of the families, and raised charges on the residents under their in-patient charges system. With regard to Mrs. Coffey’s particular case, her daughter Mrs. Byrne provided the Ombudsman with copies of invoices for these in-patient charges, and of receipts of monies received. Details on the Patient Accounts Invoices for in-patient charges matched details on receipts issued to Mrs. Byrne and showed that the money was received by the health board.
Given the fact that the Manager of the home at the time of Mrs. Coffey’s admission was a NAHB employee on leave of absence, and that he had previously held the position of Director of Services for Older Persons at the NAHB, it was not credible that the administrative arrangements for payment to the home were made due to its lack of knowledge of the Irish system.
In support of its argument that Mrs. Coffey was in receipt of a subvention, the HSE sought to rely on the fact that the family filled in an application form for a nursing home subvention at the office of their local representative, in 2002, and that it was retained on file by the Health Board. That application, made in September 2002, was in respect of a woman who lived in Dublin close to her family and who sought to be accommodated in Dublin. When, in 2003, the matter of a home in Roscommon was raised with the family, the NAHB entered into an agreement with the home to pay the full cost of care. This was clearly a very different proposition, and not one to which the previous application for subvention could be considered to apply. It is the view of this Office that if, at that time (March 2003), the NAHB was minded to apply the subvention to the arrangement, it should have engaged the family, outlining all of the details of the new situation to them, and informing them of their options and entitlements. The family could have chosen to use the subvention at another home. This did not happen. It did not happen because the NAHB, under its arrangement with the home, took responsibility for payment of the entire fee.
The amount of that subvention offered to the family at that time (€2.79 per day) bore no resemblance to amounts paid subsequently by the NAHB to the Roscommon home. An ‘’Enhanced subvention’’ was arranged by the health board when the home increased its fees, however neither Mrs. Coffey, her family, nor any of the persons who, under the regulations, could have made such an application on her behalf, did so. It appears that the NAHB used this scheme to meet an emerging shortfall due to an increase in the nursing home fee, and that it did so because of its arrangement to cover the fees in full. The family was not informed, and it was not until May 2008, over five years after Mrs. Byrne’s admission, that the family was told by the HSE of its view that their mother was on an enhanced subvention, rather than in a contract bed as they had assumed. This coincided with the decision of the Appeals Officer to refuse to overturn the HSE’s decision not to repay hospital charges, following which the HSE increased the amount payable by Mrs. Coffey. It is significant that when Mrs. Byrne queried this change, Patient Accounts had to seek clarification from Nursing Home section and that it found it to be a “special arrangement” which Patient Accounts section described as “unusual”.
The Ombudsman accepts that the NAHB personnel involved in this case were concerned to make suitable arrangements for Mrs. Coffey and people like her. The NAHB was faced at the time with an inadequate supply of public long-stay places, particularly for people of maximum dependency, and with budgetary constraints. They were concerned with providing care to people in need of it and, in this case, worked towards ensuring that the financial burden was absorbed by the NAHB, and not by the family. Placing patients from Dublin in Co. Roscommon had financial advantages for the NAHB, although one must question the appropriateness of placing elderly patients so far away from their immediate family and friends.
The implications of the HSE’s position that Mrs. Coffey was in receipt of a subvention, and not in a contract bed were that the NAHB took on the role of promoting the services of one particular private company by way of introducing its own patients to the company and encouraging them to avail of the services of that company. It further supported that private company by taking on the role of collector of the fees due to the company by some of its private patients. And all of this is in the context that the Manager of the company was a senior NAHB official on leave of absence. Arrangements such as these could not be considered as consistent with good practice and would have posed very serious ethical and professional questions for the Northern Area Health Board.
The HSE’s response to the Ombudsman’s Draft Investigation Report is set out in Chapter 10 of this report. In brief, the HSE did not contest the draft findings as presented to it, and accepted that Mrs. Byrne was entitled to repayment of the “recoverable health charges”.