Analysis: Despite a 2016 Government commitment to introduce a statutory right to home care, a system is still not in place nearly a decade on
The value attached to independent living and 'aging in place' approaches have contributed to the provision of home care being preferred over residential care for many. But while the Fair Deal scheme provides a statutory right to residential care, no equivalent programme exists for home care.
Despite a Government commitment to introducing a statutory entitlement to home care in 2016, progress has been limited with a system still not in place nearly a decade later. Advocacy groups for service users have noted that homecare services are "based mainly on trust" with no independent oversight or regulations.
While improving the provision of home care receives attention from the perspective of those in need of care, the importance of stability in the sector for those working in care receives less attention. Care is labour-intensive, and the demand for personal care and home support services in Ireland is soaring.
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From RTÉ Radio 1's Drivetime, Sean Moynihan from ALONE on the ome Care Coalition's pre budget submission
Home care workers deliver home support for a person in their domestic home setting (often older persons or persons with a disability). Care workers are integral to the delivery of a high-quality service that supports independent living and allows individuals remain living in their own home for longer.
Employment arrangements vary significantly, so tracking the exact number of people working in the sector is difficult. It was estimated in 2023 that the Health Service Executive (HSE) employs over 5,300 home carers with 13,000 are employed in the private and nonprofit sector. Other arrangements exist too, from being self-employed to working in private homes via an intermediary platform or cooperative. Some workers are employed directly by families, often as live in carers, or are working under entirely informal arrangements
The delay in establishing a statutory right to home care provision contributes to deficiencies in the provision of care (including lengthening waiting lists of over 5,000 people in June 2024), but also to a lack of stability for workers. As a result, the home care sector is in a vicious cycle of recruitment and retention. Private agencies and nonprofit providers claim that the insufficient funding dedicated to the sector has meant that working conditions are effectively set by the Government and providers are unable to cover higher wages rates or payments for travel time within the constraints of existing tenders.
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From RTÉ Radio 1's Saturday with Colm Ó Mongáin, the home care headache that won't go away
Research indicates that employees in the care sector earn less than employees with comparable qualifications and work experience in other sectors. Coupled with a lack of training and resources, high workloads and high levels of stress, the attractiveness of the home care sector remains low. A cross-departmental Strategic Workforce Advisory Group was established in March 2022 to examine the challenges in carer roles and an overview report six months later presented a suite of 16 recommendations spanning the areas of recruitment, pay and conditions of employment, barriers to employment, training and professional development, and sectoral reform, including a recommendation urging for increased use of work permits.
The Migrant Rights Council of Ireland have identified home care as one of the sectors with high levels of informal employment. Lessons can be learned from the UK on the importance of having a well-designed and regulated care system. The Royal College of Nursing there has called for a government inquiry into treatment of migrant care workers as mounting claims of exploitation and modern slavery emerge.
More recently, Home and Community Care Ireland, a representative body for care providers, noted that failure to develop a workforce strategy for home care and delay to the statutory scheme are inextricably linked. At the nub of the issue is funding. Within the European Union, the right to affordable long-term care is set out in principle 18 of the European Pillar of Social Rights.
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From RTÉ News in 2022, report states there's not enough staff to provide home care support for eligible older people
However, a criticism of the current approach to care provision is that it is built around a low-investment, low-access and low-quality model. Indeed, opposition parties have recently criticised the Government’s approach, noting that the focus has "become entirely about regulating a market of providers, instead of providing a statutory right of access". Furthermore, it has been observed that the projected increase in nursing home residents has not materialised over the past decade. That data coupled with the waiting lists for home care suggests care needs are being met by unpaid family members, which has knock-on consequences for labour supply in the wider economy.
So how can Ireland achieve a system that provides quality care and rewarding work? Ultimately this comes down to political will to design a funding model which fully recognises the value of long-term care. A key feature of the Fair Deal scheme is that a portion of an individual’s assets covers the cost of residential nursing home care. This is currently not a feature of home care provision and amending that would likely be met with some criticism.
A criticism of the current approach to home care provision is that it is built around a low-investment, low-access and low-quality model
Other approaches to funding include the German model. In Germany, long-term care insurance (Pflegeversicherung) was reformed in 2023 with the rate of contribution increasing. Controversially this rate differs between people with children, who pay a greater percentage of their gross annual salary into long-term care contributions, and those without children.
This is based on the view that those without children have greater disposable income, and that children will support aging parents in the future, reducing dependence on care services. This view illustrates an assumption of familial based care to an extent. Investment is specifically ring fenced for long term care which supports wage demands and increased staffing levels in the future.
In contrast, long term care and social and domestic work in many countries fare poorly in financial allocations when included in broader healthcare budgets. Ireland fits this description. Raising taxes, means tests and other such measures are generally not attractive options for political parties entering an election cycle, but the future of care, both for recipients and workers, may well depend on it.
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The views expressed here are those of the author and do not represent or reflect the views of RTÉ
