| Author | Brendan Walsh1,2, Sheelah Connolly1,2 1 Economic and Social Research Institute, Ireland 2 Trinity College Dublin |
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| Overview | The Long-Term Care (LTC) system in Ireland relies heavily on unpaid family care and shares many similarities with systems in Southern Europe [1]. The formal care sector is a mixture of public and private provision and financing, with the majority of care funded by the State but privately provided. The most dominant feature of this system is the Nursing Home Support Scheme (NHSS, commonly called the ‘Fair Deal’ scheme), which provides, on a statutory basis, financial support for those who need residential care [2]. There is currently no statutory entitlement for home-based or community-based care. However, a more sophisticated system of integrated home- and community-based care is currently under development based on plans outlined in Sláintecare – an ambitious framework for reforming the Irish health and social care system to ensure that access to services is based on need rather than ability to pay [3,4]. Funding for LTC has increased significantly in recent years and in 2023, approximately €2.5 billion was spent by the State on LTC, representing over 10% of the total public health and social care budget [5]. Slow progress on developing unique health identifiers and health information systems, a shortage of care workers, and the lack of a single assessment tool to assess care needs are key impediments to the development of a LTC system that can meet the varied needs of the population. Demographically, Ireland is also experiencing a period of strong population growth, especially at older ages [6]. Ireland now has among the highest life expectancy in the world [7]. These demographic factors are driving the need for a sustainable LTC system to meet the needs of this growing and ageing population. |
| Governance and system organisation | There are three key public bodies involved in the governance of LTC in Ireland – the Department of Health, the Health Service Executive (HSE), and the Health Information and Quality Authority (HIQA). The Department of Health is responsible for providing strategic leadership for health and social care and translating relevant government policies into actions and legislation. There are three ministers within the Department of Health, with the Minister of Mental Health and Older People responsible for LTC. The HSE manages the operation of public health and social care services. The HSE also commissions, and often directly provides, LTC services. Currently, the HSE is a centralized body, but in 2024, 6 regional HSE Health Regions were established, in line with Sláintecare recommendations, to provide more decentralized control of health and social care [5]. This will provide more autonomy to regions in determining how best to meet the needs of regional populations. HIQA is an independent authority that monitors and regulates the quality and safety of health and social care providers. All residential LTC providers must be registered with HIQA in order to provide care. Currently, HIQA’s is legally responsible for the monitoring, inspection and registration of all residential care. No such regulation exists for home support providers, however, plans are in place for HIQA to begin regulating home support providers. The varied roles played by the Department of Health, the HSE, and HIQA means that a disconnect exists between oversight, regulation, and commissioning of care with no one authoritative body with overall responsibility for the LTC system. |
| Financing and coverage | Currently, Ireland lacks universal healthcare and has a mixture of public and private financing and provision of health and social care services [8]. Medical Cards are a form of healthcare entitlement (public healthcare coverage) provided by the State that grant the cardholder access to a range of health services free from co-payment or at a reduced cost [9]. Medical Cards are primarily intended to help individuals who may have difficulty affording healthcare expenses. Eligibility for a Medical Card is primarily determined by household income. All households with income below a certain threshold (which varies by the age of the household members, and the number of dependents within a household) are entitled to a Medical Card. However, some people may also access a Medical Card on a discretionary basis if they have certain health conditions or if they have high healthcare expenditures. While Medical Cards play a key role in accessing healthcare, they are less relevant for accessing LTC. In Ireland, the State is the main funder of LTC, but co-payments and privately funded care are common. Financing and coverage differ across LTC services, and in some cases, financing is linked with eligibility. In residential care, the NHSS was established to provide a statutory basis for the financing of residential care for people with care needs. Needs eligibility for the NHSS is based upon a care assessment, with a co-payment based on an income and assets means test payable by the resident or their family. Annually, NHSS residents are required to pay 80% of their assessable income, and 7.5% of their assets (the first €36,000 of assets are not included) towards their stay. Under the NHSS scheme, approximately a quarter of the cost of a residential stay is covered by the resident, with the remainder covered by the state [10]. In theory, NHSS residents can choose the nursing home in which to receive care; however, in practice, choice is sometimes negated by availability. Currently, care provided through the public home support scheme is provided without co-payments for recipients. While no co-payments are required for other LTC services such as day centre care or Meals on Wheels, due to a lack of services in some regions, individuals with a Medical Card are prioritised. The lack of provision of some services means that many individuals purchase care directly from private providers and must fully pay for this care. The Department of Social Protection is responsible for providing payments (e.g., carer’s allowance, carer’s benefit) to people who provide informal care to someone with care needs. These payments are subject to stringent income and working hours rules, and are mainly targeted towards lower income households. Carer’s allowance, which is €12,896 per annum, is available for carers who provide care for at least 35 hours per week if they work less than 18.5 hours per week and earn less than €23,400 per annum (or €46,800 as part of a couple). Carer’s benefit is similar, but is available for people who are required to leave or reduce their employment to provide care. Eligibility for carer’s benefit requires an amount of social insurance (PRSI) contributions to have built up from previous employment and also requires the carer to work less than 18.5 hours per week and earn less than €18,500 per annum. |
| Service Delivery | |
| Service Delivery Overview | Historically, residential and institutionalised care were dominant features of the LTC system in Ireland [11]. Individuals with more complex care needs still rely on residential care in nursing homes and while potential substitutes such as more intensive home support packages exist, they have low levels of coverage [12]. Recently, publicly funded LTC is orientating more towards home- and community-based care, though these services are still aimed at people with relatively less complex care requirements. In recent years, LTC has increasingly relied on the for-profit sector for provision of services [13]. |
| Community-based care | Home support (‘home help’) has been a part of the Irish health and social care system since the 1970 Health Act [14]. Home-based services mainly cater towards older people with domestic care needs and less complex healthcare needs. The average home support package equates to approximately 5-7 hours per week per recipient. These packages mainly provide help with getting in and out of bed, dressing, and personal care. While more intensive home support packages are available, they are not commonly provided. The majority of home support is provided by for-profit providers [14]. Enhanced community care (ECC) programmes have become more prominent in the LTC system in recent years. One such programme, the recently established integrated care program for older people (ICPOP), provides care for older people with more complex care needs and is based upon a multidisciplinary team intervention. In general, packages delivered through ICPOP are of short duration (up to six weeks). Another ECC programme, Community Intervention Teams (CiTs), are increasingly being used for older people who have had a health shock and/or may have been discharged from hospital. CiTs are designed to support people in their home, often in coordination with home support, and aim to allow for earlier hospital discharge and reduce the probability of readmission to hospital. |
| Residential care settings | The majority of residential care is now provided by for-profit providers. In 2024, approximately 70% of the 552 nursing homes providing residential care in Ireland are operated by for-profit providers, with a smaller number of large operators providing almost 40% of long-term residential care beds [15]. Most of these larger operators are part of larger international chains of residential care providers. The HSE and a small not-for-profit sector also provide residential care, but the percentage of care provided by these sectors has reduced considerably in recent years. Day centres are used to provide shorter-term stays, including for rehabilitative care, and are more generally provided by the HSE or not-for-profit providers.
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| Enabling environments and assistive technology | There has been an increase in the use of assistive technologies in LTC in recent years; with much of these technologies geared towards the home setting. The Sláintecare Integration fund (which seeks to further the aims of Sláintecare including a focus on prevention and community-based care) has funded a number of assistive technology projects. However, the roll out of these technologies is still in its infancy. |
| Workforce | There is a lack of information on the LTC workforce in Ireland, particularly within for-profit providers. Simple statistics on the number of LTC workers, their activity, and qualifications are generally lacking. LTC workers employed by the HSE generally receive significantly higher wages and better conditions than those employed by for-profit providers [16]. A cross-government departmental Strategic Workforce Advisory Group recently published a report on home carers and nursing home health care assistants [17]; the report made a number of recommendations, including increasing salaries to a living wage level, promoting training and career opportunities, and developing a competency framework for training and professional development. |
| Information systems | Data and information systems within the health and LTC systems are poor [18]. Ireland lacks a unique health identifier across its health and social care systems. Many providers of care have limited information communication technology (ICT) systems. |
| New models of care and innovations | Since the onset of Covid-19, HSE expenditure on home- and community based care for older people has exceeded expenditure on the NHSS [15]. This increase in funding and the establishment of ECCs and ICPOP, and increases in funding for home support reflect a new focus on a model of care that revolve around home- and community-based care [19]. Other new local approaches to LTC such as the development of senior living residences in some urban areas also reflect a more person-centred approach to residential care. However, these new models of care tend to be sporadic across the country and there are no plans to develop these at scale nationally. |
| Performance | |
| Availability & accessibility | A key impediment to LTC is accessing required services as appropriate times. This issue is in part caused by the lack of a population-based resource allocation mechanism across the wider health and social care system. This makes it difficult to match population needs with LTC service supply [20]. The NHSS has worked well in meeting the needs for individuals with complex care needs. However, placing residential care on a statutory footing, without similar schemes for home- and community based care, may have exacerbated the lack of non-residential LTC services and may in part explain the regional inequalities and unmet needs that exist for home support and community-based services. |
| ADDTIONAL INFORMATION | There have been a number of reforms and changes in the Irish health and social care system in Ireland in recent years. The publication of the Sláintecare report in 2017 and subsequent policy recommendations as well as issues that arose during the Covid-19 pandemic, have put renewed emphasis on LTC and home- and community-based care in particular. In 2024, 6 regional HSE Health Regions were established, and a population-based resource allocation mechanism based around these Health Regions has been announced. The Government have announced plans to introduce a statutory scheme for home support (though plans on when such as scheme may be introduced are unknown), while ICPOP teams and CiTs are becoming more central to health and social care. In 2024 a new independent Commission on Care for Older People was established to examine the care service and support needs of older people and make recommendations for strategic developments for care [21]. |
| Suggested Citation | Walsh B. and Connolly S. (2024) Long-term care system profile: Ireland. Global Observatory of Long-Term Care, Care Policy and Evaluation Centre, London School of Economics and Political Science. https://goltc.org/system-profile/ireland |
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KEYWORDS / CATEGORIES | |
| Countries | Ireland |
