We didn’t have to be told. The health service is in a mess, number 21 out of 22 in the “Western World”. When we look at the financial resources devoted to health (based on 2001 figures), Ireland is the lowest spender, along with Finland, devoting 7.3% of GDP to public spending on health compared to an average of 9% across 22 countries. (1)
It would be wrong, however, to zone in on the health system as the only indicator of how older people are doing in Ireland. Older people, as Age Action Ireland has been saying for years, are not a health issue – although they may have health issues, and of course as they get older they are more likely to encounter the health system, often and disproportionately in Accident and Emergency Departments.
Worse still for the grey and the balding, ESRI reports on poverty show that older people are increasingly at risk of experiencing income poverty. There are, of course, debates about whether we should be focusing on ‘relative income poverty’ rather than the ‘consistent’ version but it incontrovertible that 21.9% of the population lives below 60% of median income and among those aged 65 and over this rises to 44.1%. (2)
To identify what is available for older people we might mark at what point they come to be recognised as a particularly category. For many, it is at 66, when eligibility for the old age pension begins. (3) Virtually free telephone rental and an allowance for calls, free travel by public transport, and free television licence follows, and at 70 everyone gets a
medical card entitling the holder to free GP and hospital services. Older people will often come to particular attention as ‘older’ people if they are taken to an Accident and Emergency
Department and then channelled towards the geriatricians.
Several organisations are specifically concerned with the interests of older people.
- Age and Opportunity celebrates older age with its country-wide Bealtaine festival each May, and with its “Go for Life” programme. Positive Ageing is the fuel which drives the Irish Senior Citizens Parliament to highlight the views of older people, and it galvanises the Federation of Active Retirement Associations in working to ensure that older people have exciting and worthwhile retirements.
- Age Action Ireland is involved in campaigning, research, Third Age learning, carer support, and information services.
- The Senior Helpline, based in Summerhill, Co Meath, allows older people a friendly listening post.
- The Carers Association, and Caring for Carers, concentrate on caring issues (although not exclusively involving older people) and the Alzheimer’s Society provides a wide range of services for people suffering from Alzheimer’s disease, and their families.
- The National Council on Ageing and Older People, a Government-appointed body, has produced many valuable reports and advises the Minister for Health and Children.
How Many Older People are there in the Republic?
As Dr Garret FitzGerald has shown out there is no demographic time bomb in Ireland, but there is an opportunity to plan for 46 years hence when about 24% of Irish residents will be 65 and over, compared to 11.1% in 2002. (4) We are living longer, with life expectancy for men projected to rise from 74 to 79.4 and for women from 79 to 84. The age group 80 and over will rise from 23% to 27% of the total population.
Life expectancy in the Republic today is lower at 65 than in any of the other countries that made up the fifteen-member European Union, and in terms of health-life expectancy (that is, how long people are likely to remain healthy into old age) it is second from the bottom of a table of 23 countries worldwide.
All of this raises major policy issues concerning older people: poverty, discrimination, accommodation, health, employment, long-stay care, and pension provision.
In the face of the marked increase in personal incomes in Ireland during over the past decade, older people have become increasingly likely to experience “relative income poverty”. In 1994, only 5.9% of the elderly had an income that was less 60% of median income; by 1997 this had risen to 24.2% and by 2001, 43.3% were in this category. Older females are particularly vulnerable to income poverty with 50% having an income below the 60% poverty line, and 62.1% below the 70% poverty line. (5) The Household Budget Survey, 1990-2000, showed that 38% of pensioners lived in the lowest 20% household income group; five years previously the figure was 30%.
This increase in relative income poverty among the elderly reflects the fact that while social welfare pensions have risen significantly in real terms, increases have lagged behind wages and salaries. (6) This worrying trend highlights the need social welfare pensions – which are the sole income for a high proportion of older people in Ireland – to be increased in line with increases in wages and salaries, rather than rises in the cost of living.
Discrimination against older people has been described as “widespread” by The Equality Authority. (7) The Employment Equality Act, 1998, for example, had age as a ground on which discrimination was forbidden in the workplace, but ironically people aged 65 and over were not covered by its provisions. This situation has been rectified by the Equality Act, 2004, partly to take account of the Government decision that most new entrants to public service posts can work beyond the normal retirement age of 65. This should, among other things, end the foolishness of excluding people over 65 from State temporary tour and heritage guide jobs.
Such attitudes percolate, too, into the health arena where women over 64 are still refused participation in Breast Check screening. We are told that when the programme goes country-wide, consideration will be given to including older women. Dr Eamon O’Shea, of NUI Galway (8) and Professor Des O’Neill, of Tallaght Hospital, have spoken of how health services can be subject to the negative influence of ageism. (9)
More generally, some older people have difficulties getting car insurance, and travel insurance has become a constant issue. Even the VHI charges €179 for annual travel insurance for over 65s but €49 for everyone else.
Government policy has long been that older people should be facilitated to stay in their own homes as long as they wish. By European standards, the Republic of Ireland has a very high rate of home ownership and about 87% of older people own their own homes. 6.6% live in local authority housing and under 3% in private rented accommodation.
However, as Dr David Stratton, Age Action Ireland’s Head of Research and Policy, has pointed out, the downside of this high ownership is that older people’s houses tend to be built longer, have fewer facilities and need greater maintenance. (10) His research shows that neighbours, location, garden, familiarity and design are the factors most liked by older people about their houses. Comfort was not a big issue. Maintenance, the garden, design, and location were the factors least liked. Surprisingly personal security was low as an issue.
The Years Ahead…A Policy for the Elderly (11) recommended that the Government should explore, with financial institutions, ways in which elderly people could be encouraged to make greater use of their homes as a financial asset. Such schemes are now on the market, but have met with a varying response following warnings about diluting one’s main asset for cash.
While housing quality has improved and older people have recorded increasing satisfaction with their housing, there has been insufficient flexibility in housing for older people.
(i)Streamlining of the state-provided supports to assist with repair and maintenance of older people’s houses.
(ii)More sheltered housing.
(iii)Flexibility, with tax incentives, to allow older people trade down to more suitable, perhaps sheltered, accommodation.
(iv)Encouragement of construction of houses designed to suit all generations.
There are few more fraught issues than caring, with an estimated 148,754 people providing unpaid help for someone with a disability or health problem. Many carers are middle-aged women in rural areas. Of these, the number providing care for 43 hours or more a week is over 40,000. Nearly 85,000 are caring for one to 14 hours a week. Two-thirds of carers are women, with one in ten women aged 40 to 50 years reported to be a carer. (12) Carers can be eligible for Carers’ Allowance, which is means tested, or Carers’ Benefit which is insurance-based, and recipients of both are entitled to a respite-care grant.
In a submission to the Oireachtas Joint Committee on Social and Family Affairs (September 2003), Caring for Carers pointed out that the vast majority of carers are looking after frail older people. Carers believed their main need was for respite care in the home, and day care services.
Despite huge expenditures – for example, €115 million alone in 2003 on nursing home subventions, increases in carers’ payments, and the cost of home helps – the State is floundering in its efforts to meet the requirements of frail old people.
Figures from the Eastern Regional Health Authority’s three health boards, for example, indicate that community care services are patchy and under-resourced with little hope of improvement. For example, the Northern Area Health Board says that services under the headings Home Help, Home First, and Home Care packages are likely to remain at the same level in 2004 as in 2003. In the South Western Area Health Board, while €11.3million was spent in 2003 on home help services, increases in 2004 will be paltry as the Board will be sharing not much more than €1 million extra for the service with the two other health boards. The picture is about the same in the East Coast Area Health Board.
Few would argue with a Comhairle report that calls for the development of Home Support Care Packages. (13) There is a need for more personal support for carers and their families, and additional income support for carers who look after highly-dependent persons.
Criteria for respite care need to be more transparent and applied systematically to cater for on-going caring and crises. If carers can take regular breaks, fewer people will have to resort to institutional care.
Better financial support for carers is needed, through for example, dropping the means test for Carers’ Allowance; among the benefits of such improvements could be a lessening in demand for institutional care.
Nursing homes, their cost, utilisation, and the difficulty of finding a suitable one, are the subject of major controversies. The Republic’s 5% rate of long-stay care for older people is lower than that in many European countries. Despite constant stories that acute hospital beds are being “blocked” by older people, nursing home interests (the Federation of Irish Nursing Homes and the Irish Nursing Homes Organisation) repeatedly report that they have empty beds, and that there is accommodation for many of the patients who could be released from acute hospitals. In the Eastern Regional Health Authority alone, it is said 550 patients are inappropriately placed in hospitals, patients who could be in residential care except for a deficiency in subsidies. (14)
The total cost of subsidies to nursing home patients has risen to €115 million from about €5 million in 1993, but even with this increase there is still a huge gap between the maximum subsidy payable and the fees charged by private nursing homes, which range from €450 to €1,000 and more per week. Rarely are ‘enhanced subsidies’ given.
There are about 26,300 long-stay beds in the Republic (over half in the private sector) and it is estimated that an additional 2,700 will be needed in seven years time. Private nursing homes are planning to build another 2,000 places, and the Government is committed to providing 800 ‘extended care’ and ‘community nursing unit’ places per year over seven years.
Whoever creates the beds, however – and there has been little debate on the right mix between public and private beds – the financing and standard of nursing home care will be continuing problems. Both the Mercer Consultants report, Study to Examine the Future Financing of Long-Term Care in Ireland and the Review of the Nursing Home Subvention Scheme, suggest a number of possible solutions. (15)
(i)The introduction of a social insurance scheme to provide for long-term care.
(ii)Recoupment of costs by making posthumous deductions from assets.
(iii)A significant increase in the State financing of home care.
(iv)More emphasis on quality of care – why should State long-stay care units not be subject to independent inspection?
(v)Better co-ordination between community care, nursing home and acute hospital
services (as in the Slán Abhaile programme in the Royal Hospital Donnybrook, Dublin).
The Government decision that new entrants to the Public Service can work beyond 65 has perhaps been motivated more by pension funding problems than a concern for the rights of older people, but it represents a welcome change in attitude.
Of course, not everyone wants to be in paid employment until 65: one study showed that more than two-thirds retired before 65, although this retirement was often unplanned. (16) Those who do remain working tend to be the self-employed, and farmers. One’s life style should, of course, be a matter of choice, and it is reassuring that retirement can be regarded as a positive state, as indicated by the finding that “the retired are generally satisfied, though those who want paid work are somewhat less positive than those who do not want paid work”. (17)
One study showed that 25% of over 55s not in full-time employment were interested in paid jobs. However, they did not want to be hit heavily by tax, and they wanted flexible working arrangements. (18)
Unfortunately, many jobs for older people are in the often poorly-paid services sector. Older people, too, continue to report ageist attitudes on the part of employers, and not only in the private sector. The National Economic and Social Forum has pointed out that ageist attitudes persist in government departments. (19) Civil servants have succeeded in a legal case where it was proven they had been passed over for promotion because of their age.
An on-line recruiter, Monster.ie, found that 37% of Irish respondents felt that age was obviously a factor in considering people for jobs. A further 40% said it made a bit of a difference. (France and the UK had the highest number of workers who felt age was obviously an issue in recruitment. The Republic’s figures were more in line with those of Scandinavian countries.)
A factor compounding the risk of unemployment for older people is the declining tendency to participate in education and training with increasing age. This is illustrated in a 1997 OECD International Adult Literacy Survey, which showed a participation rate of just over 9% among 55-64 year olds.
(i)The National Economic and Social Forum report, Labour Market Issues for Older Workers, indicates that the majority of companies do not have structures or practices to cope with an ageing workforce. (20) This is an area from which a major thrust needs to come to improve the participation rate of older people in employment.
(ii)IBEC and the Chambers of Commerce have recently highlighted the skills and experience offered by this group, and it is encouraging that the proportion of people aged 50 to 69 years in employment has risen since the mid-1990s, reversing a long-term downward trend. (21)
(iii)Part-time work, tax incentives, flexible hours, training opportunities and fluid pension arrangements would make the labour market a happier place for older people.
Pensions are becoming a defining issue as people grapple with reports that their cover might be insufficient. The Government has been encouraging people to take out pensions, the aim being that 70% of the workforce would have an occupational pension, as opposed to the current coverage of 50%. Since the passage of the Pensions Act, 2002, The Pensions Board has been actively promoting Personal Retirement Saving Accounts, which were provided for in the Act, and which have the virtue of being portable. However, take-up has been low, although it has been described by Anne Maher, Chief Executive of the Board, as still encouraging. She has suggested that the Government might have to make second-tier pensions compulsory.
The debate has been complicated by the increasing use by companies of Defined Contribution, rather than Defined Benefit, schemes. Even the current majority who have Defined Benefit schemes are under pressure. It has emerged that the Electricity Supply Board is facing a €500 million or so shortfall in its scheme and that workers might be expected to raise their contributions. Mercer, a human resources company, is also proposing that the “high solvency” requirements for funds be amended.
(i)Sophisticated publicity to get across the message that, if a 20 to 30-year-old wants to retain half their salary on retirement, he or she will need to invest 15% of income in a pension.
(ii)Encourage Special Savings Incentive Account holders to transfer their savings habit into pensions when the scheme ends in three to four years.
(iii)Drop the stricture that employer contributions to Personal Retirement Saving Accounts are treated as benefit-in-kind.
(iv)Offer larger pensions to employees (State and private sector) who delay retirement beyond 65 or 66.
The Republic is now a prosperous country; it enjoyed growth rates not so long ago of 9% and even following a slow-down is expecting a growth in GNP of 4.8% in 2004 and 5% in 2005. Our problem is a legacy of low expenditure on health and social provision. While there has been a significant jump in such expenditure in recent years, this was from a low base. In 1999, the Republic’s social services expenditure was 14.5% of GDP compared to 27.5% for the EU as a whole.
This low health and social expenditure particularly affects the old. Cutbacks, or static budgets, in relation to various community and domiciliary care services bite hard, as telephone calls to Age Action Ireland from people who are affected highlight all too graphically. Legislation and policy are unkind to older people, although that is changing, and over 65s are excluded from participation in a number of areas.
Housing is often inappropriate, and long-stay care is of varying quantity and quality. This is not to gainsay the successes, only to highlight that provision for older people is often unfocused, inconsistent, and under-funded.
Doctors, health boards, nurses, home helps, volunteers and grey organisations (such as Age Action Ireland) all aim to enhance the lives of older people. They do it in different ways and sometimes with little cognisance of each other’s work.
Rarely, however, have senior politicians initiated, or even entered, debates on matters affecting older people. Discussion has usually revolved around the increase in the old-age pension and whether it is above or below inflation. Despite the fact that two organisations (the Irish Senior Citizens Parliament and Age Action Ireland) are part of the Voluntary and Community Pillar in Social Partnership, and therefore have (tiny) influence in negotiating with government on national agreements, ageing is low on the political agenda. However, raising the profile of older people is not necessarily the same thing as improving policies. Including older people in our society requires us to address the major policy issues that affect them.
1.Anne Nolan and Brian Nolan, “Ireland’s Health Care System: Some Issues and Challenges” in Tim Callan (ed.), Budget Perspectives 2005, Dublin: ESRI, 2004.
2.Christopehr T. Whelan et al, Monitoring Poverty Trends in Ireland: Results from the 2001 Living in Ireland Survey, Dublin: Economic and Social Research Institute, 2003, p. 12 and p. 28.
3.The weekly rate of payment for the Old Age Contributory Pension is currently €167.30, for the Old Age Non-Contributory Pension it is €154.
4.Garret FitzGerald, “Set Retirement Age Makes No Sense”, 50+ (journal of Age Action Ireland), issue no. 5, 2003-2004, p. 16.
5.Chrisopher T. Whelan, op. cit., p. 28 and p. 30. .
6.Ibid., p. 31.
7.The Equality Authority, Implementing Equality for Older People, Dublin: Equality Authority, 2002.
8.Eamon O’Shea, Healthy Ageing in Ireland: Policy, Practice and Evaluation, Dublin: National Council on Ageing and Older People, 2003 (Report No.77).
9.Comments at the launch of an anti-ageism campaign by the Equality Authority, the National Council on Ageing and Older People and the helath boards, October 2004.
10. David Stratton, The Housing Needs of Older People, Dublin: Age Action Ireland, 2004.
11.The Years Ahead …A Policy for the Elderly, Report of the Working Party on Services for the Elderly, Dublin: Stationery Office, 1998.
12.Central Statistics Office, Census 2002, Dublin: Stationery Office.
13.Comhairle, Supporting Carers: A Social Policy Report, Dublin: Comhairle, 2002.
14.Anne Nolan and Brian Nolan, op. cit.
15.Mercer Consultants, Study to Examine the Future Financing of Long-Term Care in Ireland, undertaken for the Department of Social and Family Affairs, Dublin: Stationery Office, 2002; Eamon O’Shea, Review of the Nursing Home Subvention Scheme, Dublin: 2002.
16.Helen Russell and Tony Fahey, Ageing and Labour Market Participation, Dublin: The Equality Authority, 2004 (Equality Research Series).
18.Public and Corporate Economic Consultants, Labour Participation Rates of the Over 55’s in Ireland, A study for the Expert Group on Future Skills Needs and the National Competitiveness Council, Dublin: Forfas, 2001.
19.National Economic and Social Forum, Equality Policies for Older People: Implementation Issues, Dublin: National Economic and Social Forum, 2003 (Report no. 29).
20.National Economic and Social Forum, Labour Market Issues for Older Workers, Dublin: National Economic and Social Forum, 2003 (Report no. 26).
21.Helen Russell and Tony Fahey, op. cit.
*Paul Murray is Head of Communications with Age Action Ireland.
This article is based on a paper given in Armagh to the Centre for Cross Border Studies, June 2004.