Season 2, episode 17

Voices of Care – S2E17 – Tadhg Daly

12 May 2024

Tadhg Daly, Chief Executive Officer of Nursing Homes Ireland, discusses increased workforce pressures and impact of nursing home closures.

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Episode chapters

00:00 Intro  

00:22 Nursing Homes Ireland 

01:32 Workforce Pressures 

03:11 Impact of Nursing Home Closures 

05:25 Demographic changes and older population 

06:41 Benefits of increased nursing home capacity 

07:47 HIQA’s Positive Feedback 

09:26 Funding and Operational Costs  

12:42 Immediate Challenges and Call for Funding  

15:26 Long-Term Recasting of Fair Deal  

18:03 Contributions of the Nursing Home Sector  

20:35 Outro 

[00:00:00] Hello, I’m Suhail Mirza and welcome to this episode in season two of Voices of Care. My guest today is Tadhg Daly, CEO at Nursing Homes Ireland. Tadhg, thank you so much for making the trip over from Ireland.

[00:00:14] Yeah. Thank you Suhail. Thank you for the invitation. I’m delighted to be here in London to have a chat about some of the challenges and as you say, the opportunities there as we navigate the older population.

[00:00:22] Well, I’m looking forward to hearing it. Now, your, I don’t want to remind you, 16th year as CEO and never a busier time. And your organization represents the voluntary and private sector as I understand.

[00:00:33] That’s right. Nursing Homes Ireland was founded in 2008 and I’ve been the founding CEO. So yeah, never a dull moment. But yeah, it’s the representative organization rather for the private and voluntary sector. Our members provide care in a home from home to about 25,500 older people, directly employ 45,000 staff, and are economic dynamos in many parts of the country. But ultimately, you know, the nursing home sector and the care our members provide is a vital part of a well functioning health service providing care in local communities across Ireland.

[00:01:05] And you’re part of, in terms of a wider advocacy, for the whole social care sector, part of the Five Nations Care Forum.

[00:01:12] That’s right. Yeah. I mean, ultimately, you know, many of the challenges that we face in Ireland are the same challenges, definitely in the wider United Kingdom and indeed across the world. So I’m delighted to be part of the Five Nations Care Forum, where we share experiences, knowledge and indeed initiatives so that we can continue to advance the cause of social care.

[00:01:32] Absolutely. Now, the reports that have come out recently, whether it’s from the regulator or whether it’s from the Economic and Social Research Institute in January of this year, in 2024, came out saying that the sector was under threat of failure. I mean, this is around an issue that’s been around a long time closure of homes, workforce. Can you just paint a bit of a high level picture of what’s been called, what you’ve called, a crisis of care and a failure by the state to support the sector?

[00:02:01] That’s right. I mean, ultimately, what we’ve seen over the last couple of years is significant pressure on a sector that was already under pressure and a failure by the state to A) acknowledge those pressures, and B) to introduce the policy and indeed the resourcing to address them. So between 2018 and 2022, over 60 nursing homes have closed. That’s out of a total of 450. It’s 12, 13% of the provision. And on the one hand, it’s a loss of beds, but on the other hand, it’s a loss of a community service because in many parts of urban and rural Ireland, the nursing home that is closed will not reopen. And the prospect of additional capacity being provided in those areas is very slim. So it is a serious crisis. And it’s not just Nursing Homes Ireland saying it. As you’ve said, there has been a myriad of reports now over the last number of years around the pressures on Fair Deal, around the whole regulatory framework and indeed on the whole workforce issue. So they’re the three big ticket issues, if you like, funding, regulation, and workforce. And as a society, we have to grapple and get our heads around those and look for solutions and work collaboratively to develop those solutions so that we can have a sustainable, viable, future-proofed sector.

[00:03:11] And in terms of, you talked about that permanent, potentially permanent loss of beds in particular areas, I think the Economic and Social Research Institute’s report highlights, I think I’m right in saying 1 in 5 of the closures have been smaller care homes in perhaps in areas where actually they’re the only supplier.

[00:03:27] Absolutely. And that is the issue. So while on the one hand, you know, people in the podcast might say numbers, it’s not about numbers. We’re talking about real people here. We’re talking about your family and my family, your sister, your brother, my mother, my father. And for those people who live in urban or rural Ireland, there’s not much point in saying to them that there’s a nursing home available 30, 40 or 50 miles away. They want to stay in their own local community and they want to age in place. And we as a society have a responsibility to ensure that we can support that. But unfortunately, we’re losing a whole swathe of those nursing homes across the country. And if we don’t act and act quickly, we’re going to lose more, not just the small. We’ve seen some medium homes closing, and I’ve also spoken with many of the providers across the country of so-called larger homes. And they’re also feeling the incessant inflationary pressures and wondering how can they keep going in the current environment.

[00:04:20] Yeah. And you mentioned, of course, staffing as an issue. I think some of the analysis shows something around 38% of the care staff turnover or staff turnover, 54% nursing. So it’s really around job losses and a tight labour market where there is insufficient supply.

[00:04:36] Absolutely. I mean, the entire health service is challenged if you like, in respect of workforce. So on the one hand, yes, it’s about planning for beds, but it’s also about planning for the workforce. And what’s that future workforce look like in terms of health care assistants and nurses. So we need to make the career in nursing homes more attractive. We need to remunerate staff properly. We need to have continuing professional development education and training so that it is a more attractive place to work. And then once we once we recruit people into the sector to retain them. And that’s crucially important because what we find in the social care sector is our members work hard at recruiting from overseas, for example. And then people come to Ireland and they migrate to the public system because they can offer better terms and conditions because of the funding constraints and the discrimination and funding ultimately.

[00:05:25] Which we’re going to touch upon, I think it’s a fundamental point. Placing the work that the sector does, the voluntary and independent sector in a broader context. This is a really important time for Ireland. I think the stats in demography show the over 85s are going to double over the next 20 years. And I think the startling stat I saw the over 65 cohort is going to grow 18 times faster than the under 65s. So this is a real pressing issue right now.

[00:05:51] Yeah, absolutely. And I think we have an opportunity now if you like to address some of those issues now, because if we leave it too late it will be much more difficult, probably more costly, and very difficult to address. So you’re absolutely right. And what we see in the nursing home sector, because over the last number of years, there’s been increased provision of home care and day care. It means that people now requiring nursing home care have more complex care needs, have higher dependency, older age profile and a reduced length of stay. So it is really the over 85 population that is the target population, if you like, for nursing home care, that population is going to double in the next number of years. The ESRI themselves and the Department of Health have estimated somewhere between eight and 10,000 additional beds required. And at the moment, what we’re seeing is a loss of beds. So the trend is completely going the wrong way.

[00:06:41] And what’s astonishing about that is I think the statistics and research show that if you have a 10% increase in nursing home bed capacity, this actually has the positive effect of freeing up something like 53 acute beds, which are far more expensive. So it’s not a cost. It’s actually an investment to be made in this sector to help the whole ecosystem.

[00:07:00] Absolutely, as I said at the outset, you know, it’s a fundamental part of a well functioning health service, because what we’ve seen in Ireland is that the acute hospitals are under extreme pressure. So, yes, on the one hand, it is, you know, part of that ecosystem of care, because, you know, a person doesn’t exist in isolation. The nursing home sector is part of that, but it’s also the right place for the person. It’s also, again, back to the individual, for the person you know, spending too long in an acute hospital is not good for them or their families. They need to be back in their own community, back in the nursing home where they have activities, where they have stimulation, where they have rehabilitation. So it’s the right location on the one hand and the right place for someone to receive their care. But as you quite rightly point out, it makes no economic sense as well and that’s critical.

[00:07:47] And for residents, they want to live in these environments that support them thrive locally. And I wanted to touch upon the Health Information and Quality Authority, the regulator report, overview report published in December 2023. I think they undertook something like 726 inspections. And one of the things that struck me was how positive it was in terms of the comments around what the sector was doing. Your members, 88% compliance. So the sector has actually been recognised for its contribution?

[00:08:15] Absolutely. The sector has been through a very difficult period in Ireland and indeed across the world, you know, post pandemic. And thankfully we’re post that particular challenge. But you’re right. The regulator in its most recent overview report highlighted that 86% compliance rate in the sector public, private and voluntary. On top of that, the regulator undertook a nursing home resident experience survey and 90.3% of residents had a good or a very good experience. So I’m very proud as the CEO of Nursing Homes Ireland to acknowledge the commitment, the care of the staff in the sector because they’re the people who deliver that care. So the sector is deeply committed to care of the older person. But on the one hand, we’re operating now almost with one hand behind our backs in trying to compete and in trying to continue to push standards higher and higher. And on the other hand, you have government trying to, I suppose, lowball fees and drive down the cost, drive down the standards and drive down quality because that’s the ultimate, its closure or reduction in quality. And nobody wants to reduce quality. So they’re forced into an option where they have no option but to close.

[00:09:26] And that’s a stark reality. And let’s dive into that because we’re going to use the F word, which is funding or two F words fair funding. And I’d like you to sort of expand upon what you said earlier, this issue, which has come out in numerous reports, the PwC report that came out earlier, obviously, the Economics and Social Research Institute, this idea that there’s a level of discrimination between the publicly provided, state provided care and the care that your members provide, something startling 55 to 60% higher fees paid for essentially the same care.

[00:10:02] That’s exactly the point. And that’s at the nub of the issue really. It is discriminatory in respect of the funding. So the Fair Deal is a scheme of financial support for those requiring care, but to the end user and to the resident, they’re blind to the cost. But effectively, the providers and the private and voluntary sector are expected to provide care for something in the region of about €692 per resident per week, less than it provides in their own state facilities. So the state knows the true cost of care, but they’re expecting the private sector to do it for that figure. And that is leading ultimately to the crisis that we find ourselves in. So we’re not looking for anything special here. What we’re looking for is fairness and we’re looking for, you know, stability into the sector so that we can continue to grow and develop, you know, the well functioning health service that we have currently.

[00:10:53] Well, there’s a double whammy to this. And you talked about stability. PwC in their report looking at the sector, talked about the financial sustainability of the sector being at profound risk because there’s a second issue, not only the funding, but the costs that have now been absorbed by your members to provide the care. I think there’s something like 36% increase in operational costs over the last few years. So that is also paying a tremendous amount of pressure.

[00:11:22] It is absolutely. I mean, the sector, the nursing home sector in Ireland under the Fair Deal is effectively a price taker. So the state effectively sets the fees and sets the tariffs. They call it a negotiation, but it’s not a negotiation in the true sense of the word. And in effect, as you quite rightly point out, PwC’s report in 2023, based on 2022 figures, highlighted 33% of all nursing homes were operationally losing money. And, as you said, 36% increase in costs as against 11% increase in revenue. So that’s unsustainable clearly. And for some businesses, you know, you can maybe sustain that for a year or two. You can delve into your reserves, maybe, you know, go back to your banks and your funders again, but you can’t do that in perpetuity. And that’s what’s happened. We’ve reached, we’ve gone beyond a crisis for some people. I’ve, you know, nearly 60 members across the last number of years that are no longer members purely because they’ve lost their livelihood. And the people that reside in them have lost their homes. So, you know, unless and until we act and act quickly, we are going to see more closures. That’s inevitable. But I’d be hoping with all of the reports and the independent reports and even the report just recently launched by the ESRI, you know, I’d be hoping that government would take heed of those reports and engage with ourselves constructively and collaboratively so that we can address the immediate and the more medium and long term issues.

[00:12:42] Well, let’s look at how we’re going to do that. The sector, I think, benefits from someone who spent their entire career as an advocate on behalf of different groups, whether it’s children, older people, and a year as president of the Union of Students, I think, has got you ready for these battles. But we’ll look at the longer term Fair Deal in a moment. But there’s an immediate challenge that needs addressing. And the PwC report talks about it. What does that mean on the ground right now in terms of the operators and preventing these failures of operations?

[00:13:13] Absolutely. And the immediate priority for all of us collectively, government, HSE, HIQA, Department of Health and ourselves should be to do everything in our power to ensure that there’s no further closures. So our submission to government in the pre-Budget last October was of the order of €201 per resident per week, so about 191 million. And while that might sound like a lot of money in the overall scheme of things, it is relatively insignificant given the financial position Ireland Inc, as it were, finds itself. So that’s an immediate ask, is to stabilize the sector, inject confidence back into the sector. Because if you’re a provider currently you’re seeing nothing happening. You’re saying, look, this is going to get worse before it gets better. Am I better off closing my home now? So we need to ensure that those providers that are currently operating get that confidence and get the funding so that they can sustain existing services.

[00:14:05] And that will also have an impact, because obviously, if you are having 60 homes closing between 2018 and 2022, forget about the fact that it has a huge impact because people are going to go to an acute setting which is far more expensive. But from an investment perspective, it’s surely a disincentive in terms of development and investment of new facilities.

[00:14:24] Well, and look, there has been significant investment over the last number of years, quite a number of European investment. But Ireland is an attractive place to invest. I mean foreign direct investment is a huge part of our economy, whether it’s in pharmaceuticals or whether it’s in IT. So, you know, the nursing home sector should be no different and we should be treated no differently. But you’re right. I mean, talking to members now, clearly there’s no further development planned, because of the concern around future funding, because it just doesn’t make sense. And to build a new home now, in the order of €200,000 a bed. So a 50 bed nursing home is going to cost 10 million. That’s a significant amount of money. And if you don’t have the return on that investment, then it isn’t going to happen. So we are facing an existential crisis. There’s absolutely no doubt in my mind. But it’s not too late to act. That’s the key point. We should be ambitious. We should be positive, notwithstanding the challenges, and look for solutions all the time. There’s no point in cursing the darkness. We need to…

[00:15:23] Let in the light.

[00:15:23] Absolutely, burn our fingers lighting the candles.

[00:15:26] Absolutely. Now, on that point, you’ve talked about the immediate need and the submission you’ve made to the government, but there’s a more fundamental change that needs to be made. If you can take us through the Fair Deal provision, it’s been around since, I think 2009 or whatever it was. It’s meant to provide a fair cost of care. It clearly isn’t from what you’re saying. I think even Simon Harris, the former minister of health, saying it’s not working for some providers. That system needs to be recalibrated and re-engineered for today’s reality, doesn’t it?

[00:15:55] Absolutely. And it needs to be fully recast. I mean, from a resident point of view, it works well. But from the provider point of view, it’s not working. And there’s been three reviews now.

[00:16:04] In 2017, there was a review.

[00:16:06] Correct. And that pricing review said, we need to introduce a more sophisticated model that looks at the resident care needs. At the moment what you have is you have one fee for the entire population of a nursing home. What we need to look at and back to the resident here. We need to look at the residents, see what their needs are, put a care plan in place that meets their particular set of circumstances and needs, and then provide the funding to be able to meet that. So, what we need effectively is a fair cost of care model that is dependency led. So you’re looking at the actual inputs for that particular resident. So look, that has to happen. There’s no two ways about it. There’s a myriad of reports that have said that. And we’ll be at the table working constructively with government to re-engineer and recast Fair Deal. But we need to do it pretty quickly.

[00:16:56] You said earlier, sorry Tadhg, that you said earlier it has to be recast to take into the realities of the complexity of care. I think something like 66% of residents are high dependency, 54, 56% have dementia. So we have to put that. And there’s also the staffing element because the cost per worker per bed has also dramatically increased.

[00:17:15] Yeah, absolutely. And look, what’s the equation here is the resident ultimately at the top of the of the pyramid if you like. But there’s also the provider and the staff. And you’re quite right. So what we need is a financial model that recognises those three parties. On the one hand that the resident gets the high quality care that they require and that the staff are appropriately remunerated for the work they do. I mean, I’m amazed on an ongoing basis by the caring, committed staff right across the health service, but more particularly in the nursing home sector. And that the provider then also has a return, because if you don’t have a return and if it isn’t profitable, you can’t reinvest, you can’t upgrade your facility. So the recasting has to look at that, I suppose, in the round, if you like, so that we look at all those three elements.

[00:18:03] If we can finally, perhaps as part of this advocacy, what would be on offer if we did have that immediate injection, if we did have a fair deal that represented the fair cost of care for staff, for residents, but also for the regulator, because everybody’s a stakeholder here. Perhaps, it’s indicated in the HICA review in 2023 December. There is a high level of compliance and great care delivered. Perhaps you can expand upon what the sector could actually contribute even more in that context that you’re advocating for.

[00:18:36] I suppose ultimately, from an NHI point of view, as I say, I’m very proud to lead an organisation which has given a huge service to care for of the older person over the last number of years. So I suppose the private sector has the agility, if you like, to move quickly and to respond quickly. So I think we can be very creative and as I say, ambitious for our care of the older person. There’s new design guidelines that have been published recently by the Department of Health. Obviously, if we were to recast the Fair Deal, but ultimately it comes down to ending the discrimination in funding because the funding, if you like, unlocks all of those issues, and unlocks the key. The private sector will respond and has responded and will continue to respond positively to that ageing population. But it needs to be supported in policy and in resourcing.

[00:19:27] And that also includes a strategy in terms of the workforce in support of its development and progress.

[00:19:33] Look, the Irish government is currently constituting a commission on care. That would be a worthwhile and positive development. We’ll contribute to that. But I suppose what I’m concerned about is we don’t want to see, all of the issues that we’ve highlighted, as it were, pushed into that commission on care and delaying the necessary adjustments that are required because the changes, the longer we delay the changes that are required, the more difficult it will be in a number of years, to turn back the clock, as it were. We are now in 2024. In another 4 to 5 years, there’ll be a significant increase in that population over 85 that we spoke of. So if we don’t have the facilities and the staff to be able to care for those people. We are facing a very difficult situation, primarily for older people and their families, but also for the wider health service.

[00:20:21] Well, on that warning note, but also on the hope that there can be transformation and can be change. Tadhg Daly, thank you very much for your passionate advocacy and for taking your time to come and join us.

[00:20:33] Thank you Suhail, I enjoyed that.

[00:20:35] My pleasure. If you’ve enjoyed this episode of Voices of Care, please like, follow, and subscribe wherever you receive your podcasts. And if you want to learn more about how we are truly enabling the healthcare workforce of the future, please visit In the meantime, I’m Suhail Mirza. Thank you very much for joining and look forward to seeing you on the next episode.


Meet our host, Suhail Mirza

Suhail says: “I have never seen the healthcare system under so much transformation, but our Voices of Care podcast is an opportunity to listen, understand and help shape the future of care for all of us.

Join me, and a lineup of leaders and luminaries from across health and social care, as we debate how we can enable the workforce of the future and truly deliver the care service that Britain deserves.”

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