Since March 2020, Ireland has contended with what is likely the defining health crisis of our time, the COVID-19 pandemic. Since its arrival to our shores, the coronavirus has placed an unprecedented strain on our country’s capability to deliver effective social care services to our most vulnerable people. The Health Information and Quality Authority (HIQA) has witnessed first-hand the profound impact that COVID-19 has had, and continues to have, on the people who live in residential care services and their families.

As Ireland emerges from the shadow of the pandemic, it is vital that we take time to reflect on what we have learned from regulation over the past decade and begin to chart a path forward to improve health and social care for everyone. The first steps on this path have been outlined in HIQA’s report on ‘The Need for Regulatory Reform’ of social care services, published in February of this year.

Since its establishment in 2007, HIQA has been tasked with achieving better, safer health and social care for the people of Ireland. During this time, we have observed the transformation of Ireland’s health and social care landscape. This transformation has far outpaced accompanying regulatory policy. 
The report on regulatory reform examines the current regulatory framework as it applies to social care services in Ireland, and examines what works well within the current provisions and what changes are required for the safe delivery of these services. 

COVID-19 has added layers of complexity to the situation. Practices that were previously acceptable are no longer robust enough to safeguard the wellbeing of residents in the event of further waves of the virus. It is important to note that COVID-19 has not in itself signalled the need for regulatory reform, rather it has acted as a catalyst for issues that were already in need of urgent consideration. 

Out of this calamity, some good must follow.

The changing face of social care
The ways in which we provide care to vulnerable people Ireland are changing. Institutional and residential approaches are being challenged, with a developing trend towards community and homecare models. Critically, however, there is currently no overarching social care policy or legislation that outlines clearly what the State’s role is in identifying and addressing the social care needs of its elderly and vulnerable populations.

Our neighbours in Europe have a diverse range of social care services available to them, which come with different levels of regulation or quality assurance mechanisms. Some of these services mirror our own residential forms of care like nursing homes or residential disability services but, in addition, there are various forms of homecare, community mental health care, day care and assisted living. 

At present in Ireland, regulations put greater emphasis on the location of the care rather than the type or the needs of the people. This contrasts greatly with neighbouring countries, who have tailored regulation for homecare, nursing care and personal care. 

A ‘one-size-fits-all’ approach can no longer effectively regulate an increasingly diverse range of services, nor does it capture all the services being used in Ireland today. 

Sláintecare – A vision for a modern healthcare service
Sláintecare is the cross-party vision for reform of Ireland’s health and social care sector, first announced in 2017. The product of many years of hard work from representatives across the political spectrum, Sláintecare’s principle policy objective is to get ‘the right care, in the right place, at the right time’, meaning people should have their care needs met in their own home for as long as is possible. 

At present, there is no statutory entitlement to formal homecare. Moreover, access and eligibility vary widely across the country. In Europe, the majority of homecare services are informal and provided by family, friends and neighbours. This can be at least 80% of the total hours of care provided. However, in Ireland, the percentage of informal homecare provided may be closer to 90% based on evidence from disability services. 

Whilst we welcome developments being progressed by the Department of Health to progress a Statutory Homecare Scheme, it is important to outline that a reform of homecare is not the solution in itself, but a vital component of broader reform that is needed in a range of community housing and day care options where services are smaller and integrated.  These developments should also have an accompanying accountability framework to ensure good governance. This will go some way towards ensuring a single-tiered universal health model which supports integrated care.

Safe health and social care for all
Everyone in Irish society is entitled to safe care and yet HIQA does not presently have a legal mandate to assess the quality and safety of some the services being provided to a significant proportion of our older and vulnerable population. 

It may come as some surprise to discover that no independent regulation of private hospitals, homecare services or other community based social services, currently takes place in our country.
To be effective, regulation must respond to people’s needs and adapt to changing circumstances. HIQA constantly seeks to improve regulatory practice and explores how care could potentially be regulated into the future.
But what other steps are necessary to protect the most vulnerable people in our society? HIQA strongly believes that statutory measures to protect the health, human rights and wellbeing of individuals are required as a matter of urgency.

Such safeguarding legislation would set out clear definitions of offences in respect of the abuse of vulnerable adults. It would also give statutory powers of enforcement and prosecution, currently only available to HIQA in the regulation of nursing homes and disability centres, to other health authorities in Ireland. 
What we need now is strong political will and the collaboration of all stakeholders to achieve a health service that Ireland can be proud of.

COVID-19 has crystallised the need for reform. It has forced us, as a society, to re-examine practices once considered commonplace.

Many businesses have adapted to the pandemic by employing a remote working model. As a result of its success, we may see a permanent shift to a hybrid working model, something seldom considered prior to 2020.
In the same way, COVID-19 has forced us to fundamentally reconsider the manner in which we provide health and social care services and, critically, how they should be regulated.

The pandemic has solidified the argument for the restructuring of models of care for older people in a way that provides for differing supports, at different times, based on individual ability and need. The requirement for models of care that are diverse and truly person-centered is embedded in our argument for regulatory reform.

It is HIQA’s view that a modern health and social care sector should be subject to a framework which is fit for purpose, adaptable to changing needs and preferences, and responsive to risk and concerns for people’s welfare. 

This may, in part, be achieved by developing a policy that considers social care in its entirety given that the principle issues are consistent across all populations who use social care services. It is hoped that the recommendations contained in our report form an integral part of the debate around how we can better care for all citizens into the future.