The Impact of Social and Economic Policies on Older People in Ireland

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The Impact of Social and Economic Policies on Older People in Ireland

THE IMPACT OF SOCIAL ANDECONOMIC POLICIES ON OLDERPEOPLE IN IRELANDByEamon O'SheaNATIONAL COUNCIL FOR THE ELDERLYREPORT NO. 24


This Report has been prepared for the European Community Observatoryon ong>Socialong> ong>andong> ong>Economicong> ong>Policiesong> ong>andong> Older People by Mr. EamonO'Shea, Department ong>ofong> ong>Economicong>s, University College Galway, ong>andong>revised by himforTHE NATIONAL COUNCIL FOR THE ELDERLYCORRIGAN HOUSEFENIAN STREETDUBLIN 2Cover Design by Declan BuckleyNATIONAL COUNCIL FOR THE ELDERLY 1993First published in 1993. Reprinted in 1995.Price: £3.00


EUROPEAN YEAROF OLDER PEOPLE ANDSOLIDARITY BETWEEN GENERATIONS


Table ong>ofong> ContentsFOREWORD 9AUTHOR'S ACKNOWLEDGEMENTS 11CHAPTER 1 AN INTRODUCTION TO 13SOCIAL AND ECONOMICPOLICIES AND OLDERPEOPLEBackgroundPopulation AgeingPensions ong>andong> IncomesOld People in the Labour MarketHealth Careong>Socialong> Stong>andong>ingCHAPTER 2 LIVING CONDITIONS AND 22WAY OF LIFEIntroductionong>Socialong> InsuranceOld Age Contributory PensionOther Contributory PensionSchemesNon-Contributory PensionSchemeOther Non-Contributory PensionSchemesOccupational PensionsPensions PolicyStong>andong>ard ong>ofong> Living ong>ofong> ElderlyPersonsRecent RetireesPolicy Issues ong>andong> IncomeAdequacy for Old PeopleHome Living ArrangementsHousingSheltered HousingBoarding OutContact with Kin7


CHAPTER 3 THE LABOUR MARKET AND 46OLDER WORKERSIntroductionong>Theong> Labour Market in Irelong>andong>Labour Force ParticipationRetirement Hazard RatesUnemployment ong>andong> OlderWorkersInstitutional Routes out ong>ofong> theLabour Marketong>Socialong> Dynamics in the Transitionfrom Work to RetirementDiscrimination ong>andong> Older WorkersPolicy IssuesCHAPTER 4 HEALTH AND SOCIAL 61SERVICESIntroductionong>Theong> Need for Health ong>andong> ong>Socialong>ServicesInformal Care in the CommunityMedical ProvisionPublic Long-Stay CarePrivate ong>andong> Voluntary NursingHomesFuture Provision ong>ofong> Long-StayBedsCommunity CareFinancing StructurePublic Policy: Principles ong>andong>PrioritiesRecent ReformsInnovationsCHAPTER 5 CONCLUSIONS 84REFERENCES 878


ForewordThis report was written in conjunction with similar studies in all themember States ong>ofong> the European Community in preparation for 1993 —European Year ong>ofong> Older People ong>andong> Solidarity between Generations.ong>Theong>se studies provided the basis for the first annual report ong>ofong> a specialEuropean Community Observatory on the effects ong>ofong> ong>Socialong> ong>andong> ong>Economicong>ong>Policiesong> on Older People throughout the Community.*ong>Theong> report here presented covers a broad range ong>ofong> key policy areas suchas living conditions, the labour market, family caring ong>andong> the health ong>andong>social services. In the Council's view the author has provided a veryconcise elucidation ong>ofong> current policy issues. He brings us up to date inrelation to the current state ong>ofong> research ong>andong> poses important questionsfor the future.ong>Theong> Council is very pleased to publish this useful report, confident thatit will be seen as an informative contribution to the issues to be discussedduring the European Year ong>andong> beyond.Lady Valerie GouldingChairmanNational Council for the ElderlyJanuary 1993'ong>Socialong> ong>andong> ong>Economicong> ong>Policiesong> ong>andong> Older People — First Annual Report ong>ofong> the EuropeanCommunity Observatory edited by Alan Walker. Anne Marie Guillemard ong>andong> Jens Alber.Brussels: Commission ong>ofong> the European Communities. DGV. Employment. ong>Socialong> Affairs.Industrial Relations. 1991.


Author's AcknowledgementsThis study arises from my participation in the European CommunityObservatory on Older People. ong>Theong> EC Commission, ong>andong> Odile Quintinong>andong> Eamon Mclnerney in particular, deserve special appreciation forthe support ong>andong> encouragement they have given the Observatory sinceits inception in 1991. Members ong>ofong> the Observatory have greatly influencedmy work on this study, providing many valuable insights onmethodology ong>andong> structure.I would also like to thank Joe Larragy for his comprehensive ong>andong>helpful comments on an earlier draft ong>ofong> the report. Claire Noone ong>ofong> theDepartment ong>ofong> ong>Economicong>s in UCG deserves special thanks for tidyingup rather a lot ong>ofong> loose ends. My thanks is also extended to the manypeople in Government departments ong>andong> voluntary bodies who generouslyshared their expertise with me ong>andong> took the time to deal with anyqueries I had about policies for older people.Finally. I would like to thank the National Council for the Elderly foragreeing to publish this report ong>andong> to the European Commission forallowing them to do so.Any errors, obscurities or inadequacies in the report remain my responsibility.11


CHAPTER 1An Introduction to ong>Socialong> ong>andong> ong>Economicong>ong>Policiesong> ong>andong> Older PeopleBackgroundIn many European Community countries the discussion on health ong>andong>social security has, until recently at any rate, been dominated by concernsabout the impact ong>ofong> ageing on the economic ong>andong> social fabric ong>ofong> society.Irelong>andong>, however, has not been overly concerned with this issue, mainlybecause its elderly population is not expected to increase significantlyuntil the second decade ong>ofong> the next century'. This is not to say that oldpeople have not figured at all in policy debate; there has been muchdiscussion about their health care needs ong>andong> the desirability ong>ofong> alteringthe balance ong>ofong> care away from institutions ong>andong> towards care in thecommunity. More recently, concern has been expressed about the futuredirection ong>ofong> pensions policy ong>andong> a major report on this topic is due outshortly. For all that, however, Irelong>andong> has been more concerned with itsbulging young population, ong>andong> the associated problems ong>ofong> unemploymentong>andong> emigration, than with the position ong>ofong> older age groups.This first section provides an overview ong>ofong> the main issues that nowconfront policy-makers in Irelong>andong> with respect to older people. In thefirst instance the demographic structure ong>ofong> the elderly population isoutlined, together with future projections. Following this there is a briefdiscussion on the main policy areas to be taken up later in the report.ong>Theong>se areas include: pensions ong>andong> incomes, labour market relationships,ong>andong> health care. Finally, the overall position ong>andong> status ong>ofong> old people inIrish society will be briefly considered.Population Ageingong>Theong>re are just under 400,000 people aged 65 or older living in Irelong>andong>,representing 11 per cent ong>ofong> total population (Table 1.1). Proportionately,this is not high by European stong>andong>ards ong>andong> reflects, in part, continuedhigh levels ong>ofong> fertility in the population which has tended to balance outimprovements in life expectancy. Emigration also affects the proportion13


TABLE 1.4: Projected elderly population by age, by sex (000)AgeGroupMale1986FemaleMale1996FemaleMale2001FemaleMale2011Female65-7475-8485+All ElderlyTotal Pop.% Elderly112.048.78.0168.71,769.79.5128.569.717.4215.61,771.012.2106.252.49.3167.91,703.39.8126.579.520.8226.81,709.513.3105.352.010.4167.71,672.710.0122.081.623.9227.51,680.713.5Source: Central Statistics Office. Population ong>andong> Labour Force Projections, 1988.124.152.311.2187.61,727.310.9142.479.328.1249.81,738.414.4% Change 1986-2011All Male Female11115514-21174011-211146216-2


1961197119811991200120112021YearTABLE 1.5: Elderly population by age category (*/•)60 — 7473.474.374.070.468.773.073.6Age Category75 — 84 85+22.521.221.424.424.920.820.94.24.54.55.26.46.25.5All Elderly100100100100100100100Source: Census ong>ofong> Population (various); Population ong>andong> Labour Force Projections,Central Statistics Office, 1988.Pensions ong>andong> IncomesMost old people in Irelong>andong> receive either a non-contributory or contributoryold age pension. ong>Theong> former is a means tested social assistancepayment, while the contributory pension is an entitlement under thenational social insurance system. Currently all employees in the countryare covered directly or indirectly under the basic social insurance scheme.ong>Theong> most recent evidence suggests that just under 50 per cent ong>ofong> thelabour force are also covered under second tier occupational pensions,with numbers in such schemes increasing steadily over recent years(Keogh ong>andong> Whelan. 1985).A number ong>ofong> issues arise with respect to pensions policy. Some ong>ofong> themhave recently been addressed by the Pensions Act 1990. which broughtin legislation dealing with the regulation, supervision, ong>andong> coverage ong>ofong>occupational pensions. ong>Theong>re is still some concern, however, about thelimited coverage ong>ofong> occupational schemes, ong>andong> ways ong>ofong> extending thenumbers in such schemes are now being discussed. A more long-termconcern for the Government is the future cost to the exchequer ong>ofong> thesocial insurance system ong>andong> the associated question ong>ofong> whether separateprovision needs to be made for pensions within that scheme.ong>Theong> adequacy ong>ofong> the incomes received by old people either throughsocial insurance or social assistance is also a cause for concern. One ong>ofong>the features ong>ofong> the Report ong>ofong> the Commission on ong>Socialong> Welfare (1986).was a tendency to label old people as a group that had done well underthe social welfare system ong>andong> for whom little or no additional provision,beyond that contained in the existing social welfare code, was required(Blackwell. 1987). While the elderly have fared relatively well, ong>andong> allthe evidence points to a reduction in the risk ong>ofong> poverty for them as agroup (Callan et al. 1989). the reality is that a small, but significant,number ong>ofong> old people may be existing on very low incomes relative to18


their overall needs. Any reform ong>ofong> the pension system, public ong>andong>private, will have to address the issue ong>ofong> adequacy ong>ofong> income in relationto needs.Old People in the Labour Marketong>Theong> position ong>ofong> older workers in the labour market has not receivedadequate attention in Irelong>andong>. In the past it was not unusual to find arelatively high participation rate for older workers. ong>Theong> reason for thiswas related to the structure ong>ofong> the economy — in particular, the highproportion ong>ofong> older workers engaged in farming. In recent years,however, as the importance ong>ofong> farming has declined ong>andong> as unemploymenthas contributed to a discouraged older worker effect, participationrates for persons in age categories above 55 years have declinedsignificantly. ong>Theong> duration ong>ofong> unemployment for older workers is alsohigh relative to other age groups. Retirement at a fixed age (i.e.. at 65)is no longer common; many workers now leave the labour force muchearlier due to redundancy, disability or "voluntary" retirement.However, "voluntary" retirement is not always due to "pull" factors(such as a desire for more leisure): "push" factors may also be acontributory factor.It is perhaps not surprising that the position ong>ofong> older workers in thelabour market has not received as much attention as younger workers.In periods ong>ofong> excess supply ong>ofong> labour early retirement ong>andong> the enforcedexit ong>ofong> older workers from the labour force is more acceptable to all.including the unions. This is the de facto position in Irelong>andong>. While thereis no evidence ong>ofong> active discrimination against older workers, on-goingconcern about youth unemployment ong>andong> emigration has created a fertileground for a two-tier treatment ong>ofong> the unemployment problem. Schemeswhich facilitate the reclassification ong>ofong> older unemployed workers to thestatus ong>ofong> retirees are a symptom ong>ofong> this approach. ong>Theong>se ong>andong> relatedissues will be considered more fully in Chapter Three.Health CareRecent policy on old people in Irelong>andong> has been based on the report ong>ofong>the Working Party on Services for the Elderly (1988) (hereafter referredto as ong>Theong> Years Ahead). This report emphasises the importance ong>ofong>support for old people living in the community, rather than providingfor them in hospitals or other institutions without very good reason. Itmust be said, however, that while policy statements on care ong>ofong> the elderlyhave been ong>ofong> the enlightened variety, the resources necessary to provideoptimal care in the community have not always been forthcoming.19


Recent evidence has highlighted the patchy nature ong>ofong> community carefacilities, particularly with respect to home nursing, home helps ong>andong>paramedical services (Blackwell et al.. 1992). ong>Theong> role ong>ofong> informal carersin maintaining old people living in their own homes has also been undervalued.Part ong>ofong> the reason for this may be concern on the part ong>ofong> theauthorities that the inclusion ong>ofong> carers in the policy process would giverise to increased demong>andong>s on the exchequer for compensation to coverthe real opportunity cost ong>ofong> their work.ong>Theong> desirability ong>ofong> improving assessment ong>andong> rehabilitation facilitieswithin long-stay institutions has also been spelt out by some commentators(O'Shea et al., 1991). In particular, the role played by consultantgeriatricians in improving the placement ong>ofong> old people has beenhighlighted. Unfortunately, the commitment ong>ofong> resources to this areahas also been less than optimal, though some improvements should beacknowledged.Of crucial importance in the long-term care ong>ofong> old people is the integrationong>ofong> public, private ong>andong> voluntary provision. ong>Theong>re are particularadvantages in treating the public long-stay sector ong>andong> the regulatedprivate nursing home market as close substitutes. ong>Theong> main benefit isthat it widens the choice available to health boards when decisions aboutthe placement ong>ofong> older people have to be made. It remains to be seenwhether recent legislative ong>andong> policy initiatives will have the desiredeffect ong>ofong> promoting greater integration between the sectors. A complementaryapproach to care provision involving home care, communityservices ong>andong> in-patient care would also improve the situation ong>ofong> oldpeople in need ong>ofong> care. If this is to happen, services on the ground wouldhave to be more formally co-ordinated than they are at present, whilegreater co-operation would also be required across the various governmentdepartments responsible for the setting ong>ofong> overall policy goals. ong>Theong>views ong>ofong> old people themselves also need to be taken into account whendecisions about placement are being made.ong>Socialong> Stong>andong>ingong>Theong> vast majority ong>ofong> elderly persons in Irelong>andong> are fit, independent, livein good housing ong>andong> are reasonably well-ong>ofong>f. Paradoxically, some ong>ofong> thisgroup may be just as badly ong>ofong>f as the minority ong>ofong> old people who are ill,poor or very dependent. ong>Theong> explanation for this deprivation lies insocietal attitudes to ageing which results in the displacement ong>ofong> ableolder people, not just from the labour market, but from all aspects ong>ofong>social ong>andong> economic life. Displacement may eventually lead to dependencywhere none should exist.20


ong>Theong> absence ong>ofong> much discussion on this issue may stem from a lingeringbelief in some quarters, related to a more traditional value system, thatold people continue to enjoy power ong>andong> status in society. This can onlyexplain the paucity ong>ofong> social thinking in this area, although it must beacknowledged that the evidence from the surveys that have been donedoes not confirm any widespread neglect ong>ofong> old people by kin or community.Nevertheless, the general absence ong>ofong> old people from economicong>andong> political life should caution us against too much optimism regardingtheir role ong>andong> stong>andong>ing in Irish society today.21


CHAPTER 2Living Conditions ong>andong> Way ong>ofong> LifeIntroductionIn this chapter the main policy issues considered are: the structure ong>ofong>the social insurance system, social security, pension systems ong>andong> proposalsfor future developments; the relative income position ong>ofong> oldpeople in society; their housing ong>andong> living arrangements; ong>andong> the levelong>ofong> contact old people have with the rest ong>ofong> society. ong>Theong> starting point ong>ofong>the discussion is the social insurance system. This is a useful place tobegin, since all income earners in the country are nowadays covered,directly or indirectly, under the basic social insurance scheme.ong>Socialong> Insuranceong>Socialong> insurance was first introduced in Irelong>andong> in 1911. Initially coveragewas restricted to sickness benefits ong>andong> the scheme was confined topersons in manual employment whose earnings were under a specifiedlimit. It was 1961 before the contributory old age pension was introducedong>andong> paid out ong>ofong> the social insurance fund. In 1974 the social insurancescheme was extended to all full-time employees by the abolition ong>ofong> theearnings limit for non-manual employees. Coverage was extended toself-employed persons in 1988. but only for old age ong>andong> widows ong>andong>orphans pensions. At present, all income earners, with few exceptions 1are covered directly or indirectly under the social insurance system(Table 2.1).ong>Theong> social insurance scheme is financed from contributions (Pay Relatedong>Socialong> Insurance (PRSI)) collected from employers ong>andong> employees ong>andong>paid into the social insurance fund. ong>Socialong> insurance contributions onbehalf ong>ofong> employees are based on a percentage ong>ofong> earnings (12 per cent'Those not covered include the following groups: relatives assisting on farms, ong>andong> thoseengaged in full-time home duties including persons looking after dependent relatives (seediscussion to follow).22


TABLE 2.1: Number ong>andong> categories ong>ofong> persons covered for socialinsurance pensions in 1989-90CategoryPersons covered for all pensions (Employees engaged in industrial,commercial ong>andong> service-type employment) (Class A)Persons covered for old age ong>andong> survivors pension only (Selfemployedpersons with an annual income in excess ong>ofong> IR£2,500(Class S)Persons covered for survivors pensions only (Permanent ong>andong> pensionableemployees in the public service*) (Classes B, C, D, H)TotalNumber973,120125,083170,1001,268,303"Main cover provided by non-contributory occupational pension schemes.Source: Department ong>ofong> ong>Socialong> Welfare, 1991.for employers, ong>andong> 8 per cent for employees) up to an income ceiling ong>ofong>IR£19,000 for employees ong>andong> IR£20300 for employers. A breakdownong>ofong> the percentage contribution attributable to pensions is not publishedby the Department ong>ofong> ong>Socialong> Welfare. However, Mangan (1991) reportsone estimate which suggests that the percentage contribution payablefor pensions in 1991 was 11 per cent (7 per cent borne by the employerong>andong> 4 per cent by the employee). Total expenditure on contributorybenefits/pensions for old people accounts for just under 50 per cent ong>ofong>the total social insurance fund.Not all categories ong>ofong> the workforce are obliged to pay the full or stong>andong>ardrate ong>ofong> contribution. However, there is a link between contribution ong>andong>benefit entitlement. For instance, self-employed contributors are eligiblefor old age ong>andong> widows contributory pensions only ong>andong> this limitedcoverage is reflected in the lower level ong>ofong> contribution paid by them. Inaddition to variation in contribution conditions entitlements to benefitsis conditional upon all claimants having a certain number ong>ofong> contributionspaid or credited in a specific period ong>ofong> time. If overall contributions areinsufficient to meet the outgoings from the fund the deficit is made upby State subvention. ong>Theong> amount varies from year to year depending onthe circumstances (for instance, the State accounted for 17 per cent ong>ofong>the fund in 1989 ong>andong> only 6 per cent in 1990).Old Age Contributory Pensionong>Theong> entitlement to an old age contributory pension is conditional on anindividual meeting certain contribution conditions during their workinglife. At present approximately 19 per cent ong>ofong> old people (over 65 years23


ong>ofong> age) are receiving an old age contributory pension (Table 2.2) ong>Theong>weekly rate ong>ofong> payment varies according to the average number ong>ofong>contribution weeks worked up ong>andong> currently ranges between IR£61.60ong>andong> IR£66.60 (from July 1992). Recipients receive a flat rate weeklypayment plus an allowance for adult ong>andong> child dependants. ong>Theong> pensionbecomes payable once a person reaches 66 years ong>ofong> age. ong>Theong> rate ong>ofong>payment is higher than the rate paid to short-term unemployed workers— the latter typically get 78 per cent ong>ofong> the rate received by pensioners.This difference is not surprising since the long-term needs ong>ofong> the elderlyin Irelong>andong> have always been considered by the authorities to be greaterthan the short-term needs ong>ofong> the sick ong>andong>, especially, the unemployed(Hughes, 1985).TABLE 2.2: ong>Socialong> security pension* for people aged 65 years ong>andong> overin 1990Type ong>ofong> pension/benefitOld Age (NOOld Age (C)Retirement Pension (C)Widows (C)Widows (NOInvalidity (C)Deserted Wives (C)Deserted Wives (NC)Lone Parents (NC)Other Provision (i.e. non socialsecurity provision)*Does not include adult dependants.C = Contributory.NC = Non-Contributory.Source: Department ong>ofong> ong>Socialong> Welfare, 1991.Recipients as %ong>ofong> all thoseover 65 years29.9418.8612.2814.283.400.320.060.090.0120.76100.00Expenditure as %ong>ofong> all State exp.on social securityfor old persons*30.8029.7017.8017.603.400.500.100.100.020.00100.00ong>Theong> relationship between the contributory old age pension, unemploymentbenefit, ong>andong> child benefit is particularly important since thesethree areas account for such a significant proportion ong>ofong> overall socialexpenditure. During the 1980s child benefit increased faster than old agepayments, though the trend has been more erratic, with large increasesin the early eighties followed by some years ong>ofong> decline, especially towardsthe end ong>ofong> the decade. ong>Theong> 1990 payment for child benefit is, for example,less, in real terms, than the figure for 1982. In contrast, the differential24


etween contributory pensions ong>andong> unemployment benefit has widenedin favour ong>ofong> the former over the same period. In 1980 the real paymentfor old age pensioners was 20 per cent higher than the benefit paid tounemployed persons (Table 2.3) During the 1980s the old age rateincreased by 1.2 per cent per annum compared to an increase ong>ofong> only0.4 per cent per annum for unemployment benefit. This meant that thegap between the two had widened to 30 per cent by 1990. In recent yearshowever, particularly between 1986 ong>andong> 1990, the real change in old agecontributory pensions, although positive (1.5% for one adult, 1.3% fora couple) has been below the increase for most other welfare categories.TABLE 2.3: ong>Socialong> welfare payment rates 1980 — 1990(constant 1985 prices)19801981198219831984198519861987198819891990YearPer annum1980—1990UnemploymentBenefit£38.039.041.838.338.338.739.539.940.240.139.60.4% ChangeOld AgeContributorypension£45.648.753.148.749.650.251.451.852.352.351.51.2Child Benefit£21.423.929.727.224.825.124.129.228.627.726.52.2Total change1980—19904.212.9Source: National ong>Economicong> ong>andong> ong>Socialong> Council 1990. Table 7.2.23.8ong>Theong>re have been much more substantial increases for those schemes(e.g., long-term unemployment assistance ong>andong> supplementary welfareallowance) which were recognised as having the lowest rates in the mideighties(Callan ong>andong> Nolan, 1992).Other Contributory SchemesIn 1970 a retirement pension scheme was introduced for persons whowanted to leave the labour force at the age ong>ofong> 65. ong>Theong> level ong>andong> structure25


ong>ofong> payment is the same as that for the old age contributory scheme.Currently 13 per cent ong>ofong> old people are in receipt ong>ofong> retirement pensions.A contributory pension scheme for widows has been in operation since1935. A widow may qualify for the contributory pension on the basisong>ofong> her deceased husbong>andong>'s social insurance contributions or her owncontributions. ong>Theong>re is no means test, nor is there a minimum age forentitlement. During the 1970s similar schemes have been introduced forfamilies who do not have a breadwinner for reasons other than death.For example, the Deserted Wives Benefit Scheme was introduced in1973 ong>andong> it operates on similar lines to the contributory widows pensionscheme. In 1970 an invalidity pension scheme was implemented toprovide cover for insured persons who are permanently incapacitatedfor work.Non-Contributory Pension SchemeOld age non-contributory pensions were introduced in Irelong>andong> in 1908under the Old Age Pensions Act (for persons aged 70 years or over). Itwas not until the 1970s that the pension age was reduced to its currentposition — 66 years. Similarly, it was not until 1974 that provision wasmade for payment ong>ofong> an allowance for an adult dependant (usually thespouse) under pension age. Currently, the pension consists ong>ofong> a flat rateweekly pension payment plus allowances for child ong>andong> adult dependants.ong>Theong> pension is means tested ong>andong> the current weekly rate ong>ofong> payment isIR£55. ong>Theong>re is very little difference between the assistance rate paid toold people ong>andong> the level ong>ofong> payment paid to the long-term unemployed— the latter is 98 per cent ong>ofong> the old age rate. Close to 30 per cent ong>ofong>all old people aged 65 years or over in the country are in receipt ong>ofong> anon-contributory old age pension (Table 2.2).Other Non-Contributory SchemesBefore 1935, in cases where the main breadwinner in a family died, thesurvivors had to rely on public assistance payable on a weekly basis. Toqualify, claimants had to satisfy the authorities, on a regular basis, thatthey had insufficient income. Since 1935 a non-contributory pensionscheme exists for widows ong>andong> orphans. ong>Theong> scheme is means tested ong>andong>operates along the line ong>ofong> the non-contributory old age pension. Fourper cent ong>ofong> elderly people currently receive payments under this scheme.Other allowances also exist which include cover for older persons indifficult family situations. In 1970 a deserted wife's allowance was introducedfor situations where the husbong>andong> left the family ong>andong> refused to26


support them any longer. In 1990 a lone parent allowance scheme wasintroduced under which payments are provided for all families withinsufficient income, irrespective ong>ofong> the cause ong>ofong> the lone parenthood ong>andong>the sex ong>ofong> the parent. This allowance is set to replace all the socialassistance schemes which had previously provided help for lone parents.Occupational Pensionsong>Theong>re is no direct provision made for income related second tier pensionsunder the State social security system. Instead, this type ong>ofong> pension coveris provided by occupational schemes for about 50 per cent ong>ofong> persons inemployment (Table 2.4) This figure is inflated somewhat by the welldevelopedong>andong> long-established pension arrangements in the publicsector. When the latter is excluded only 34 per cent ong>ofong> the labour forceare covered for occupational pensions. In 1985 there were an estimated2,457 schemes in existence in the private sector. ong>Theong> State promotesTABLE 2.4: Membership ong>ofong> occupational schemesSectorIndustrial ong>andong> large service firms (exc. building & construction)Small service firms ong>andong> non-ag. self employedAgriculture, forestry & fishingPrivate sector building ong>andong> constructionNon-commercial publicAll sectorsSource: Keogh & Whelan, 1985.Covered57007510047Not Covered4310010025053private occupational schemes through tax deferral, whereby the levyingong>ofong> income tax is deferred until the person concerned is actually paid thepension. ong>Theong> cost ong>ofong> tax deferral is not inconsequential to the exchequer,amounting to an estimated IR£365 million in 1989 (National PensionsBoard).Private sector occupational schemes are the product ong>ofong> voluntaryarrangements between employers ong>andong> employees, whereby a proportionong>ofong> pay is set aside to finance the scheme. ong>Theong>se funded schemes, as theyare called, are normally placed under the control ong>ofong> trustees who holdong>andong> invest the funds under the terms ong>ofong> a trust deed. In contrast,occupational pensions in the public sector are financed mainly on a "payas you go" basis with cover provided as part ong>ofong> the public servants termsong>ofong> employment. This means that the cost ong>ofong> paying the benefits toworkers who have retired is paid out ong>ofong> revenue coming into the schemein much the same way as salaries ong>andong> wages ong>ofong> employees are paid.27


ong>Theong>re are two basic types ong>ofong> occupational schemes operating in Irelong>andong>.ong>Theong> first ong>andong> most prominent type is the defined benefit (guaranteedincome) scheme which sets out the members' entitlements on retirement.For instance, the member may be entitled to a fixed amount ong>ofong> pensionor one based on salary ong>andong> years ong>ofong> service. Generally, most schemesong>ofong> this type are integrated with the State social insurance pension systemong>andong> take into account members entitlements under the latter. Definedcontribution (or money purchase) is the other type ong>ofong> pension schemeavailable in Irelong>andong>. Employer ong>andong> employees contribute to the schemeat an agreed rate ong>andong> the benefits on retirement depend on the totalamount contributed ong>andong> the investment returns obtained. A minority ong>ofong>schemes are ong>ofong> this sort, though many smaller schemes have recentlybeen set up in this way.Pension schemes now play an important role in the savings ong>andong> investmentbehaviour ong>ofong> the Irish economy. Over the past fifteen years thevalue ong>ofong> assets ong>ofong> funded pension schemes has grown from 5.5 per centong>ofong> GNPin 1975 to an estimated 38 per cent ong>ofong> GNP in 1991. Contributionong>andong> investment income continue to significantly exceed benefit paymentsthereby leading to substantial asset accumulation. This trend is likely tocontinue for some time as most occupational pension schemes will notreach maturity until well into the next century.Pensions PolicyMost ong>ofong> the recent changes in public pensions policy have been concernedwith increasing the scope ong>andong> coverage ong>ofong> the contributory pensionscheme. This has now largely been achieved for the working populationwith the recent extension ong>ofong> the scheme to the self-employed. ong>Theong> maincategories still not covered are assisting relatives ong>andong>, in particular, thosepeople engaged full-time in home duties ong>andong>/or looking after dependentrelatives. ong>Theong> National Pensions Board 2 is currently examining theextension ong>ofong> coverage to these categories ong>andong> a report is expected shortly.However, it is unlikely that direct payment or salaries for carers will berecommended, mainly because ong>ofong> the implications that this would havefor the exchequer. Nevertheless, it should be possible to allow insurancecredits for employed persons forced to take time ong>ofong>f work to look afteran elderly family member, at least up to a specified time limit. Similarschemes are already in operation in many European countries for thetemporary care ong>ofong> sick children by working parents.ong>Theong> financing ong>ofong> State social security pensions is also being examined byBoard was set up in 1986 to advise the Minister for ong>Socialong> Welfare on thedevelopment ong>ofong> the pension system in Irelong>andong>.28


the National Pensions Board. In particular, the question ong>ofong> whether acontinuation ong>ofong> the present system, whereby pensions are financed by acombination ong>ofong> income from contributions ong>andong> subvention from taxation,is the optimal approach is being addressed. Alternatives include thefinancing ong>ofong> pensions entirely from contribution income (which impliesan increase in the latter) or moving to a system based solely on generaltaxation. If the social insurance system continues to be used to fundpensions then it is likely that a separate accounting system will evolvesooner rather than later. At present the social insurance system workson a "pay as you go" basis whereby estimated expenditure for the yearsahead is established ong>andong> the proportions to be met from contributionincome ong>andong> from taxation are then decided. Given the projected increasein the number ong>ofong> people qualifying for pensions in the future it is unlikelythat this approach will continue to be practicable.Another issue which will have to be addressed is the adequacy ong>ofong> the basiclevel ong>ofong> social welfare pensions. ong>Theong> Commission on ong>Socialong> Welfare,reporting in 1986, recommended basic weekly levels ong>ofong> payment, whichin 1991 money terms would be IR£60.80 for social assistance ong>andong>IR£67.00 for social insurance. Currently, the non-contributory old agepension is 90 per cent ong>ofong> the "adequacy" rate set by the Commission,while the contributory pension is 96 per cent ong>ofong> its "adequacy" rate. ong>Theong>government under the Programme for ong>Economicong> ong>andong> ong>Socialong> Progress(agreed with the social partners) has promised to increase State socialsecurity rates, in line with the recommendations ong>ofong> the Commission onong>Socialong> Welfare, but only as resources permit. It would be unfortunate ifthe (largely correct) conventional wisdom that old people have faredrelatively well in recent years was to undermine efforts to improve theirincome position even further. What must be underlined is that there isnot a single homogenous stong>andong>ard ong>ofong> living applicable to all old peoplein the State. Consequently, those old people identified by Blackwell(1984) as being worst ong>ofong>f financially, such as the very old, those livingalone, ong>andong> those who depend exclusively on social welfare pensionsshould be brought up to the "adequacy rate," even in the absence ong>ofong>the requisite growth in the economy.Much progress has been made with respect to improving the regulatoryframework ong>ofong> occupational pension schemes. ong>Theong> setting up ong>ofong> a NationalPensions Board in 1986 has proven to be the catalyst for major changesin this area. ong>Theong> Board has produced separate reports on: ong>Theong> Regulationong>ofong> Occupational Pension Schemes (1986), Tax Treatments ong>ofong> OccupationalPension Schemes (1988) ong>andong> Equal Treatment for Men ong>andong>Women in Occupational Schemes (1989). ong>Theong>se reports have formed thebasis ong>ofong> the Pensions Act 1990, the main provisions ong>ofong> which cameinto force on 1 January 1991. This Act, for the first time, provides29


comprehensive protection for the pension entitlements ong>ofong> occupationalscheme members ong>andong> their dependants. Until the enactment ong>ofong> the newlegislation the regulation ong>ofong> this sector had been governed mainly by 19thcentury trust law. ong>Theong> implementation ong>ofong> the Act is the responsibility ong>ofong>a new Pensions Board (An Bord Pinsean, set up in January 1991) whosebrief is to monitor ong>andong> supervise the operation ong>ofong> the Pensions Act.ong>Theong> main provisions ong>ofong> the Act are as follows:- ong>Theong> preservation ong>ofong> pension rights- A funding stong>andong>ard for defined benefit schemes- Equal treatment for men ong>andong> women- ong>Theong> disclosure ong>ofong> informationUp to now few private sector schemes made adequate provision toprotect the pension entitlements ong>ofong> workers who change jobs. Thismeant that many workers did not achieve the level ong>ofong> pension covercommensurate with their period ong>ofong> time in schemes. For other workersthe inadequate protection ong>ofong> pension entitlements on leaving may havebeen a barrier to mobility between jobs. Under the new Act a workerentitled to a preserved benefit may now opt for a transfer ong>ofong> the fullvalue ong>ofong> the preserved benefit, including any revaluation, to the pensionscheme ong>ofong> a new employer, or to a life ong>ofong>fice annuity contract. ong>Theong> newAct also sets out minimum stong>andong>ards ong>ofong> funding for defined benefitschemes. Schemes must have adequate resources to pay people thebenefits they have built up if the scheme, for whatever reason, has tobe wound up. It is the responsibility ong>ofong> the trustees to ensure that thestong>andong>ards set out in the Act are complied with.ong>Theong> Act also sets out the information requirements associated withoccupational pension schemes. Trustees must provide details about therules ong>ofong> the scheme, basic information about how it works ong>andong> detailsabout a member's benefit entitlements under the scheme. Finally, theAct requires equal treatment for men ong>andong> women in relation to eligibilityfor membership, obligations to contribute, levels ong>ofong> contributions, benefitrights, ong>andong> retirement ages.Stong>andong>ard ong>ofong> Living ong>ofong> Elderly Personsong>Theong> primary source ong>ofong> information on old peoples incomes is theHousehold Budget Survey (1987). In that survey resources are examinedfrom the perspective ong>ofong> the household rather than the individual. Thisapproach has advantages (Blackwell, 1984):- ong>Theong> household is usually taken to constitute a unit for the purposesong>ofong> consuming goods ong>andong> services30


- Resources are usually shared within the household- Alternative sources ong>ofong> information on incomes are not readilyavailable.ong>Theong>re are some limitations, however, not least that elderly persons inmore complex households tend to get lost in the data. Moreover,information on the incomes ong>ofong> persons living in institutional care is notincluded.ong>Theong> most important limitation ong>ofong> all, however, is that the main purposeong>ofong> the Household Budget Survey is to determine in detail the currentpatterns ong>ofong> household expenditure in the economy: information collectedon incomes is secondary to this main objective. ong>Theong> result is that theexpenditure estimates are likely to be far more reliable than the figuresfor income. Evidence ong>ofong> the unreliability ong>ofong>the latter is the deficitbetween disposable income ong>andong> total expenditure, which is more thancan be attributed to definitional ong>andong> time reference problems. ong>Theong> underestimatefor income reflects the difficulty ong>ofong> collecting consistent datadirectly from private individuals in a household survey. People areunderstong>andong>ably reluctant to give full details ong>ofong> their personal incomes tointerviewers.Notwithstong>andong>ing these caveats, an analysis ong>ofong> the Household BudgetSurvey shows that the total direct weekly income ong>ofong> households withspouse ong>andong>/or children, headed by an elderly retired person (averageage 73.5 years compared to an average ong>ofong> 50 years for all households)is IR£63 (Household Budget Survey, 1987). This is 31 per cent ong>ofong> thetotal gross earned income ong>ofong> all households in the State. ong>Theong> inclusionong>ofong> welfare payments ong>andong> the tax system reduces the gap between elderlyong>andong> other households. When both ong>ofong> these factors are taken into accountthe income ong>ofong> retired elderly households improves to 63 per cent ong>ofong> thefigure for all households.This gap is reduced further when the composition ong>ofong> households is takeninto account ong>andong> adult equivalent rates are compared. ong>Theong> average sizeong>ofong> retired elderly households is 2.02 persons compared with 3.50 personsfor all households. If each child is counted as 0.25 ong>ofong> an adult, theaverage size ong>ofong> all households is reduced to 2.35 adult equivalents. 3Making these adjustments leaves the per capita disposable income positionong>ofong> retired elderly at £62 per week. This compares to a national percapita disposable income ong>ofong> £86. Interestingly, the per capita income forretired persons in single person households without spouse or childrenis £63 per week. For a complete picture, account should also be takenThis is not the only adult equivalent rate that could be used. See Callan ong>andong> Nolan.ong>Economicong> ong>andong> ong>Socialong> Review. July 1989.31


ong>ofong> the imputed value ong>ofong> non-cash benefits which elderly persons canobtain. One estimate suggests that the average non-cash benefit perrecipient is approximately 19 per cent ong>ofong> the money value ong>ofong> the noncontributorypension, personal rate (Blackwell, 1984).ong>Theong> breakdown ong>ofong> household income by source ong>ofong> income is revealing(Table 2.5). For elderly households without spouse or children Statetransfers constitute 57 per cent ong>ofong> gross income; for elderly householdswith wife ong>andong>/or children Sate transfers amounted to 53 per cent ong>ofong> grossincome. ong>Theong> corresponding figure for all households in the economy isTABLE 2.5: Sources ong>ofong> household incomeSource ong>ofong> IncomeSalaries/wagesSelf-employed — FarmSelf-employed — Non FarmPublic Pensionsong>Socialong> Assistance*Other ong>Socialong> SecurityPrivate/Occ. PensionsSavings/InterestIncome from PropertyOtherTotalPension Householdsa b4.93.71.943.81.911.619.74.41.56.6100.03.11.94.350.01.61.325.74.02.45.7100.0'Long-term social welfare.(a) Retired head ong>ofong> household without spouse/children.(b) Retired head ong>ofong> household with spouse/children.Source: Household Budget Survey, 1987.All Households62.05.96.45.12.210.33.31.10.73.0100.018 per cent. Private pensions account for 20 per cent ong>ofong> gross incomesfor single elderly households ong>andong> 26 per cent for elderly households withwife or children. Income from investments ong>andong> property constitute onlya small percentage ong>ofong> elderly gross income. Similarly, income from wagesong>andong> salaries is small, absolutely, ong>andong> relative to the proportion ong>ofong> allhouseholds in the State.Of particular importance to elderly person households is the trend inpurchasing power ong>ofong> their social welfare pensions. In this regard, theelderly have fared quite well during the 1970s ong>andong> 1980s. During the1970s in particular State expenditure on social welfare was channelledtowards households with old age pensioners. In contrast, households inwhich a young family was being raised ended the decade relatively less32


well ong>ofong>f (Breen et al., 1990). Table 2.6 shows the increase in real termsong>ofong> old age pensions, both contributory (social insurance) ong>andong> noncontributory(social assistance), during the period 1966 to 1985. ong>Theong>non-contributory old age pension had a higher average annual rate ong>ofong>change in the period 1966/76, while the real rate ong>ofong> growth ong>ofong> contributorypensions was higher in the period 1976/86.TABLE 2.6: Index ong>ofong>f the real value ong>ofong> selected welfare payments, certainyears (C.P.I. 1966 = 100)Paymentsong>Socialong> InsuranceOld age pension(couple aged 70/80)Unemployment benefit(single man)Unemployment benefit(couple)19661001001001976Widow's pension(four children)Disability benefit(couple & four children)ong>Socialong> AssistanceOld age pension(couple)Unemployment Assistance(single man)Unemployment Assistance(couple & four children)Widow's pension(four children)1001001001001001001611331411491601932181641602052102584.92.93.54.14.86.8Note: Payments ong>andong> prices at May each year.Source: Report ong>ofong> the Commission on ong>Socialong> Welfare, Table 7.1 p.130.1301141331985192145162AverageAnnual %Change1966/19762.71.32.9AverageAnnual %Change1976/19854.42.71.83.42.31.33.33.13.3Pensions have also increased relative to gross average earnings ong>ofong>workers. ong>Theong>re was a real increase ong>ofong> 17 per cent in the value ong>ofong> socialwelfare pensions between 1980 ong>andong> 1987. This compares favourably withan increase ong>ofong> only 6 per cent in real average industrial earnings duringthe same period. A comparison with after tax earnings would reveal aneven greater differential given the substantial tax "take" over this period(Callan et al., 1989). For single pensioners, the ratio ong>ofong> contributory33


pension to net earnings increased from 29 per cent in 1980 to 39 per centin 1987 (Table 2.7); in recent years the ratio has declined to 35 percent (NESC. 1990). ong>Theong> corresponding replacement rate 4 for singleunemployed persons is 27 per cent in 1990.TABLE 2.7: Net disposable incomes per annum ong>ofong> selected social welfarerecipients relative to disposable income ong>ofong> average male worker(1980—1990)19801981198219831984198519861987198819891990YearContributorypension% ong>ofong> earnings29.432.139.037.038.438.437.738.537.035.635.2Single PersonUnemployedbenefit% ong>ofong> earnings24.525.730.729.229.729.729.029.628.427.327.1Source: National ong>Economicong> ong>andong> ong>Socialong> Council, 1990.Married Person,2 childrenUnemployedbenefit% ong>ofong> earnings48.951.258.955.155.454.955.354.553.752.351.7All ong>ofong> this has contributed to the significant improvement in the incomeong>ofong> elderly households relative to other households since 1980. This isreflected in the results ong>ofong> recent surveys on poverty (Callan et al., 1989).Old people (males ong>andong> females) aged 65 years or over are now a lowrisk poverty group relative to other age categories in society, irrespectiveong>ofong> the cut-ong>ofong>f point, i.e.. whether a 40, 50 or 60 per cent line is taken(Table 2.8). Somewhat surprisingly households headed by elderly womenhave a lower risk ong>ofong> poverty than households headed by elderly men(e.g. 13 per cent ong>ofong> men aged 65 years or over are below the 50 per centpoverty line compared to 5 per cent ong>ofong> women). One possible explanationfor this may be the relatively high proportion ong>ofong> elderly men engaged insmall farming in Irelong>andong>; the latter activity has been identified as carryinga higher risk ong>ofong> poverty compared to other labour force categories.Another possible reason may be that households headed by elderlywomen simply contain more people making a contribution to householdincome.This figure is sensitive to the specific illustrations chosen ong>andong> relates only to averageearnings.34


TABLE 2.8: Risk ong>ofong> poverty by age ong>andong> sex ong>ofong> household head, 1987Age ong>andong>Sex Category40% line%Relative Poverty Line50% line%60% line%MaleUnder 3535-6465 ong>andong> over4.510.37.719.421.413.028.832.722.0FemaleUnder 3535-6465 ong>andong> overSource: Callan et al., 1989.11.77.42.421.714.44.741.638.026.5ong>Theong> position ong>ofong> households headed by an elderly person has alsoimproved over time. ong>Theong> proportion ong>ofong> old people below each povertyline decreased significantly between 1973 ong>andong> 1987 (Table 2.9). At the40 per cent line the improvement was concentrated in the 1973-80 period.For the 60 per cent line the decline was exclusively in the later subperiod;while at the 50 per cent line there was a significant decline in bothperiods. Even though households headed by an old person constituted 23per cent ong>ofong> all households in the sample in 1987 they comprised only 10-12 per cent ong>ofong> the households in poverty. Finally on the issue ong>ofong> relativeTABLE 2.9 : Risk ong>ofong> relative poverty for households headed by an oldperson, 1973, 1980 ong>andong> 1987 (proportion ong>ofong> old people below eachline)197313.233.844.819807.124.446.619875.69.723.7Relative Poverty Line40%50%60%Source: Callan et al., 1989.deprivation, the risk ong>ofong> poverty for households headed by retired oldpeople is less than the risk associated with other labour force categoriessuch as farmers, the unemployed ong>andong> the disabled (Table 2.10).Notwithstong>andong>ing the reduction in the risk ong>ofong> poverty, the proportion ong>ofong>old people living in households in the bottom quintile ong>ofong> the incomedistribution is high relative to other age groups (Table 2.11). Thirty percent ong>ofong> old people are at the bottom, compared to 4 per cent for the 45-65 age group ong>andong> 7 per cent ong>ofong> the 21-44 age group. ong>Theong> opposite is the35


TABLE 2.10: Risk ong>ofong> poverty by labour force status ong>ofong> head ong>ofong> household(HOH) 1987Labour Force Status ong>ofong> HOHEmployeeFarmerSelf-employedUnemployedIII but intending to seek workIII ong>andong> not intending to seek workRetiredHome DutiesAll householdsSource: Callan et al., 1989.40% line1.924.17.212.830.67.35.17.97.550% line4.435.811.658.951.225.011.412.317.560% line11.145.019.174.465.363.021.542.130.0TABLE 2.11: ong>Theong> age category distribution ong>ofong> persons in households byquintile ong>ofong> gross income distribution (1987)Gross Income Quintile21—44 45 — 65Bottom2nd3rd4thTopTotal7162325291001416202228100Source: Household Budget Survey, 1987 (Table 2); own calculations.65+303316129100case with respect to the top quintile ong>ofong> the income distribution, whichcontains only 9 per cent ong>ofong> all old people, compared to almost 30 percent ong>ofong> each ong>ofong> the other two age categories. A similar picture emergeswhen the proportion ong>ofong> retired old people at each quintile is comparedto other categories ong>ofong> the work force (Table 2.12). Once again relativelymore retirees are found in households in the bottom quintile ong>andong> relativelyfewer at the top.TABLE 2.12: ong>Theong> labour force status ong>ofong> persons in households by quintileong>ofong> gross income distribution (1987)Gross incomequintileBottom2nd3rd4thTopTotalEmployee15193045100Selfemployed1418232223100Unemployed203322169100Source: Household Budget Survey, 1987 (Table 2); own calculations.Retired26351812910036


ong>Theong> change over time in the distribution ong>ofong> elderly households by quintileong>ofong> gross income is shown in Table 2.13. Whereas, there was a significantreduction in the proportion ong>ofong> elderly households in the bottom categorybetween 1973 ong>andong> 1980. there was a slight increase between 1980 ong>andong>1987. As we have already noted redistribution in the seventies wasdominated by the transfer ong>ofong> resources from families at work, irrespectiveong>ofong> the burden ong>ofong> dependency, to households in which most or all ong>ofong> themembers were past retirement age (Breen et al.. 1990). That bias hasbeen less obvious in the 1980s, with other categories, such as the longtermunemployed ong>andong> child benefit recipients, receiving significant realincreases in Sate transfers. Moreover, the fact that older workers havebeen particularly prone to long-term unemployment in the 1980s meansthat their income may have been depressed prior to retirement, therebyaffecting their position in the distribution ong>ofong> income.TABLE 2.13: ong>Theong> distribution over time ong>ofong> elderly headed households bygross income quintileBottom2nd3rd4thTopTotalGross income Quintile197349221298100198039371275100198741301496100Source: Household Budget Survey; Rottman & Reidy, 1988 (Appendix, Table7.10); own calculations.Recent RetireesInformation from surveys suggests that the overall replacement rate forretired employees is relatively high, at 73 per cent (Whelan ong>andong> Whelan,1988). This means that the post-retirement income ong>ofong> the average respondentis just under three-quarters ong>ofong> his or her previous income fromwork — a drop ong>ofong> about a quarter. It is not surprising, therefore, to findthe same authors concluding that, on the whole, the recently retired areless prone to poverty than the population as a whole. However, olderpeople forced into retirement through ill-health or redundancy weremuch more likely to be classified as being in poverty than people whohad chosen retirement. Similarly, retirees from lower social classes hada much higher risk ong>ofong> poverty. Females were also more likely to sufferincome disadvantages in the transition to retirement.In general, recent retirees are better ong>ofong>f than other older people in respectong>ofong> household amenities (Table 2.14). Similarly, with the exception ong>ofong>37


TABLE 2.14: Household amenities for old peopleAmenitiesGardenInside WCFixed bath/showerSeparate kitchenFixed sinkTVWashing MachineTelephoneRefrigeratorCarCentral heatingElectric/GasfireRadioVacuum cleanerSource: Whelan & Whelan. 1988.Old People(>65)89.167.260.675.778.180.666.918.762.839.38.863.995.535.8RetiredSample92.194.388.498.897.696.071.640.892.548.131.673.697.878.7AllHouseholds90.578.673.183.0—85.658.429.675.059.123.7———car ownership, the recently retired are better ong>ofong>f than the population asa whole. That is not to say. ong>ofong> course, that the position ong>ofong> retirees maynot deteriorate over time. ong>Theong> evidence reported above relates only toa point in time for recently retired individuals. It should also be bornein mind that the amenities survey data for all households ong>andong> for thoseheaded by a person aged 65 years or over was collected in 1977 ong>andong> 1982respectively. Significant improvements since then may have affected thecomparison.Policy Issues ong>andong> Income Adequacy for Old Peopleong>Theong>re is general agreement that the incomes ong>ofong> older people haveimproved significantly over the past two decades. During the seventiesin particular, a disproportionate share ong>ofong> State subsidies, both in cashong>andong> through services, were concentrated on the elderly. Improved ong>andong>more widely available occupational pension schemes have also raisedincomes. ong>Theong> result has been a substantial reduction in the risk ong>ofong>poverty for old people.ong>Theong>re is not much information on whether significant differences inincome exist among categories ong>ofong> older people. However, we do knowthat redundancies ong>andong> ill-health, linked to social class, increases the riskong>ofong> deprivation among older people (Whelan ong>andong> Whelan. 1988). ong>Theong>risk ong>ofong> poverty is also likely to increase for old people living alone,especially women ong>andong> the very old (Blackwell, 1984). Both ong>ofong> thesecategories are much less likely to be receiving income from occupational38


pensions, or be covered by social insurance ong>andong>, therefore, tend to relyon social assistance for the bulk ong>ofong> their income. Beyond this, there isno evidence ong>ofong> extreme income polarisation among older people thoughsome old people are clearly better ong>ofong>f than others. This should not besurprising since people carry with them into old age the advantagesong>andong> disadvantages that they have accumulated during their life. Lifeexperience is. therefore, likely to be a significant factor influencing thequality ong>ofong> life in old age.Policy-makers have tended to focus on old people as a homogenousgroup rather than concentrating on particular sub-groups within thesector. Consequently, there has not been any recent policy initiativesseeking to improve the position ong>ofong> one group relative to another. Olderpensioners do receive an additional allowance but that has been in placesince 1972. Similarly, an additional allowance for pensioners living alonehas operated since 1977. ong>Theong> worry is that the needs ong>ofong> those old people(admittedly a minority) who continue to live in absolute poverty may beoverlooked in light ong>ofong> the common perception that old people are nowrelatively well-ong>ofong>f. In the report ong>ofong> the Working Party on Services forthe Elderly (1988) particular attention is paid to the need to bring aboutan increase in the incomes ong>ofong> old people living in absolute poverty. Ifthis is to happen it will fall to the State, since the expected increase inoccupational pension provision is unlikely to do much to alleviate theincome deprivation ong>ofong> these people.Home Living ArrangementsIn addition to changes in the age ong>ofong> the population, recent decades havebrought about significant changes in household size ong>andong> composition.ong>Theong> number ong>ofong> old people in multi-person households (3 or morepersons) fell from 228.550 (73 per cent) to 202,961 (55 per cent) between1961 ong>andong> 1981. Over the same period the number ong>ofong> elderly people inhouseholds consisting ong>ofong> man ong>andong> wife rose from 30,058 (10 per cent)to 65.364 (18 per cent). ong>Theong>se trends are important in the sense thatsmall households ong>andong> confinement to one generation per household tendto reduce the potential source ong>ofong> household carers ong>andong> hence to raisethe demong>andong> for other services.Perhaps even more significant is the increasing number ong>ofong> elderly personsliving alone in private households. From 32.210 (10 per cent) in 1961,this number has risen to 68.034 (18 per cent) in 1981 ong>andong> to 81,174 (21per cent) in 1986. This trend is expected to continue into the future (to25 per cent by the end ong>ofong> this decade). When compared to other OECDcountries, however, where typically around 40 per cent ong>ofong> old peoplelive alone, the Irish level is still relatively low.39


ong>Theong> impact ong>ofong> living alone on the demong>andong> for institutional care dependscrucially on the willingness ong>andong> ability ong>ofong> carers to continue caring whenthe caree lives outside their own home. Most caring is done withinhouseholds, but not exclusively so, ong>andong> there is no evidence ong>ofong> widespreadneglect by carers when an elderly person lives alone (O'Connoret al., 1988). ong>Theong>re is, however, evidence that living alone is one ong>ofong> thefactors likely to influence the placement ong>ofong> an elderly person into publiclong-stay institutional care (O'Shea ong>andong> Corcoran, 1989).Housingong>Theong>re is a high level ong>ofong> home ownership among old people in Irelong>andong>.Almost 80 per cent ong>ofong> elderly householders are owner occupiers comparedwith 77 per cent (which is still high in European terms) ong>ofong>households generally. ong>Theong>re is, however, no comprehensive up to dateinformation on the quality ong>ofong> housing for elderly persons in the country.ong>Theong> evidence which is available tells us that there are vulnerable oldpeople living in poor quality housing with few amenities. A survey byWhelan ong>andong> Vaughan (1982) found that elderly persons, especially thoseliving alone, tended to live in older dwellings compared to the rest ong>ofong>the population. ong>Theong>y were also more likely to live in households withoutwater ong>andong> sanitation. Power (1980) confirmed that old people livingalone were more likely to live in poor accommodation.ong>Theong>re is no doubt that an improvement in the housing conditions ong>ofong> themost vulnerable old people has taken place in recent years. This hasbeen the result ong>ofong> the work ong>ofong> the Special Task Force on HousingConditions for the Elderly, the Essential Repairs Scheme, the HouseImprovement Grant for Disabled Persons Scheme ong>andong> continuing (ifscaled down) local authority building programmes for the elderly. Nevertheless,ong>Theong> Years Ahead (1988), while acknowledging that the vastmajority ong>ofong> old people are now well housed, recommended that therelevant authorities carry out a comprehensive survey into the housingconditions ong>ofong> the elderly in order to establish the true picture. As partong>ofong> this survey special attention should be paid to old people living inprivate rented accommodation who, although small in number, are aparticularly vulnerable group. ong>Theong> most disadvantaged ong>ofong> all old peopleare, ong>ofong> course, those who are homeless. This group have traditionallyfound shelter in county homes ong>andong> in hostels run by voluntary groups.It is not known, however, how many elderly persons in the voluntarysector are there because ong>ofong> homelessness, nor whether they will continueto find accommodation in such homes.Local Authority housing is an important part ong>ofong> the strategy to ensuregood quality accommodation for elderly persons. Since 1972 local auth-40


orities have been allocating at least 10 per cent ong>ofong> all new dwellings toold people. At present the stock ong>ofong> local authority dwellings for theelderly is estimated to be approximately 12,000 units. What has beenhappening, however, is that although the proportion ong>ofong> housing unitsfor old people has generally been increasing, the absolute number ong>ofong> newlocal authority dwellings built every year has been falling, particularly inrecent years. Should this continue to happen, the likelihood is, giventrends in population, that there will be a shortage ong>ofong> local authorityhousing for old people before very long.In recent years public resources have been directed more towards encouragingthe development ong>ofong> voluntary housing than to the building ong>ofong>public housing. A new scheme ong>ofong> financial assistance for voluntarygroups providing housing for disadvantaged groups was introduced in1984. Funding from statutory resources is, at present, confined to 90 percent ong>ofong> the cost ong>ofong> an eligible project, subject to a maximum ceiling ong>ofong>IR£22,500. ong>Theong> recent provision ong>ofong> housing by voluntary groups supportedby the exchequer has been an important innovatory componentong>ofong> housing policy in Irelong>andong>. That said, the voluntary sector contributesless than in many other countries to housing the elderly. Moreover, ifthis sector is to expong>andong> further then statutory funding for the maintenanceong>andong> repair ong>ofong> buildings will have to be provided. In addition, resourceswill have to be made available, where appropriate, for the infrastructuralong>andong> manpower support which will sometimes be necessary to ensure thatold people can continue to live in this type ong>ofong> housing as they becomemore frail.Sheltered HousingSheltered accommodation usually provides grouped housing with a rangeong>ofong> support services including a warden ong>andong>/or alarm system. ong>Theong> usualtarget population for sheltered housing is elderly persons who, althoughnot in need ong>ofong> hospitalisation, are too frail or vulnerable to remain inprivate accommodation. Sheltered housing is usually defined by thepresence ong>ofong> a warden, although some schemes have only a part-timewarden ong>andong> others rely solely on an alarm system to attract attention asrequired. A variety ong>ofong> sheltered schemes exist in Irelong>andong> with considerabledifferences in size, design, on site facilities, ong>andong> communitycare services provided. ong>Theong> most recent information suggests that thereare 117 sheltered housing schemes (broadly defined) in the countryincorporating 3,504 units, with just over 1,000 persons on waiting lists(O'Connor etal., 1989).Establishing the optimum number ong>ofong> units is a difficult task. Indicationsfrom other countries suggests a target rate ong>ofong> between 25 ong>andong> 50 units41


per 1.000 elderly people. If this target is used for Irelong>andong> then the currentnumber ong>ofong> sheltered housing units is considerably below what might beconsidered even adequate, let alone optimal. However, much moreinformation on normal housing needs is required before more definitivestatements can be made in this area. It is important to avoid a caringsystem whereby frail elderly persons have to be kept on the move to getthe care they need. That is why most emphasis should be placed onbarrier free, normal housing in the community.This raises the fundamental issue ong>ofong> what factors are important whenselecting old people for placement in sheltered housing. ong>Theong>re is broadagreement that the state ong>ofong> current private housing accommodationshould affect decision-making ong>andong> poor housing conditions have beenidentified as the single most recurrent reason for old people moving intosheltered housing (O'Connor et al.. 1989). But the physical ong>andong> mentalhealth ong>ofong> the applicants also matters. Most crucially ong>ofong> all it will only bewhen sheltered housing is seen as part ong>ofong> an integrated system ong>ofong> carethat optimal placement will occur. This means that community careservices, organised to meet the requirements ong>ofong> old people in shelteredhousing, have a vital role to play in the success ong>ofong> schemes. For example,day centres incorporating paramedical ong>andong> preventive services based insheltered housing schemes could enable suitable elderly persons toremain for much longer in this environment.Boarding OutBoarding-out is an innovatory form ong>ofong> community living that is increasinglybeing used as an option in the care ong>ofong> old people. Section 10 ong>ofong> thenew Health (Nursing Homes) Act. 1990. provides health boards inIrelong>andong> with the power, under the regulations, to make ong>andong> carry outan arrangement for the boarding-out ong>ofong> elderly persons. Boarding-outentails the placement, usually with a non-relative in a private household,ong>ofong> a suitable old person with the carer receiving some reward for his orher care ong>ofong> the person placed. This option has already been triedsuccessfully in some health boards in Irelong>andong>. It is particularly suited toold people who can no longer live on their own but who do not needday-to-day nursing care. Under the new Act there are strict guidelineslaid down regarding the stong>andong>ard ong>ofong> the homes chosen for boarding-outas well as ongoing monitoring ong>ofong> the quality ong>ofong> care within the household.Each home is inspected every six months by a public health nurse ong>andong>should a crisis occur the health board assumes direct responsibility forthe care ong>ofong> the old person. Carers, at present, receive approximatelyIR£20 per week from the health board towards the cost ong>ofong> placementwhile the elderly person pays a similar amount from his or her pension.42


ong>Theong> potential ong>ofong> boarding-out as a general option in care ong>ofong> the elderly hasnever been properly evaluated. However, existing small scale research inthis area, while based on rather restrictive assumptions concerningoutcomes ong>andong> quality ong>ofong> care, does lend support to boarding-out as alow cost alternative to institutional care (O'Shea ong>andong> Costello. 1991).Clearly, more documented research is required before boarding-out canbe fully endorsed as a national option in care ong>ofong> the elderly. In particular,the relative health outcomes ong>ofong> boarding-out versus alternative regimesong>ofong> care must be established. ong>Theong> marginal cost ong>ofong> expong>andong>ing boardingoutmay also be different than the average cost; more carers may onlycome forward if payment rates are higher. Moreover, the quality ong>ofong>carers may become variable as may the quality ong>ofong> housing. At present,stong>andong>ard criteria are not in place to assess the suitability ong>ofong> carers orhousing. Such criteria would have to be developed if the service is toexpong>andong> from its present base.Most importantly ong>ofong> all. the extent to which the existing community careservices can absorb an expansion ong>ofong> the boarding-out option needs tobe established. De-institutionalisation has already caused major problemsfor an over-stretched community care system (O'Connor. 1987:Blackwell et al. 1992). If that system is to be placed under additionalpressure by having more boarding-out places then the quid pro quo mayhave to be an expansion ong>ofong> community facilities.Contact with KinIt is important when talking about social contact ong>andong> older people to beaware that desolation rather than isolation may be the fundamentalcause ong>ofong> loneliness in old age (Townsend. 1957). Thus, for example.Power (1980) found that a majority ong>ofong> elderly bachelors living in ruralareas in Irelong>andong> had adjusted to their solitary lifestyle ong>andong> were less proneto depression than old people in general. However, notwithstong>andong>ing thiscaveat, it remains true that the persons who suffer most from lonelinessare more likely to be those who live alone without any social contact.Much ong>ofong> the information on the social contact ong>ofong> elderly persons inIrelong>andong> is now ten years old (Whelan ong>andong> Vaughan, 1982). Overall,about 92 per cent ong>ofong> respondents in their survey had talked to someoneon the two weekdays immediately preceding the interview (Table 2.15).Most contact had been with a friend or neighbour (81 per cent). Contactwith children was next most significant — about 50 per cent ong>ofong> respondentshad seen their children within the past two days. Those livingalone, had, not surprisingly, much less contact with their children (33per cent). Many older people living alone are. in any event, childless.43


TABLE 2.15: Details ong>ofong> when respondent last talked to relatives ong>andong> friends, classified by area ong>ofong> residenceong>andong> type ong>ofong> householdTime ong>ofong> most recent contactwithChildren/Grong>andong>childrenOn last 2 weekdaysWitin last 7 daysWithin last monthMore than a month agoHas no children/grong>andong>childrenBrothers/Sisters/Nieces/NephewsOn last 2 weekdaysWithin last 7 daysWithin last monthMore than a month agoHas no shiblings or nieces/nephewsOther relativesOn last 2 weekdaysWithin last 7 daysWithin last monthMore than a month agoHas no relativesFriends or neighboursOn last 2 weekdaysWithin last 7 daysWithin last monthMore than a month agoNot applic.All personsOn last 2 weekdaysWithin last 7 daysWithin last monthMore than a month agoWhelan ong>andong> Vaughan, 1982, Table 9.2.Urban AreasMarried Other AllSingle 0.5—Couple Type ong>ofong>38.7 7.5 5.0 6.3 42.5 17.7 17.7 12.7 22.8 29.1 12.8 24.4 16.7 33.3 12.8 86.1 12.7 1.3 54.7 15.4 8.4 2.1 19.4 13.8 18.9 23.9 33.0 10.4 16.1 19.3 11.2 35.5 17.9 88.3 10.4 Household57.410.72.91.627.419.715.914.834.115.620.317.516.527.917.877.517.71.2— — 93.7 6.3 —— 0.7 0.7 — 92.4 7.6 —— 2.21.392.27.4Household53.410.94.22.528.918.416.715.931.817.318.219.115.730.216.980.915.61.11.60.891.67.20.30.9Rural AreasSingle Married OtherCouple 26.4 48.5 12.2 18.3 1.5 6.5 1.5 5.3 58.1 21.4 21.6 15.9 23.0 12.9 8.1 20.7 33.8 41.7 13.5 8.7 18.9 20.7 24.3 19.1 10.8 11.8 43.2 41.9 2.7 6.5 86.5 85.2 9.5 14.1 2.7 0.7 1.4 — — — 94.6 91.7 5.4 8.4 —— —— Type ong>ofong>Household61.37.33.36.831.217.616.218.332.115.824.323.416.727.58.180.116.12.60.70.590.67.91.30.2AllHousehold48.09.43.56.033.117.916.617.433.614.523.222.915.431.37.381.515.12.30.70.491.27.71.00.1Single32.59.73.33.950.019.620.310.528.121.615.824.313.838.27.986.311.12.00.794.06.00.00.0All AreasMarriedCouple51.217.07.43.820.515.015.622.137.89.518.619.211.539.011.786.612.40.70.392.17.90.00.0OtherType ong>ofong>Household53.58.53.24.929.918.516.217.032.715.722.921.216.627.711.679.116.82.11.30.891.17.91.00.0AllHousehold50.210.03.84.631.518.116.716.832.815.021.221.415.530.911.181.215.31.81.00.691.77.60.70.0


Proximity was a major factor in determining contact with children forall old people, though the increased ownership ong>ofong> cars ong>andong> telephonesover the past decade has probably reduced the primacy ong>ofong> this factor.ong>Theong> survey had. however, little to say about the depth, range ong>andong>frequency ong>ofong> elderly contacts.Whelan ong>andong> Whelan (1988) emphasise the importance ong>ofong> family as animportant ong>andong> preferred source ong>ofong> social contact for recently retiredworkers. No significant differences among social classes emerged withregard to contact with kin. Families are an important ong>andong> preferredsource ong>ofong> social support across all classes. In general, however, the effectong>ofong> contact on morale ong>andong> well-being is dependent on dimensions ong>ofong>contact other than its quantity. It is the quality ong>ofong> contacts together withthe maintenance ong>ofong> independence within the exchange which mattersmost in network relationships.45


CHAPTER 3ong>Theong> Labour Market ong>andong> Older WorkersIntroductionIn this chapter the position ong>ofong> older workers in the labour market isconsidered. In particular, their labour force participation 1 rates, unemploymentrates ong>andong> duration ong>ofong> unemployment are compared to otherage groups in society. Exit from the labour market for older workers is nolonger regulated only by public retirement systems. Instead, redundancy,disability ong>andong> voluntary early retirement are increasingly determiningthe labour force status ong>ofong> older workers. This raises the related questionong>ofong> whether older workers are being discriminated against. Both "push"ong>andong> "pull" factors are likely to influence the decisions made by olderworkers. That is what makes the social dynamics ong>ofong> the relationshipbetween employers, older workers ong>andong> the State so crucial to ourunderstong>andong>ing ong>ofong> how the labour market works. In the first instance,however, it is necessary to consider the overall performance ong>ofong> the Irishlabour market during the past decade.ong>Theong> Labour Market in Irelong>andong>ong>Theong> Irish economy did not perform well in the first half ong>ofong> the 1980s.This is reflected in a fall ong>ofong> 6.5 per cent in total employment (NESC,1990). Since 1986, however, the Irish economy has performed relativelywell; the result has been an increase in employment ong>ofong> 3.6 per cent,though the relationship between output growth ong>andong> employment gainsremains weak. Neither is there a one-for-one relationship betweenincreases in employment ong>andong> reductions in unemployment. ong>Theong> labourmarket is much more complex than this simple relationship allows,reflecting the interdependence between developments on the demong>andong>side ong>andong> supply responses. For instance, an increase in demong>andong> may'ong>Theong> labour force participation rate is defined as the ratio ong>ofong> persons in the labour force(employed ong>andong> unemployed) to the population in the relevant age group.46


encourage people outside the labour market to re-enter ong>andong> thereforeadd to the numbers seeking work. ong>Theong> issue is further complicated inIrelong>andong> by the openness ong>ofong> the labour market, with net migrationparticularly responsive to changes in employment opportunities in thecountry. Indeed any discussion on the true rate ong>ofong> unemployment mustbe qualified by consideration ong>ofong> the underlying rate ong>ofong> emigration,particularly as the majority ong>ofong> those leaving the country do so becausethey cannot find a job (Sexton et al.. 1991).Unemployment in Irelong>andong> is measured by the Live Register (LR) (thenumber ong>ofong> people signing on) ong>andong> on a much less timely basis by theLabour Force Survey (LFS). In the LFS a sample ong>ofong> about 45,000households are interviewed ong>andong> a person is classified as unemployed ifhe or she is not working but is actively seeking a job. Unlike the LFS,the LR is not specifically designed to measure unemployment ong>andong> morethan likely contains some people who are receiving benefit but are notavailable for work in the strict sense ong>ofong> "'actively seeking a job." Unlessotherwise stated the LFS is the source for all rates ong>ofong> employment ong>andong>unemployment reported in this study.FIGURE 3.1: Unemployment Rate 1960-1990


Figure 3.1 shows the rate ong>ofong> unemployment as measured by the LabourForce Survey. Unemployment increased significantly in the 1980s reachinga peak ong>ofong> 17.5 per cent in 1987. Between 1987 ong>andong> 1990 the rate ong>ofong>unemployment declined by 23 per cent on foot ong>ofong> rapid economic growthduring the period. Since then, however, unemployment has increasedagain as net outward migration has declined due to the slackness ong>ofong> theUK labour market. Not only is the overall rate ong>ofong> unemployment high,so also is the rate ong>ofong> long-term unemployment which is reflected in along average duration ong>ofong> unemployment. For instance, at the beginningong>ofong> the 1980s 39 per cent ong>ofong> males on the live register were unemployedfor more than one year; at the end ong>ofong> the decade the proportionunemployed for more than one year had risen to 46 per cent. What isalso striking about unemployment in Irelong>andong> is how it is concentrated inthe lower social classes (Breen et al., 1990); for instance, the risk ong>ofong>unemployment among non-agricultural unskilled workers is significantlygreater than for people working in the services sector.Labour Force Participationong>Theong> overall labour force participation rate in the economy has remainedrelatively stable, at approximately 52 per cent, between 1975 ong>andong> 1990.ong>Theong> difference between the participation rates ong>ofong> men ong>andong> women is,however, significant (Table 3.1). Male labour force participation averages71 per cent ong>andong> does not differ very much by marital status or acrossregions. Female participation is much lower than males, averaging 32per cent, with significant differences across regions ong>andong> between singleong>andong> married women. ong>Theong> overall labour force participation ong>ofong> womenhas, however, been increasing over time; for instance, whereas only 5per cent ong>ofong> married women were in the labour force in 1961, the ratehad increased to 20 per cent at the end ong>ofong> the 1980s. New opportunitiesfor female employment, the removal ong>ofong> legal barriers (in accordancewith EC regulations), changes in family formation, ong>andong> demong>andong>s forhigher stong>andong>ard ong>ofong> living have all combined to raise participation ratesfor women.Traditionally, the labour force participation rate ong>ofong> older workers inIrelong>andong> has been higher than in other countries. This has been largelydue to the structure ong>ofong> the economy — in particular, the high proportionong>ofong> the older population engaged in farming. In recent decades, however,the decline in the numbers engaged in farming ong>andong> improvements in thesocial welfare system have contributed to a reduction in the labour forceparticipation ong>ofong> older workers. More recently, the "shake out" ong>ofong> olderworkers from the labour force has been greatly influenced by the dramaticincrease in unemployment in the economy. Many older workers48


TABLE 3.1: Labour force participation rates (%)MALE19751976197719781979198019811982198319841985198619871988198919901991Year


females aged 65 years or over during the period 1926 to 1989 is clearfrom Table 3.2. In 1926 close to 75 per cent ong>ofong> elderly males were activein the labour market. By 1960 participation was down to 50 per centwhile the rate for 1990 is 16 per cent. Female participation rates havealso declined, though from a much lower starting base than for males.TABLE 3.2: Labour force paricipation rates by sex for people aged 65ong>andong> over, 1926 — 1988 (selected years)1926*1936*1946*1951*1961*1966*1971*1979#1981*1985#1988#1989#1990#1991#YearSources: * Census ong>ofong> Population.# Labour Force Survey.Males73.563.762.858.451.548.444.026.023.816.018.016.815.915.8Females23.421.918.817.015.013.211.34.64.83.53.53.13.13.0ong>Theong> downward trend is similar for older workers (males ong>andong> females)aged between 60 ong>andong> 64 years. In 1975 the labour force participationrate ong>ofong> male workers in that age category was 77 per cent; by 1990 therate had fallen to 57 per cent (Table 3.1). ong>Theong> rate for females in thiscategory declined from 19 to 15 per cent. ong>Theong> participation rate has alsodeclined for males in the 55-59 age categorv. though less dramatically,declining from 87 per cent in 1975 to 80 per cent in 1990. ong>Theong> rate forwomen in this category was largely unchanged during that period,at around 22 per cent. ong>Theong> participation rate for females increasedsignificantly in the remaining age categories, with the most dramaticincrease occurring in the 25-34 age category. Among women, therefore,two opposing trends are evident, increasing participation rates for youngerage categories ong>andong> earlier retirement for older groups.Overall employment rates for males have fallen from 71 per cent in 1978to 60 per cent in 1990 (Table 3.3). In contrast, the rate ong>ofong> employmentfor females has been relatively stable during this period; the increase inemployment rates for women in age category 25-44 has ong>ofong>fset the declinein the very young ong>andong> very old groups. Similar reductions in employment50


TABLE 3.3: Percentage at work by age category, males ong>andong> females.1975-1990*19751977197919831984198519861987198819891990199115-24M F67.365.662.049.546.746.142.440.240.340.341.638.945.444.249.844.343.641.640.138.536.636.937.134.425-44M F89.288.689.982.381.379.079.378.879.379.681.880.221.921.227.632.031.531.033.336.237.138.140.942.645-64M F81.480.879.475.574.371.270.970.870.269.269.970.121.821.021.222.320.419.919.721.120.319.922.022.565+M F28.125.725.419.718.315.317.316.617.416.415.315.37.25.54.64.53.43.43.42.83.43.12.92.8TotalM F70.969.671.163.862.360.159.658.859.058.860.058.727.426.327.528.127.126.326.727.527.327.428.828.9'Labour Force Survey was not taken in years 1976, 1978, 1980, 1981 ong>andong> 1982.Source: Labour Force Survey (various years).are evident for very young ong>andong> very old male workers. Increased participationin education ong>andong> changes in the structure ong>ofong> work, particularlythe decline in the numbers engaged in agriculture, allied to higher ratesong>ofong> unemployment ong>andong> migration have been responsible for the observedpattern ong>ofong> employment in the Irish economy.ong>Theong> long-term decline in overall employment rates has recently beenpunctuated by relatively strong gains in employment, most notablybetween 1987 ong>andong> 1990 when the level ong>ofong> employment increased by46,000 or 4.3 per cent (Gray. 1992). Although employment fell slightlyin 1991. due largely to a sharp decline in agricultural employment, theforecast for 1992 ong>andong> beyond remains reasonably optimistic, though anyimprovement is unlikely to lead to a major reduction in unemployment.Retirement Hazard RatesOne way to identify the trend towards earlier retirement from the labourforce is to calculate the retirement hazard rate. ong>Theong> latter represents theprobability ong>ofong> retirement at age T given labour force participation at ageT-l. A crude calculation ong>ofong> the retirement hazard rate can be made fromthe participation rates shown in Table 3.1. This is done by assumingthat the cross-section participation probabilities are the same as theparticipation probabilities as an individual ages (Hurd. 1990). Using thismethod ong>ofong> calculation, the probability ong>ofong> retiring in 1975 at ages 60-64.given labour force participation at ages 55-59. was 0.113 for men ong>andong>51


197519821990YearTABLE 3.4: Retirement hazard ratesAge Categories55-59 to 60-6460 — 64 to 65+Men Women Men Women0.1130.1510.2820.1490.1940.330Source: Author's calculations based on Table 3.1.0.6350.6870.7220.6190.7370.7880.149 for women (Table 3.4). Thus, even for the relatively small numberong>ofong> women in the labour force, their retirement probabilities were higherthan for men. By 1990 the retirement hazard rates for both men ong>andong>women had increased significantly, though the rate for women is stillhigher than the rate for men. ong>Theong> hazard rates for males ong>andong> femalesover 65 years ong>ofong> age are roughly similar, though, once again, both ratesincreased between 1975 ong>andong> 1990.Unemployment ong>andong> Older WorkersAll age categories (male ong>andong> female) experienced an increase in unemploymentduring the 1980s (Tables 3.5 ong>andong> 3.6). : Most ong>ofong> the increaseswere concentrated in the first half ong>ofong> the decade, reflecting the dismalperformance ong>ofong> the Irish economy during that period. ong>Theong> unemploymentrate for males ong>andong> females in the age categories 55-59 ong>andong> 60-64 followed the general upward trend; the rate for males almost doubledTABLE 3.5: Unemployment rates for men by age category 1981-1990*YearAge Category198119831984198519861987198819891990


TABLE 3.6: Unemployment rates for women by age category 1981- 1990*YearAge Category


scheme which formally requires them to be unavailable for work. Furtherinvestigation is required before anything more definitive can be said onthis issue.ong>Theong> increase in unemployment in Irelong>andong> has not involved a proportionaterise in short ong>andong> long-term unemployment. ong>Theong> number ong>ofong>people with one to four weeks unemployment experience has increasedvery little relative to the amount ong>andong> proportion ong>ofong> long-term unemployment.Similarly, the admittedly truncated evidence from redundancydata suggests that inflows into unemployment have not been sufficientlylarge on their own to cause the huge increase in rates ong>ofong> unemployment.This leaves longer spells ong>ofong> unemployment as the primary reason for thegrowth in unemployment.Older unemployed workers have suffered most hardship in this regard,experiencing longer spells ong>ofong> unemployment than younger workers. In1989 almost half ong>ofong> male unemployed workers aged 60-64 years wereunemployed for more than two years. In contrast, just over 31 per centong>ofong> male workers aged between 25 ong>andong> 34 years were out ong>ofong> work for twoor more years at that time (Table 3.7). ong>Theong> proportion ong>ofong> older workersunemployed for more than two years fell to just over one-third between1989 ong>andong> 1991 reflecting, once again, the impact ong>ofong> the Pre-RetirementAllowance Scheme in taking older people ong>ofong>f the live register. Generally,however, if one ignores this artefact the Irish data points to an increasein median unemployment duration as age rises, with very few exceptions.TABLE 3.7: Duration ong>ofong> male unemployment: percentage unemployedby age category (April, 1989 ong>andong> 1991)AgeUnder 20 years20 — 24 years25 — 34 years35 — 44 years45 — 54 years55 — 59 years60 — 64 yearsTotal MalesLess than6 months1989 199157.742.735.429.027.926.221.233.760.146.739.530.627.824.233.536.9Source: Statistical Bulletin: various.6 months to1 year1989 199125.018.617.715.715.715.314.717.223.218.917.314.814.414.718.116.81 to 2years1989 199114.816.615.515.215.115.517.015.614.314.614.413.613.614.314.714.1More than2 years1989 19912.622.131.440.141.342.947.133.62.319.428.841.144.146.733.732.2Institutional Routes out ong>ofong> the Labour MarketPublic systems ong>ofong> old age ong>andong> retirement pensions (contributory ong>andong>non-contributory) are no longer regulating final exit from the labour54


market. Traditionally, most older workers could expect to move straightfrom work to retirement, without any intermediate stages. More ong>andong>more, however, exit from the labour market now affects a significantnumber ong>ofong> older people before they qualify for a public pension. ong>Theong>result is that other forms ong>ofong> social security are now used to ease thetransition between leaving work ong>andong> ong>ofong>ficially recognised old age. Inparticular, unemployment ong>andong> invalidity payments have, in manyinstances, been turned into a sort ong>ofong> quasi-old age insurance. Or alternatively,as we have seen in the preceding section, new schemes havebeen introduced which reclassify workers into an ong>ofong>ficial retirementcategory.Most ong>ofong> our information about the reasons for retirement from thelabour market in Irelong>andong> comes from a survey by Whelan ong>andong> Whelan(1988). Although the focus ong>ofong> their work is on those people who retiredas employees in the previous five years (thereby omitting older personswho have not been in the labour force for a number ong>ofong> years, as well asignoring the self-employed) it is the only data we have on routes out ong>ofong>the labour market for older workers. All ong>ofong> the evidence suggests thatretirement is no longer a phenomenon that only occurs when a personreaches 65 years ong>ofong> age. ong>Theong>re is a wide dispersion around that age. Infact, only one quarter ong>ofong> employees had retired at 65 years ong>ofong> age.Differences also emerge in the age ong>ofong> retirement by social class. Thosein the lowest social classes are most likely to retire earlier than later.For example, almost three-quarters ong>ofong> those retiring early were frommanual backgrounds although they comprised less than three-fifths ong>ofong>the sample. Almost 1 in 4 manual workers retire before 60 years ong>ofong> agecompared with less than 1 in 7 prong>ofong>essional ong>andong> managerial workers.ong>Theong> poor labour market performance ong>andong> conditions in Irelong>andong> mayhave also led to some older workers seeking ong>andong> settling for the statusong>ofong> disabled. ong>Theong> concern in recent years with youth unemployment mayhave created a climate favourable to the reclassification ong>ofong> older workersinto disablement categories. Almost 30 per cent ong>ofong> respondents in theabove survey had retired on health grounds (Table 3.8). Though wehave no way ong>ofong> telling whether this is more or less than in previous yearsthe fact that so many workers retired for health reasons cannot beexplained by working conditions, or the inadequacy ong>ofong> health ong>andong> safetyregulations in the work-place. ong>Theong> fact that there were significant variationsby social class in the reasons given for retirement does nothingbut support the view that in a labour surplus economy a climate existsfor the classification ong>ofong> some older workers into the disabled category.Many older workers retire because they have been made redundant.ong>Theong> evidence from the survey referred to above is that 13 per cent ong>ofong>55


TABLE 3.8: Reasons for retirement by social class (per cent by row)ong>Socialong> ClassCompulsory RetirementHealth Age Redundancy% % %OtherTotalTotal%%NProng>ofong>essional ong>andong>ManagerialRoutine Non-ManualManualTotal13.725.034.628.348.733.327.933.59.511.715.013.128.430.022.525.510010010010095120280495Source: Whelan ong>andong> Whelan (1988).older workers had retired for this reason. Further deterioration ong>ofong> thelabour market since the survey was taken has, more than likely, meantthat redundancy has become even more important as an influence onfinal exit. Given that older workers in Irelong>andong> have always found itdifficult to find jobs even in times ong>ofong> relatively buoyant labour demong>andong>(Whelan ong>andong> Walsh, 1977) it is perhaps not surprising to find thatduration ong>ofong> unemployment is so pronounced in this age category. Redundancyis also more common for older workers in the private sector wherethe risk ong>ofong> layong>ofong>f is three times more likely than in the public sector."Push" rather than "pull" factors now determine the exit ong>ofong> many olderworkers from the labour market. "Push" factors are stronger in thelower social classes, where the risk ong>ofong> redundancy is relatively higher;voluntary ong>andong> mong>andong>atory retirement is more ong>ofong>ten found in high statusoccupations. ong>Theong> public system ong>ofong> pensions is, therefore, no longer theprime determinant ong>ofong> exit from the labour market for many olderworkers. ong>Theong> concept ong>ofong> retirement, old age, invalidity ong>andong> unemploymenthave all been modified. ong>Socialong> expenditure on old people isno longer confined to the pension system. Instead, the risks associatedwith old age are spread across a whole range ong>ofong> social security schemes,particularly those ong>ofong> unemployment ong>andong> disability.ong>Theong> danger is that insurance based systems will be undermined bythe transfer ong>ofong> the risks ong>ofong> old age to means tested social assistanceprogrammes. Moreover, although old people are currently considereda deserving welfare category they may not always enjoy that status,especially as numbers ong>andong> expenditure increase during the next twodecades. If the trend continues whereby older workers are de factoretired once they lose their jobs, for whatever reason, provision willhave to be made for a flexible adjustment to both the public ong>andong>occupational pension systems to allow older workers to qualify forpayment at an earlier stage ong>ofong> the life cycle. Otherwise, stable ong>andong>56


universal coverage which currently exists under contributory pensionschemes (qualifying age 66 years) will be replaced by intermediaryprovisions which are essentially selective, stigmatising ong>andong> non-automatic.In other words, the rights accorded under intermediary arrangementsmay be very limited compared with those that are guaranteedwithin the framework ong>ofong> social insurance schemes.ong>Socialong> Dynamics in the Transition from Work to RetirementRetirement from active life in Irelong>andong> has become less optional; unemploymenthas also meant that it has become more common at an earlierstage ong>ofong> the life-cycle. For older workers who become unemployed theirworking lives are effectively finished. This, in turn, may have a damagingeffect on their psychological well-being. Recent evidence suggests arelatively strong association between long-term unemployment ong>andong>psychiatric disturbance (Whelan et al., 1991). ong>Theong>re is no evidence,however, ong>ofong> any marked differential by age in respect ong>ofong> the effect ong>ofong>unemployment on psychological distress. Men in the age category 55-64are, if anything, more likely to have lower levels ong>ofong> stress compared tomen in the preceding age category 45-54 (Nolan. 1991).Retirement from the labour market, whether voluntary or involuntary,does, however, require an adjustment on the part ong>ofong> the retiree tochanged economic ong>andong> social circumstances. ong>Theong> absence ong>ofong> social contactong>andong> structured activity, allied to feelings ong>ofong> economic worthlessnessmay, for instance, cause severe dislocation. On the other hong>andong>, ong>ofong>course, retirement may result in more opportunities to engage in leisurepursuits, something denied an individual during their working life. Ingeneral, the costs ong>andong> benefits associated with retirement are likely tovary from person to person, but there are some general points that canbe made. ong>Theong> most obvious ong>ofong> these is that negative attitudes to workdo not automatically result in a positive response to retirement whenthe latter replaces work. Indeed, the evidence seems to suggest thatenjoyment ong>ofong> work, where it does have an effect, has a positive influenceon retirement (Whelan ong>andong> Whelan, 1988).Evidence from the same source suggests that variations in the enjoymentong>ofong> retirement cannot be explained by the amount ong>ofong> time devotedto leisure activities after retirement. Instead, the major factor in thesuccessful adjustment to retirement seems to be the development, overa lengthy ong>andong> preferably predictable pre-retirement period, ong>ofong> a sufficientlyvaried ong>andong> full lifestyle. This lends support to the view thatmore flexible work arrangements ong>andong> retirement procedures, includingthe promotion ong>ofong> more varied lifestyles, should be a necessary part ong>ofong>public policy in this area. Flexibility ong>ofong> this sort might encourage old57


people to develop a hobby or become a member ong>ofong> a voluntary organisation,both ong>ofong> which are positively ong>andong> significantly related to theenjoyment ong>ofong> retirement.ong>Theong>re are significant differences among social classes in attitudes to ong>andong>enjoyment ong>ofong> retirement. For instance, manual workers are least likelyto indicate that they are enjoying retirement. ong>Theong>y experience greaterdiscontinuity between work ong>andong> retirement than other groups. All ong>ofong>this suggests a role for publicly provided programmes to prepare oldpeople for retirement. Without such an intervention there may be nohope ong>ofong> preventing some ong>ofong> the basic inflexibilities ong>andong> injustices in thework-place from spilling over into retirement.Discrimination ong>andong> Older WorkersAge discrimination is not an issue that has received much attention inIrelong>andong>. Consequently, it is not surprising that older workers receive nospecial protection or rights under Irish law. Yet, it is clear that thedecline in the activity rates ong>ofong> older workers, their longer spells ong>ofong>unemployment ong>andong> the tacit encouragement they ong>ofong>ten receive to leavethe labour force points to some element ong>ofong> discrimination. ong>Theong> fact thatthere has been no explicit discussion on inter-generational conflict in thelabour market may have less to do with its absence ong>andong> all to do withthe subtle societal pressures on older workers to submit to a passiveong>andong> dependent mode ong>ofong> thought ong>andong> action. Certainly, labour marketflexibility has usually been defined for older workers in one directiononly — exit from the labour force.Finding evidence to support the view that older workers are discriminatedagainst in the labour market is difficult. Certainly one doescome across job advertisements which place age restrictions on applicants.This is not surprising since there is no legislation in place to preventthis happening: in contrast laws do exist to prevent discrimination onthe basis ong>ofong> gender. ong>Theong>re are also suspicions that older unemployedworkers receive lowest priority for retraining ong>andong> are ong>ofong>ten selected outong>ofong> placement schemes on the basis ong>ofong> age. Claims that there have beensystematic efforts to reduce the youth unemployment problem throughthe redundancy ong>ofong> older workers are even more difficult to substantiate.Not surprisingly there have not been any explicit public policy statementsin this regard. Nevertheless, schemes designed to change the labourmarket position ong>ofong> older workers have been tried. For instance, earlyretirement schemes have been available at different times in the publicsector, especially during the 1970s ong>andong> early 1980s. Such schemes were,however, less an attempt to reduce overall participation rates ong>andong> morean effort to reduce the exchequer pay bill. Reclassifying older unem-58


ployed persons as early retirees (e.g.. the Pre-Retirement AllowanceScheme discussed above) is, ong>ofong> course, another way ong>ofong> altering the labourforce status ong>ofong> older people. ong>Theong> benefit to the government ong>ofong> thisreclassification is that measured unemployment is lower than it wouldotherwise be. but at a cost ong>ofong> displacing workers from the labour market.Policy IssuesIt is not possible to separate the discussion ong>ofong> retirement from the stateong>ofong> the labour market. For example, there is little doubt that in periodsong>ofong> labour surplus early retirement is more acceptable to everybody.ong>Theong>re is no evidence, however, ong>ofong> a direct relationship between retirementong>andong> the provision ong>ofong> jobs for unemployed younger workers. Certainlyearly exit from the labour market in Irelong>andong> has not succeeded inalleviating the problem ong>ofong> unemployment. Moreover, as Layard (1986)points out. early retirement as a policy to combat unemployment restson the fallacious argument that output is fixed. Thus, increasing outputis a much more satisfactory way ong>ofong> reducing overall unemployment thanpolicies which encourage early retirement. ong>Theong> problem in Irelong>andong> isthat the relationship between output ong>andong> employment is weaker thanelsewhere, mainly because ong>ofong> the structure ong>ofong> the economy, in particularthe absence ong>ofong> a strong indigenous industrial base.Once early exit occurs it is very difficult for older workers to reenterthe labour market. All the evidence suggest that they become"unemployable." This means that non-age specific forms ong>ofong> social securityare used as a proxy for pensions in order to ease the transitionto ong>ofong>ficial retirement age. ong>Theong> result is lower, ong>andong> perhaps uncertain(depending on eligibility criteria), payments for older workers. If theduration ong>ofong> unemployment is very long this may also mean an extensionin the number ong>ofong> years spent in poverty for some people. This is perhapsthe most pressing problem facing policy-makers seeking to reform thepension system. What is needed is a flexible pension system that takesaccount ong>ofong> earlier exit from the labour market ong>andong> an uncertain futurewith regard to re-entry.ong>Theong>re is no evidence ong>ofong> widespread support for any earlier retirementthan 65 years ong>ofong> age. Most people enjoy work. Even the observed"voluntary" nature ong>ofong> retirement before that age is open to question.Individuals may be left with no choice if employers give a clear signalthat they want workers to leave. ong>Policiesong> which would support a voluntaryphasing out ong>ofong> work ong>andong> phasing in ong>ofong> retirement pensions, so thatworkers could leave the labour force at their own pace ong>andong> in their owntime, would be an important first step towards extending the range ong>ofong>choices for older people. This might have implications for the financing59


ong>ofong> pensions if more workers sought early retirement. Bringing forwardthe payment ong>ofong> pensions (public ong>andong> occupational) could impose substantialcosts on the exchequer as well as on employer ong>andong> companyprong>ofong>its. Nevertheless, as Conniffe ong>andong> Kennedy (1984) point out, contributingto the financing ong>ofong> genuinely chosen retirement may be betterthan paying for involuntary idleness.While some countries have recently been considering schemes to encouragethe retention ong>ofong> older workers in the labour force in the light ong>ofong> adeclining supply ong>ofong> young people coming in to the market, Irelong>andong> isstill in a position ong>ofong> excess supply in all age categories. This means thatolder people may be encouraged to accept early retirement, not becausethey want it, but because ong>ofong> pressure within firms, or their own viewthat retirement may lead to a younger person getting a job. ong>Theong> factthat this does not happen does not change the perception that early exitis the correct ong>andong> moral response to unemployment, at least at themargin.It would be wrong to end this discussion with the impression that thingsare all bad; there are some straws in the wind that may herald thebeginnings ong>ofong> a more positive attitude to older workers. Recently, somelimited schemes have been introduced which seek to take advantage ong>ofong>the knowledge ong>andong> experience ong>ofong> retired workers (mainly management)in the business sector. ong>Theong> Industrial Development Authority (IDA)now operates a Mentor Scheme whereby retired experts in various fieldsare contracted to companies for a specific period ong>ofong> time. Each mentorcounsels only a small number ong>ofong> businesses ong>andong> services are providedon a voluntary basis. This scheme is relatively new ong>andong> has not yet beenevaluated. For the first time, however, the value ong>ofong> older workers hasbeen explicitly recognised in ong>ofong>ficial circles.60


CHAPTER 4Health ong>andong> ong>Socialong> ServicesIntroductionThis chapter covers the impact ong>ofong> health ong>andong> social services on olderpeople in Irelong>andong>. ong>Theong> majority ong>ofong> old people are fit ong>andong> healthy ong>andong>live independent lives. However, close to 5 per cent ong>ofong> people aged 65years or over are in long-stay institutions, while an estimated 17 per centare receiving varying levels ong>ofong> informal care in the community. ong>Theong>issues covered in this section include the organisation ong>andong> financingong>ofong> available services, current policy developments, reform proposals(especially for the private nursing home sector) as well as the the mostrecent major innovations. First ong>ofong> all, however, it is useful to considerthe need for health ong>andong> social services among the elderly population.ong>Theong> Need for Health ong>andong> ong>Socialong> Servicesong>Theong> first real indication ong>ofong> the needs ong>ofong> old people living in the communitycame from a survey by Whelan ong>andong> Vaughan (1982). ong>Theong>ir results showthat the proportion ong>ofong> old people experiencing difficulty with specificactivities such as mobility, bathing, dressing, hearing ong>andong> sight, increaseswith age for both men ong>andong> women (Table 4.1). More recently O'ConnorTABLE 4.1: Difficulty in carrying out day to day activities (%)Activity with which elderly peopleexperience difficultyGetting on or ong>ofong>f a busClimbing a flight ong>ofong> stairsWalking half a mileTaking a bath without helpDressing without helpHearing easilySeeing to read a newspaperSource: Whelan ong>andong> Vaughan, 1982.Men Aged65-69 70-79 80 +3728232088134136262512191667646055274236Women Aged65-69 70-79 80 +4030261781013614845391817228276747240384461


TABLE 4.2: Level ong>ofong> care required by elderly persons, classified by theirage (based on data from households which contained an elderly person)Age GroupA Lotong>ofong> Care%11.017.924.221.814.810.3100.0SomeCareOccasionalCareNoEstimatedCare%41.034.714.87.22.10.2100.0TotalNumber(000)120.1109.455.237.314.54.965 — 6970 — 7475 — 7980 — 8485 — 8990 ong>andong> overTOTALEstimatedTotalNo. ('000)%13.220.117.331.712.65.1100.0%8.427.324.525.410.93.5100.023.9 25.0Source: O'Connor et ai, 1988.17.3275.2341.5etal. (1988) have examined dependency among old people living in theirown homes with a carer available (Table 4.2). ong>Theong>ir results show that66.300 old people (19 per cent ong>ofong> elderly in the community) receive carefrom family ong>andong> friends. For those receiving care the intensity variesfrom "a lot ong>ofong> care" (36 per cent) to "some care" (38 per cent) ong>andong>"occasional care" (26 per cent) ong>Theong> need for "a lot ong>ofong> care" increaseslinearly with age. from 2 per cent in the 65-69 age category to over 50per cent in the 90 plus category. That even more people are not receiving"a lot ong>ofong> care" in the older age categories is. perhaps, not all thatsurprising, given that the sample is drawn from people living in thecommunity. By definition, if the very old continue to live at home theyare more than likely fitter than the average for their age group.Even more recently, Blackwell et al. (1992), using a stong>andong>ardised Guttmanscale based on activities ong>ofong> daily living, report that 46 per cent ong>ofong>elderly people being looked after at home are in the lowest category (A)ong>ofong> dependency (Table 4.3). ong>Theong> remainder are spread across successivelyhigher dependency categories as follows: Category B (19 per cent).Category C (13 per cent). Category D (9 per cent) ong>andong> Category E (6per cent). Approximately 7 per cent ong>ofong> the sample are non-scale, butwould be closest to Category C if scaled using a Likert format.Blackwell et al. 1992 also provide information on the distribution ong>ofong>scale dependency among old people in public long-stay institutions.ong>Theong>re are proportionately fewer old people in the lowest category ong>ofong>dependency ong>andong> more in higher categories, compared to the situation inthe community (Table 4.3). It should be noted, however, that there is62


TABLE 4.3: Dependency ong>ofong> elderly persons living in the community ong>andong>aggregated across four selected public long stay institutionsCategoryItemsDescriptionCommInstitANo disabilityCannot bathe without help45.521.8BCannot walk outdoors without helpCannot walk indoors without help19.77.0CCannot dress without helpCannot get out ong>ofong> bed without helpCannot sit/stong>andong> without helpCannot use the toilet without help13.013.1D8Cannot wash hong>andong>s ong>andong> face withouthelp9.116.1E9Cannot feed without help5.639.3Non-ScaleALLSource: Blackwell, O'Shea, Moane ong>andong> Murray, 1992.7.1100.02.7100.0quite a difference in the distribution ong>ofong> dependency among the institutionssurveyed. For instance, while one institution contained only 7per cent ong>ofong> old people in the lowest category ong>ofong> dependency, anotherhad 38 per cent ong>ofong> its residents in that category. ong>Theong>se differences arenot always explained by the nature ong>ofong> the care provided in the institutions(see later discussion on public long-stay care).O'Connor et al. (1986) also provide some broad measures ong>ofong> dependencyfor elderly persons being cared for in nursing homes. ong>Theong>ir results showthat old people in nursing homes are not homogenous with respect todependency characteristics. Overall. 38 per cent ong>ofong> old people in nursinghomes are self-reliant with respect to personal care, 50 per cent areambulant without assistance, ong>andong> 63 per cent are mentally alert. ong>Theong>reare, however, significant numbers ong>ofong> residents very dependent on eachong>ofong> these dimensions. Unfortunately, it is not possible to compare thedependency information from nursing homes with the results from thecommunity or from public long-stay institutions. ong>Theong> scales used tomeasure dependency are different, as indeed are the objectives behindthe measurement.ong>Theong>re is. therefore, no comparative information on the disability ong>ofong> oldpeople across all types ong>ofong> long-stay facilities. All we have in this regard63


are broad indicators ong>ofong> the medical ong>andong> social status ong>ofong> residents (Table4.4). Most old people (46 per cent) in long-stay institutions are categorisedas chronically ill. A significant number (34 per cent) have,however, been admitted because ong>ofong> social factors; for welfare accommodationthe proportion ong>ofong> old people admitted for social reasons risesto 60 per cent. Welfare homes were originally intended to meet theneeds ong>ofong> dependent old people where relatives or other suitable personswere not available to provide them with the assistance they needed intheir own home. Better health ong>andong> the increasing mobility ong>ofong> elderlypersons, allied to more emphasis on community care, have combined toreduce the need for welfare home provision, though not to reduce thenumber ong>ofong> existing social cases being cared for in these homes.TABLE 4.4: Medical/social status ong>ofong> patients resident in long-staygeriatric units in December 1988Statusong>Socialong>Acute illnessChronic sicknessTerminalMental Hong>andong>icapChronic PsychiatricOtherNot StatedTotalHealthBoardGeriatricHospitals/Homes17.34.559.93.43.27.24.40.1100.0Source: Department ong>ofong> Health, 1988.HealthBoardwelfareHomes64.91.221.70.22.09.61.30.0100.0VoluntaryApprovedNursingHomesPer cent34.25.945.24.80.85.51.22.5100.0OtherPrivateNursingHomes57.13.528.52.21.54.11.21.8100.0Total34.04.246.33.12.26.42.71.0100.0Informal Care in the Communityong>Theong> ability ong>ofong> old people to continue to live in their own homes veryong>ofong>ten depends on the provision ong>ofong> high levels ong>ofong> care by family ong>andong>friends. O'Connor et al. (1988) provide the most comprehensive informationon informal carers in the community. ong>Theong>y estimate that thereare just over 66,300 old people in the community who require some levelong>ofong> care ong>andong> that 50,800 ong>ofong> these are looked after by members ong>ofong> thehousehold. Half ong>ofong> all carers are aged between 40 ong>andong> 60 years, while25 per cent are themselves elderly. Fifty per cent ong>ofong> carers spend betweenfour ong>andong> seven hours a day caring for old people, with 35 per centdevoting more time than this. Over half ong>ofong> the latter are required to be64


on call 24 hours a day always or almost always. ong>Theong> majority ong>ofong> carersexperience restrictions in their own life due to their caring role; forexample, 57 per cent feel overwhelmed by caring some or all ong>ofong> the time;58 per cent believe that caring puts constraints on their social life. Onefifthong>ofong> carers have given up work to care for an old person.Blackwell et al. (1992) also confirm the major role played by family ong>andong>friends in looking after old people. ong>Theong>ir study shows that co-residentcarers, who are 75 per cent female, spend an average ong>ofong> 47 hours a weekproviding care, a figure which increases considerably as dependencyworsens. Old people in the highest category ong>ofong> dependency receive anaverage ong>ofong> 86 hours ong>ofong> care per week. For high dependent categories,most time is spent providing help with physical activities such as washing,dressing, using the toilet ong>andong> feeding; for low dependent elderly mostcare is concentrated on instrumental activities ong>ofong> daily living such ashousekeeping, shopping, ong>andong> preparing meals. A significant proportionong>ofong> carers (over a third) experience strain in a variety ong>ofong> areas, with 46per cent finding caring a physical strain; for carers ong>ofong> very dependentold people 80 per cent find caring a physical strain.ong>Theong>re are substantial opportunity costs ong>ofong> caring. Of the carers interviewedby Blackwell et al., 21 per cent said that they would look forpaid work if they were not caring for an elderly person; whether theywould find work is. ong>ofong> course, another matter. Carers also experiencerestrictions on the amount ong>ofong> unpaid work they can engage in at home,ong>andong> in the amount ong>ofong> leisure activities they can pursue. O'Shea ong>andong>Corcoran (1989) report that carers provide an average ong>ofong> 8 hours ong>ofong> careper day to old people living at home but on the margins ong>ofong> institutionalcare. Caring involved giving up work in the market place, work in thehome ong>andong> leisure time. When each ong>ofong> these components is valued inmonetary terms, at an appropriate rate, care in the community is nolonger a cheap option.Most caring is done by older women. Consequently, the ratio ong>ofong> womenaged 45-69 to people over 70 years ong>ofong> age is a useful indicator ong>ofong> thecaretaker potential within the family system (Table 4.5). ong>Theong> ratio inIrelong>andong> has been declining slowly since 1926; currently it stong>andong>s at 1.4.ong>Theong> ratio is expected to rise to 1.9 by the year 2011, but to fall again to1.5 by the year 2021. Caretaker potential has fallen more slowly inIrelong>andong> than in many other European countries, reflecting the peculiardemographic characteristics ong>ofong> the country, referred to earlier in thisreport. ong>Theong> expected increase in the rate during the nineties also reflectsprevious demographic experience with respect to emigration ong>andong> fertility,while the expected decrease in the second decade ong>ofong> the nextcentury relates to the fact that the major increase in the elderly popu-65


19261936194619511961196619711979198119861991200120112021YearTABLE 4.5: Care-taker potentialWomen aged 45-69/Population aged 70 +1.91.91.71.61.61.71.61.61.61.41.41.71.91.5Source: Census ong>ofong> Population (various years); own calculations.Women aged 45-69/Population aged 75 +3.63.83.43.12.93.03.02.82.72.52.42.73.22.7lation is not expected to occur until that time. This is not to argue thatpublic provision ong>ofong> services for old people is. as a consequence, lessimportant in Irelong>andong> than elsewhere. Carers require complementarypublic provision ong>ofong> community facilities ong>andong> support systems, otherwisetheir task is made more difficult, if not impossible. Moreover, simplylooking at caretaker potential tells us very little about the factors affectingthe decision to become a carer in the first place.Changes in family formation ong>andong> in labour force participation can havean impact on the willingness ong>andong> ability ong>ofong> families to engage in care, ina number ong>ofong> ong>ofong>ten conflicting ways. For instance, the decline in averagefamily size in Irelong>andong> — from 4.0 children born per woman in 1971 to2.3 in 1987 — might, at first sight, seem to imply a decrease in thenumbers available for the future pool ong>ofong> potential carers. However,balanced against this is the fact that more children are now survivingthan previously, ong>andong> their increased longevity means that more ong>ofong> themare likely to reach an age when caring becomes a reality.ong>Theong> rise in the labour force participation ong>ofong> married women has implicationsfor caring. ong>Theong> overall rate increased from 8 per cent in the early1970s to 24 per cent at the end ong>ofong> the 1980s . For the age category 45-64. which contains many potential carers, the rate increased from 13 percent in 1979 to 21 per cent in 1990. A rise in labour force participationmeans that opportunities for "market" work at a certain wage are beingsubstituted for "home duties". In turn, this means that the opportunitycost ong>ofong> engaging in home care is likely to have increased. That shouldlead — other things being equal — to a diminution in the amount ong>ofong>66


informal care within the home. Some ong>ofong> the increase in the number ong>ofong>married women at work has. however, reflected an increase in part-timeworking. ong>Theong> number ong>ofong> women engaged in regular part-time workingincreased from 27,000 in 1977 to 50,000 in 1987; ong>ofong> the latter 72 per centare married. For some ong>ofong> these women, work outside the home maynot greatly impede their willingness ong>andong> ability to engage in caring.Moreover, income earned from paid work outside the home may facilitatethe "buying in" ong>ofong> care that, formerly, was provided free.ong>Theong>re is no doubt that family carers make an enormous contribution tocare ong>ofong> the elderly in the community ong>ofong>ten at substantial personal costin terms ong>ofong> opportunities foregone, as well as physical ong>andong> mental strain.Yet. there is very little recognition by policy-makers ong>ofong> the role playedby informal carers. ong>Theong> vast majority ong>ofong> carers interviewed by Blackwellet al., expressed a desire for direct payment for caring. Yet currentpayment rates, through the Carers Allowance Scheme 1 (even followingrecent changes in eligibility) are restrictive ong>andong> ong>ofong>ten derisory in comparisonto the effort expected ong>ofong> carers. Furthermore, this scheme isnot, in any case, specifically designed to provide either compensationfor caring or to encourage care in the home. Its primary aim is to ensurethat the incomes ong>ofong> carers who qualify for assistance do not fall belowcertain limits.Support from statutory sources in the form ong>ofong> more ong>andong> better services,respite care ong>andong> advice is also inadequate. Evidence from elsewheresuggests that carers can ong>ofong>ten be kept happy in their work for quite smallamounts ong>ofong> exchequer expenditure (Wright. 1987). A great number ong>ofong>carers enjoy what they do, receiving many intangible benefits ong>andong> greatfulfilment (Clifford, 1990). It would be a pity if the natural willingnessong>ofong> so many people to care for their kin was eroded by the parsimoniousresponse ong>ofong> the State to their material needs. ong>Theong> irony is that moreresources devoted to relieving carers now, resulting in an increase in theprovision ong>ofong> informal care, would more than likely lead, in the future,to a reduction in exchequer expenditure on institutional care. O'Connoret al. (1988) have warned that the lack ong>ofong> statutory support services forcarers is likely to result in a breakdown ong>ofong> the family caring system ong>andong>a consequent admission ong>ofong> the caree to institutional care. Ultimately,more resources must be allocated to support the carers ong>ofong> old peopleliving at home. It is the only policy that makes sense if we want to shiftthe balance ong>ofong> care away from institutions ong>andong> towards care in thecommunity.'This is a means tested payment for persons residing with ong>andong> providing full-time careong>andong> attention for a social welfare recipient (including invalidity ong>andong> blind pensioners) aged66 years or over who is so incapacitated as to require full-time care ong>andong> attention.67


Medical ProvisionAcute hospitals are primarily geared to diagnose ong>andong> treat short episodesong>ofong> acute illness in patients who are otherwise healthy. Consequently,they are not always willing to accept old people with longer length ong>ofong>stays "blocking" beds which could otherwise be used for more pressingacute cases. Concerns along these lines have increasingly been heard inIrelong>andong>, especially in the light ong>ofong> the overall reduction in the number ong>ofong>acute beds in recent years. However, acute hospitals may, very ong>ofong>ten,have no choice but to keep old people once they are admitted becauseong>ofong> the absence ong>ofong> suitable facilities elsewhere, particularly if communitycare services are inadequate ong>andong> day hospital facilities are not available.Old people aged 65 years or more account for over 25 per cent ong>ofong>admissions ong>andong> over 40 per cent ong>ofong> bed days in acute hospitals in Irelong>andong>(Hospital In-Patient Inquiry, reported in ong>Theong> Years Ahead, 1988). ong>Theong>elderly are much more likely to have had a hospital stay than people inother age categories (Nolan, 1991). For instance, whereas 10 per centong>ofong> all people surveyed by Nolan had spent some time in hospital duringthe previous twelve months, nearly 18 per cent ong>ofong> people aged 75 yearsor over had been in hospital. ong>Theong> average duration ong>ofong> stay in acutehospitals also rises with age; for those aged 75 plus the average lengthong>ofong> stay is 18 days compared to 6 days for people aged 25-44. Length ong>ofong>stay has, however, been falling for all age categories with older agegroups experiencing a faster decline than others. Hospitals containing adepartment ong>ofong> geriatric medicine tend to have a shorter duration ong>ofong> stayfor old people than other acute hospitals (ong>Theong> Years Ahead, 1988).ong>Theong> supply ong>ofong> hospital based geriatric medicine is inadequate in Irelong>andong>.Until recently there were only ten general hospitals with geriatric departments,under the direction ong>ofong> twelve physicians in geriatric medicine.Based on a physician to population norm ong>ofong> 1:80,000 ong>Theong> Years Ahead(1988) made the case for an additional eleven specialist geriatric departments.ong>Theong>re is also general agreement that the absence ong>ofong> intensiverehabilitation services for old people is contributing to unnecessary longstays in acute hospital beds (Dublin Hospital Initiative Group). Someaccount has now been taken ong>ofong> these concerns in the recent review ong>ofong>rehabilitation services undertaken for the Dublin region.Public Long-Stay Careong>Theong> best estimate ong>ofong> the number ong>ofong> old people in long-stay care is 19,120,or close to 5 per cent ong>ofong> the elderly population (O' Shea et al., 1991).Just over half ong>ofong> these beds are in the public sector; 29 per cent are inthe private sector ong>andong> the remainder (18 per cent) are in the voluntary68


sector. Of the total number ong>ofong> beds currently in the public sector, 7,005are in health board geriatric institutions (45 institutions), 1,589 are inwelfare homes (42 homes) ong>andong> 1,465 are in district hospitals (30hospitals). This gives an overall provision ong>ofong> 26.1 public long-stay placesper 1,000 elderly population (Table 4.6).TABLE 4.6: Residential facilities for older people in Irelong>andong>SectorHealth Board Geriatric Hospitals (Public)Health Board Welfare Homes (Public)Health Board District Hospitals (Public)Private Nursing HomesVoluntary HomesTOTALSource: O'Shea et al, 1991.Facilities45423026259438Places7,0051,5891,4655,5523,50919,120Places per 1,000elderly population18.24.13.814.49.149.7Health board geriatric institutions mainly cater for more dependent oldpeople. However, they also contain a significant proportion ong>ofong> lowdependency persons (Blackwell et al., 1992). Admissions procedureshave not been so finely tuned as to allow in only the most heavilydependent people. Moreover, once admission has taken place, there hasbeen, more ong>ofong>ten than not, no effort made to get old people back outagain into the community. For some people the situation is complicatedby the fact that they have nowhere else to go; these people ong>ofong>ten endup in care for the rest ong>ofong> their lives. While geriatric hospitals ong>andong> welfarehomes cater mainly for old people, district hospitals contain a mixtureong>ofong> long-stay, acute ong>andong> maternity beds. Most ong>ofong> the long-stay residentsin district hospitals will have some minor medical ong>andong>/or surgical ailments;long stay is usually defined as any person occupying a bed formore than 30 days.Private ong>andong> Voluntary Nursing HomesPrivate nursing homes provide for-prong>ofong>it care for old people right acrossthe dependency spectrum, but not usually for those who are ill. Mostrecent estimates suggest that there are 262 homes in this sector providinga total ong>ofong> 5,552 beds; this yields a ratio ong>ofong> 14.4 places per 1,000 elderlypopulation (O'Shea et al., 1991). ong>Theong> number ong>ofong> places in the voluntarysector (59 homes) is estimated to be 3.509, giving a ratio ong>ofong> 9.1 placesper 1,000 elderly population. ong>Theong> voluntary sector is not-for-prong>ofong>it care,mainly provided by Religious Orders. As in the case ong>ofong> private homes.69


there is some public subvention ong>ofong> old people resident in voluntaryhomes. ong>Theong> rules governing eligibility for subvention will be discussedlater in this section.Future Provision ong>ofong> Long-Stay Bedsong>Theong> number ong>ofong> long-stay public beds has been reduced in the pastdecade, both absolutely ong>andong> relative to other sectors. In 1980. for everyone bed in a voluntary or private nursing home there were 1.9 in thepublic sector; by 1988 the ratio had fallen to 1:1.3. ong>Theong> likely futuresupply ong>ofong> public long-stay beds can be distilled from discussions containedin ong>Theong> Years Ahead (1988). ong>Theong> recommendation in that report is for anorm ong>ofong> 10.0 long stay beds per 1,000 elderly persons, in the context ong>ofong>a norm ong>ofong> 2.5 beds per 1,000 people in the specialist departments ong>ofong>geriatric medicine ong>andong> 3.0 beds per 1,000 for rehabilitation purposes ingeneral ong>andong> community hospitals. In addition, a norm ong>ofong> between 20ong>andong> 25 places per 1,000 elderly is recommended in welfare accommodation.ong>Theong> latter is defined to include sheltered housing, boardingout hostels ong>andong> some (not clarified) forms ong>ofong> community hospital provision.Currently, the number ong>ofong> elderly persons in long-stay public beds(excluding welfare homes) is 8.470. ong>Theong> future provision ong>ofong> public longstaybeds, based on the norm ong>ofong> 10 places per 1.000 elderly population(for the year 2011) will be 3.800. less than half the existing'level. Whilenew forms ong>ofong> welfare accommodation will meet most ong>ofong> the additionalrequirements (it is proposed to make between 7.600 ong>andong> 9.500 placesavailable) for public care, the private sector may also be used to meetpart ong>ofong> the need.ong>Theong> overall demong>andong> for private ong>andong> voluntary care is. however, verydifficult to predict. ong>Theong> decline in religious vocations would, none theless, lead one to the view that voluntary provision is likely to fall in thefuture. Predicting the future demong>andong> for private care is more complex.For one thing, most decisions about nursing home care are taken byfamilies, with demong>andong> likely to be affected by demography, income ong>andong>relative prices. Demographic changes are likely to increase the demong>andong>for private care. So also will improvements in income, although here theeffects are likely to be weak (O'Shea et al., 1991). ong>Theong> effect ong>ofong> relativeprices on placement depends on the financial burden ong>andong> time constraintsfaced by families wishing to care for their elderly kin at home comparedto the cost ong>ofong> residential care. Very ong>ofong>ten hard pressed carers may haveno alternative but to place old people in a nursing home such is theinadequate nature ong>ofong> statutory ong>andong> exchequer support for ongoing carein the home. Residential care, even though expensive, may. in someinstances, be cheaper for families than the reorganisation ong>ofong> lifestyle ong>andong>career which full-time caring implies.70


Public policy feedback loops are. therefore, important. Governmentpolicy can affect income, prices ong>andong> carers' ability to look after theirelderly relatives. This is especially true in relation to the supply ong>ofong> publiccare, particularly in the community. Recent legislative initiative withrespect to the regulation ong>andong> financing ong>ofong> private homes is also likely tohave some effect on provision. A more stringent regulatory environmentis likely to cause some, currently below stong>andong>ard, nursing homes to goout ong>ofong> business, unless prepared to implement substantial ong>andong>. thereforefor them, costly changes in structures ong>andong> practices. On the other hong>andong>,more flexible public subsidisation arrangements are likely to proveattractive to some prospective entrants (particularly if this means higherpayments), thereby leading to an increase in supply. Barriers to entryin the industry are quite weak with economies ong>ofong> scale not a deterrentto potential entrants.Community CareOne ong>ofong> the key elements ong>ofong> public policy initiatives designed to keep oldpeople living at home is the development ong>ofong> a good community careservice. ong>Theong>re has been criticism concerning the role ong>andong> adequacy ong>ofong>community care in this country. A report by O'Connor (1987) for theNational ong>Economicong> ong>andong> ong>Socialong> Council suggests that the State moreusually intervenes to substitute for the family when family care is absentor breaks down than it does to ong>ofong>fer practical support to ensure thecontinuation ong>ofong> family care, in a complementary sense. One thing iscertain, cutting back on support services for families caring for elderlyrelatives at home is a false economy, leading sooner rather than later tohigher rates ong>ofong> institutionalisation than are necessary (National PlanningBoard. 1984).ong>Theong>re is evidence that access to home helps, public health nursing,paramedical services, ong>andong> meals-on-wheels is limited ong>andong> variable withinong>andong> among regional health boards (O'Connor. 1987; Blackwell et al..forthcoming). All indications are. for example, that the public healthnurse is not in a position to give old people the level ong>ofong> care she wouldwish (SEHB, 1979). ong>Theong> current ratio ong>ofong> public health nurses per 1,000elderly (over 65) population is just over 3.0 (Table 4.7). Nurses do not.however, allocate all ong>ofong> their time to old people. Most recent estimatessuggest that less than half ong>ofong> nursing time is taken up with care ong>ofong> theelderly (ong>Theong> Years Ahead. 1988). Although reliable ong>andong> value freeinformation is scarce with respect to the optimal level ong>ofong> nursing provisionfor old people living in the community. ong>Theong> Years Ahead (1988) reportdid imply a de facto under-provision ong>ofong> services, recommending that anadditional 243 public health nurses be appointed (albeit only as resourcespermit).71


TABLE 4.7: Public health nursing (PHN) posts* by health board regionHealth BoardEasternMidlong>andong>sMid-WesternNorth EasternNorth WesternSouth EasternSouthernWesternTOTAL•Position at 31st December, 1987.Source: ong>Theong> Years Ahead (1988).No. ong>ofong> PHNsassigned toCommunityCare36578103105971301291471,154PHN per1,000 ong>ofong>totalpopulation0.300.380.330.350.460.240.340.420.33PHNs per1,000 oldpeople aged65 years ong>andong>over3.591.551.353.483.213.192.093.043.13A similar picture emerges when one examines the current provision ong>ofong>home help ong>andong> meals-on-wheels services. Both ong>ofong> these services areespecially vulnerable at times ong>ofong> financial cut-backs because healthboards are not legally obliged to provide them. For instance, between1982 ong>andong> 1988 expenditure on the home help service declined by 8 percent in real terms while grants for meals declined by 4 per cent (NationalCouncil for the Aged, 1989).In both the Eastern ong>andong> Western Health Board close to 5 per cent ong>ofong>elderly people receive meals services. In the rest ong>ofong> the country theprovision ong>ofong> meals is much lower (Table 4.8). ong>Theong> number ong>ofong> old peoplereceiving home help is also relatively low at just over 3 per cent ong>ofong> theTABLE 4.8: Meals service for elderly people by health boardHealth BoardEasternMidlong>andong>Mid-WesternNorth EasternNorth WesternSouth EasternSouthernWesternSource: Department ong>ofong> Health.Percentage ong>ofong> Population aged 65 ong>andong>over receiving Meals Service4.91.80.41.92.4n/a2.14.772


total elderly population (Table 4.9), prompting calls for major ong>andong>immediate improvements in resources for the service (ong>Theong> Years Ahead,1988). O'Connor et al. (1988) report that the provision ong>ofong> home helpservices to caring households in their survey was practically non-existent.Moreover, only 30 per cent ong>ofong> carers who had requested home-helpactually received the service. What seems to be happening is that thehealth authorities are treating home help ong>andong> informal care by familymembers as substitute services rather than complements. ong>Theong>re is alsoevidence that scarce community care services like home helps are nowmuch more targeted; for instance. Lyons et al. (1991) report for onegeographically defined area ong>ofong> Dublin that old people who live alone orwho are very elderly are more likely to be in receipt ong>ofong> home help thanother categories ong>ofong> people.Health BoardEasternMidlong>andong>Mid-WesternNorth EasternNorth WesternSouth WesternSouthernWesternTOTALTABLE 4.9: Home help services* by health boardPercentage ong>ofong> population**aged 65 ong>andong> over receivingHome Help Services(1990)3.33.02.93.22.82.23.23.33.1Home Help (full ong>andong>part-time) per 1,000elderly persons***(1987)29.9515.4123.0622.8627.7415.6723.5616.4722.00•Most home helps are employed part-time. In 1987 there were 7,904 part-timehome helps, 112 full-time, ong>andong> 101 home help organisers.** Source: Department ong>ofong> Health. ong>Theong> population figure is taken from the PreliminaryReport by Age Group ong>ofong> the Census ong>ofong> Population, 1991.•••Based on Table 6.5 ong>ofong> ong>Theong> Years Ahead (1988). Population estimates are takenfrom the 1986 Census ong>ofong> population.Some evidence on the importance ong>ofong> community care factors in determiningplacement can be gleaned from the work ong>ofong> O'Shea ong>andong> Corcoran(1989). ong>Theong>y estimate a logit function which identifies general practitioner,home help ong>andong> public health nurse (among other factors) asimportant positive influences on the placement ong>ofong> old people in theirown homes. Both general practitioner ong>andong> home help were found to behighly significant. Evidence from elsewhere also suggests that someapplicants for residential care could be maintained at home with aguaranteed delivery ong>ofong> formal intensive domiciliary care (Avon County73


Council ong>Socialong> Services Department. 1981). Other reports suggest thatsome institutionalised old people could be discharged to domiciliary careif appropriate community services were available (Hakansson. 1986).ong>Theong> closing ong>ofong> hospital beds has put increasing pressure on communitycare resources in Irelong>andong>. This is recognised by the many recommendationscontained in ong>Theong> Years Ahead (1988) for improvements incommunity care resources. ong>Theong> most recent Programme for ong>Economicong>ong>andong> ong>Socialong> Progress agreed by the social partners has also acknowledgedthe strain on community care services. For the first time, social expenditurehas been linked to economic development. Specifically, a sevenyear programme has been agreed with the objective ong>ofong> improving communitybased services for old people, persons with mental hong>andong>icap ong>andong>those with psychiatric problems. ong>Theong> overall additional monies (to beshared among the three sectors) includes the following:- A capital investment ong>ofong> IR£100 million pounds (at 1990 prices) overthe course ong>ofong> the programme- Progressive increases in the annual level ong>ofong> current expenditurewhich will, by the final year ong>ofong> the seven year programme, be £90million above the present annual level in real terms. This is anaddition to the extra £5 million which was specifically allocated toservices for the elderly in 1989However, even with such improvements it is difficult to forecast at whatpoint optimality in the mix ong>ofong> care will be reached. It is easier to locateoptimal placement in theoretical balance ong>ofong> care models (Mooney. 1978)than it is to assign elderly persons in reality, especially given the absenceong>ofong> much information on relative costs ong>andong> benefits.What is now seen as crucial to the success ong>ofong> home care options is tohave someone in the community with specific responsibility for thecare ong>ofong> at risk elderly persons (6'Shea et al.. 1991). This would allowinformation about actual ong>andong> potential need to be generated so thatservices might be planned in an orderly manner. ong>Theong>re have been anumber ong>ofong> attempts in the United Kingdom to develop schemes thatorganise individual packages ong>ofong> care to help keep disabled or frail elderlypersons in the community (Dant ong>andong> Gearing. 1990). Drawing on thelessons from the United Kingdom ong>andong> other countries suggests thatresources should be targetted at those old people who are on the marginong>ofong> institutional care. Case management ong>ofong> itself will not. however,necessarily produce better quality care. A prerequisite is the harmonisationong>ofong> policy across government departments, the integration ong>ofong>funding services ong>andong> the willingness to commit any additional resourcesidentified by the case worker.74


ong>Theong> question ong>ofong> who should co-ordinate services on the ground is alsoimportant. ong>Theong>re are many suitable cong>andong>idates, for example, socialworkers, home help organisers, public health nurses, etc. ong>Theong> primecong>andong>idate in this country would be the district liaison nurse, first proposedin ong>Theong> Years Ahead (1988). (though she would have to receive trainingto enable her to manage effectively). Whatever structures are put inplace it makes sense to begin the process ong>ofong> care with a definition ong>ofong>need provided by those working closely with old people rather than, forexample, to hong>andong> down centrally determined planning norms, veryong>ofong>ten derived from consideration ong>ofong> need ong>andong> service provision in othercountries.Financing Structureong>Theong> rules governing the financing ong>ofong> long-term care for old people arecomplex. ong>Theong> following is meant to be a rough guide to the proceduresfollowed with respect to the public ong>andong> private funding ong>ofong> care. Oldpeople in public long-stay beds (53 per cent ong>ofong> all long-stay residents)receive free care, except that the institution retains almost all ong>ofong> theirold age pension. Long-term care in a private institution is paid bythe old person themselves. Up to recently, however, old people in"approved" private homes (see later discussion), who qualified on thebasis ong>ofong> limited means, received a subsidy from the exchequer. Thissubsidy typically amounted to between 20 ong>andong> 33 per cent ong>ofong> the weeklycost ong>ofong> care. Legislation has now been enacted to change the basis ong>ofong>public assistance for private ong>andong> voluntary residents. In future, subventionwill be based on means ong>andong> dependency ong>andong> will not be tied toparticular homes, as was formerly the case. Voluntary homes havemainly been run by religious ong>andong> have survived on the basis ong>ofong> limitedpublic subvention, charitable donations ong>andong> the un-paid labour ong>ofong> themainly religious staff.Most old people living at home are entitled to free general practitionerong>andong> community care services under the General Medical Services (GMS)scheme. Entitlements under the scheme are assessed by ong>ofong>ficials fromthe regional health board on the basis ong>ofong> a means test. Recent evidencesuggests that over 80 per cent ong>ofong> people aged 75 years or over, ong>andong> twothirdsong>ofong> those aged between 65 ong>andong> 75 years are covered for free carein the community. ong>Theong> proportion ong>ofong> persons covered under the GMSdiffers across regions. This is perhaps not surprising, given the discretionthat each regional health board has in the application ong>ofong> the means testcriteria.ong>Theong> precise breakdown ong>ofong> financing shares between public, private ong>andong>voluntary provision is not available for Irelong>andong>. While we know exactly75


how much is spent on public long-stay hospitals (IR£63 million in 1989),a figure for how much public subvention is paid to private ong>andong> voluntaryhomes has never been published. Nor is it possible, except in the verybroadest terms (by multiplying the estimated average yearly cost ong>ofong> careper occupied bed by the number ong>ofong> beds in the system) to estimatehow much is spent by old people on private long-term care. Similarly,disaggregating public expenditure on community care to cover onlyservices for old people is difficult in the Irish context. Resources areallocated on a programme basis, not by client group, ong>andong> no estimatesexist with respect to the latter.ong>Theong> overall financial resources needed to run the health care system aretightly controlled by the Department ong>ofong> Finance. Regional health boardssubmit spending estimates for approval to the Department ong>ofong> Health.ong>Theong>se estimates are then pruned in the light ong>ofong> financial restrictionsdetermined largely by the Department ong>ofong> Finance on the basis ong>ofong> budgetaryguidelines ong>andong> political realism. Up until recently (i.e., the early1980s) the allocation ong>ofong> resources was determined on an incrementalbasis, based on a largely Keynesian approach to economic development.This philosophy accounted for the large rise in public expenditure in thecountry, particularly during the 1970s. In recent years, however, theshare ong>ofong> public expenditure on health care as a percentage ong>ofong> GDP hasdeclined significantly (from 8.0 per cent ong>ofong> GDP in 1980 to an estimated5.5 per cent in 1991), as spending has been much more tightly controlledas part ong>ofong> the process ong>ofong> restoring order to the public finances. Unfortunately,just as resources had formerly been increased incrementallywithout much concern for the efficiency ong>ofong> spending, so also may cutbackshave occurred in the same manner. ong>Theong>re is no evidence ong>ofong> any microeconomicreasoning being applied in order to determine the most suitableareas for retrenchment.One ong>ofong> the major tenets ong>ofong> recent policy statements with respect to careong>ofong> the elderly has been the desire to move away from institutional careong>andong> towards care in the community. Some progress has already beenachieved with respect to a reduction ong>ofong> public long-stay beds in thesystem. This has not been counter-balanced, however, by an expansionong>ofong> community care services; instead, the savings have mainly been takenup as real gains to the exchequer. While the various regional healthboards have notional control over the allocation ong>ofong> funds (once themoney is received from the exchequer via the Department ong>ofong> Health)the reality is that real cutbacks have severely curtailed their ability toeffect a transfer ong>ofong> resources. Consequently, at a time ong>ofong> reducedemphasis on long-stay care, the resources are not always there to supportcarers looking after old people in their own homes. Voluntary provisionhas, therefore, borne the brunt ong>ofong> recent cut-backs in the system, not76


just through the greater burden on carers, but also the increased relianceon voluntary services, such as meals-on-wheels, home helps, ong>andong> visitinggroups. Voluntary organisations supply about half ong>ofong> all home helpsproviding care in the community, with only part ong>ofong> their funding comingfrom the exchequer; meals-on-wheels is run almost entirely by thevoluntary sector with, once again, only partial funding from theexchequer (approximately one-third).ong>Theong> real cost ong>ofong> care in public long-stay institutions is approximatelyIR£200 per occupied bed per week. For more intensive specialist ledgeriatric units, with assessment ong>andong> rehabilitation facilities, the cost ong>ofong>care per occupied bed may double, even treble in some cases (Blackwellet al.. 1992). ong>Theong> cost per patient treated is, ong>ofong> course, significantly lowerfor hospitals with a high rate ong>ofong> turnover. Nursing costs in all publicinstitutions are also likely to increase linearly (ong>andong> significantly for somecategories) with level ong>ofong> dependency.Very little is known about the cost ong>ofong> care in private nursing homes. Asa proxy we have to rely on the available information on the pricescharged to residents. One estimate suggests that the model fee categoryfor private homes is currently between IR£135 ong>andong> IR£155 per week(O'Connor et al, 1986); though homes at the upper end ong>ofong> the marketare likely to charge as much as IR£300 per week. ong>Theong>re is no ong>ofong>ficialrate stipulated for nursing home charges, either by the Department ong>ofong>Health or by the Irish Private Nursing Homes Association. ong>Theong>re issome evidence ong>ofong> a less than scientific approach to setting prices. Proprietorsong>ofong>ten set fees on the basis ong>ofong> what they think the market willbear, what they have heard about other homes' charges, the money theyneed to finance improvements ong>andong> so on (Challis ong>andong> Bartlett, 1988).Public Policy: Principles ong>andong> Prioritiesong>Theong> Inter-Departmental Committee on Care ong>ofong> the Aged which reportedin 1968 provided the impetus ong>andong> philosophy for public policy forthe aged up until very recently. In contrast to the haphazard ong>andong>institutionally biased nature ong>ofong> care that went before, the Care ong>ofong> theAgeditpoxt (as it became known), recommended that the basic objectiveong>ofong> policy should be to enable old people to live in their own homes foras long as possible. For this objective to be met, significant improvementsin community care would have to be undertaken. Specifically, the Reportrecommended improvements in the areas ong>ofong> home nursing, home help,paramedical care ong>andong> a more flexible general practitioner service. ong>Theong>emphasis ong>ofong> the Committee on an integrated approach to care led tong>ofong>urther suggestions concerning the income maintenance ong>andong> housing ong>ofong>old people. It also called for a re-organisation ong>ofong> existing institutionalcare ong>andong> the introduction ong>ofong> a new form ong>ofong> welfare home provision.77


ong>Theong>re is no doubt that the Care ong>ofong> the Aged Committee approached itstask with what was for the time a radical belief — "that it is better, ong>andong>probably much cheaper, to help the aged to live in the community thanto provide for them in hospitals or other institutions". Within thisframework public ong>andong> family care were regarded as complementary notsubstitutable forms ong>ofong> care. ong>Theong>se were novel ong>andong> innovative conceptsat that time (in many senses they still are) for a system ong>ofong> care stillrooted to the stigmatizing institutionalisation ong>ofong> elderly persons. What isdisappointing, however, is that twenty years later, the most recent policydocument on care ong>ofong> the elderly in Irelong>andong> (ong>Theong> Years Ahead. 1988)should have to make, more or less, the same call for a move away frominstitutional provision towards care in the home. Despite considerableimprovements in community services, especially during the 1970s, thebalance ong>ofong> care between community ong>andong> institution had not alteredsignificantly.Not surprisingly, therefore, the recommendations contained in ong>Theong>Years Ahead document confirmed the primacy ong>ofong> community care forold people. ong>Theong> major principle underlying the analysis contained in thepolicy document is that the dignity ong>andong> independence ong>ofong> old people canbest be achieved by enabling them to continue to live at home. with, ifnecessary, support services provided by the State. To facilitate care inthe home specific monetary proposals are made to increase the amountong>ofong> resources for community nursing, home helps ong>andong> paramedical services.This is a fundamental change from the earlier Care ong>ofong> the Agedreport where no such budgetary provision was made. At the same time,however, the underlying budget constraint is recognised ong>andong> redeploymentong>ofong>, rather than increases in. resources is to be the source ong>ofong> fundingfor the improvement in services.Recent initiatives (discussed above) designed to increase the overalllevel ong>ofong> funding for community care, through the Programme for ong>Economicong>ong>andong> ong>Socialong> Progress, have recognised the weakness ong>ofong> redeploymentas a major source ong>ofong> funding. Closing long-stay institutions is a protractedbusiness with many obstacles to be overcome, not least the effect thatclosure has on employment in an area. Moreover, community carefacilities have to be available ex-ante if old people are to be maintainedin the community. Ex-poste provision will not reduce the unmet needsong>ofong> old people currently living in the community, thereby making it morelikely that their demong>andong> for institutional services is constant or increasingat a time when the authorities are seeking to reduce the number ong>ofong> beds.Changes are also planned for the future in respect ong>ofong> the organisationong>ofong> service delivery for old people. It is proposed in ong>Theong> Years Aheadthat services for the elderly should be organised, as far as possible, in78


local districts serving a population ong>ofong> between 25.000 ong>andong> 30.000 people.Within each district co-ordination ong>ofong> services would be the responsibilityong>ofong> a district liaison nurse supported by a district team. At the area level,which would incorporate three to four districts, a community physicianwould act as overall co-ordinator ong>ofong> services for the elderly. ong>Theong> rationalefor these proposals is to improve the comprehensiveness, co-ordinationong>andong> integration ong>ofong> services for old people across existing programmes ong>ofong>care (community, acute, long stay ong>andong> psychiatric). In that regard, therecommendations also cover the desirability ong>ofong> closer liaison betweencarers in the home, the voluntary sector ong>andong> the housing authorities. Inpractice, the district liaison nurse, supported by the overall co-ordinatorong>ofong> services would be the catalyst for organisational change in the newsystem. ong>Theong>re has not been such a role up to now which, to some extentat least, explains the slow progress in moving away from institutions ong>andong>towards care in the home.Some old people will, ong>ofong> course, continue to need long-term care inan institution. ong>Theong> recommendations contained in ong>Theong> Years Aheadrecognise this need by incorporating suggestions for the radical restructuringong>ofong> existing long-stay hospitals to enable them to function ascommunity hospitals. ong>Theong> latter would continue to provide long-termcare but would be much more concerned than before with providingassessment ong>andong> rehabilitation for old people. In addition, convalescentcare, respite care, ong>andong> general support services for carers would beprovided in the hospital. ong>Theong> key element ong>ofong> this proposal is the formalrecognition ong>ofong> the need for pre-admission assessment ong>andong> post-admissionrehabilitation under the guidance, wherever possible, ong>ofong> a specialistphysician in geriatric medicine. Where assessment prior to admission tolong-term care is currently routine practice all the evidence points to amuch more effective use being made ong>ofong> long-stay beds than in thoseplaces where admission is still ong>ofong>f waiting lists.Progress has been slow, however, in achieving the radical overhaul ong>ofong>the institutional sector envisaged in ong>Theong> Years Ahead. Not all healthboards nor institutions have welcomed the challenges ong>andong> opportunitiespresented by the report. Some people are concerned about the implicationsong>ofong> the new proposals for existing work practices, pay ong>andong> conditions.Others are sceptical that the resources required to implementthe necessary changes will ever be made available. Without resourcesong>andong> organisational reform the concept ong>ofong> the community hospital willremain an aspiration rather than a reality. This would be a pity since avaluable opportunity would be missed to put in place a more dynamicprocess ong>ofong> care for old people in place ong>ofong> the current, rather static, longstayapproach ong>ofong> many institutions.79


Recent ReformsMost recent reform proposals concern the regulation ong>andong> public subventionong>ofong> the private ong>andong> voluntary nursing home sectors. ong>Theong> arrangementswith regard to the public subvention ong>ofong> old people seekingadmission to private nursing homes were, until recently, anomalous,inconsistent ong>andong> far from simple. For instance, payments to nursinghomes under Section 54 ong>ofong> the Health Act 1970 were not means-tested,while those under Section 26 ong>ofong> the same Act were subject to thestringent examination ong>ofong> income ong>andong> assets. ong>Theong>re were also differentrates ong>ofong> payment across schemes which did not appear to relate in anysystematic way to means, dependency, or cost ong>ofong> care. Furthermore,insidious differences in the treatment ong>ofong> subvention emerged between"approved" ong>andong> "non-approved" beds in the nursing home sector. Thisdistinction was related primarily to exchequer budgetary restrictions ong>andong>not to quality ong>ofong> care.ong>Theong> general unsatisfactory nature ong>ofong> the relationship (described above)between the State ong>andong> the private ong>andong> voluntary nursing home sector ledto many calls for legislative, regulatory ong>andong> financing changes (NationalCouncil for the Aged, 1986; ong>Theong> Years Ahead, 1988). This resultedeventually in the enactment ong>ofong> the Health (Nursing Homes) Act 1990by the Irish parliament. Under new regulations (to be introduced laterthis year (1992)) the current anomaly ong>ofong> approved ong>andong> non-approvedbeds in the nursing home sector will be removed. Instead, elderly personswho meet income ong>andong> dependency requirements will be subsidised aslong as they choose care in a registered home. ong>Theong> health board will beable to vary the subvention in accordance with the individual's dependencyong>andong> income. ong>Theong> proposal is that there will be payments for threecategories ong>ofong> dependency — light, moderate ong>andong> heavy, where the latteris defined to include persons with dementia.ong>Theong>re have been no ong>ofong>ficial proposals yet on how the financial circumstancesong>ofong> the elderly person will be taken into account in theallocation ong>ofong> subsidy. Means testing is always likely to prove administrativelycumbersome ong>andong> complex. This is exacerbated with respectto old people who may be short ong>ofong> cash but rich in capital assets (O'Shea,1991). In addition, household or family income may be sufficient, butnot forthcoming, to purchase private care for an elderly relative. ong>Theong>issue ong>ofong> whether decisions on subvention should apply with equal vigourto elderly persons seeking admission to public long-stay care is alsoimportant.One suggestion (O'Shea et al., 1991), is that only the income ong>ofong> theelderly person should initially affect eligibility for subvention. Underthis scheme, elderly persons defined as Category I (the current medical80


card population), would be entitled to full public subsidisation either ina community hospital or in a nursing home. Institutions would, however,be allowed to keep a predetermined proportion ong>ofong> residents' pensionsas is currently the practice. More restrictively, elderly people in CategoryII (a higher income cut-ong>ofong>f point) would have to pay for the cost ong>ofong>accommodation in long-stay care (public or private) but would be entitledto full subvention for nursing ong>andong> paramedical services. Elderly personsin Category III (those persons in the top income bracket) would not,however, be entitled to any subvention ong>andong> would have to bear the fullcost ong>ofong> long-term institutional care (Fig 4.1).In contrast, if elderly persons are looked after at home no categorywould be liable for the cost ong>ofong> community care services, except perhapsfor nominal charges designed to counteract frivolous consumption. ong>Theong>implicit assumption is that equal subsidies should be available to provideold people on the margin ong>ofong> institutional care with specific ong>andong> coordinatedpackages ong>ofong> care designed to keep them living in their ownhomes for as long as possible.FIGURE 4.1: Financing schemes for long-stay careCoverageNursing HomeAccommodationNursing ong>andong>paramedicalservicesCommunity careSource: O'Shea et al, 1991.1Fully covered(Net ong>ofong> Pension)Fully coveredFully covered(Nominal meanstestedcharges)CategoryIIPaid by clientFully coveredFully covered(Nominal meanstestedcharges)IIIPaid by clientPaid by clientFully covered(Nominal meanstestedcharges)ong>Theong> assets ong>ofong> the elderly person would only be taken into account ona retrospective posthumous basis. ong>Theong> scheme requires imaginativecontracts between elderly persons ong>andong> the authorities whereby the latterwould be entitled to recoup part ong>ofong> the expense ong>ofong> long-term residentialcare from the estate ong>ofong> the elderly person. This claim could only beexercised, however, after his or her death. In cases where a spouse wasstill alive, recoupment could not occur until after his or her death. If thetotal realised value ong>ofong> the estate is below a certain threshold (IR£30,000)all claims by the health board would be forfeited. ong>Theong> final monies duewould relate to the number ong>ofong> years spent in subsidised care, operatingalong the lines ong>ofong> a retrospective deductible payment.81


ong>Theong> National Council for the Elderly (1991) broadly concur with theapproach described above though they would favour treating all personsnot in possession ong>ofong> a medical card in the same way. thereby leavingonly two categories ong>ofong> eligibility. ong>Theong>y recommend that all old peoplein receipt ong>ofong> a medical card should receive full subvention to cover thecost ong>ofong> long-term care while those without a card should be assessed fora tapered subvention on the basis ong>ofong> means, social circumstances ong>andong>dependency.Whatever subvention scheme is eventually put in place there should nolonger be any distinction between the criteria used to determine publicsubsidy for old people in public community hospitals ong>andong> those in privateor voluntary nursing homes. Nor should institutional care be financedat the expense ong>ofong> community care. Accepting this principle means thatsubvention for in-patient care should not be granted unless it is clearthat a similar subsidy would not have succeeded in maintaining oldpeople in their own home. ong>Theong> subsidy, if applied to community care,could be used to buy resources like home helps, community nursingong>andong> paramedical services, as well as perhaps making some financialcontribution to informal carers. It is precisely these services that havebeen identified as important in slowing down or preventing entry intolong-stay care.It also seems reasonable that an elderly person seeking a subvention toenter a private or voluntary home should be subject to the same assessmentprocedures as a person entering a long-stay public bed. In addition,similar rehabilitation opportunities should be available to that person.However, it would hardly be either efficient or practicable to proposethat all nursing homes should have to invest in expensive assessmentong>andong> rehabilitation facilities. Instead, the resources ong>ofong> the communityhospital (when in place) might be used to determine whether a subvention-seekingelderly person needs long-term care in a private orvoluntary nursing home. If. following assessment, an elderly person isplaced in a nursing home, rehabilitation facilities, jointly provided bythe public sector ong>andong> the nursing homes, should also be made availableto that person. In that way some old people may. eventually, be able toreturn to the community, following a successful rehabilitation programme.It is hard to disagree with Neill et al. (1988). however, that themain problem lies not in residential homes but in the way in which, orcircumstances in which, decisions to enter them are taken.InnovationsOne ong>ofong> the problems with regard to the promotion ong>ofong> innovation in theIrish health care system is that many ong>ofong> the things that are worthwhile.82


for instance, more day hospital ong>andong> day care provision, would require asubstantial increase in resources. In the absence ong>ofong> resources, many localinitiatives have ong>ofong>ten been more concerned with innovation for thepurpose ong>ofong> saving money, rather than improving outcomes for oldpeople, though these are not always mutually exclusive objectives.For all that, progress can be reported in some areas. ong>Theong> number ong>ofong> dayhospitals has been increasing, albeit slowly. ong>Theong> Eastern Health Boardhave, for example, introduced a mobile day hospital service as a pilotproject to bring the benefits ong>ofong> the day hospital to old people in ruralareas. Boarding-out for old people is now more common than before,with many health boards implementing pilot projects in this area. Boarding-outhas been an integral part ong>ofong> service provision for old people inthe Western Health Board for many years.Improvements have also been made with regard to placement decisionmaking.Assessment is now more likely to take place before an oldperson enters long-stay care. Opportunities for rehabilitation withinlong-stay institutions is also more common. ong>Theong> level ong>ofong> communicationong>andong> co-ordination between community ong>andong> institutional services hasimproved accordingly, with some institutions making use ong>ofong> liaisonnurses to ease the transition to community care for people who mighthave formerly remained in care. Respite beds have been introduced intosome institutions, thereby allowing family carers a break from caring.More flexibility with respect to eligibility for payment has also meantsome improvement in the financial circumstances ong>ofong> family carers.Innovations have also occurred in the voluntary sector. Many localcommunity groups have sought to initiate networking relationships, witha view to promoting the integration ong>ofong> old people into the social fabricong>ofong> society. Old people are encouraged to meet ong>andong> engage in socialactivities in accordance with their preferences. Neighbourhood watchschemes have also been set up to deal with the increasing vulnerabilityong>ofong> old people to crime, especially in remote rural areas. Schemes tocombat crime ong>andong> isolation have also been introduced in urban areas.For instance, an emergency alarm call system has been implemented inone inner city area in Dublin. ong>Theong> alarm links the homes ong>ofong> vulnerableold people to a twenty-four hour answering service, thereby providinga useful support system, especially for these people living on their own.Initiatives with regard to arrangements for the terminally ill are alsodeveloping. ong>Theong> hospice movement has always had a long tradition inIrelong>andong> but, up to now, has been mainly confined to Dublin. Recently,there have been attempts to raise the necessary voluntary funds to setup hospice movements in other centres ong>andong> regions.83


closer co-operation is required among the departments ong>ofong> Health. Environmentong>andong> ong>Socialong> Welfare, if the diverse needs ong>ofong> old people are to betaken into account. After all, the co-ordination ong>andong> integration ong>ofong> serviceprovision at local level can only occur if overall policy is being formulatedin a rational ong>andong> coherent manner across the responsible agencies.86


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NATIONAL COUNCIL FOR THE ELDERLY PUBLICATIONS1. Day Hospital Care, April 19822. Retirement: A General Review, December 19823. First Annual Report, December 19824. Community Services for the Elderly, September 19835. Retirement Age: Fixed or Flexible (Seminar Proceedings), October 19836. ong>Theong> World ong>ofong> the Elderly: ong>Theong> Rural Experience, May 19847. Incomes ong>ofong> the Elderly in Irelong>andong>: And an Analysis ong>ofong> the State's Contribution, May 19848. Report on its Three Year Term ong>ofong> Office, June 19849. Home from Home? Report on Boarding Out Schemes for Older People in Irelong>andong>,November 198510. Housing ong>ofong> the Elderly in Irelong>andong>, December 198511. Institutional Care ong>ofong> the Elderly in Irelong>andong>, December 198512. This is Our World: Perspectives ong>ofong> Some Elderly People on Life in Suburban Dublin,September 198613. Nursing Homes in the Republic ong>ofong> Irelong>andong>: A Study ong>ofong> the Private ong>andong> Voluntary Sector,September 198614. "Its Our Home": ong>Theong> Quality ong>ofong> Life in Private ong>andong> Voluntary Nursing Homes in Irelong>andong>,September 198615. ong>Theong> Elderly in the Community: Transport ong>andong> Access to Services in Rural Areas,September 198616. Attitudes ong>ofong> Young People to Ageing ong>andong> the Elderly, Second Edition 1992.17. Choices in Community Care: Day Centres for the Elderly in the Eastern Health Board,September 198718. Caring for the Elderly. Part I. A Study ong>ofong> Carers at Home ong>andong> in the Community,June 198819. Caring for the Elderly, Part II. ong>Theong> Caring Process: A Study ong>ofong> Carers in the Home,November 198820. Sheltered Housing in Irelong>andong>: Its Role ong>andong> Contribution in the Care ong>ofong> the Elderly,May 198921. Report on its Second Term ong>ofong> Office, May 198922. ong>Theong> Role ong>andong> Future Development ong>ofong> Nursing Homes in Irelong>andong>, September 199123(a) Co-ordinating Services for the Elderly at the Local Level: Swimming Against the Tide, AReport on Two Pilot Projects, September 199223(b) Co-ordinating Services for the Elderly at the Local Level: Swimming Against the Tide,Summary ong>ofong> an Evaluation Report on Two Pilot Projects, September 199224. ong>Theong> ong>Impactong> ong>ofong> ong>Socialong> ong>andong> ong>Economicong> ong>Policiesong> on Older People in Irelong>andong>, January 199325. Voluntary-Statutory Partnership in Community Care ong>ofong> the Elderly, January 199326. Measures to Promote Health ong>andong> Autonomy for Older People: A Position Paper,August 199327. Co-ordination ong>ofong> Services for the Elderly at the Local Level, (Seminar Proceedings)September 199328. Voluntary-Statutory Partnership in Community Care ong>ofong> the Elderly, (ConferenceProceedings) September 199329. Dementia Services Information ong>andong> Development, (Seminar Proceedings) September 1993.30. Bearing Fruit, A Manual for Primary Schools, September 199331. In Due Season, A Manual for Post Primary Schools, September 199332. Measures to Promote the Health ong>andong> Autonomy ong>ofong> Older People in Irelong>andong>, (ConferenceProceedings) February 199433. ong>Theong>ories ong>ofong> Ageing ong>andong> Attitudes to Ageing in Irelong>andong>, (Round Table Proceedings)May 199434. Third Term ong>ofong> Office Report, July 199435. ong>Theong> ong>Economicong>s ong>andong> Financing ong>ofong> 'Long-Term Care ong>ofong> the Elderly in Irelong>andong>, August 199436. Home Help Services for Elderly People in Irelong>andong>, November 199437. Older People in Irelong>andong>: ong>Socialong> Problem or Human Resource, A Submission to the Nationalong>Economicong> ong>andong> ong>Socialong> Forum, November 199438. ong>Theong> ong>Economicong>s ong>andong> Financing ong>ofong> Long-Term Care ong>ofong> the Elderly in Irelong>andong>, (SeminarProceedings) November 199439. Health ong>andong> Autonomy Among the Over-65s in Irelong>andong>, December 199440. Support Services for Carers ong>ofong> Elderly People Living at Home, December 199441. Home Help Services for Elderly People in Irelong>andong>, (Conference Proceedings) March 1995

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