(These comments were written by a social worker involved in the home help campaign in 2012. Many frontline social workers and SWAN Ireland members were, and are, involved in this campaign).
1. There are two strands to the home help/home care services issue. Firstly, it brings into question the increasing privatization of home care services across the country. I am aware that out of the four care agencies people can access in one part of Dublin (after a tendering process there are now only four “approved” care agencies that people can access in the public service), three are private companies. The home help staff in the other not-for-profit organisations are slowly but surely being made redundant as the people they care for pass away and their hours are decreased. Alongside this is the fact that the majority of these workers are women, they are on temporary contracts, have no sick leave entitlements, get no travel subsistence even though they use their own cars for their jobs, have no pensions and can be “let go” at any time by their employers. These women are being put under increasing pressure from their employers through a reduction in the amount of time they can spend with each service user (15 or 30 minutes is the maximum amount of time allowed in many cases), each home help staff has to ring their employer when they arrive at a service users home to “clock in” and they have to ring again before they leave to “clock out”. If they are late arriving to the next service users house they have some of their pay taken from them.
2. The second issue is that of the people trying to access these services. For any social workers who work with older persons or people with disabilities you may have cause to be involved with the home care services, with home care agencies and with the home care package application process. I am familiar with these services and with the older persons accessing these services. I know that the older persons I meet experience high levels of social exclusion and social isolation. I know that they find the support given to them by care staff and other healthcare professionals invaluable. I know that human contact and emotional support is hugely important to them. I also know that due to personal care needs being prioritized (to the detriment of other, just as valuable needs) in the home care applications many people that need other types of support are being de-prioritized. This is creating a two-tier system. A person’s quality of life (QOL) is not (always) realised by simply having their basic personal care needs being met. QOL includes physical well being, intellectual well being, sensory stimulation, technological aids, human support, service delivery, residential, financial, social, mental health, reminiscence, autonomy, resilience, choice, adaptability (Georgiou, 2008), among others. Due to the lack of variety/availability of community supports for older persons/persons with disabilities etc, the home help staffs are most often than not the people who primarily support service users in achieving their QOL. With continued and increasingly severe cutbacks in the home help services how can they continue to do this?
3. In the HSE service plan 2012 executive summary the intention to prioritise personal care over home help is highlighted, “Home Support: We will focus on the maintenance of home care packages at 2011 levels and on re-focusing home help services to prioritise personal care (bold font my emphasis). Home care packages which support the most dependent to remain in their own homes will not be reduced in 2012 and the number of people in receipt of them will be the same as in 2011. There will be reductions of 4.5% nationally in the level of home help hours provided but this reduction will be compensated by a more rigorous approach to the allocation of these supports to ensure that the people most in need receive them by de-prioritising non-personal care. Service efficiencies will mean that despite this level of reduction, the reduction in the number of people in receipt of home help services will be kept to 1.2%.” (pg. 7) This immediately instigates a two-tier system. It infers that some people are more “deserving” of assistance than others based solely on their physical abilities. It completely de-prioritises people with mental health issues. It also implicitly infers that home care services are not based on relationship building, care, support etc. By this “standard” vital supports provided by home help staff such as walking to the shop with a person, making them a cup of tea, sitting with them and talking, housework etc are all “de-prioritized”. But even more worryingly this “standard” is depriving people of exercising a full and meaningful life, it is literally depriving them of their human rights because simply having a basic need such as ones personal care needs being “met” does not in anyway imply you have a good quality of life (QOL). As already mentioned there are many strands to QOL such as: physical well being, intellectual well being, sensory, technological aids, human support, service delivery, residential, financial, social, mental health, reminiscence, autonomy, resilience, choice, adaptability (Georgiou, 2008).
4. Care should never be privatised, not because public services are always better but because care work is at its core a human endeavour and should not be about profit. By their definition private companies, whatever service or product they provide, are “for profit”. That is their core agenda, their top priority, no matter how “humanly” or benignly they package what they are selling or offering.
5. Local, not-for-profits are much more likely to be part of the community they are based in. Large multi-national private companies are not. The core message being sent when large private companies are welcomed in is that community does not matter. That people, solidarity and social capital does not matter.
6. As far as I can ascertain the HSE are only providing information for the 26 “chosen” care companies on their website with no unbiased info as to ALL options available e.g. the not-for-profits in local communities that were not “successful” in the tendering process. Through working in the area, I also know that the notion that service users have an actual choice in the care they are provided is a complete load of nonsense. While talking to another person who works in the general care area my thoughts were confirmed as this person spelled out that the new process “gives the illusion” that care is a choice but if a person chooses to have one provider care for them over another, they could be waiting months for care as the provider they chose could have a huge wait list. The concept of “choice” for the service user in all of this is an illusion. If choice was an actual option then there would be a procedure as to how a service user could go about choosing their care provider. Once the topic of home care was discussed with the service user, a process would kick into action whereby the service user would, in conjunction with their chosen advocates, meet, interview, talk to, discuss, their care options and preferences with each care agency. They would choose an agency. They would then meet a potential carer who is a match for their personality and care needs. THEN the application for said care would begin. AFTER the service user has decided, in an autonomous way, the care provision they need and want. Instead, the current process is to decide that the service user probably does need home care, discuss it with them giving them their “options”, home care, nursing home or no support, then immediately fill out a long de-humanising application form (approx. 10 pages). Bring said form to care coordinator. Beg care coordinator to prioritise person. The more physically in need the person is the better. Mental health needs are at the bottom of the barrel. No one will get assistance with housework anymore. For example a person who is 80 years old and has severe depression which means they can’t find the energy to dress themselves or eat, let alone clean their bathroom, dust their living room or make their bed will not “qualify” for a home care package even though living this way can perpetuate the depression as their physical surroundings are a reminder of how their depression is impeding them from carrying out activities they used to be able to do. And applying to have someone accompany you to do your shopping, go for a walk or for social interaction due to social isolation…not possible. The problem is that the process holds an implicit passivity to it and reduces people to purely physical issues (As far as I am aware people are more than just vessels to be cleaned*, people require social, emotional and intellectual stimulation in order to fully function as humans). I truly believe that people’s human rights have a huge potential to be infringed. People in Ireland don’t seem to think that human rights effect people here. It is as if being a western country negates one suffering from human rights abuses. Covert human rights abuses occur every single day in this country. Just because you can’t see it doesn’t mean it doesn’t exist (e.g. industrial schools, clerical abuse, Magdalene laundries).
7. While there is no legislative basis requiring the health services to provide home help/home care services, being part of a developed, civilised society assumes that one supports and cares for all persons in said civilised society in the manner to which the majority of citizens agree to. This includes upholding people’s fundamental human rights. Article 25 of the European Charter of Fundamental Rights states “The Union recognises and respects the rights of the elderly to lead a life of dignity and independence and to participate in social and cultural life”. Article 26 of the European Charter of Fundamental Rights states “The Union recognises and respects the right of persons with disabilities to benefit from measures designed to ensure their independence, social and occupational integration and participation in the life of the community”. Article 45.1 of Bunreacht na hEireann states “The State shall strive to promote the welfare of the whole people by securing and protecting as effectively as it may a social order in which justice and charity shall inform all the institutions of the national life”. As a social worker who sees human rights as an integral and core basis for my work I firmly believe that the Irish government, the public health service and we, the citizens of this country are allowing marginalised populations human rights to be infringed upon if we choose to stand idly by and watch as our care services become fully privatised. I believe it is my duty as a social worker to speak out about these injustices (once social workers become a registered profession as of next year it will also be my legal duty to do this).
8. The review process in care agencies is currently “self-evaluation” which is (without being overly cynical) a waste of time when it comes to assessing anything especially when receiving a budget depends on having a positive review. One of the reasons the not-for-profits may have been deemed as “not up to certain standards” is because their budgets have been systematically cut year after year. This has meant that these agencies have had to do much more with fewer resources. According to the home help staff themselves, the workers in these organisations have to pay for their own training and continued development as this is not provided through the HSE. They also have to drive their own cars for work purposes and do not get any mileage towards this. If a worker gets caught in traffic on her (the overwhelming majority of care workers are women) way to a service users home, she gets her wages cut corresponding to that amount of time. Workers now have to ring their managers when they get to a service users house to “clock on” and when they are finished (within the allotted 15 minutes/30 minutes) they must ring again to say they are leaving and how many minutes it will take them to get to the next house. They must repeat this at every service users house. Workers are expected to tend to all of a service users care needs within 15 minute or 30 minute slots (how long does it take you to get up, shower, dress, eat breakfast and wash up in the morning?) It takes me 1 hour, and I am a healthy, fit person with no mobility, memory, sight, hearing etc issues. How does that ethos fit in with a person’s dignity and human rights???
9. The HSE went through a tendering process for the approved care providers. The HSE would not show SIPTU what the tender process entailed or the details of the tender process when this was requested of them. Why might privatising the home care services benefit the bureaucratic model? A) The public health services will no longer have direct responsibility for ensuring home help staff are adequately trained, vetted and paid for their work e.g. home help staff working for not-for-profits that are directly funded by the public health service are paid at a certain level. This was agreed by the HSE and unions previously. The carers working in private companies are not included in this and therefore they can be paid whatever their employers decide (not falling under minimum wage of course). B) Any negative reactions, issues etc in the future relating to care in the home can now be foisted on to the private companies themselves as the public sector has abdicated itself of responsibility. The reason cited for the successful tenders was that the companies who secured the tenders adhered to a “high standard of care provision”, (parliamentary questions, 11/10/12). It would stand to reason that this means that the other agencies (mainly the not for profit) don’t adhere to high standards of care. But apparently all of the agencies adhere to a high standard of care (parliamentary questions, 11/10/12). The reason for the tender process was to introduce “higher standards of care”. But no one knows what these higher standards consist of or how an agency (voluntary or private) might adhere to them.
10. Finally, and another blindingly obvious piece of the argument is that the home help campaign is about women’s rights. The fact that the overwhelming majority of home help staff is women cannot escape people’s mind. The fact that the majority of care work in Ireland (and around the globe) is carried out by women cannot escape people’s minds. The fact that this industry is unregulated and lacks proper workers rights and employment benefits cannot escape people’s minds. The fact that our state expects women to stay at home (article 41.2.1 of the constitution) and provide care to children, the elderly and those with disabilities (Barry and Conroy, 2012) cannot escape people’s minds. The conclusion I draw from this is that the Irish state does not consider care work as “work”. It considers caring to be something that women should do as passive agents as opposed to something which is considered a valid form of work which one is doing to contribute towards society (In other words, if a person does not do something that produces a monetary value then it’s not worth anything in the eyes of our conservative/capitalist state). This indicates to me that this campaign is about many people’s basic human rights – a woman’s right to be included fully in society, elderly people’s right to have a good quality of life and people’s rights to be treated fairly as workers.
*Insert sarcastic tone here