Is a shift towards for-profit care homes a fair deal for all?

Nursing home models don't fully address fears about dementia and long-term care. As the population ages, the Government urgently needs to plan, writes Suzanne Cahill

In Ireland, following that broadcast, a flurry of activity took place that has hopefully resulted in better safeguards for frail nursing home residents, although we are still awaiting safeguarding legislation. Picture: Pexels

These are exciting times for dementia, both in terms of research and practice. New drugs that, in some few cases, work for those with early Alzheimer's disease by removing toxic plaques in the brain, generate hope.

However, a lot more research is needed here.

There is also increasing interest in the many different ways a person’s quality of life can be enhanced, focusing attention on creative psycho-social interventions and on the design of care and home environments.

Despite this, more than two thirds of people surveyed in Ireland in 2025 say they are afraid of dementia.

So why this fear? Is it the fear of developing symptoms such as memory loss, disorientation, word-finding problems, and other cognitive difficulties? Is it the fear of being labelled with dementia: A condition that may be stigmatising given the hypercognitive world we live in? Or is it the fear of entering a nursing home, where we know that more than two thirds of all residents have dementia. The reality is: It is probably a combination of all of these fears.

The fear of long-term care admission, and the familiar cry of “please never put me in a nursing home”, may not be entirely surprising. For, until the beginning of the last century, dementia (called something else then) was considered a type of insanity or madness, and the person with advanced dementia often lived out their remaining years in "lunatic asylums", "madhouses", or "workhouses".

These institutions were custodial in nature. Harsh treatments were the norm.

Textbooks dating back to the 16th and 17th century noted the prison-like conditions the person was subjected to, often being bound to beds with chains and shackles

Sadly, contemporary beliefs may be anchored in traditional practices and the legacy of this way of thinking remains in some countries today. The reality for some people who have severe dementia is: Locked nursing home units; poorly trained staff; an absence of psycho-social stimulation, and behaviours such as agitation and aggression, controlled by physical and chemical restraints.

But in Ireland, what is the reality of daily life inside nursing homes and why do Irish people fear long term care admission? Some months back, those of us who watched that harrowing  RTÉ Investigates  programme, that looked inside two Irish privately run nursing homes, were shocked at the appalling scenes of neglect and institutional abuse caught on camera.

Examples include the warehousing of frail residents due to staff shortages, the falsification of documents, absence of adequate activity programmes, some quick-fix solutions adopted for lifting residents, and the cheap short-cut measures used when tending to toileting and incontinence needs.

The two nursing homes filmed were part of the Emeis group — Ireland’s largest private provider, who managed 27 nursing homes at the time.

An earlier exposé of the same company (operating under a different name at the time) in France revealed systemic profit-driven mistreatment of older people in care homes, cost-cutting, and the misuse of public funds.

In Ireland, following that broadcast, a flurry of activity took place that has hopefully resulted in better safeguards for frail nursing home residents, although we are still awaiting safeguarding legislation.

But for me, the programme has raised further fundamental questions. The first is about nursing home policy and the Department of Health’s alleged strategic role here. The second relates to the future ownership and operation of nursing homes, especially giving our changing demographics. By 2051, older people in Ireland will account for up to 25% of the overall population.

Suzanne Cahill: 'The Irish market is said to be particularly attractive to them since fair deal funding guarantees their income stability supplemented through private equity investment.' Picture: Paul Sharp/Sharppix

For, as many people know, the nursing home landscape in Ireland has changed significantly in the last two decades, shifting from being predominantly State (health board) delivered, to nowadays being outsourced to for-profit providers.

Another notable trend has been the quiet and gradual influx into the Irish market of international for-profit providers.

Expanding exponentially, and squeezing out a number of the smaller, family-run rural nursing homes, they now control around 40% of all private beds

Most are either partially or fully private equity funded. The Irish market is said to be particularly attractive to them since fair deal funding guarantees their income stability supplemented through private equity investment. About three quarters of the cost of a fair deal resident is covered by State funding.

A further worrying trend is the separation of the nursing home building/real estate (ProCo) from the daily operational business that goes on within (OpCo). The ProCo (essentially the real estate component) is responsible for the development and maintenance of the property while the OpCo has responsibility for care provision, staffing, administration, service delivery, and so on.

This model is fragmented, profit-driven, and may deliver sub-optimum care. Also, given its real estate component, the model may have an implicit instability. Nor is it likely to work well for the main occupants of nursing homes — people living with dementia  for whom small-scale, customised, stable environments are so important.

So returning to the question: Are Irish people frightened of nursing home admission and will their fears intensify over future years? The answer is very likely yes.

Should the Government limit the number of nursing home beds that, in the future, will be controlled by profit-driven investment funds? Also who should vet potential overseas private for-profit providers to avoid the "care practices" observed on the  RTÉ Investigates programme from reoccuring?

Given how the country is now approaching a period of rapid population ageing, these are questions that demand urgent answers.

• Suzanne Cahill is an adjunct professor of social work and social policy at Trinity College Dublin. She holds an honorary professorship in dementia care from the University of Galway. She is also an affiliated professor in health and welfare at the University of Jönköping, Sweden. She is the lead author of a new book, Human Rights in Dementia Care: A Good Practice Guide.