Valuing Care: Why Dignity Should Not Diminish with Age

I work closely with nursing home providers across the spectrum, from smaller, community-based providers to larger groups. Combined with my earlier experience as a nurse, it gives me a very real insight into how we care for some of the most vulnerable people in our society. It is a privilege, but it is also, at times, deeply confronting.

We talk a lot about standards, compliance and funding models. But behind all of that are people, older people, who have lived full lives, raised families, contributed to communities, and now rely on us to care for them with dignity and respect. It is, after all, where most of us hope to get to one day, if we’re lucky. And yet, there is a question that is difficult to ignore.

When we look across the wider care system, there are stark differences in how care is designed, funded and experienced. In some areas of disability services, as distinct from older person residential care, small, home-based models support just a few individuals with highly personalised care. These environments prioritise familiarity, autonomy, and a sense of home.

It is also difficult to ignore the scale of funding differences across the system. In some disability settings, individual packages can exceed €10,000 per week, reflecting very complex needs. In contrast, the funding available for an older person in residential care under the Fair Deal scheme is typically in the region of €1,200 – €1,300 per week.

In the disability sector, policy has been moving away from larger congregated settings towards smaller, community-based homes that better reflect how people want to live. At its core, this shift reflects a human rights approach, aligned with the principles set out by the United Nations on dignity, autonomy and inclusion. This is increasingly recognised as the direction of travel.

While these principles are formally articulated in the Convention on the Rights of Persons with Disabilities, the reality is that many people living in nursing homes are living with complex care needs such as dementia. They require high levels of support and, in practice, experience many of the same challenges around dependency, autonomy and quality of life.

It raises a simple but important question – if we recognise the value of small, home-based, person-centred care models in one part of the system, why would we not apply the same thinking more consistently to the care of older people?

There are good examples in Ireland that show what is possible. The CareBright dementia village in Bruff, Co. Limerick – designed by architect John Quinn (Quinn Architects) – is built around a small-scale, household model of care. Residents live in ordinary homes, shared by just a few people, supported by consistent carers, prioritising familiarity and dignity. Crucially, it is not significantly more expensive to deliver, estimated at 30% above traditional models, which highlights whether better outcomes are possible with relatively modest additional investment.

If we are serious about delivering dignity in care, then we need to be equally serious about how we fund it. We are, in effect, asking providers to meet modern standards with a legacy funding model. The Fair Deal scheme is designed to fund care delivery, it was never intended to support the level of capital investment now required to modernise facilities. As a result, operators are expected to upgrade buildings, reconfigure rooms, and meet evolving resident expectations without a funding mechanism that enables them to do so.

This is particularly acute for smaller, community-based homes. Across the country, many of these providers are already under pressure. These are often the very homes that provide the most personal, familiar environments, yet they are the least equipped to absorb the cost of change or access large-scale capital.

Standards have rightly evolved over the past 30 years. Expectations now centre around single, en suite accommodation and more appropriate living environments. But the funding supports available do not match that ambition. A once-off grant of €25,000 does little to enable the level of redevelopment required to convert multi-occupancy rooms or futureproof facilities.

The risk is clear. Without meaningful support, we may lose exactly the type of provider the system should be protecting – those deeply embedded in their communities, delivering care that is personal, consistent and connected.

At the same time, the provider profile of those entering the sector is evolving. Investment, modernisation and scale all have an important role to play in meeting future demand and improving facilities. But if smaller, community-based homes are to remain part of the future landscape, they must also be supported to modernise and redevelop.

The challenge is not choosing one model over another, but making sure we do not lose the more personal, familiar environments that many smaller homes provide.

But it also raises an important question: how do we ensure that efficiency does not come at the expense of individuality? Because ultimately, this is not just a policy discussion. It is personal.

The urgency of this conversation is only increasing. Ireland’s population aged over 85 is projected to more than double between now and 2040, with some regions expected to see increases of over 150%. As demand grows, so too does the importance of asking whether our funding models, care environments and wider policy thinking around older people are evolving in step with the complexity of need and the standards of dignity we increasingly recognise elsewhere in the care system.

We have just over 32,000 nursing home beds in Ireland. It is a relatively small number of people currently, but they are among the most vulnerable in our society, and they deserve to be protected as such.

With that in mind, we should be asking ourselves, are we doing enough?