Health (Nursing Homes) (Amendment) Bill 2006: Second Stage (Resumed).

Thursday, 22 June 2006

Dáil Eireann Debate
Vol. 622 No. 94

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Question again proposed: “That the Bill be now read a Second Time.”

Mr. M. Higgins: Information on Michael D. Higgins  Zoom on Michael D. Higgins  Since I last spoke on this Bill and the need for a rights based approach to nursing home provision and clarification on the constitutional legal issues regarding the provision of a bed in a private nursing home for a public patient with a medical card, none of the questions I asked has been answered.

I will refer to two communications. The first is from the HSE which I received yesterday and which states regarding Galway:

In ten years in Galway, 49 public nursing home beds were provided — 12 in Áras Ronán on the Aran Islands, 17 in Carna and 20 in Áras Mac Dara.

  11 o’clock

The second communication I received was from someone who sent me details of canvassing by private consortiums to build private hospitals in grounds owned by the public hospitals in Galway. Regarding this, Professor Drumm of the Health Service Executive issued a statement yesterday on the co-location of private hospitals on public sites which states, “Expressions of interest were sought on May the 19th from interested parties to develop co-located hospitals on the grounds of 11 hospitals”. The statement lists these hospitals which include Galway University Hospital, and continues, “Expressions of interest are to be submitted to the National Hospitals Office by June 30th at which time short listing will take place”. We will not debate it here. The statement continues:


No one states how the successful applicants are to be chosen in any accountable or transparent way.

The land available, originally given to the public hospitals in Galway, had a stipulation that it would be available for public health. This is a raid on public property by private hospitals and individuals. A Deputy from my constituency suggested this is all in the interest of public patients. When the classy private patients have been removed from public hospitals, more space will be available for public patients. This is the type of thinking offered by Deputy Grealish. At present, in preparation for the closing date, letters are being circulated to consultants in Galway asking whether they would like a bit of this. It is not that there will be one private hospital on public property in Galway, apparently there will be two.

In ten years in the entire County Galway 49 public nursing home beds were provided. At the same time, we are told in a chilling sentence that there are no proposals for any public nursing home space in the next five years, except for some assistance to be provided to a voluntary organisation which has gathered pounds, punts and euro to provide spaces in the face of Government failure.

Why are the public not in revolt at this appalling behaviour? Old people are entitled under any concept of citizenship to decent rights. The Government, the Department, the HSE — and the health boards before it — seek to hide from the public the implications of the Health Act 1970 and the constitutional case taken in the High Court which suggests that a person on a medical card is entitled to a public nursing home space and where it is not provided should be entitled to a bed in a private nursing home. Nobody in the administration wants to clarify the entitlements of an elderly person, while the rapacious supporters of the small rump of the Government, the PDs, canvass on how to steal public property from the public who want to see nursing home beds provided on public ground and step down facilities and who do not want rich people to be canvassed on how to steal from the public in the name of health.

Mr. Boyle: Information on Dan Boyle  Zoom on Dan Boyle  It is always difficult to speak in the House after Deputy Higgins. However, I will try to rise to the challenge. I agree with what he stated on the rapaciousness which exists in particular elements of the Government regarding the provision of extra facilities which should already exist but sadly are still lacking.

[349]This legislation is badly needed. It has widespread support in the House as a legislative base for filling the gaps on an independent inspectorate for nursing homes. Unfortunately, a more embracing and holistic approach to legislation dealing with care of the elderly is necessary. This Government tends to make things up as it goes along, reacts to crises and introduces legislation to plug gaps which become apparent. It is unfortunate that given this is its ninth year in office, we have not had before us more embracing legislation to deal with the wider area of care of the elderly. Models and methods of looking after our ageing population exist and this Government should respond in innovative and better resourced ways. However, it chooses not to.

It is welcome that at least this Bill will replace the extremely ineffective 1993 Nursing Home (Subvention) Regulations under section 7 of the Health (Nursing Homes) Act 1990. We know to our cost it was particularly ineffective legislation. The inspection regime which followed from it was shown to be all too wanting, most notoriously in the case of Leas Cross. Many of us in this House suspect that Leas Cross is not an isolated example and many more such examples could exist in our system. We have not put in place a strengthened inspection system nor have we provided the resources to establish the extent to which these problems exist in our society.

Many aspects of this issue involve societal problems and the Government cannot and should not be expected to solve all of them in the first instance. However, the Government does have a right and a duty to ensure at least basic standards apply. As Deputy Higgins stated, the philosophical approach of the Government on this must be questioned. It has been found wanting. This Government considers a problem in terms of the easiest possible solution in the quickest possible time. These problems are endemic and should be sorted out from the first base.

In trying to introduce out of sight out of mind solutions, the Government’s approach is to try to get as many elderly people as possible into nursing homes, provide as many nursing homes as possible by the private sector in locations far removed from family, community and wider society and then throw up its hands when we discover Leas Cross situations. The first source of possible solutions to these problems should be found within the community and family structures. The fact this Government fails to recognise that and fails to provide adequate resources means a band-aid approach exists among families and they find they are forced to use nursing homes. Social welfare rules restrict pensioners from receiving carer’s benefit, and 50% of carers are over 60.

A facility exists in my constituency which is a model that should be replicated around the country. It takes a holistic approach to care of the elderly. The Westgate Foundation in Ballincollig has independent living units, day care facilities and [350]bed and medical facilities for people who find themselves immobile and in need of medical attention on an ongoing basis. The Government’s policy is to try to parcel it out, as is done with waste management. Perhaps that is a cruel analogy. The Government’s approach to this problem, as with many other problems, is to see how the private sector with its profit motive can deal with and solve the problem. Neither I nor my party accepts that, nor do many other Members on this side of the House or the vast majority of people.

The Green Party recently issued its policy document, Citizenship, Equality, Respect: A Policy on Ageing and Older Persons. If this Bill were more embracing and holistic, it would include many of the principles we are trying to advocate. In circumstances where elderly people find themselves in nursing homes on a long-term basis, or even to the end of their lives, is it enough for us to refer to legally enforceable standards of care and sanitation? Surely they deserve more, such as the right to the maximum quality of life, the feeling they are in an institution which they consider a home and the right to participate in the decisions that affect the community in which they find themselves.

We have legislation that gives parents the right to be involved in their children’s education and there is even a role for student councils in secondary schools so students can be more involved in decisions that affect those schools. The nursing homes legislation should therefore refer to the elderly themselves. What role do they have when living in nursing homes and how do they articulate their needs and enforce their rights? Unfortunately the Government is continuing to enforce standards from the outside. It only ensures that minimum standards are maintained and then walks away for a given period.

Inspections of nursing homes will be quite infrequent. Experience shows that inspections under the existing system very often occurred with the prior knowledge of the nursing home authorities. We need to know that this will not apply under the new inspectorate and that the spot-checks will be unannounced. The checks should ensure the standards that apply on the day on which they are carried out apply day in, day out.

Deputy Michael Higgins stated nursing homes are regarded as the first resort under Government policy although they should be the last resort. There seems to be no policy to deal with the intermediate circumstances in which people find themselves. Between the family home, the hospital and nursing home, there is an utter dearth of step-down facilities. With a bit of imagination and innovation we could prevent circumstances in which people effectively find themselves incarcerated in nursing homes throughout the country. Such people find themselves cut off without adequate support when their conditions [351]could be dealt with a little more effectively on a short-term to medium-term basis.

The wider issue is that the Government’s policy of continuing to depend on nursing homes as the main means of caring for the elderly, with which policy the inspectorate will have little to do, is very expensive, particularly when nursing homes are largely privately owned. Before the recess, we will have to deal with the short-term bill for nursing home charges, which will probably be in excess of €1 billion. Upon a nod, the House will be expected to decide on the first tranche of this, which will amount to €340 million, just to deal with the original payments. Ultimately, successive Governments, including the current one, made serious errors in this area. That the bill was allowed to accrue and that a wrong principle was put into practice does not escape the fact that the policy the Government wishes to pursue will result in a continuing added cost to society.

We believe the money could be used more effectively by resourcing family units, the carer sector and community structures. The Government needs to come out of its shell on this issue. Does it not believe there is a more effective approach than throwing money at the problem in such a way that it only benefits a small number and barely affects those in need of care who are meant to benefit therefrom?

Mr. M. Higgins: Information on Michael D. Higgins  Zoom on Michael D. Higgins  The Government is cutting the home help service.

Mr. Boyle: Information on Dan Boyle  Zoom on Dan Boyle  That is the effect of it.

As a member of the Committee of Public Accounts, I believe we will not only be revisiting individual care-related issues such as that which arose in Leas Cross, but that we will also be presented with a report by the Comptroller and Auditor General on how public money has been wasted and should have been used far more effectively to care for our ageing population.

Consider how the Government responded to the child care problem. It was forced by policy initiatives and all Opposition parties into accepting that there should be direct payments to help with the care of children in family units. This principle should also be applied to families with ageing members. That we have a split standard shows the Government is again acting on a panic basis in respect of what is regarded as the most sexy political issue.

If the Government is to think on a long-term basis, which it is incapable of doing, it needs to recognise that we have an ageing population. When I and my peers were being educated at third level, the IDA used to broadcast an advertisement saying we were the young Europeans and that 50% of the population was under 25. This figure has increased significantly but a time will come, in 20 or 25 years, when quite a large proportion of the population will be over 60. What are we doing now to anticipate their needs [352]and involve them in making the decisions that will meet these needs? In this regard, there is a dearth at the heart of Government thinking.

My Green Party colleague Deputy Gormley, our spokesperson on health, stated the party supports the legislation as it stands but believes it is a stop-gap measure and that there are many more areas in need of legislative redress in order to recognise and meet the needs of the elderly. Unfortunately, I am not confident that the Government will be able to meet those needs.

Mr. Ring: Information on Michael Ring  Zoom on Michael Ring  The issues addressed in this Bill are creating many problems for the elderly and particularly for families who need to put one of their loved ones into either a private or public nursing home. I compliment Deputy Michael Higgins on his speech because what he says is correct.

Everyday I see very vulnerable people who are not well off and have no resources of their own. Vulnerable families are assessed by the HSE and told by it that their loved ones need a long-stay bed. They face very serious problems and I hate to say they are being forced by the State to put their loved ones into private nursing homes. They are given a list of such homes and a subvention form. This is not correct and I want the Government to write to the carers of the elderly to clarify the law, which it does not seem to know. The Ombudsman, however, made it quite clear some years ago. When I was deputy spokesman for health, I highlighted on many occasions the Ombudsman’s view that if one is over 70 and has a medical card, one is entitled to a State bed. If that is not correct, I ask the Minister of State to refute it. Doctors, nurses and the Health Service Executive should be aware of the law of the land. They should not intimidate people and pressurise them to put their loved ones into private homes when they do not have the resources to fund it. People are being pressurised on a daily basis. The State may not have enough beds but it is not the job of the families to provide them. That is the job of the State.

The Sacred Heart Home in Mayo is an excellent, well-run home but in recent years all the Health Service Executive could do was reduce the number of beds in that home. A problem arose with the floor in the home and I understand, although I am open to correction, that it has not resolved that problem to this day yet it has no problem upsetting families when they are under pressure.

I could give many examples of people being pressurised who were unable to stand up for themselves. I am thinking of the woman who came to my clinic crying and saying she was being intimidated by a doctor. She said she was unable to put up with it any more. I had to write to that doctor, explain the law of the land to him and ask him to stop upsetting the woman who was in need of full-time care herself. She was trying to look after her sister but was unable to do it, yet she [353]was told that she must fill in the subvention form and that her sister must go into a private home. That is not the law of the land and that must be spelled out to the doctors and to the Health Service Executive. If people want to or have to go into private homes the procedures should be explained to them in a simple way. The options should be outlined to them and they should not be forced out of hospital.

I made the point yesterday to Professor Drumm that the Health Service Executive cannot have it both ways. Some weeks ago it announced the home care package. I am sure the Minister of State heard about that because we had a big spin about it. All the spin doctors were out, and there are more spin doctors in the country than there are medical doctors. They were spinning as usual about the home care package, which is amazing because I have tried to get the home care package for some of my constituents or at least a copy of the guidelines, rules and regulations without success to date. I am waiting for many weeks for a reply to a Dáil question, and it is no longer easy to get a reply from the Health Service Executive on the number of home care packages produced in Mayo. I know how many — none. There is little point in announcing fancy schemes and ideas without having the scheme approved, publishing the rules and regulations and having applications dealt with quickly. We cannot have it both ways. We cannot expect people to bring their loved ones home from hospital without any back-up or help from the State.

I will give the Minister of State another example of what is going on with the Health Service Executive when there is a small cut-back. Belmullet is approximately 70 miles from Castlebar, more than 100 miles from Galway and more than 200 miles from Dublin. Elderly people living there want to remain at home. Every report and statistic shows that people want to stay at home, be looked after in their own homes and die at home. They do not want to take up a State bed. They want to stay in their own beds in their own homes in their own part of the country. The situation now, however, is that many elderly people on social welfare payments who have no resources, money or family back-up must travel to Dublin or Galway to keep a hospital appointment. That is not their fault, nor is it their fault that their appointment is for 9 a.m. We have very little infrastructure to allow them get a train or a plane to bring them to Dublin. We have no Luas in Belmullet, Castlebar or Mayo. Our people cannot hop on the Luas to keep hospital appointments. They must travel more than 200 miles.

The Health Service Executive in Mayo has new criteria. I raised this matter with Professor Brendan Drumm yesterday and I hope the Minister of State and his officials will raise it also. It has decided that it will provide transport to only three or four categories of patients. We now have a situation where many sick elderly people in need of hospital appointments will be unable to [354]take up those appointments because they do not have the resources or the money. In the past the former health boards supported them and arranged for them to be brought to hospital appointments. When I raised that yesterday with Professor Drumm he told me that there was no cut-back. If there is no cut-back I want the Minister of State and his Department to write to the Health Service Executive today and tell it to go back to the old scheme and abolish the existing scheme. What is going on is not right. We cannot have it both ways.

I will outline what the former health board is doing in my county. They wonder about the reason State beds are taken up, accident and emergency units are over-crowded and the health service is in disarray. I will explain the reason. It is because we did not do our business in this House. Previous Ministers did not do their business. There are no step-down facilities available. There is no place for an elderly person to go when discharged from hospital needing a week or two in a nursing home to recuperate. There are no step-down facilities for those people. We cannot force people out of hospitals and into their own homes without back-up. We will not give them the necessary back-up at home and we will not give them the back-up in hospital.

I raised this problem with the Minister of State, and to be fair to him he wrote to me and did his best. He outlined all the extra money he provided for home help yet I am aware of elderly people in their 80s and 90s who previously got four hours home help a day but which has been reduced to two hours. The home help service has been taken from some of them. When I raised that with Professor Drumm yesterday I was told there were no cut-backs and that anybody who needs home help will get it. I know many people who need home help but they are not getting it. It is hypocritical of the State to say on the one hand that it cannot provide funding and does not have the beds yet the people who want to stay at home are not being supported or given the necessary back-up and resources.

In the Sacred Heart Home I mentioned earlier there are two beds for cancer patients. That hospice unit has been open for many years but the beds are vacant. The Health Service Executive placed a number of advertisements for a doctor post in a newspaper and I wondered why no doctor would take up that job. I put down a Dáil question on that matter, but it took a long time to get an answer. Eventually I had to threaten to make a freedom of information request. I am not sure whether I did that but eventually I got information on the advertisement, the salary the HSE was offering to pay the doctor who would take up the job. I now know the reason the job has not been taken up. It is because the pittance the HSE was offering was less than somebody would earn working on an island looking after ten medical card patients. We are not serious about dealing with health if that is the situation. People had to [355]leave my county to go to other counties in their last days to be looked after. That is sad. If we were serious about health and if the HSE was serious about filling that position in the Sacred Heart Home, it would be filled.

I will give another example to the Minister of State. Since I became a Member of this Dáil 12 years ago, we have been talking about providing a nursing home for Ballinrobe. It was an issue in every election for the past 12 years yet 12 years on there is not a brick laid to start building that nursing home in Ballinrobe. We urgently need nursing homes. I am talking about a public nursing home on which a commitment was given that it would be built, but it has not happened. If the former Western Health Board did its job properly, that nursing home would be up and running now and patients discharged from the old general hospital who still need full-time care would be in it. We cannot have it both ways. The State cannot lecture people about keeping their loved ones at home if it is not making any effort to provide for them.

The time has come. People are depending on the private sector. We have an Alzheimer’s unit in Ballindine provided by a man called John Grant. I take this opportunity to compliment John Grant and his staff on the efforts he has made over the years and the beds he has provided. He has done an excellent job for people who found themselves under pressure because the Health Service Executive was unable to meet their needs. They had to go to the private sector where people like John Grant operate, who through voluntary contributions raised money to provide an excellent unit in Ballindine. Compliment and say well done to people such as Mr. John Grant. We had no Ministers with the foresight he showed in erecting buildings and knowing that these additional Alzheimer beds were needed in Ballindine.

I will finish on the topic of the elderly and I want to again raise this issue as regards the Ombudsman. I want to ask the Minister of State and the Government to spell out the situation for a person over 70 years of age with a medical card. Is he or she entitled to a State bed? The Ombudsman says such people are entitled to a State bed. On the question of subvention, why are these forms being thrown at them when they find themselves in need of a State bed? It should be explained to these people first that they are entitled to a State bed, while they might have to wait a while. In the meantime the Health Service Executive should be paying if it wants to put them into private sector beds, not putting pressure on the people who cannot afford it. The HSE takes their pensions off them and that is fine — I have no problem with this and that is how it should be. However, it should not be putting pressure on family members at home on social welfare or low incomes to try and meet the shortfall.

[356]As regards the Bill, I hope this will deal with what has been happening in recent years, particularly in the west where we get a lower subvention than people on the east coast. The time has come for this to be resolved. Whatever people get on the east coast should be replicated along the west coast. We cannot have two types of payment, one for the east coast and one for the west. In the west, of course, we are getting the lower and not the higher end of the payment. As regards people who are in private nursing homes, it is time for a stronger inspectorate, with more people on the ground visiting these homes on a daily basis to ensure, where the State is providing subvention, that we have an input into the level of care such people are receiving. These people are entitled to the assurance that there is somebody to protect their interests because, while sometimes the private sector homes do an excellent job, there will always be those willing to take short-cuts. We saw that in Dublin, in Leas Cross, and I am sure there are more nursing homes throughout the State where the care is not being given, even though they are being well paid to look after people. The inspectorate should be in place.

The elderly built this State. If one listened to the media last week one would think only one person built up the State. That is not the case. Both men and women, who are now elderly, worked very hard and paid their taxes to the State. They raised their families and presumed, on paying their taxes, that when they reached the end of their days if they needed health care, nursing home beds or to be protected and looked after, the State would do that for them. They expected this because they paid their dues to the State. They are the people who went without many necessities during difficult times. They did what was right and the Minister of State and the Government should ensure they are protected. Whatever they need at the end of their days, whether a nursing home bed, a home care package, home help, or a doctor calling to see them on a regular basis, we should ensure they are protected because they have paid their dues.

I want this to happen. We do not want lecturing any more. We do not want spin doctors. We want medical doctors and people to look after the elderly.

Mr. P. McGrath: Information on Paul McGrath  Zoom on Paul McGrath  I welcome the opportunity to contribute my tuppence worth to the state of nursing homes and what the Government is doing as regards care of the elderly. I am glad the Minister of State responsible, Deputy Seán Power, is here to hear my contribution. I hope he takes on board some of what I have to say.

I note in particular from the Minister of State’s statement that when he introduced this Bill to the Dáil he said, “The aim of this scheme is to provide financial assistance to older people towards the cost of maintenance in private nursing homes”. We all know there is something [357]called the nursing home subvention scheme. I am sure that many other public representatives, like myself, have been inundated, not so much by the elderly but perhaps neighbours, nephews, nieces or cousins on their behalf, who face a major dilemma as regards how this nursing home subvention and care for the elderly works in this country. The situation is as outlined by my colleague, Deputy Ring. If some elderly person is in hospital and a neighbour comes in to visit, at some stage he or she will be told the elderly person is ready to be discharged and asked if he or she is taking responsibility for the person.

I came across a case recently involving a woman, Biddy, who was 85 and able to look after herself. A neighbour was told Biddy was being discharged the following day and it was expected the neighbour would look after her. This neighbour had looked after her over a long period out of the goodness of her heart. She would continue to look after her, but was being given total responsibility by the health services, although she was just a neighbour. She had no family connection with the woman and was not going to inherit her property. She would not gain any financial reward, and indeed did not want any. Nonetheless, this responsibility was being foisted on her.

She felt like an outcast, she said, on telling the hospital ward sister that she had a family to care for as well, and that while willing to do the best she could, she was not prepared to take full responsibility. The enormous burden of responsibility was being put on her shoulders, she felt. Because she was not prepared to accept it she was made to feel she was dealing inappropriately with this elderly person, her neighbour.

Will the Minister of State say whether this is what we are trying to do? Are we trying to force neighbours, distant relations and so on to look after the elderly? Again, as Deputy Ring pointed out, these are the people who built this State. All of these elderly people went through very difficult times in the formation of this State in the 1930s, the 1940s and the 1950s. I am not too old, but knocking on a bit, too, I suppose, like the Acting Chairman.

Mr. S. Power: Information on Seán Power  Zoom on Seán Power  Not old enough to be retiring.

Mr. P. McGrath: Information on Paul McGrath  Zoom on Paul McGrath  I recall the American wakes that took place in the small villages in the 1950s, where many of the people who are now very elderly saw their children emigrate to England and America, never to return in many cases. Those are the elderly people who made sacrifices, gathering a few bob to give their children the chance to go. As my mother used to say, they lived on “the clippings of tin” to keep alive. Times were extremely difficult in the 1950s and 1960s. Now, when such people have a dependency on the State, we are pulling the rug from under them. This legislation is being introduced as something of a sticking plaster job. We have had difficulties as regards the repayment of moneys to various [358]people, so the Government has decided to seal the door tightly in case of further crisis. Effectively, it is a battening down the hatches exercise, and that is why this is being introduced.

The Minister of State took the opportunity in his speech to outline what he believes will be a good propaganda campaign as regards how to look after the elderly. I know the Minister of State for quite a time and believe him to be a decent man. However, the way we are addressing the difficulties for the elderly is not up to standard at all. There was a flurry of activity towards the back end of last year, when the Tánaiste announced there was a new package for subvention, and that the threshold for housing in the Dublin area would be €500,000, as the cut-off point for nursing home subvention. In a rural setting the property valuation was to be set at €300,000. Those were to be the cut-off points. I talked recently to an officer in the health board and we discussed the whole question of subvention, with reference to a particular case. I asked him to confirm that in a rural setting the first €300,000 of income was to be disregarded. That was not the case, he said, but rather the perception. The spin doctoring made it sound like we were changing the system dramatically and that if one’s property was worth less than €300,000, it could be disregarded, while it could be disregarded in Dublin if it was less than €500,000. Assets above that value would only be examined when assessing nursing home subvention.

Nothing could be further from the truth. No change was introduced by the Minister. Instead of saying that if one’s assets are worth more than €90,000, one does not have a chance of getting subvention, we are saying that if one’s assets are worth more than €300,000, one has not got a chance of getting subvention. In between, we have changed nothing. The window dressing does not work and people are not fooled by this anymore.

We must address the real issues. People would prefer to stay in their homes, if possible, or at least in their communities. We should facilitate them in doing that. If we look around the country, some excellent schemes have been built. A priest in County Clare pioneered a scheme with small villages where elderly people could live in sheltered accommodation within their community. This has worked very well and it has been done on a voluntary basis. It is the kind of model towards which we should move.

Will the Minister examine what has been happening in the UK for a long time? There is a major problem in that country due to the great number of elderly people and it has been addressed in a good fashion. I am sure there are deficiencies, just like there are everywhere else. However, I am aware of a scheme which operates there, with which I am impressed, consisting of two-storey town houses joined together along a row. One entered an outer door into a long corridor and there were many self-contained apart[359]ment units at the bottom of the corridor which were relatively small, about 600 or 700 sq. ft. The first floor also had self-contained apartments. There were facilities for a live-in caretaker, nurse or administrator. There was an intercom system in each apartment and, every morning, the caretaker could call each apartment to ensure the occupier was up and about. Each apartment had a pull cord so that if an emergency arose, the caretaker could be alerted.

The block also contained community rooms so that even though each unit was self-contained, the elderly people could come together on a regular basis to play bingo or to have their hair done. Lunch was available at a reduced cost two or three days a week. There were two or three extra available rooms which could be booked for family visitors. This system operated very well. It created its own little community and there was even an occasional wedding. People had come separately to the community, romance blossomed and couples went on to get married like Darby and Joan. Birthdays also added to the community spirit. There would be a little function in the community room with a birthday cake and so on.

This system delivered security for the elderly because there was only one outside door. It created a sense of community and back-up when it was needed. The financial arrangements involved were suitable. A subsidy was paid by the state towards the rent of these units so that it was in the reach of ordinary people to be able to pay their rent. Their rent was akin to what they might pay in a council house, but the block was not owned by the council. It was privately owned and operated mainly by pension companies. The block of homes with which I am familiar was owned by the local pension board of the gas works. That board had built and operated it and was able to make returns on it, yet it was subsidised accommodation with all the advantages I have just mentioned.

Let us contrast that to what is happening here. We have been running down the number of beds available. We have been reducing the number of public beds available for elderly people. In Mullingar, St. Mary’s Hospital was built in 1841 and is one of two remaining in the country. The building is not ideal for a hospital and needs to be replaced, but it should be preserved as an administrative building or something. In recent decades, we have reduced the number of public beds from 250 to 120. We are making it more difficult for people to get in there.

We are forcing elderly people into the nursing homes at a time when their number is increasing. In 1995, there were approximately 400,000 people over 65 in Ireland. It is projected that the number of people over 65 by 2020 will grow to around 700,000. That represents a 75% increase over a 25-year period, which is very high. Various Governments have identified this problem and decided that more nursing homes must be built.

[360]Incentives were given to the private sector to build nursing homes. Looking at the demographic trends, people in the private sector thought they would have many customers and they rushed to build nursing homes. However, many of these homes are finding it difficult to survive. I am aware of homes that are below capacity and are struggling to survive. I have a friend who runs a private nursing home and I am told that the critical mass for a nursing home is about 28 patients. To make it viable and to survive, 28 patients are needed owing to nursing cover and so on. Anywhere below that number leaves the owner in a difficult situation. Many beds are not being used, but the Government is not providing the wherewithal to use them.

What is the standard cost in a nursing home? In my area, it costs between €500 and €600 per week, and there may be extras on top of that. How does an ordinary person survive? The old age pension is a maximum of €190 per week. The subvention is a maximum of €190 per week, if the person can jump all the hurdles put in his or her way. That makes €380. A shortfall of €170 to €200 per week has to be met. From where can people get that and how can they manage to meet that cost? Based on what is contained in the Bill in terms of what the Minister proposes, some older people will have to sell their property and the assets it would realise would have to go towards funding their nursing home care.

The Acting Chairman and I are familiar with people who go into nursing homes. I have yet to meet a person who when going into a nursing home would say, “I am in here now to die — this is the last of it, the final furlong”. Such a person would say, “I am in here for a little while until I get a bit stronger; I am going to build myself up over the next two or three weeks and I will be back home then”. Such a person expects that he or she will return to his or her own home. How then can one countenance a situation where one would have to say to such a person that he or she will not return to his or her home because it must be sold to keep the person in the nursing home? What kind of a blow is that to such people? Is it appropriate that we should do that bearing in mind what has been said about how our elderly people have built up this State?

I wish to return briefly to the issue of St. Mary’s Hospital in Mullingar. The most recent Government announcement is that the 120 beds in that hospital will be replaced by two 50-bed units on the site of that hospital and by a further 50 bed unit in Castlepollard. The proposed unit in Castlepollard has been promised for 20 years and I am sure it is simply yet another promise but we will have to wait to see if it will be delivered.

When our demographics point to our having many more elderly people in our State, should we be decreasing the number of public beds? There were 250 beds in that hospital and there are now only 120 beds in it. Will it be replaced with a 150 bed unit? I suspect that at some stage in the [361]future there will be a 50 bed unit in Castlepollard and one 50 bed unit in Mullingar and the provision of the second unit that was mentioned will be put on the long finger. That is not good enough and provision in this respect should be addressed at the earliest possible time.

I wish to make a further point to which I ask the Minister of State to pay particular attention when replying to the debate. What is the position under the Health Act 1970 in regard to people who have to go to hospital or to a nursing home? We were promised in the 1970 Act, which is law, that hospitalisation would be free of charge for anybody, but that is not the case. It is not only I or other Members who have made that point, a former Ombudsman, Mr. Michael Mills, completed a specific report on this matter and obtained legal advice on it. He said that in his view the Nursing Home Act 1970, which is law, means people are entitled to be in nursing homes free of charge. How does the Minister of State reconcile that with what is in this legislation? How will he address that issue? Will he amend the 1970 Act to state that is not the case? We should not have such confusion. It will lead to further difficulties down the road. When a case on that basis is taken by a person and he or she cites the legal advice and the report of a former Ombudsman, will we all again be held indicted for not living up to our responsibility?

Mr. Timmins: Information on Billy Timmins  Zoom on Billy Timmins  The most contentious issue we associate with nursing homes and the care of elderly people is that which was highlighted recently, namely the nursing home inspections. Many of us have consistently raised this issue over many years, but it never received publicity until recently. A report may be on the desk of the Minister or someone else on how these inspections should be carried out and implemented. Given a year has passed since the bad publicity surrounding many private nursing homes, it is time a proper nursing home inspectorate was established. A considerable degree of good work is done by many nursing homes and many elderly and middle aged people are treated very well in them, but other nursing homes, particularly old converted buildings, convents or school houses, leave much to be desired. I have had relatives in nursing homes and I am familiar with the difference in standards across them. The standard in some is excellent and in others it is very poor.

Many people in nursing homes are vulnerable. They do not have the wherewithal or a mechanism to make a complaint. In many cases, there are afraid to make a complaint because they believe they will be moved on. I am familiar with a case where an individual in my constituency made a complaint about a nursing home, following which the family was asked to take their elderly parent out of the home. The family was reluctant to follow up on the complaint. I have taken up this issue with the Department and [362]tabled parliamentary questions on it, but I found it difficult to get the bottom of it.

New nursing homes should be single storey structures and we should not permit them to be two-storey or multistorey structures. I am aware of a nursing home in Kilkenny that is an old two-storey building which was converted for that purpose. There is a lift in it and when part of the lift was damaged the spare part needed to repair it had to sent from Italy. The lift was of out commission for several days during the summer and the elderly people on the upper floor could not come down to the lower floor or go outside. They were basically trapped in the building and I fear to think what would have happened if there had been a fire. New nursing homes should be only single storey buildings. I do not know the provisions of the building regulations in regard to them, although I admit that most nursing homes I have seen are single storey buildings. I would like the Minister of State to examine that point.

In regard to the county development plan in Wicklow, where there are very restrictive planning practices, I put forward a proposal that nursing homes should be allowed to be located on greenfield sites, even if not connected to the main sewerage scheme. That proposal was accepted following much difficulty. An argument is often made that nursing homes should be located in towns where people have access to the church and other facilities. However, many people were reared and lived all their lives in a rural environment and they want to spend their time in a nursing home in a rural environment. Such provision should be encouraged. I am aware that some nursing homes are located in rural areas, although there are not many of them in my county, but I hope more will materialise in time.

The main purpose of this legislation is to put the concept of subvention on a legislative footing. Section 7B of the principal Act deals with that aspect under two issues, namely, dependency — in other words, the physical needs of a person — and the means of the applicant. I may have interpreted the section incorrectly and the Minister of State might clarify it. It refers to excluding 95% of the estimated value of the house and that 5% of the value of the house would be taken on board. I assume it will be taken on board as an income. If a person’s house is valued at €1 million, the income one would be assessed as having is €50,000 a year. Perhaps I am misreading the section but that is my understanding of it. The section goes on to deal with the position in the case of threshold limits. For example, if a person has a principal residence the value of which is above €500,000 and if it is located in the Dublin area, he or she would perhaps be refused subvention and if a person has a house valued at €300,000 in an area outside Dublin city and county, he or she perhaps would also be refused subvention. I assume I am correct in my interpretation of that provision. This provision could exclude many people from qualifying for subven[363]tion. The average price of houses have increased by 270% in the past ten years across the country and in some places they have increased by
300%. Taking the value of a person’s residence into consideration is not a very exact science. The taking into account of property valuations will impact on people across the board because such means is not a tangible asset for people who do not intend to sell their property. If that is the case under this legislation, it means people living in the greater Dublin area will never qualify for subvention. The Minister of State might be able to clarify that provision in case I am misinterpreting it.

  12 o’clock

Deputy Paul McGrath mentioned in 1970 Act and a commitment that the State would be responsible for the welfare of older people and would provide facilities such as nursing homes. I have a letter from the Wicklow Active Retirement Association. The members believe that little or nothing has been done by the State to implement the commitment in the Health Act 1970, and it is difficult to disagree. They believe older people are being forced into private nursing homes, thus causing them and their families financial hardship. I do not have a difficulty with the many tax incentives put in place to encourage the building of private nursing homes. If people are willing to invest in them, that is fine. However, the amount charged for care is prohibitive. Given the tax reliefs and the subventions paid, the development of existing old district hospitals might provide better value for money.

Many older people already attend day care centres at these hospitals, so it might be a natural progression for them to move into care there when necessary. Hardly a week passes without me being contacted by someone trying to get a place in their district hospital. It is not that they want free care, rather that they want to be in the vicinity of people they know and to remain in the environment with which they are familiar. Many parts of the country do not have private nursing homes.

These district hospitals provide a good service and provide respite and step-down beds for people coming from acute beds thereby taking pressure off the main hospitals. However, the staff in these hospitals often have to struggle for resources. Despite the fact that facilities have improved tenfold over the past 20 years, the district hospitals face a constant struggle for more staff and beds. There are three district hospitals in County Wicklow: Baltinglass, Rathdrum and Wicklow town, and they are constantly looking for more resources. The local people want to use these hospitals rather than private nursing homes, irrespective of the payment issue.

The break-up of the old Eastern Regional Health Authority brought a change in the catchment areas for district hospitals and, as a result, we now have an imbalance in Wicklow. Approxi[364]mately 90,000 people are in the catchment area for Rathdrum and Wicklow and about 12,000 in the Baltinglass catchment area. The Department should take another look at this. The policy of the Health Service Executive is to have no borders, so to speak. The catchment area for Baltinglass should revert to the old area because people in south Wicklow have attended day care there and had relatives there. Now that some of them may wish to access the hospital, they have been refused access and told to go on the waiting lists for Rathdrum or Wicklow. This makes little sense because there is already a greater demand on those two hospitals. If the numbers were broken down on a population basis, we would revert to the old system. I have raised the matter several times but have had no success to date. Therefore, I would appreciate it if the Minister would take the issue on board and do something about it.

The Bill has nothing to do with sheltered housing, but the issue is related to Government policy. The Wicklow Active Retirement Association has asked what sheltered housing is available for the area and how the association can go about acquiring it. We all know excellent funding mechanisms are in place for sheltered housing and they work well. We have seen many parishes and communities avail of this funding to build sheltered housing on parish or community grounds.

We should encourage the building of sheltered housing as an add-on or attachment to our old district hospitals because these already have a staff in place and provide a secure environment. Statutory bodies should be more proactive in this regard. Perhaps they should contact all the active retirement groups that have been set up in recent years and provide them with details on how to go about providing sheltered housing. There is possibly, if memory serves me right, 100% funding available for such schemes.

Many people cannot survive alone in their house but they do not want to go into a nursing home. They would prefer a type of halfway house and sheltered housing would meet that need. There is an excellent sheltered housing scheme in Carnew, County Wicklow, and in many other places throughout the country. However, many areas do not have these facilities nor the wherewithal to provide them. If we provided the information to the active retirement associations on how to go about sourcing funding for sheltered housing, most communities would be willing to provide sites. Most district hospitals have extensive sites and the sheltered housing could be on them.

Some people referred to the home care package which provides assistance to people in their homes. Many people do not want to leave their homes and would not have to if the home care package were enhanced and more readily available. Last year, I tried to source home care for some people in my area, but there was a limit on what was available and no more could be pro[365]vided. We should allocate more funding to this area to make life easier for elderly people, thereby taking the pressure off having to provide nursing home subvention.

People often only need a mechanism to help them stay in their home. They might not want to go into a private nursing home, but they see no other solution and this often costs the State more. We must look after our elderly and our young people, and resources should never be the issue in this regard. We need to put this legislation and the infrastructure in place to provide people with an option. I repeat, not a week goes by without some family contacting me to find a place in the local hospital. Unfortunately, unless someone in a public bed dies, no place is available.

I broadly welcome the legislation. I compliment the many people working in public nursing homes and hospitals and those working in the many private homes, especially the two Cheshire homes in Shillelagh and Tullow who work with people with disabilities. Facilities have improved, but this is mainly as a result of proactive chairmen or executives in charge who know how to source funding and go about these improvements.

The Department should take a more proactive role in providing information to people on their entitlements, ranging from the small security alarm to family income supplement. There is a significant information deficit with regard to what is available. We often pat ourselves on the back for passing legislation, but the tangible results seldom filter down to the people because it takes so long going through the Department and the Health Service Executive that the people at the bottom do not get the information.

I wish to ask the Minister of State about another issue which is not directly related to the Bill but is related to the health area, namely, the provision of community first responders and defibrillators. I know he was at a recent successful launch in Kilcullen. It should be a legal requirement for nursing homes and public hospitals to have these. Many do not have this equipment which only costs €1,600. I have asked the Minister for the Environment, Heritage and Local Government on several occasions over recent years to make it a condition of planning permission for buildings that will attract over a certain number of people that defibrillators are provided and that it be a legal requirement for staff to be trained in their use. This equipment saves lives and would be of particular value in nursing home establishments.

Mr. Deenihan: Information on Jimmy Deenihan  Zoom on Jimmy Deenihan  I am delighted to have the opportunity to speak on the Bill. I compliment the Minister of State, Deputy Seán Power, on bringing forward the Bill and on his commitment to older people since he became Minister of State.

We owe it to our older people to ensure they can live out their lives in comfort and in the confidence that the system supports and respects them. [366]Some 11% of our population is over the age of 65. In 1986, we had approximately 390,000 people over 65 in the country. Today we have approximately 465,000, and that will have increased before the next census. It is estimated that by 2036 we will have more than 1 million elderly people. Government and State agencies face a major challenge to ensure that we put in place the services to cater for our increasing elderly population.

We owe it to our older people to provide services. These people built up our economy and produced the present generation and we must give them every support possible. It has been Government policy going back to 1990 to support older people to stay in their own houses for as long as possible. The welcome introduction of subventions changed that philosophy to some extent. It created the impression that the Government and agencies were anxious that people should go into residential care. However, we need to strike the balance between the incentive for people to stay in their houses for as long as possible and go into residential care when they have no other option.

While people may have reasons for wanting to leave the homes and communities where they have lived all their lives and go into residential care, generally older people want to stay in their own houses where they have community and local support. They want to remain in their own houses for nostalgic and family reasons. They may have been born there and generations before them may have been born there. They know the geography and the environment of the house. As they get older they know how to move around the house without sustaining injury. They like to look after furniture and other possessions they may have bought years earlier and to which they may have sentimental attachment. The house could contain old photographs that are important to them. They have accumulated memorabilia etc. All these matters are important for old people and they cannot take them into residential care. They generally need to leave almost everything behind. While they can bring a photograph album, they cannot bring furniture or pottery, for example, which is a source of comfort for many old people. It is important to give them the option to stay in their own homes for as long as possible.

Accommodation and hygiene facilities have improved considerably. In the 1960s many houses had no running water or toilet. Young people today would not understand that was the reality. There are now very few houses without running water, and basic toilet and bathroom facilities. However, they can be improved. A number of schemes are available to allow people improve their accommodation, including the essential repairs grant, disabled person’s grant and housing aid scheme for the elderly. With the increase in building costs, at times it is impossible to get a builder to carry out house improvement or repair, because builders are so busy. Many of them are [367]not prepared to take on small jobs like putting in a bathroom, repairing a room or even replacing a roof on a house. While at one time builders appreciated getting these types of jobs, now they are not interested.

The grant aid available is derisory compared with what should be available. An ordinary job is likely to cost at least €10,000. Generally people would get a grant of €5,000 for such a job, leaving them to make up the remaining €5,000 somehow. It is very hard for an old person to go to a bank or credit union to get a loan. Obviously elderly people are at a disadvantage because they might not live long enough to pay off the loan. Older people do not like to borrow money to make up such a deficit. Essential repairs should be at least 90% funded, with a small contribution from the householder in order to ensure that people can live in comfort with a roof that does not leak and have a decent toilet. The essential repairs grant generally covers only windows, roofs and doors, and does not cover basic facilities such as toilet facilities and showers. Although the essential repairs grant has been improved considerably and it is possible to get up to €20,000, it is still not adequate.

Older people need to be able to get a hot meal each day and they need good hygiene conditions. They need an accessible shower even more than having a bath, as they find it difficult to get into and out of a bath. They should have a decent shower at least and should have the facilities to cook at least one hot meal a day. In such circumstances, people live longer, more comfortably, and in better health and humour. While the disabled person’s grant scheme has been improved, it should be reviewed further and made more generous. A very small number of people will benefit from it.

The housing aid scheme for the elderly, administered by the Health Service Executive, has been quite effective in the provision of storage heating, for example, and other minor repairs. It is not hamstrung by the same bureaucracy, as is the case with the essential repairs or disabled person’s grants. It generally provides quick aid to elderly people to install heating, showers or for other minor jobs perhaps including adapting the house for disabled people. More provision should be made for the scheme. In my county the funds get exhausted after four or five months and there is a long waiting list. In some cases by the time people get the grant they may have already gone into residential care or may even have died.

The other aids for elderly people are the home help scheme and the carer’s allowance. Last year in the southern region the hours of home help provided were cut considerably. People who were getting one hour’s home help found it cut to half an hour. Those getting four hours’ home help found it cut to two hours. When the country is flush with money, it is very difficult to explain to older people why the person, who comes to cook [368]the dinner, wash the clothes, clean the house, keep them company and keep them abreast of what is happening in the locality, can only come for two hours instead of four hours, when in reality it should be six hours. The provision of home help should be extended rather than cut back.

I do not have the figure for the number of carers in the country. However, those in receipt of carer’s allowance constitute only a small proportion of those who provide care and attention. Many carers do not receive recognition. They should have their work recognised within the PRSI system by treating it as an insurable occupation, even where the care is provided to a family member. Although the carer’s allowance has been reviewed and improved and a more generous means test has been introduced with the result that more people qualify for the allowance, the scheme needs to be further reviewed to ensure more carers can access it.

If a person’s home setting is physically appropriate and personnel are available to provide home support, it will encourage him or her to stay at home rather than enter residential care. The benefit to society is that this option costs less. The cost to the State of residential care is in excess of €1,000 per week. Keeping people at home, on the other hand, provides employment opportunities for local people who can supplement their income by offering home help services. The home help scheme is a good, well managed service offered by many community groups through FÁS. It should be extended and made more attractive.

The community has a major role to play in home care. Every reasonably sized community should have a facility for older people who wish to have a shower or hot meal, read the newspapers or interact with their peers. I am involved in a project in Knockanure, County Kerry, where a derelict school has been renovated to provide facilities for older people. We have installed a state-of-the-art shower room, laundry service and kitchen, as well as a multi-purpose open area which can be used as a restaurant, for adult education and entertainment purposes and to host functions for funeral or party groups. It can also be used by the Health Service Executive with nurses, doctors, chiropodists, physiotherapists and other health professionals able to visit the facility. Similar facilities are in place elsewhere, for example, in Mulranny, County Mayo, but additional resources are required to develop more of them. The Knockanure project is a good example of how community facilities can succeed and could serve as a model for other parts of the country.

When home and community supports are available, people are less inclined to enter residential care. However, for those with no other option, the nursing home subvention is not sufficient to cover the cost of residential care. Sufficient private nursing care beds are available, but an inadequate number of public beds means people [369]cannot afford nursing home care, even with a subvention. Those unable to afford private care should be given the option of a public bed, but this is not feasible because so few beds are available. The result is the practice whereby the Health Service Executive contracts beds from private operators.

Residents of private homes must use their savings to fund the cost of care. Once these have been spent, they face the prospect of leaving the home either to return to their families or to avail of an alternative arrangement, of which there are few. The maximum subvention, including enhanced subvention, is approximately €300. Nursing homes must charge in excess of €500 just to survive and meet the costs of electricity, insurance, water and refuse charges, staff costs for nurses, carers, cleaners and so forth. For this reason, a number of them have closed in recent times.

The level of nursing home subvention needs to be reviewed because it is insufficient to allow people to maintain themselves in residential care. I am sure the Minister of State will have heard stories of people being placed under severe pressure to meet the costs of care, including being forced to sell their homes and use their savings. If a person has €100,000 in savings, it will be quickly eroded if the weekly cost of care, after subvention has been deducted, is €300. This is a major problem.

I recently learned of the retirement village concept, which has long been in vogue in Australia, New Zealand, the United States, Scandinavia and, more recently, Britain. A typical retirement village is located in a parkland setting of between 25 and 40 acres. It will usually consist of 150 to 200 individual houses and apartments grouped in courtyard style and clustered around a central garden area. A central services complex contains a wide range of communal services, including shops, restaurant, bar, chapel, library, therapy pool, gym and meeting and activity rooms. A nursing home with medium to high dependency care rooms provides 24 hour medical support to all village residents who also have access to physiotherapy and other services. All residential units have alarms connected to the medical centre and all residents are provided with a wide range of domestic and maintenance services. This type of retirement village is being developed for
the first time in Ireland in Carnelly Village,
Clarecastle, County Clare.

The Department should examine the concept of the retirement village given its manifold benefits. For example, elderly people with a range of health problems and disabilities can live a normal domestic life in their own home with comprehensive back-up services. In addition, all services and requirements are met on site with residents having an option of accessible transport services to nearby towns, access to a wide range of activities, clubs and hobbies, 24-hour medical assistance and an on-site ambulance service. [370]Facilities also include a 24-hour on-site security presence and daily assistance with domestic chores as well as delivery of meals if required, emotional support and assistance from qualified personnel and other services.

The best approach to care is to keep people at home for as long as possible for the reasons I have outlined, especially given the affinity of Irish people to their hearth and home. Home services and visits should be provided to ensure people are living comfortably and the community network, which provides support to those living at home, is strengthened. Where this is not an option, the possibility of moving to a retirement village or sheltered housing should be considered. The final option should be to move into residential care. Implementing this approach should be the Minister of State’s objective. He has a further nine months in office in which to achieve it, after which he could well be replaced by Deputy Wall.

Mr. Wall: Information on Jack Wall  Zoom on Jack Wall  This Bill offers the opportunity to discuss a major problem faced by Irish people, namely the age of our population. I cannot believe the Bill’s provisions on means testing are not being opposed by my party. Throughout Ireland’s history, people have always maintained that their home is their kingdom. This will be the only instance where the Government and its agencies will use the home as part of the means test. Senior citizens will be forced to have their houses evaluated before they can receive the care they need. It is unthinkable that a person may have worked a lifetime to obtain a family home and at the end, due to the necessity to sell their home, all the work done over the years and time and effort put into rearing their family in the family home may be put in jeopardy by this legislation.

There are other worrying aspects to this. In recent months, I dealt with the case of a woman who had to leave an excellent job in England to return to Ireland to care for her mother. While looking after her mother, who lived in a house that had been improved by her family over many years, the woman received the carers allowance but when she later began to suffer ill-health, her mother had to be moved to a nursing home. The woman was subsequently paid a disability allowance, which was lucky because, if she was not, the old legislation would have probably required the sale of the home to pay for the mother’s care and, despite all the effort and time spent caring for her mother, the woman would have had to seek alternative accommodation.

This Bill does nothing to allow someone who spent a lifetime caring for a loved one to remain in the family home, yet everyone seems to agree on its importance. The other day, Deputy Ring criticised a different Bill as being difficult to understand. I find it difficult to understand how we can allow this Bill through the House without a vote on Second Stage. What will happen to the people who live in homes which they consider as [371]their kingdoms? If the house is of a certain value, it may have to be sold when a family member needs care.

I cannot understand why we are being so selective in our decisions on who to exclude under the provisions of this Bill. It is not unusual that a relative could care for a loved one in the family home for 20 or 30 years without any payment, yet such a person is being excluded under this legislation because he or she is not a spouse or child of the applicant or a relative in receipt of disability or similar allowance. No heed is given to the relative who may have eked out an existence from a small family holding while also caring for loved ones. I hope, when this Bill is on Committee Stage, amendments are tabled to change that aspect of the means test because it is not acceptable in its present form to anyone who works with senior citizens.

Who is to determine long-term care? The care may be short-term from the point of view of the family concerned. The care recipient may improve through medical care to the point where he or she can return home. However, we are insisting on including this as part of the means test.

Yesterday, the Taoiseach lost his cool with Deputy Joe Higgins over the family home, yet today we are allowing this Bill to pass through the House. I wonder whether it is constitutional to allow the family home to be assessed in this manner. I will raise this matter with the Labour Party spokesperson on health and, if amendments are not brought, I will consider my response in terms of the amendments I can bring.

The Minister for Justice, Equality and Law Reform admitted that he would like to charge senior citizens for their long stays in the general hospitals. I know people stay a long time because I have advised people to remain in hospitals because step down facilities were not available to them. They had no choice other than to try to go back to the family home where no one was in a position to care for them. There were two parts to the nursing home subvention. The first subvention amounted to €192 and it was divided into three so that if a person was fit enough to shave, for instance, he would not receive the maximum payment. Yet, can anyone show me one nursing home that would assess a person on that basis? If a person could say his brother-in-law or sister-in-law was mobile, would a nursing home say they would be charged less? It has not happened and it will not happen. The maximum fee is charged for everyone.

Enhanced subvention was later introduced, causing constant suffering for the unfortunate people who were trying to get the money together for care. It was a complex, pressurised situation because we did not have proper step-down facilities. There should be an orchestrated plan to provide step-down facilities rather than putting the family home, which is dear to everyone, under [372]threat. This Bill places the family home under threat, and we can like it or lump it. I have raised it at Labour Party parliamentary party meetings and will continue to do so. I will table amendments to have this legislation changed in that regard. I ask the Minister of State to examine the relevant section as well.

St. Vincent’s Hospital, Athy, should be developed to allow more step-down beds. A great team works there and the facilities of the wheelchair association, sheltered housing and a day care centre are available. It is an ideal location to link with Naas General Hospital and provide step-down facilities for senior citizens who will probably return to the family home.

The Minister of State should also consider those excluded by the means test. There is no logic to the treatment of the case I mentioned. After leaving a good job in England to return to Ireland, a woman became ill while caring for her mother. She was fortunate to be in receipt of disability allowance, otherwise the family home would have had to be sold. If she had been in receipt of the carer’s allowance, the family home would have been sold because of its value and the inability of this society to care for a person in those circumstances.

Mr. Durkan: Information on Bernard Durkan  Zoom on Bernard Durkan  Hear, hear.

Mr. Wall: Information on Jack Wall  Zoom on Jack Wall  Other speakers referred to facilitating older people in the family home. It is not easy because of the high percentage of people in employment. No one is critical of this but we must assure those who work that care of the older person is being provided in the home. This is not the case at present. I know of some people who have not been paid for the home care package for four weeks. What good is a home care package if it is not efficient and streamlined? This is a stumbling block.

At local authority level, major problems exist with the disabled person’s grant and the essential repairs grant. In many instances, insufficient staff are available to investigate the problems and consultants must be employed for this purpose. Small builders, who would do the job out of friendship, are losing out. Everyone involved must endure months of waiting, agony and torment. The person who needs the repairs is unfortunate because he or she could not afford it originally, everyone is on the builder’s back because of the bills accumulated and the public representative is trying to co-ordinate matters but failing.

This process should be streamlined because it is not working efficiently. The application for the disabled person’s grant must be submitted to the council and be referred to the Health Service Executive, the medical director of services, back to the council and then to the engineer before the applicant must seek three quotations. The council must then choose one of the bids before informing the applicant that work can proceed. Forests in South America are in danger because [373]of the amount of paperwork involved in the disabled person’s grant and the essential repairs grant. The person most worried of all is the senior citizen who cannot enjoy retirement without the necessary facilities. This Bill will create problems for everyone because taking the family home into account for assessment creates the doubt that the owner may not be able to pass it on to a family member and keep the family tradition in the community. The family home is one’s kingdom and should never be considered in a means test. I hope common sense will prevail and that after Committee and Report Stages, the home will remain the pearl in family life. There should be no threat to the family home. It is unbelievable that the family home is under threat to protect a senior citizen or provide for a senior citizen in a long-term nursing home. The mind boggles.

I hope mechanisms are put in place to access the disabled person’s grant and the essential repairs grant. The HSE team that carries out necessary repairs could be increased to meet the demand for the disabled person’s grant and the essential repairs grant. The team is very helpful to senior citizens. Streamlining this process and providing a home care package would represent value for senior citizens. These people have worked hard to provide for us and we will wish for the same level of care when we reach that age. I hope we will never see the family home considered as part of a means test of any payment.

Mr. Kirk: Information on Seamus Kirk  Zoom on Seamus Kirk  I was in the Chair before the current Acting Chairman and listened to interesting contributions on this matter. In a few years, care of the elderly will be near the top of the pile of major policy issues for the Government of the day and will be a challenge for the Department of Health and Children. The solution to the accommodation needs of individuals who are in their golden years will not necessarily be found in the policy initiatives that will come directly from the Department of Health and Children. There are other Departments which will play a role in that regard and the need for collaboration and co-ordination of public policy is fairly obvious.

For a long time institutional care was seen by many families as the ready-made solution for the care of an elderly person with a certain level of dependancy who, where family help was not available, could not be looked after in a family setting. With the development the private nursing home matrix across the country, we all are aware that the cost of nursing home care is substantial. A stay in a nursing home, particularly on the east coast, is very expensive. In one way or another, either the families who have a responsibility for the elderly person or perhaps a combination of the families and the State through the contribution of the subvention scheme, are paying substantially for that care in a nursing home.

The effect of virtual full employment on the availability of family support means the extent of [374]family help available in the home setting is not what it was in previous years. I remember talking to an official, originally from Sweden, at an OECD function somewhere in Europe ten or 12 years ago when I was a Minister of State in the then Department of Agriculture. When the subject of the care of the elderly came up in general chat, he told me that in Sweden family help to look after the elderly was no longer available and they had to look after the elderly in institutional care. In Ireland at the time, which is relatively recently, the thrust of family attitudes towards elderly parents was to keep them in a home setting as long as possible and I hope this continues to be the underlying attitude of family members. It is not always possible. We must be realistic. If people must go out to work and do not have helpers available to look after their elderly parents, the option of putting them into a nursing home is obviously considered.

With advances in medicine people are living longer. The longer people live, the greater the level of dependency increases. Once the level of dependency increases, it can be difficult to look after the elderly in a home setting.

A number of today’s speakers raised the issue of day facilities and Deputy Deenihan referred to the development in County Kerry. There are two good examples of day facilities of which I am aware and they are ideal models for any development of such facilities. One is in the Acting Chairman, Deputy O’Sullivan’s, constituency in Ballincollig in County Cork and the other is in Summerhill in County Meath. These are excellent examples of where, through the combination of the statutory and voluntary sectors, the provision of transport and a day care outlet can help considerably to keep senior citizens in a home setting. If people can be looked after in a day care facility when siblings are at work, it makes it much easier to look after them in the home setting for a much longer period. I am sure the officials and the Minister of State, Deputy Seán Power, are aware of these two projects. Lessons are clearly there to be learned from the experiences gained and gleaned from those involved with the development of these two projects. They provide a template to copy for people who are interested in developments in this area in other parts of the country.

There is a number of relevant schemes available such as the housing aid for the elderly scheme and the disabled person’s grant scheme. We in County Louth have an excellent co-ordinator dealing with the housing aid for the elderly scheme who is getting great value for money and helping out many families by stretching his budget considerably through his good organisational and co-ordinating skills. Perhaps the scheme is not so successful in other parts of the country and there may well be a need to look at it to see whether it can be streamlined, enhanced or made more helpful to those who need modifications or adjustments to their home setting.

[375]House design can pose a serious problem where an elderly person or a person with a degree of immobility or disability lives in a two-storey house, with deep stairs, where all the bedrooms are upstairs. In one case in Dundalk of which I am aware, a widow lived on her own in a fine three-bedroom house which was built in the late 1950s by the then Dundalk Urban District Council. The three bedrooms were upstairs and because of her arthritic condition she simply was not in a position to use those bedrooms and temporary sleeping accommodation had to be provided on the ground floor. There is a number of observations one can make about that. First, she was living in a three-bedroom house and there was serious underutilisation of the house as a unit and, second, the temporary accommodation led to conditions which were clearly unsatisfactory. While the housing aid for the elderly scheme personnel made changes and modifications, these did not entirely meet the needs of that person. If there was greater flexibility in the availability of housing, the quality of life of the individual could be improved considerably and perhaps the dwelling could be freed up for a young family which might need housing in the area. I recall speaking to some of the officials about this issue, particularly in the context of planning and the layout and design of a housing scheme. If, rather than providing for one house design only in a housing scheme, they could design developments to include different models within the same housing scheme, people could start off in a conventional house and with the passage of time, move to more person-friendly accommodation such as an OPD designed or purpose-built house thereby freeing up their house for others. I realise that with the enhanced asset value of housing, it is not so easy.

Deputy Wall referred to sheltered housing of which there are some excellent models around the country. There are two in south Monaghan which come to mind, one of which, in Lisdoon, I visited recently. It is a credit to the local voluntary committee which planned, designed and executed the project. It has 14 two-bedroom units and a community house including bedroom accommodation at a reasonable cost for visitors of elderly relatives living in the scheme. Of course it has kitchens and facilities for visiting HSE personnel. It is clearly a model for other similar developments around the country.

Local authority housing policy is also a relevant issue. For obvious reasons, local authorities think in terms of providing three-bedroom houses, whether through Part V or however, for young families, but houses for persons in their golden years are down the priority list. With the changes in demographics which are clearly coming and which have been quoted here by a number of speakers, it is necessary to examine the planning and design of housing schemes to make provision for the sheltered housing concept in as many villages and towns as possible, and to ensure people [376]live as near as possible to basic community facilities such as shops and the church, particularly in the case of the elderly, and the school. Sheltered housing developments should be located as near as possible to such community facilities and that is an obvious policy objective.

  1 o’clock

I am another public representative who wrestles on a daily basis with the exigencies of the subvention scheme, which is, perhaps, too complex. I acknowledge that the State must bear a significant cost but the scheme is important in the context of helping families to support elderly relatives who need institutional care. It is a vital support, without which families would not get by. Means testing on the basis of the value of the family home is a thorny and sensitive issue but it must be recognised that, inevitably, such homes will be inherited and they are a significant asset. The State, in consideration of these matters, must take property into account. However, the simplification and streamlining of the means test as well as the widening of the eligibility criteria so that more people can avail of it should also be an objective. I commend the Minister of State, Deputy Seán Power, who has a deep personal interest in developing this area. If he remains in office for a long time, his workload will increase given the impending demographic changes.

Minister of State at the Department of Health and Children (Mr. S. Power): Information on Seán Power  Zoom on Seán Power  I thank Deputies for their participation in the debate over recent weeks. They covered many of the issues affecting elderly people and they are very much in touch with their constituents and the difficulties a number of them encounter. It is Government policy to help older people maintain themselves in their homes and communities for as long as possible, in line with their wishes, and to provide for appropriate residential care where this is no longer possible. The subvention scheme, which was introduced in 1993 on foot of the Nursing Homes (Subvention) Regulations, provides financial assistance to older people towards the cost of private nursing home care. It was never intended that the subvention payment would cover the full cost of care.

The Bill is designed to ensure that the existing subvention scheme for private nursing home care is firmly grounded in primary legislation. Once enacted, it will replace the 1993 regulations. The Bill will also go a long way towards helping the Health Service Executive to implement the scheme on a standardised basis across the country by ensuring increased clarity and reducing room for interpretation. Since it was established as a national body, the HSE has striven towards the implementation of common frameworks and processes throughout the State in regard to services for older people, including the subvention scheme, and the legislation contributes to that overall goal.

[377]Significant changes are projected regarding older people, especially in the medium to long term, to which a number of Members referred. It is estimated that, this year, 463,000 people will be aged 65 years and over. Latest population projections suggest that this figure will increase to more than 1.1 million by 2036, with an increase in the old age dependency ratio from 18% to 39%. The number of people aged 85 and over is projected to increase from 46,700 to 155,500 during the same period, and this trend is expected to continue until 2056 when the old age dependency ratio is projected to reach 60%. These demographic trends clearly demonstrate there will be an increase in the pressure for services and a corresponding increase in the cost of care. Funding the long-term care needs of older people, both in residential and community facilities, is among the most difficult and complex areas in the health sector. It is for this reason that an interdepartmental group was set up last year to examine the long-term care of older people, and its report is being considered by Cabinet. It deals with a number of the issues raised by Members.

Significant progress has been made in increasing the funding available for services for older people in recent years and this increase, together with the investment package provided for in the 2006 budget, is indicative of the Government’s commitment to the ongoing development of health funded services for older people. Our focus is on keeping people in their homes and communities for as long as possible with the appropriate supports in place. This is what the majority of older people want and this will contribute greatly to their quality of life in their later years. I do not say everything is fine because services for the elderly were underfunded for a long time. However, the funding announced in the budget will be the beginning of major investment in such services. There will always be those who require residential care, and following the enactment of this Bill and in light of the deliberations of the working group on long-term care, we must consider the future of care for older people, both in residential and community settings. We will try to achieve an equitable, balanced approach, both for residential and community care and for public and private provision.

I will respond to a number of issues raised by Deputies during the debate. Many of them referred to nursing home standards. Public consultation on the legislative proposals contained in the draft heads of the health Bill 2006 has concluded. Under the proposals in the draft heads, the health information and quality authority, HIQA, will set standards on safety and quality of services provided by, or on behalf of, the Health Service Executive and will monitor and advise the Minister and the executive on compliance with those standards. Provision is also being made to give the HIQA the power to investigate, at the [378]request of the Minister or the HSE, the safety, quality and standards of such services and to make recommendations it deems necessary. The chief inspector of social services will be required to monitor against standards set by HIQA.

Standards for private nursing homes are set out in the Care and Welfare Regulations 1993 and private homes are also inspected under these regulations. The Department’s focus is on protecting vulnerable older people and providing for the highest possible standards of care for older people in all long-stay facilities. In advance of the HIQA being fully established and functional, the Department set up a working group which is developing national standards that both private and public nursing homes will have to meet. This group is chaired by the Department and members include representatives of the Department, the HSE, the social services inspectorate and the Irish Health Service Accreditation Board, IHSAB. These standards are being developed in line with best international practice and will put the resident at the centre of care. It is intended that these standards will be ready in draft form in July and a consultation process will follow, thus enabling all interested parties to give their views. The IHSAB has developed accreditation standards which, when introduced, will be voluntary. There will not be a statutory obligation on a nursing home to comply with them. The accreditation standards are the very highest level quality of care which can be achieved in the setting and which all service providers should work towards. Thus, the standards being developed by the interdepartmental working group will provide a foundation that must be achieved and that enables organisations to aim for and work towards accreditation under the IHSAB scheme.

The issue of standardising enhanced subventions was raised. The HSE continues to have discretion on enhanced subvention. Where a person cannot meet the costs of care without undue hardship, the HSE can pay enhanced subvention and is given discretion so that the granting of it can be flexible. Amounts of enhanced subvention vary from case to case and depend on the particulars of the case in question, the cost of nursing home care in the area and the resources available to the HSE. An additional €20 million has been allocated to the nursing home subvention scheme in 2006 and the aim is to standardise means tests and bring greater consistency to the different levels of enhanced subvention support throughout the country.

A number of Members also sought clarification on the operation of the subvention scheme. The Bill provides the framework for the subvention scheme and provides that the HSE must issue guidelines on how the scheme will work. For example, it must outline the process to be followed to decide the amount of subvention to be paid to an applicant. The Bill also provides that [379]these guidelines must be issued on the Internet. This will ensure the guidelines are easily accessible to those requiring information on how the scheme works.

Members raised a number of other issues and I will try to deal with them as quickly as possible. When the scheme was first introduced in 1993, £5 million was provided for its operation. The following year, that sum was increased to £15 million and this year, €160 million will be spent on the scheme. I am aware the scheme is far from perfect and major changes must be made to it.

In particular, I wish to raise the issue of the tenders sought from nursing homes in 2005. At the time, the Eastern Regional Health Authority sought tenders for high dependency and intermediate care. In that instance, nursing homes were being asked to provide for the needs of patients who had been inappropriately accommodated in acute hospitals. Such patients required specific care of a type that would not normally be found in most private nursing homes. Given the specific nature of the requirements, some applicants were not in a position to meet them and consequently, they were not granted a contract.

However, that does not mean that such nursing homes are not in a position to provide traditional nursing home care. The inference that a large number of nursing homes are not in a position to provide care only serves to create undue worry for people. An inspection system is in place and, as I noted earlier, it will be improved. On its introduction, the new system will apply to both public and private nursing homes. However, it is unfair to create the impression that many nursing homes do not provide proper care.

Members again mentioned home care packages today. It is completely incorrect to assert that the Government is doing nothing for the elderly as nothing could be further from the truth. In the last budget, it provided major resources to try to improve the lot of older people in respect of areas such as home help and home care packages. A total of 1,100 home care packages were allocated last year and the Government has provided sufficient money to allow for 2,000 additional home care packages, which will be spread nationwide.

Deputy Ring questioned whether any packages had been allocated to County Mayo. As I cannot confirm this, I will investigate the matter and report back to him. However, I would be surprised if they have not been so allocated, certainly by the end of the year. It is intended to spread them throughout the country as they are of major benefit and can keep people out of nursing homes or hospitals. Moreover, having the proper home care packages in place can help those who wish for an early discharge from hospital. The packages have been tested on a pilot basis and as they worked exceptionally well, [380]the Government will continue to invest in them. Deputy Ring also mentioned Ballindine and the great work carried out by John Grant and his staff there. I had the pleasure of visiting that facility quite recently and I agree with the Deputy’s statements in this regard.

The issue of the differing subvention rates paid around the country was raised, as was the issue of enhanced subvention. As I noted earlier, the HSE has discretion to pay a higher rate of subvention in cases in which a person would suffer undue hardship. The level of enhanced subvention is at the discretion of the HSE and depends on individual circumstances.

Deputy Timmins’s contribution mentioned the wonderful facilities to be found in the Carnew community care village and I will have the pleasure of visiting it within the next two weeks. I am sure the Deputy is correct and I look forward to the visit.

Last year, the Government provided approximately €120 million for home help. This year, that sum has been increased by €30 million. While I am aware that Members have cited cases in which home help hours have been reduced, this can depend on a person’s individual circumstances. It can be difficult to try to explain this and I hope it will not happen this year. The Government has provided a significant increase in this regard. It is a facility that can mean much to people, can give them great comfort and can allow them to live in their own communities.

A number of Members asked about the cases pertaining to people who were eligible for public nursing home care but could not access one and were forced to enter a private nursing home and to pay for it. A number of legal cases are pending in this regard, which the State will defend. However, as we must await their outcome, it would not be appropriate for me to make any further comment in this regard.

Deputy Wall laid a heavy emphasis on the inclusion of the family home in the Bill. While I appreciate this is a sensitive issue for families, this is not a new provision. It existed in the regulations for the subvention scheme when it was first introduced in 1993. Nevertheless, I realise this is a sensitive issue. One must consider whether a person who occupies a house worth several million euro should be in a position to make some contribution. A group has been studying the financing of the long-term care of older people. This matter is under serious discussion by the Government and announcements will be made in this regard in the near future. Hopefully, the issues raised by Deputy Wall and other Members will be addressed.

I thank Members again for their contributions, most of which were extremely constructive. I look forward to the further Stages, at which time the views put forward by Members will be considered [381]in detail. I commend the Bill to the House and thank Members for their participation.

Question put and agreed to.

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