Thursday, 16 June 2011
Seanad Éireann Debate
Minister of State at the Department of Health (Deputy Kathleen Lynch): I thank the Cathaoirleach and Senators for giving me the opportunity to make a statement on the fair deal nursing home support scheme. I acknowledge that the events of the past few weeks have been very worrying for older people and their families owing to the uncertainty surrounding the funding of the scheme. As I am sure Senators are aware, the HSE recommenced issuing approvals last Monday for financial support under the scheme. It will work through the applications which have been processed to final stage in the past few weeks in chronological order. The Minister for Health, Deputy James Reilly, has also identified savings in other non-service related spending areas which will be used to facilitate the payment of financial support to an additional 1,700 applicants between now and the end of the year. On this basis, it is estimated that the total number who will be in receipt of financial support by the end of the year should be almost 24,000.
For those Senators not familiar with the scheme, it is a system of financial support for individuals in public, voluntary and approved private nursing homes. The scheme is available to anyone who has been assessed as needing long-term nursing home care, including dementia-specific nursing home care. The introduction of the scheme brought about a fundamental change in the way in which long-term nursing home care was funded. It supports individuals in need of long-term nursing home care, not the facility providing such care. This means the money follows the patient, regardless of whether he or she chooses a public, private or voluntary nursing home. This ensures facilities are not being funded for empty beds.
Under the scheme, individuals contribute up to 80% of their assessable income and a maximum of 5% of the value of any assets per annum towards the cost of their care. The first €36,000 of an individual’s assets, or €72,000 in the case of a couple, is not counted in the financial assessment. An individual’s principal residence is only included in the financial assessment for the first three years of his or her time in care. This is known as the 15% or three year cap. It means individuals pay a 5% contribution based on their principal residence for a maximum of three years, regardless of the length of time they spend in nursing home care. After three years, even if an individual is still in long-term nursing home care, he or she will not pay further contributions based on his or her principal residence. The three year cap applies, regardless of whether an individual chooses to opt for a loan. The intention of the cap is to protect the family home. In the case of a couple, the financial assistance is based on half their combined income and assets.
Under the scheme, the cost in each public nursing home is determined using the definition of “long-term residential care service”, underpinned by an agreed set of cost components which has been laid before the Houses of the Oireachtas. The cost of care is reviewed on an annual basis. When the review was carried out in 2010, the cost of care reduced in approximately 80% of nursing homes. The 2011 review is under way. The National Treatment Purchase Fund has statutory responsibility for the negotiation of prices in nursing homes, including voluntary nursing homes. It is independent in the performance of this function. It may examine the records and accounts of nursing homes and has a particular responsibility to ensure value for money for the individual and the State.
The Nursing Home Support Scheme Act 2009 defines long-term residential care services as maintenance, health and personal care services. The services which fall within the scope of long-term residential care are nursing and personal care appropriate to the level of care needs of a person; basic needs and appliances necessary to assist a person with the activities of daily living; bed and board; and laundry services. The scheme does not cover therapies because a person’s eligibility for other schemes such as the medical card or drugs payment scheme is unaffected by the nursing home support scheme. In other words, a person can continue to receive goods and services in accordance with the terms of other schemes, regardless of whether he or she is in a nursing home or elsewhere.
In determining the services covered by the scheme, it was considered very important that care recipients and taxpayers be protected and not end up paying for the same service twice. For this reason, goods and services already prescribed for individuals under an existing scheme are not included in the services covered by the scheme because it would involve paying twice for the same items or services.
Budget 2011 provided €1.011 billion for long-term residential care services. This was effectively the budget for the nursing home support scheme, albeit that transitional arrangements must also be facilitated from within the subhead, for example, people in contract beds, those who choose to remain in receipt of subvention and saver cases in public nursing homes.
In May this year the Minister became aware of a potential serious shortfall in the 2011 budget for the scheme. He requested that his officials, in conjunction with the HSE, carry out a full examination of the funding position and the sustainability of the scheme. Following that examination, it is clear that a number of factors were putting pressure on the overall budget for 2011. These included an unexpected and unexplained increase in the average length of stay for nursing home patients; the resultant higher net demand for nursing home places; the increase in nursing home costs; and payments for ancillary services for residents in nursing homes, for example, therapies and drugs which were not intended to be funded from the subhead. I understand this amounts to €48 million, not €100 million as originally indicated.
As stated, the HSE has recommenced issuing approvals for financial support under the scheme. The Minister has informed the HSE that the only items which can be posted to the long-term residential care subhead are those covered by the cost components in respect of the care services of public nursing homes. Documents have been laid before the Houses of the Oireachtas in respect of public nursing homes and the costs agreed with the National Treatment Purchase Fund for private nursing homes. The Minister has asked the HSE to put in place additional and more rigorous governance and reporting measures which his officials will monitor more closely in the remainder of the year. The fact that the scheme is relatively new means there is a lack of historical statistical data on which to base definitive conclusions or forecasts. The HSE has been asked to prioritise the full roll-out of its ICT and management systems to address the information deficit.
The Minister is anxious to try to identify the reasons behind the unforeseen increase in the number of applications and the average length of stay in nursing homes. He has, therefore, requested the HSE to undertake a clinical audit of the appropriateness of care and admissions. The HSE has commenced its review of the cost of public beds. It is anticipated that the review will show a reduction in the cost of care through skills reconfiguration and the driving of efficiencies.
The Minister has instructed the National Treatment Purchase Fund to renegotiate with private and voluntary nursing homes with a view to achieving price decreases because the increases agreed in recent months are not sustainable. The programme for Government commits us to a review of the system of financing nursing home care with a view to developing a secure and equitable system of financing community and long-term care. This commitment will be carried through.
In addition, the nursing home support scheme is due for formal review, commencing in 2012, at which time it will have been three years in operation. The reason for allowing this period to elapse is to ensure established and validated trends and statistics will be available. It is still intended to proceed with the review which will examine the ongoing sustainability of the scheme, the relative cost of public versus private provision and the balance of funding between residential and community care.
I very much regret the anxiety that was caused to older people and their families as a result of the uncertainty over the nursing home support scheme. I know what a worrying time it can be when individuals and their families have to make the decision to move into a nursing home. We moved as quickly as possible to re-establish certainty and clarity on the scheme’s future. I will ensure that the scheme continues in a fair, transparent and sustainable manner.
Senator Mary M. White: It is my pleasure to welcome the Minister of State, Deputy Kathleen Lynch, to the House. Having participated with her on the former Committee on Health and Children, I know she will efficiently address the issues that need to be resolved. I also know how passionate and genuine she is in dealing with people in need, including those who may have been forgotten.
The new fair deal scheme was welcomed by many people, including me. As my party’s spokesperson for children and older people in the last Seanad, I praised the then Minister for Health and Children, Ms Mary Harney. I felt it was one of the former Minister’s greatest achievements, but on current evidence it is anything but. There are many failings in the scheme, which is disappointing. The main factor was that we were to have equitable and consistent pricing around the country for people in private nursing homes. In addition, no elderly person or their families would have to worry about raising the money themselves because it would be levied after the resident’s passing.
However, from my experience of talking to those dealing with older people in residential care, it is apparent that it is complicated for the elderly to apply for such care. If they own their own home there are issues concerning personal capacity and an older person may need to apply for ancillary State support. The nursing home support scheme clearly states that no solicitor is required for ancillary State support, but as two medical capacity reports from two medical practitioners are required, some doctors are asking for a solicitor’s request prior to issuing the reports. This ancillary support also means that a proposed care representative has to attend a hearing in the Circuit Court, which is daunting for older persons and their relations. In addition, there is a cost involved with the solicitor and the court, plus the cost of valuing property from an estate agent. These costs are significant for old age pensioners.
Another serious issue is the lack of nursing home beds. Public nursing homes have vacant beds which cannot be filled due to a lack of staffing. One public nursing home — Brú Chaoimhín in Cork Street — was recently closed as it was not able to meet HIQA’s requirements. As a result, the residents had to be accommodated in other public nursing homes and therefore overall bed numbers have been further reduced.
Private nursing homes in the Dublin area — and most acutely in Dublin south-central, south-west and west — have literally no vacancies. Patients are thus being strongly encouraged to accept placements in Kildare, Wicklow or Meath. Once the nursing home support scheme is approved, the HSE states in its approval letter that a patient has ten working days to transfer to a nursing home. Due to the lack of beds, however, this is impossible.
Most private nursing homes are issuing a weekly charge to older people on top of their nursing home support scheme contribution of €150 per week. They went in knowing that they would be able to support themselves financially, but because of the wide range of items not covered by the scheme, a further €150 per week is being added. This was decided by nursing homes in agreement with the HSE.
In some Dublin teaching hospitals, the number of patients currently waiting for a bed in a nursing home is 50. Acutely unwell patients cannot go home, as they would be unsafe, but cannot be transferred to nursing homes either as their applications have not yet been approved. Or when the applications are approved, there are no vacancies. This is not only having a negative impact on patients’ health, as they do not receive the stimulation they need, but they are also exposed to infections. In addition, they are preventing patients in emergency departments from being admitted.
I am optimistic that the Minister for Health, Deputy Reilly, will be a good Minister. However, despite his statement on 9 June announcing that the support scheme would resume on 13 June, as of yesterday, HSE offices had not received clearance for this. Even patients approved for the nursing home support scheme are not being admitted to nursing homes as there is no guarantee that payments will be met.
There is concern that the scheme was budget-capped and that, at some point, the money will run out. Our main concern is that there does not seem to be a wait-listing system, or some alternative, while funds become available.
I was excited by the fair deal scheme when it was announced, but I am disappointed by how it has turned out. It is clear to me that the fault lies with the Department of Health because the scheme has not been adequately thought out. The Minister has a major job on his hands to bring the Department of Health — like many other Departments — up to 21st century standards in conducting its business.
Senator Colm Burke: I welcome the Minister of State to the House and thank her for providing that clarification. I welcome the move by the Minister to restart the processing and acceptance of applications under the fair deal scheme. This move brings clarity to the situation and will be a relief for thousands of older people and their families throughout the country. I hope the 2,900 applications, which are pending, will be processed as soon as possible. I call for a fast-track procedure to be used for these cases.
Long-term nursing home care is a difficult decision for families and their loved ones, and should be as anxiety free as possible. This recent episode with the fair deal scheme highlights many of the problems we associate with nursing home care in Ireland. It is incredible that a scheme such as the fair deal one could run out of money less than two years after it was established. At the time it was sold as a sustainable model for funding nursing home care. I am calling for a 20-year national strategy for the care of the elderly. It should set out an all-encompassing vision for nursing care, a detailed step-by-step plan to achieve that goal, and develop a sustainable funding model with built-in, five-yearly reviews.
Planning for long-term care for our elderly is one of the most important duties of society. It should be one of the easiest strategies to formulate because statistics and projections give an accurate idea of how many older people the population will include in 20 years time. The figures we have to face in this regard are frightening. There are currently just over 500,000 people aged over 65, and around 125,000 aged over 80. Meanwhile, we have 24,429 residents in nursing homes and in the next 20 years these figures will double. Last week, population projections predicted that Ireland will have more than 1 million people aged over 65 - and more than 270,000 people over the age of 80 - by 2030. As this will present a huge challenge to our health and social services, it is imperative to plan for it now. Such an increase in the numbers of people in these age brackets makes it incumbent upon policymakers to plan now for the challenges we will face in the future. These figures require a comprehensive, holistic plan to ensure those who have spent their lives working and contributing to our society and economy are properly cared for.
I do not want any Member to take this personally but the approach the Department of Health and the HSE have adopted since the 1970s can at best be described as piecemeal and haphazard, lacking coherence and direction. There was no eye on the future, no forward planning and no big picture. We have witnessed mismanagement and an approach that is less connected with good policy and administration and more closely resembles fire fighting.
The nursing home care system has been at the centre of some controversy in recent years, especially the nursing home charges scandal, where it was revealed that more than 300,000 people were charged illegally over a period of 28 years. It is interesting that, as far back as 1976 in the case of Maud McInerney, the High Court decided that nursing home care came under a definition of medical care and for 28 years the Department did not respond to it.
Time and again the HSE, its predecessors the health boards, and the Department of Health have been criticised for failures in the provision of nursing home care and provision. The Ombudsman’s report, entitled “Who Cares? An Investigation into the Right to Nursing Home Care in Ireland”, was published in November 2010, only a few months ago. That report states: “Access to nursing home care ... has been marked by confusion, uncertainty, misinformation, inconsistency and inequity.” It is time we ensured such mistakes are not made again. The report also states: “At the administrative and institutional level, the continuation over such a long period of such unacceptable practices suggests inflexibility, non-responsiveness and a reluctance to face reality.” The report further states:
One of the objectives in setting up the Office of the Ombudsman was to ensure we would work together to provide solutions to the problems we face, but instead we seem to have buried our heads in the sand. We need to rethink how we deal with these issues.
This characterisation of the attitude within both the Department of Health and the Health Service Executive is a cause for serious concern. If this is the prevailing mindset of those involved in the administration of policy, then we have much to worry about. Part of the problem is placing legal obligations upon a body without providing adequate resources for that body to fulfil its obligations.
It is also necessary to consider briefly the 2005 Travers report on the practice of charging persons in long-stay care in health board institutions which also criticised failures on the part of the Department of Health. It is clear that in the past the Department of Health, the health boards and the HSE have behaved in a lax and less than circumspect manner in regard to care of the elderly and nursing care in particular. This failure by the Department to fulfil its role in policy formation is a serious issue and one I hope the Minister will address with all eagerness and haste.
Too often in the past we have failed to plan in Ireland and it is the vulnerable who have suffered most from such failure. There can be no excuse, however, not to plan for the drastic increase in the number of older people. We should see this as an opportunity to take care of our elderly, to recognise them, to show our respect and to honour their contribution to this country. We need to develop a system designed to meet the needs of double what the current system is handling. We need to make certain that any system of care has at its heart humanity, respect for human dignity and compassion. Any strategy must have at its core a fundamental respect for the wishes of the individual and his or her family. The goal of any system of elder care must be to enable our elderly to live in their own homes and communities for as long as they wish. Creative solutions must be employed in order that this aim can be achieved. We should look to other countries who are further along the demographic path we are heading, emulate what is good and learn the lessons from their mistakes. We need to ensure a whole community approach is adopted comprising solutions incorporating families, the voluntary and private sectors as well as the public system. No person should fear growing old in Ireland, unsure as to whether and how he or she will provide for himself or herself and his or her care. Community care, home help, day centres, community homes and nursing homes will all have a role to play in ensuring Ireland is a country for old people. All these services and facilities must be part of that mix in a long-term plan.
We must be realistic, honest and creative in the way we plan to fund any new system. Without adequate funding, the best designed systems in the world cannot function. The current fair deal model has its strengths but it also has its weaknesses. We must face up to the simple fact that a funding model dependent on a property market is inherently unstable. In many other countries there are systems working efficiently and well and we should examine those. We can use them as templates in finding a long-term, sustainable model for ensuring the recent funding issues will not arise again. This will present the greatest challenge in the formulation of any plan, but it is one we must address head on.
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