I move: "That the Bill be now read a Second Time."
The purpose of this Bill is to promote the highest standards of care for dependent persons in nursing homes, to change the arrangements for the subvention of persons in nursing homes and to facilitate health boards to make arrangements for the boarding out of persons who can no longer live at home.
The existing legislation, the Health (Homes for Incapacitated Persons) Act, 1964, is now 25 years old. It is important that developments in relation to the care of dependent persons during that period are reflected in new legislation. We must ensure that the public will have full confidence in the standards of care available to vulnerable people in private and voluntary nursing homes. The standards of care being provided at present are of a high quality but there is a widespread consensus that aspects of the legislation need to be changed.
Private and voluntary nursing homes receive a considerable amount of public funds for the care of eligible patients under the Health Act, 1970. In 1986, the amount of the subsidy paid was £15 million. The existing arrangements for subventing the care of dependent persons have been criticised for a number of reasons. A further purpose of this Bill is to ensure scarce resources are used in the most effective way to care for dependent people.
Population projections reinforce the need to define the responsibilities of health boards and nursing homes. The 1986 census revealed 382,000 people over 65 of which 143,000 are over 75. The latest projections suggest that the number of elderly will increase slowly up to the year 2000 and then rapidly after that date. By 2011 a population of 414,000 elderly people is forecast, an increase of nearly 10 per cent. The increase in the elderly population will not be spread evenly throughout the country. Along the western sea board, the numbers of elderly will decrease by about 12 per cent by the year 2000 while in the greater Dublin area, numbers will increase by 30 per cent. The rate of increase in those reaching advanced old age will be particularly marked. These figures give some idea of the challenges facing us in providing for the care of the dependent elderly.
Most of the changes proposed in this Bill were recommended in the report of the working party — The Years Ahead — A Policy for the Elderly which was presented to me in October 1988. The Government accepted their recommendations in principle and this Bill is a mojor step towards implementing those recommendations.
The working party recommended that a licensing system for all nursing homes be introduced. This reflects the need to ensure that high standards in nursing homes are kept under regular review and are maintained at the agreed level.
It is proposed that a health board should be able to subvent the care of eligible patients, following medical and social assessment, in nursing homes licensed by the board and that the level of subvention should reflect the patient's needs.
The recommendations of the working party report reflect the views of the National Council for the Aged, which advises me on policy towards the elderly and which commissioned the first research study on nursing homes in this country. It has also recommended that a licensing system for all nursing homes be introduced and called for changes in the method of subventing the care of elderly people in nursing homes. The National Association of Widows in Ireland at their annual conference this year called for a code of standards and regulations for nursing homes and for the registration of homes. The Irish Private Nursing Homes Association have also made representations to me about the need for revised legislation on nursing homes.
This Bill addresses the main problems identified with the existing legislation, building on the recommendations of bodies with expertise in this field. It aims to ensure a high standard of care in each nursing home without interfering unduly in the management of the home. It is not my intention to put obstacles in the path of persons wishing to set up a nursing home. The Bill provides safeguards against unreasonable action by health boards while providing a framework within which nursing homes and health boards can each carry out their responsibility in caring for dependent persons.
There are at present 332 private nursing homes in operation. Of these, 286 are private and 41 are voluntary homes. Nursing homes are being opened at an increasing rate. Over the past year some 20 new homes have been opened. The greatest concentration of nursing homes is in the Eastern Health Board area. The existing homes can cater for approximately 6,500 people.
It might be helpful to Deputies if I explained the existing legal situation and the problems which have been identified in the legislation. The Health (Homes for the Incapacitated Persons) Act, 1964, is the Act which governs standards in nursing homes. Voluntary nursing homes are excluded from the scope of the 1964 Act.
Under this Act a person who proposes to set up a private nursing home must notify the relevant health board in writing one month before it is proposed to commence the home.
Regulations are laid down under the Act to govern the standards of care in nursing homes. The first regulations were made in 1966 and updated in 1985. The regulations govern the standards of care, accommodation and food, the number and qualifications of staff and the description of homes among other matters. The health boards are responsible for enforcing these regulations.
At present, the health boards inspect homes at least every six months to ensure compliance with the regulations. Nursing homes charge their clients for the care they provide, either fully or partially. Some homes are approved for subvention under section 54 of the Health Act, 1970, and in these cases residents can avail of a subvention towards the cost of their care which is paid by their health board. The current amount of the subvention is £6.78 per day.
The Eastern Health Board have made arrangements with a number of private and voluntary homes under section 26 of the Health Act, 1970, to subvent the care of dependent elderly people. Other health boards grant aid voluntary homes under other sections of the Act.
A number of unsatisfactory elements have been identified in the present legislation. For example, a health board is given very short notice, only one month, that a private nursing home is about to commence operation. A home may be set up which does not in all respects comply with the regulations and the health board may, after the fact, have to set about ensuring that the regulations are met. This is not always a satisfactory way to proceed.
The only sanction available to a board is of prosecution, a remedy which should only be used in relation to serious breaches. While the vast majority of nursing homes comply with the regulations and co-operate well with the health boards, it would be better if health boards as the statutory or regulatory authority had more flexibility in carrying out their functions. Boards should be able to ensure that a nursing home complies with the required standards before admitting its first patients. The best way to do this is to require a nursing home owner to have a licence before opening for business. Future compliance can be encouraged by a requirement that a licence be renewed on a regular basis.
There are many charitable nursing homes in operation which are not covered by the 1964 Act but which are caring for dependent persons. Many are in receipt of public funds. I agree with the recommendations of the working party report and the National Council for the Aged that all homes providing nursing home care for dependent persons should be covered by legislation. Many of these homes have in the past set the standards for the care our society gives dependent people. Compliance with licence requirements should not pose either a problem or a threat to the overwhelming majority of these homes.
I will now outline the main provisions of the Bill. A nursing home will be a home caring for more than two dependent persons. The term "incapacitated person" is replaced by the term "dependent person". A dependent person under the Bill will be someone who requires assistance with the activities of daily living, like dressing, eating, walking, washing and bathing due to physical infirmity, disease or defect or mental infirmity. These are the activities which are now used in modern nursing to assess the level of dependency of a person. Most persons covered by the Bill are elderly, but dependent people in younger age groups will also be included. All homes providing nursing care for dependent persons will be included whether or not run for profit. Acute general hospitals, maternity homes, children's homes, homes for members of religious communities and people being cared for by their families are excluded.
A person wishing to set up a nursing home will apply to the health board for a licence. The health board will consider the person applying for the licence and the proposed premises to ensure that all is in order. To assess licence applications or licence renewals, boards will require certain information relating to the suitability of the applicant and the person in charge to run a home, the standard of accommodation, the facilities offered and so on.
This information will be provided in the licence application and the type of information required will be standardised between all health boards. A licence will then be granted which will be valid for two years and then must be renewed. It will not be possible to open the nursing home until the licence has been granted and only a licensed home will be entitled to call itself a nursing home. The licensed home will be included on a health board register of all homes in the health board area. This register will be available to anyone who wishes to consult it free of charge at all reasonable times. It will enable anyone to obtain information on nursing homes licensed by the board.
The detailed requirements which a home will have to meet will be set out in the regulations. The 1985 regulations under the existing 1964 Act will continue to apply until new regulations are published. Officials in my Department are working on these new regulations which will be based on the experience gained from the existing regulations. There will be widespread consultation on these new regulations before they are enacted.
Under the provisions of this Bill, health boards will not just play a regulatory role. They will also be authorised to provide training for nursing home staff and to provide a range of ancillary services, such as chiropody and physiotherapy, on mutually agreed terms and conditions. The best features of the existing regulations will be retained, such as the requirements that health boards inspect homes on a regular basis, that qualified staff be available at all times and that proper records be kept. Through the proposed process of ongoing inspection and regular licence renewal, there will be a constant learning situation for both the boards and the authorities of the homes, which will add greatly to our ability to set and maintain good standards that are in tune with the needs of the residents.
A licence holder must apply for a new licence at least two months ahead of the expiry date. This gives the health board a reasonable period in which to respond to the application for renewal. If the board do not inform the renewal applicant of their decision within two months of the application, then the licence will be granted automatically. This decision will encourage boards to assess applications promptly and protect nursing homes from delay which might otherwise occur.
If a nursing home is sold during the licence period the licence expires, the new owner must apply for a licence within two weeks. A health board can only refuse to grant or renew a licence or revoke an existing licence for specific reasons. They can do so if they consider that the premises or the manner of running the nursing home does not comply with the regulations. They can also act if they had not been furnished with necessary information. Finally, they can use their powers of refusal if the person in charge has been convicted of a serious offence under nursing home legislation or of a serious offence which would render the person unfit to carry on a nursing home.
A health board will be able to attach conditions to a licence when they grant the licence or later. A condition could, for example, require certain improvements to be carried out to the home by a certain date. If a licence applicant or holder feels aggrieved by a health board's decision on any point, he-she can ask the board to review the decision and if still not satisfied, appeal the decision to the District Court.
Health boards will charge a fee for a licence which will help to defray their costs in inspecting homes to ensure that standards are being met. The amount of the fee will be set by regulation. The fee has not yet been decided. It will be a matter for negotiation with both the nursing homes and the health boards.
Concern has been expressed from time to time that the title "retirement" or "rest home" is being used to avoid the obligations of the existing legislation. I am not concerned with the genuine retirement home where the residents are independent and receive no nursing care. I am concerned that a home could call itself a retirement or rest home but in practice be looking after dependent persons requiring nursing care. At present health boards have no authority to inspect such homes. Under the new Bill, they will be given power to inspect any premises where they consider dependent persons are being maintained. Heavy fines will be imposed on people found guilty of caring for dependent persons without holding a nursing home licence.
Situations have arisen when standards in a nursing home have fallen so low that urgent action is needed to protect the interests of the residents. It may be impracticable to transfer the residents to other homes. One solution which has been found to work is to allow the health board assume the management of the home until the problems have been resolved. Under this Bill, a health board will have the power to assume the management of the home with the consent of the licence holder or alternatively, in pursuance of an order from the District Court, if a nursing home fails to comply with the standards of care in the regulations.
The period of the management order may not exceed three months or, if the board are acting on an ex parte court order, not more than two weeks. Any expenses incurred in managing the home during the period will be paid from the nursing home's income. The health board will be able to recover from the nursing home the salary costs of the person they appoint to run the home.
These provisions allow health boards to protect the welfare of dependent persons in nursing homes where the standards are such that the health of the residents is in jeopardy. It is intended as a temporary measure pending longer term action being taken, such as the transfer of patients to a more suitable location or a change of management of the home.
Technically, every person entering an approved nursing home is eligible for subvention since the extension of eligibility for care in public hospitals to the whole population in 1979. Under section 54 of the Health Act, 1970, a health board may pay a subvention to a person in a home approved by the Minister for Health. The scope of section 54 has been curbed as no new homes have been approved since 1980. Unfortunately, due to constraints on the financial resources in the health services it was not possible to approve new homes. Deputies may be interested to know that there are 94 approved homes out of 332 private and voluntary nursing homes. The present system of subvention discriminates against the many excellent modern homes which have opened since 1980.
Under the Bill, if a dependent person requires nursing care, but the person is not able to pay all the costs involved, that person or his or her relatives will be able to apply to the health board for a subvention. Health boards will be able to contribute to the costs of maintaining a dependent person in any licensed nursing home. The health board will assess the individual's level of dependency and their financial circumstances in making their decision to contribute to the costs involved.
It is important that an individual seeking a subvention is assessed before going into a nursing home. It may be that the health board can arrange for some other form of support to solve the problem and allow the person to remain independent and in their own home. If the person is assessed as requiring nursing home care and is unable to pay the full cost, the health board will be enabled to pay a subvention. The health board will be able to vary the subvention to match the individual's dependency.
I am proposing that there would be payments for three categories of physical dependency — light, moderate and heavy and one category for those with severe forms of dementia.
The amount of the payment will vary because the more dependent a person is the more expensive the care. The level of payment will be fixed by regulation, following consultation with the interests involved.
I wish to stress that any person in receipt of a subvention at present under section 54 will not be affected by the Bill in any way. These subventions will continue to be paid as long as the person is in the home. However, no new applications will be accepted for section 54 subventions when the provisions of this Bill take effect.
I would like to give an assurance that the overall level of financial support for people cared for in nursing homes will not diminish as a result of this Bill. This provision is not about saving money; it is about enabling health boards to target their available resources most effectively and to respond flexibly to the changing demands of dependent people for whom they have responsibility. This is the approach which the new subvention arrangements provide for.
Under a general provision of the Health Act, 1970, section 61, health boards may make arrangements to assist in the maintenance at home of a person who would require to be maintained otherwise than at home. These persons are frail elderly people who do not need nursing services but who require care and companionship.
One of these arrangements is boarding out. Boarding out is a practical response to helping an elderly person maintain his or her independence by assisting them to live in their own community, near to their family and friends. The Bill gives health boards specific legal authority to make boarding out arrangements for persons who can no longer live at home and who consent to be boarded out. Regulations governing boarding out will be made to set standards and ensure proper monitoring of placements. Health boards will be empowered to contribute to the cost of a boarding out placement.
This Bill does not set out to limit in any way the establishment of nursing homes. The State already, under the 1964 Act and the 1985 regulations, has a statutory responsibility to ensure a minimum standard of care in nursing homes. This Bill updates the existing legislation to take account of developments in the care of dependent persons by establishing a framework for licensing and registration of nursing homes.
The Bill does not interfere with a person's right to choose nursing home care. It does not attempt to direct individuals towards particular homes. It will, in fact, widen the choice of persons entitled to a subvention from the limited number of homes with section 54 approval to all homes. Where someone needs financial assistance to pay for nursing home care the purpose of the assessment is to ensure that a nursing home is the most appropriate option and that the health board are directing their resources to those in need.
The Bill promotes the welfare and wellbeing of dependent people in nursing homes. Legislation, by its nature, is concerned with minimum standards. I would hope that in partnership with the health boards and the nursing homes we could go further and agree a code of good practice for nursing home care. It would set out the best practice to which all homes should aspire. Such a code was recommended by the National Council for the Aged and I believe it could make an important contribution to achieving high standards in all homes. It is my intention to circulate a code of practice with the regulations to be made under this Bill. Dependent people and their relatives must be assured that there are many safeguards in the arrangements made for the care and protection of those who can no longer fend fully for themselves.
Nursing homes and health boards have a complementary task of caring for the elderly. The growth of the nursing home sector has been rapid in response to the number of elderly people and their increasing income. The right of elderly people to make private arrangements for nursing care in their later years is not in question, but the nursing home sector cannot be considered in isolation from publicly organised services and the standards that should be expected from all service providers. It will be necessary to consider the role that nursing homes can play in the future in caring for dependent persons through full time residential care, day care or respite care. We will have to be aware of how private and State funded services can work together effectively.
There is a need to explore the implications for policy of a closer relationship between health boards and nursing homes in the future. My officials have been discussing with representatives of the National Council for the Aged, the Irish Private Nursing Homes' Association and the health boards, the commissioning of research on this topic which I hope will be undertaken shortly.
The provisions of this Bill will make for a new relationship, a new partnership between nursing homes and the health boards. Both parties will have to work closely to ensure that the Bill's requirements are met. This co-operation will contribute to a clearer appreciation by each party of the other's difficulties and responsibilities. A co-ordinated approach between health boards and nursing homes can only improve the quality of care available to dependent people.
It is worth noting that only 5 per cent of our elderly are in institutional care at any time, under the care of health boards or private and voluntary nursing homes. A much higher proportion of the elderly — 17 per cent — are being cared for at home by their families. We must do more to support these families through help at home and respite facilities. I would like to see more arrangements between health boards and nursing homes to provide day care for dependent elderly people cared for by their families or respite facilities to allow carers a break from their heavy responsibilities. The framework provided in this Bill, should encourage this kind co-operation.
Nursing homes are an indispensable part of services for the elderly. There are many advantages to well run but home homes which are convenient to relative and which provide care at various level This Bill seeks to strike the right balance between ensuring that the interests of some of the most vulnerable members of our society are protected without undue interference in the management of homes. I would welcome all suggestions on this and committee stages to improve this Bill to promote the best interests of dependent people in nursing homes.