COMMITTEE OF PUBLIC ACCOUNTS debate -
Thursday, 9 Mar 2017

Health Repayments Scheme Donations Fund 2015

Mr. Tony O'Brien (Director General, HSE) called and examined.

Chairman

Today we are dealing with No. 7 on the agenda, the HSE's patients' private property accounts 2015, the HSE financial statement 2015, note 13, specifically in regard to the fair deal scheme; and the health repayments scheme donations fund 2015. We are here to examine them. From the HSE, we are joined by Tony O'Brien, director general, Stephen Mulvany, Pat Healy, Mairead Dolan, Michael Fitzgerald, James Gorman and Pat Marron. From the Department of Health, we are joined by Greg Dempsey, assistant secretary.

I remind members, witnesses and those in the Public Gallery that all mobile phones must be switched off. I wish to advise the witnesses that by virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to this committee. If they are directed by the committee to cease giving evidence in relation to a particular matter and they continue to so do, they are entitled thereafter only to a qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and they are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise nor make charges against any person, persons or entity, by name or in such a way as to make him, her or it identifiable.

Members are reminded of the provisions within Standing Order 186 that the committee shall also refrain from inquiring into the merits of a policy or policies of the Government or a Minister of the Government or the merits of the objectives of such policies. Finally, members are reminded of the long-standing ruling of the Chair to the effect that members should not comment on, criticise or make charges against a person outside the House or an official by name in such a way as to make him or her identifiable.

I call the Comptroller and Auditor General to make an opening statement in regard to the items on the agenda.

Mr. Seamus McCarthy

Note 13 of the HSE's annual financial statements shows that in 2015, it incurred expenditure of €968 million on the provision of long-term residential care. As indicated in the graph shown on the screen, the expenditure, which has remained relatively stable, involves payments to private nursing homes of approximately €600 million, accounting for just under two thirds of the total, and expenditure on public nursing home costs accounting for around one third.

The nursing homes support scheme, also referred to as the fair deal scheme, was introduced in 2009. It provides financial support to individuals deemed to be in need of nursing home care. The scheme is cash-limited, rather than demand-led. That means the HSE can only approve support for new applicants to the extent that its budget allocation allows. As a result, waiting times for admission to the scheme vary over time.

Operationally, the HSE carries out a financial assessment to establish how much an individual deemed to be in need of nursing home care can contribute to the cost of his or her care. The assessment takes into consideration both the applicant's income and assets. An individual's contribution, which cannot exceed his or her cost of care, comprises inpatient charges up to a maximum of 80% of his or her income and up to 7.5% of the value of property assets over three years. The HSE's inpatient charges income has remained stable at around €80 million a year, and is included in the HSE's income as reflected in the annual financial statements.

Individuals who own land or residential property, including a family home, have the option to defer the associated assessed care contribution to a future date. This option is referred to as ancillary State support or the nursing home loan. Such loans fall due for repayment usually on the death of the individual, or the prior sale of the asset. The Revenue Commissioners are responsible for collection of the repayments, the amount of which is notified to them by the HSE. The receipts collected are paid directly to the Exchequer. The cumulative position in regard to nursing home loans over the period 2012 to 2015 is indicated in the following graph which is now onscreen. The committee may wish to note that the cumulative amount the HSE notified the Revenue to recoup up to the end of 2015 was €50 million. At 31 December 2015, Revenue had collected 64% of the total amount advised to it for collection, leaving a balance outstanding at that date of €17.8 million.

The Health (Repayment Scheme) Act 2006 provided a legal framework for the repayment of charges that were incorrectly imposed by the former health boards on persons in long-stay care who, since 1976, had a medical card, or who were entitled to a medical card. That included the establishment of a special fund account, separate from the HSE's financial statements, to manage the payments. Since the establishment of the scheme, around €453 million has been repaid through the account, to just over 20,000 claimants. As the graph which is now onscreen indicates, the bulk of that was paid between 2007 and 2009. Payments amounting to €1.7 million were made in 2015.

The 2006 Act also provided for the establishment of a parallel fund account into which claimants could make a voluntary donation towards once-off improvements in public health services for dependent older persons and persons with disabilities. Since 2007, around €356,000 has been donated to the fund. Those donations, along with any interest earned, have been paid over to long-stay units. There was no activity on the donation fund account in 2015.

The 2006 Act also provided a framework assigning the HSE statutory responsibility for the operation of patients' private property accounts. The funds in the accounts are held by the HSE, in trust, on behalf of individuals living in long-stay care institutions run by the HSE. At 31 December 2015, the total value of funds held was around €129 million in over 9,600 patients' private property accounts in operation in 156 care centres throughout the country. The sum of €119 million, or 92%, was being held and managed centrally by the HSE. The remaining 8% or €10 million was held and managed by local care centres, in commercial bank accounts. Accounting records held locally record each individual patient's current balance and transactions.

The statement on internal financial control associated with the patients' private property accounts draws attention to a number of important controls in the management and operation of accounts of this nature. The statement also sets out the actions being taken by the HSE to address control weaknesses noted by our audits, for example, the absence of required routine reconciliations, insufficient segregation of duties in some care centres due to low staff levels, and inadequate documentation by some care centres over withdrawals from patient accounts.

Note 9 of the accounts discloses that at 31 December 2015, the HSE was holding interest earned totalling around €14 million which had yet to be allocated to patients. Although a central unit was established in 2006, care centres continued to hold significant funds in local bank accounts for some time thereafter. Interest earned during that time was not credited to individual patient accounts. The HSE is currently in the process of examining how those funds should be allocated.

Note 8 of the accounts also discloses that prior to the establishment of the HSE, the health boards had, based on legal advice then available to them, retained interest earned on patient account balances as a contribution towards their costs incurred in managing the accounts. Subsequent legal advice noted that they did not have the legal authority to use the funds in that way.

Additional funding will be required to repay these amounts, which relate to periods prior to 2005. The total amount involved in this regard is estimated at approximately €30 million.

Chairman

We have three specific items on the agenda today. They are the only items to be discussed. There are myriad other HSE items which we will deal with another day. However, before Mr. O'Brien makes his opening statement, I wish to make one comment to him regarding one of his previous appearances at the Committee of Public Accounts in February 2016, when we were discussing the Grace case. On that day, I understand, he told the committee that the people who in 1996 overturned the decision to remove Grace were no longer State employees. He went on to say, in respect of the Conal Devine report:

From the outset of its commencement, there was close liaison with An Garda Síochána, and it was always understood and intended that the report would be published and available, whatever action may be necessary. However, since its conclusion in 2012 [that is, the report], it has not been possible to use it for that purpose, and that is why no disciplinary action has been proceeded with on foot of the Conal Devine report.

Media reports at the weekend indicate that the communication between the HSE and An Garda Síochána commenced three years later, in 2015. In view of the conflicting information in the public arena and what Mr. O'Brien stated at a previous Committee of Public Accounts meeting, I ask him to come back as urgently as possible, within seven days, to clarify the accuracy or otherwise of his statement to the previous Committee of Public Accounts and the reasons for, and the information he used to arrive at, his conclusions. We will not have a debate on the matter now. I am asking for a straight statement to correct the record. I will not let a debate take place now. I am not even asking Mr. O'Brien to give a reply now. I simply want the record of the Committee of Public Accounts corrected.

Deputy Mary Lou McDonald

I assume, as members of the committee, we have some influence over how this matter is dealt with. The Chairman has raised the matter, so may I proceed?

Chairman

The Deputy may make a brief comment. We will not get into a debate now. There are other issues on the agenda, and we are-----

Deputy Mary Lou McDonald

I respect Deputy Fleming's role as Chairman of the committee. We are equal members of the committee.

Chairman

The Deputy may proceed.

Deputy Mary Lou McDonald

The matter has been legitimately raised. I wish to make a comment on it, if I may, and others may wish to do so equally. I think the Chairman and I are the only two members of the committee who were members of the previous committee.

Chairman

That is correct.

Deputy Mary Lou McDonald

I must put it to Mr. O'Brien that when he appeared before the committee and dealt with matters relating to Grace and Anne, I think he will concede that confused information was presented to us at times in respect of the apologies given or not given. He will recall this turn of events. I am very concerned that he has given inaccurate or misleading information to the committee in respect of the Devine report and what he claimed was a Garda insistence that reports could not be published and disciplinary actions could not be taken against HSE staff on the instruction or advice of An Garda Síochána. We now know because of a freedom of information, FOI, request by RTE that in fact there was no communication with the Garda for a full three years. I am very concerned that Mr. O'Brien was not complete in the information he gave to the committee. I am concerned also that misleading information has been given to the committee in respect of those staff who were responsible for keeping Grace in that foster home and I want him to clarify that for the committee. Is it the case that one or all of those responsible still work within the public sector? We need to know whether that is true. I am concerned that the allegation - and it has not been refuted - is that what we have witnessed here is what has been described as a clique of HSE managers protecting themselves and the system at the expense of vulnerable children and young adults. I am concerned by the allegation that records may have been tampered with or destroyed. I am concerned above all that the public airing of this turn of events, although the turn of events itself goes back further, goes back to 2012 or 2013. At every stage, Mr. O'Brien was at the helm of the HSE, and it strikes me that he came before the committee and gave, at the very least, incomplete information. This does nothing to build confidence in him and in the discharge of his duties, if he does not mind my saying so. It is not acceptable for him to come before an Oireachtas committee and behave in that way. Therefore, unlike the Chairman, who is giving him seven days to respond to these matters, I think, given the fact that the terms of reference are being debated today in the Houses of the Oireachtas and presumably will be decided at some stage today, it is important that he answer these questions today. The questions are why he did not give us the full story on the interaction with the Garda, why he gave a bogus explanation of disciplinary actions in respect of HSE staff and why we have been given a contradictory and muddled account as to the whereabouts of those staff members who were responsible for neglecting Grace and leaving her in that very dangerous situation. I think he must answer these questions today. I suspect he has all his key people with him and has the information. I expect him to answer our questions today, answer them fully and answer them truthfully.

Chairman

Is Mr. O'Brien in a position to respond to what has been put to him?

Mr. Tony O'Brien

As the Chairman will be aware, the clerk to the committee, presumably at the instigation of the committee, contacted our head of parliamentary affairs to indicate to us that the position would be as the Chairman outlined it. Consequently, I have not done what I would wish to do before responding fully to these matters, that is, to reread all the transcripts and equip myself fully to give the most complete answers the committee would expect. Therefore, I think it prudent that I accept the Chairman's invitation to provide a written response or come back within seven days rather than attempt to answer these questions today.

Chairman

As Chairman, I wish to ensure absolute fair procedure for the members of the committee, the people who elect us and the public body before us. Mr. O'Brien was not on notice before arriving here that these questions would be put to him and that he would be required to answer them today. We have a clear agenda. There was an opportunity over previous days, prior to his arriving here, for members who wanted answers today on a topic not on the agenda to notify him in advance that we would go down this road. In the interest of fair procedure, I wish to get the truth, not a quick answer. This has been ongoing for a very long time, and it is correct that Mr. O'Brien would study closely every one of his previous statements to us on these matters. The committee would not be operating according to fair procedure if it asked him to answer these questions without giving him adequate notice. I will make it clear: we will not discuss this today. Mr. O'Brien has said he will come back within seven days in person, if required. The Dáil will decide what happens in the Dáil Chamber. However, as Chairman of the committee, I am ensuring fair procedure for anybody who attends and it would not be fair to expect Mr. O'Brien to answer these questions and have read all the relevant transcripts when he was not on notice that he would be required to do so. I will be firm. I understand-----

Deputy Mary Lou McDonald

If that is the Chairman's ruling, I will of course respect it. However, to clarify, the contact with An Garda Síochána to which I refer is in respect of publication of the Devine report. Mr. O'Brien misled the committee on that score. If the Chairman's ruling is as he has outlined, that is his ruling. However, let us be absolutely honest about this: nobody should hide behind fair procedure or technicalities in the answering of these questions. Mr. O'Brien and his team are well aware of the debate that has raged around these issues, well aware that the terms of reference are to be considered and, most likely, decided today and well aware, no doubt, from media coverage, that serious question marks have arisen regarding the evidence he has given to the committee. Therefore, having had the pleasure of Mr. O'Brien's attendance at the committee on many occasions before, I have no doubt but that he would have anticipated this issue raising its head and that he has answers to these matters. If the Chairman is insistent that he be given seven days, so be it. I would like him to come back in person and then deal with the questions once we have his written responses.

Chairman

I am concluding discussion of this matter. I will rule in a moment-----

Deputy Alan Kelly

In fairness, I think-----

Chairman

Deputy Madigan had indicated.

Deputy Alan Kelly

No, I-----

Chairman

I will be making a ruling as Chairman.

Deputy Josepha Madigan

I am going to be the second questioner anyway, after Deputy McDonald. I simply wish to say that I respect the Chairman's views on this, despite the fact that there are very serious and grave concerns. It is due to the fact that the concerns are so serious and grave that the HSE is afforded an opportunity to put in a written reply within seven days. I echo that point because it is far too grave to not take it seriously.

Deputy Catherine Connolly

I agree with the Chairman's ruling. It is right in relation to fair procedures - end of story. It seems to me that the terms of reference cannot be set today. Very serious allegations and issues were raised by Deputy McDonald and others in the Dáil and it would not be right for the Dáil to conclude terms of reference in a vacuum.

Deputy Alan Kelly

I agree with the Chairman's ruling. It is the appropriate thing as fair procedure is always necessary and is of the utmost importance. There is such a range of issues here. Deputy McDonald has raised many of them. I have serious concerns that some of the people who have been mentioned are still working in the HSE. I have serious concerns around the accuracy of previous evidence given to the Committee of Public Accounts given what we now know and in correlating this information with what was told to this committee on previous occasions. Within a week this committee can have a written statement from Mr. Tony O'Brien and the HSE, and very soon after that the committee is going to have to deal with the matter. I ask the Chairman to ensure that this happens.

Deputy Catherine Murphy

I accept that fair procedure must be followed but our difficulty is that fair procedure is also required for the terms of reference that are being decided today. The timing is critically important if those terms of reference are to be right. I have a real issue with fair procedure and getting the terms of reference right from the perspective of the people who will be subject to this commission of inquiry. This information is quite critical in getting the information right. Squaring that circle is very difficult.

Chairman

I will put one question, as Chairman of the Committee of Public Accounts, and I am not trespassing into the Dáil debate. I raise this issue because of previous statements made at this committee and what happens in the Chamber is a matter for the other Members, including the members of this committee. In view of the fact that one of the reasons for establishing this commission is revelations that came to the PAC in the first instance. The committee is now gravely concerned about the information that came to us at a previous meeting of the committee. Is there a reference in the terms of reference, or the order, to deal specifically with the public statements of the HSE at the Committee of Public Accounts? This needs to be considered. I am posing the question. I am not pre-judging what is happening in the Chamber because it will come to a vote. The Committee of Public Accounts, however, might want to express its opinion this morning that the matter should be included in any terms of reference. That would leave the possibility of delaying the terms of reference being agreed and of not getting the inquiry established quickly. Are we overstepping the mark?

Deputy Josepha Madigan

Section 10 can expand the terms of reference but I do not know if that would entail-----

Chairman

Deputy Connolly has indicated on that point.

Deputy Catherine Connolly

I do not believe that the terms of reference can now be set in view of what has come out here this morning and if we are to comply with fair procedures. I agree with the Chairman's ruling but given the information that has come out today and the issues being raised - in addition to other concerns we already had in the Dáil around the inadequacy of the terms of reference - it would do a complete injustice to the situation if we were to go ahead with terms of reference this week in the Dáil without matters being clarified.

Chairman

I shall make a ruling, and I believe members will agree. I propose that the committee go into private session for a discussion among members for a few minutes. Is that agreed? Agreed. We will ask the HSE witnesses, other witnesses and all members in the Public Gallery to leave. If members have a view to express, they can do so.

The committee went into private session at 10.15 a.m. and resumed in public session at 11.30 a.m.

Chairman

We will continue our examination of the HSE patients' private property accounts 2015, HSE financial statement 2015: note 13 re fair deal scheme and the health repayments scheme donations fund 2015. The Comptroller and Auditor General has already made his opening statement. We were looking for a commitment that within seven days, the HSE would supply information to the committee in writing relating to the previous evidence presented to it and that within a further seven days, representatives from the HSE will be back to discuss the matter with the committee. Is that a "yes"?

Mr. Tony O'Brien

Yes.

Chairman

I now call Mr. O'Brien to make his opening statement.

Mr. Tony O'Brien

As we have submitted detailed information to the committee in advance of the meeting on each of the matters for examination, I will only make relatively brief remarks.

In respect of the HSE patients' private property, PPP, the HSE operates client PPP accounts on the basis of the Health (Repayment Scheme) Act 2006. The Act allows the HSE to receive and hold client PPP funds, to use funds for the benefit of clients and to invest funds on clients' behalf. The 2006 Act requires the HSE to maintain PPP accounts and to produce an annual set of financial statements for audit by the Comptroller and Auditor General. The Act also places restrictions on the HSE as to how it can invest PPP funds. Such funds must be invested with a financial institution regulated by the Central Bank of Ireland or with the National Treasury Management Agency. As part of the suite of national financial regulations, NFRs, maintained by the HSE to document the system of internal financial control, the HSE has implemented NFR 22 – patients' private property, which along with a set of patients' private property guidelines, provide detailed instructions to HSE staff on the management of client funds.

The HSE established a national co-ordinating unit for PPP, the PPP account central unit, or the central unit, in late 2006.

The central unit received all payments from the health repayment scheme in respect of payments made to clients' PPP accounts. Department of Social Protection allowances and pensions, approximately 2,500 of them, are also received by the PPP central unit weekly and lodged to each client's central PPP account. The weekly statutory contribution pertaining to each client is deducted and moneys are provided for each client to their local care centre as requested depending on client usage. Excess PPP funds from individual care centres are also transferred to the central unit where those funds can attract interest. In effect the local care centre PPP account is a current account and the central unit account is a deposit account.

The operation of the PPP process at local level in the 156 units and at central level is subject to external audit by a firm of accountants and there is also an overall audit by the Comptroller and Auditor General. The HSE has in place a clear programme of work to address the issues arising from these audits.

The PPP system currently supports more than 6,000 adults across older persons, disability and mental health services, with various levels of vulnerability and dependency, to safeguard their moneys and assist with the spending of those moneys for their direct benefit only. It is an important service for the client but also for family members.

Turning to the health repayment scheme, the 2006 Act was enacted in June 2006 to provide a legal basis for the repayment of long-stay charges for inpatient services which were wrongfully imposed on eligible persons since 1976 under the Health (Charges for In-Patient Services) Regulations 1976 as amended in 1987 or the Institutional Assistance Regulations 1954 as amended in 1965. The repayment scheme applies to eligible residents of public long-stay facilities and public contracted beds who were wrongfully charged at the time.

In accordance with the Health (Repayments Scheme) Act 2006, a repayments scheme (donations) fund was set up by the HSE for the purposes of providing improvements in public health services for dependent older persons and persons with disabilities. Projects undertaken must be once-off improvements and must not incur expenses which would, in the ordinary course of the provision of such public health services, have otherwise been expenses met by an allocation from the Minister for Finance or another Minister of the Government. Donations received are allocated to the institution or service specified by the donor, subject to the above conditions.

Governance arrangements are in place to ensure that the funds from this donations account are allocated and spent in accordance with the terms of the Act. The Health Service Executive submits detailed annual accounts of the fund and these accounts are audited by the Comptroller and Auditor General. Interim and regular reports on income and expenditure on the account are available as required.

Since the scheme commenced, a total of 212 donations have been made to date, and the value of donations received from the scheme is €348,000. All of these funds have now been allocated and expended for their intended purposes and there are no funds in the account at the end of 2016. As there is a possibility of further payments to be made under the scheme, it is the HSE's view that the donations account must remain in operation until there is a final close of the scheme.

With regard to the health repayment scheme itself, up to the end of December 2016 a total of 35,463 applications have been received. While the scheme closed to new claimants on 31 December 2007, there are instances that allow for a follow-on claim to be made. All 35,463 applications received have been concluded by the end of December 2016 with 21,877 applicants receiving an offer and a further 13,586 applications not accepted. Based on the 2016 preliminary outturn, a total of 20,283 payments amounting to €453.046 million have been made under the scheme.

The final cost of the scheme will be in the region of €486 million. A timeframe for close down of the scheme has yet to be agreed. The Department of Health in conjunction with the HSE's national co-ordinating unit for the health repayment scheme is currently reviewing the level of potential claims remaining and considering measures necessary to bring the scheme to a close, including any legislative revisions that may be required.

The nursing homes support scheme is administered by the HSE in accordance with the Nursing Homes Support Scheme Act 2009. The scheme is administered centrally, with a 2017 net budget of €940 million, and payments in respect of the costs associated with the scheme are made on a named resident basis across public, voluntary and private providers. The contributions determined under the scheme for individuals are paid directly to the public, private and voluntary providers and the income contributions for those in public centres are included in the revenue income and expenditure accounts of the HSE.

The scheme supported 23,073 people at year-end 2015, rising to 23,142 at year-end 2016. Of the 23,142 in 2016, 79% are supported in private or voluntary centres and the remaining 21% are supported through public provision.

The briefing paper submitted to the committee outlines in some detail the reasons there are different costs associated with public and private residential care provision under the scheme. The HSE published its cost of care for public residential care centres in October 2016, with a range of costs generally from €884 to €2,089 per bed per week, when compared with private residential care costs which range from €695 to €1,325 per bed per week. While this is a significant cost differential for long-stay residential care beds, there are also quite specific different drivers of these costs in evidence.

These include pay rates and conditions of employment of public versus private; the environmental implications of staffing levels in older public centres; the reduction in public beds since 2009 to comply with residential care standards; fixed costs that cannot be easily reduced in line with reductions in bed numbers; higher dependency of residents in public centres; and the necessity to provide public residential care in areas not attractive to private providers.

It is also important to note that public residential care centres are well respected and a vital component of their local community in terms of the delivery of a wide range of services, not just long-stay care. Many centres are campuses for the delivery of local services, including primary care, day services and rehabilitation. Public residential care services have a long history of service provision going back generations and the capital plan as announced in 2016 outlined a series of developments across the country in terms of both replacement and refurbishment of existing accommodation to bring the remaining centres in line with the residential care standards. This will see a significant reduction in multi-occupancy bedrooms, and allow for the provision of services in line with privacy and dignity requirements for residents.

In April 2015, additional funding was provided within an overall package of €74 million to reduce the waiting list for funding approval under the NHSS to no more than a four-week period. This has been maintained consistently since then and it has provided an essential stability in the overall context of the provision of service to people who require long-term care.

While the NHSS is a significant scheme supporting older people who need long-term residential care services, it also needs to be viewed in the context of the services that are required to maintain people in their own homes and communities for as long as appropriate. These services include home care, day care, respite, rehabilitation, voluntary and community supports. The input of paid and unpaid carers, family and neighbours are important elements of the necessary supports.

The HSE is implementing the recommendations for which it is responsible, following the review of the nursing homes support scheme undertaken in 2015 and will work with the Department of Health in relation to the value-for-money review to be undertaken this year on the costs of public long-stay care services.

That concludes my opening statement.

Chairman

The first speaker is Deputy McDonald to be followed by Deputy Madigan. The first speaker has 20 minutes; the second speaker has 15 minutes and subsequent speakers have ten minutes. The members have indicated in the following sequence: Deputies Connolly and Cullinane

Deputy Mary Lou McDonald

Fáilte arís Mr. O'Brien for a slightly deferred exchange. I want to ask about the HSE's role as trustee in these patients' private property accounts.

The funds held at 1 December 2015 amounted to €129.5 million. I do not know if Mr. O'Brien has a more up-to-date figure for 2016 as to what was held. Is the HSE's role as a trustee committed to paper somewhere? The Comptroller and Auditor General raised some control concerns in 2014 and 2015 such as absence of segregation of duties in care centres, absence of full bank reconciliations, non-compliance with HSE in respect of receipt of patient moneys, which moved on in 2015 to inadequate documentation supporting withdrawal from patient accounts in the care centres, and inadequate overpayments from client accounts, which was raised in 2014 but seems to have been remedied. I would appreciate it if Mr. O'Brien could respond to these matters.

Mr. Tony O'Brien

I will ask Mr. Mulvany, the chief financial officer, to respond.

Mr. Stephen Mulvany

I will check if we have a figure for 2016. Those accounts are not finished yet. The figure will be going downwards. We can certainly provide it if we do not have it before the end of the meeting. The HSE's role in terms of the patients' private property accounts is set out in the 2016 legislation. The trustee piece came in under the legal advice the health boards got before the HSE was established, which changed how we dealt with patients' private property. There is no actual trust document; it is an implied trustee relationship but it is governed by the 2016 Act.

Deputy Mary Lou McDonald

Should there be a document?

Mr. Stephen Mulvany

I will have to think about that but I will answer the rest of the questions.

In terms of the standards, the HSE has a set of guidance that it has published, which is detailed. It focuses primarily on making it clear that this is the patient's money. It is not the HSE's money and it is not to be used for HSE purposes. It goes into a great deal of detail about that and about the difficult part to support, which is family members interacting around patients, particularly when they do not have capacity. It covers all those issues in detail and the financial regulations which we published as well build on that. There is quite a detailed set of written guidelines.

Deputy Mary Lou McDonald

I made reference to concerns raised in 2014 and 2015 by the Comptroller and Auditor General. Is Mr. Mulvany satisfied that they have been addressed?

Mr. Stephen Mulvany

Not fully. On the standards, the report identified control breaches. The HSE keeps the patient private property money separate from its own accounts. We engage an external auditor who audits the operation of the patient private property account in the local centres, numbering close to 150. The auditor's staff prepare a financial statement, they give us a list of control issues and they also prepare one for the central account. What gives me some assurance is that the vast bulk of the money is retained in the central account. That is also audited and no material issues have ever been raised. The Comptroller and Auditor General then separately audits the overall consolidated patient private property account.

There has been progress in dealing with some of the issues raised in 2014 and 2015. They are not fully there but there is a significant programme of work with external support that is well project managed, which is approximately 70% complete. I will give the Deputy some examples.

Deputy Mary Lou McDonald

Briefly.

Mr. Stephen Mulvany

On the bank reconciliation issue and the 155 accounts, one of the basic checks is to make sure that the bank statements - there are separate bank accounts in all these local centres - match the ledgers they are keeping for each patient. That is an important control. In 14 cases over the two years, it is not that they were not doing bank reconciliations, which one could believe if one read some of the media reports, it is that they were unable to fully complete them. There were differences in 14 cases. However, if we examine the detail and separate out stuff relating to prior years, which I will come back to, there was a difference in four centres. They were unable to complete the bank reconciliation but in all cases the difference was less than €100 and it is being addressed.

Bank reconciliation is one of the core controls. The historic issues are being worked through. The fundamental principle is once it has been investigated, if it is not possible to determine exactly where the difference lies, the HSE is making good the difference.

Deputy Mary Lou McDonald

I thank Mr. Mulvany for that clarification. What is the full quantum? He said it is less than €100 in four cases. What is the total value in the 14 cases?

Mr. Stephen Mulvany

The total difference is something north of €100,000 but it is located in three or four large amounts. I stress that in no case will a patient's private property be left at a loss. The issue will be made good by the HSE if it is not possible to get to the specific detail of what is the reconciling item.

Deputy Mary Lou McDonald

When does Mr. Mulvany envisage the work will be completed?

Mr. Stephen Mulvany

I expect all that work to be completed before the end of 2017.

Deputy Mary Lou McDonald

A few issues jump out at me regarding the fair deal scheme. First, a large measure of the money goes into private nursing homes. Second, I refer to the cost differential. I have read the paper and, therefore, I take the point around pay and conditions. One can only assume that the conditions of some workers in private nursing homes are not great if one is to be discreet about it. According to Mr. O'Brien's figures, the cost per bed per week in a private home varies from €695 to €1,235 while the budgeting is much more generous for public homes ranging from €884 to €2,089 per week. I would like him to talk the committee through the mechanics of how those figures are arrived at and I would like to begin with the private nursing homes. Is it correct that the NTPF has a role in this? I would like him to explain how the rate is struck in private nursing homes and the system for the cost of care.

Mr. Tony O'Brien

I will answer regarding the private nursing homes and Mr. Healy will come in on the public homes. The legislation is clear that determining the rate paid per bed per week is a function carried out by the NTPF, not the HSE, and the HSE is simply obliged to pay that rate in respect of any eligible client or patient who elects to be placed in one of those homes having had his or her place come up in order under the scheme, given there is a degree of choice. The NTPF, therefore, is entirely responsible for the methodology-----

Deputy Mary Lou McDonald

Who in the NTPF looks after this? How does it work?

Mr. Tony O'Brien

It has a specific section that is charged with determining on behalf of the State the appropriate rate to be paid. There is also an appeals mechanism and so on but the officials do that based on their assessment of the appropriate rate against a series of criteria, which often take into account the going rate in an area. There tends to be variation by geography.

Deputy Mary Lou McDonald

Are the discussions between the NTPF and the nursing homes done nursing home by nursing home?

Mr. Tony O'Brien

That is my understanding. Some years ago, I was involved with the NTPF but I have not had any involvement for four or five years. The committee might want to take direct information from the NTPF on this matter to be sure the information is still current but there was scope for direct dialogue at that time and there is an appeals process that certainly provides for direct dialogue.

Deputy Mary Lou McDonald

It would not be a case, therefore, of dealing with a representative body to strike a rate for all the private nursing homes.

Mr. Tony O'Brien

That is not my understanding.

Deputy Mary Lou McDonald

Would it be possible to do that?

Mr. Tony O'Brien

It might be unlawful to do that having regarding to competition law. If an individual provider operated a number of nursing homes and, therefore, the direct dialogue was with that provider, that would be permitted but to engage in a price negotiation with a representative body for a group of separate and independent trading entities might fall foul of competition law.

Again, in current terms, that would definitely be a question for the NTPF.

Deputy Mary Lou McDonald

Is that the director general's understanding of the industry?

Mr. Tony O'Brien

That is my understanding. My information is at least four years old in terms of when I was last involved.

Deputy Mary Lou McDonald

In terms of striking the rate, Mr. Healy, is it similarly the case that the HSE deals individually, institution by institution, to agree the price for the cost of care?

Mr. Pat Healy

That is it exactly. It is not a question of agreeing the price. It is the actual cost of care in each of those units.

Deputy Mary Lou McDonald

Yes.

Mr. Pat Healy

Section 33 of the Act that established the nursing homes support scheme sets out the arrangements to apply there. In the briefing note that we gave the committee, at 4.3., it sets out what is included and what is excluded. Essentially, what is included is the nursing and personal care costs, bed and board, basic aids and appliances and laundry. So those costs are charged then against the nursing homes support scheme. All other costs in our long-stay facilities, as the Deputy may know, many of them may have short-stay facilities, there would be day-care services on-site and things like that.

Deputy Mary Lou McDonald

Sure.

Mr. Pat Healy

None of those costs are charged against the nursing homes support scheme but the actual cost of care is charged.

I will deal with the actual cost. The Deputy mentioned pay when we talked about the director general's introduction. In his opening statement he identified the five or six differentials which give rise to the differential between private and public cost and one of those is the pay, as the Deputy said. The basic pay rates are pretty much the same. What you will find is that the additional things like pension, maternity, sick leave and so on like that-----

Deputy Mary Lou McDonald

And good terms and conditions.

Mr. Pat Healy

-----we would be paying those where social welfare would be paying. Someone would be off and would claim from social welfare for that.

Deputy Mary Lou McDonald

Sure.

Mr. Pat Healy

We have about 25% to 30% built-in costs.

Deputy Mary Lou McDonald

I saw that in the documentation. I thank Mr. Healy and accept what he has said.

In terms of the standards of care, be it a private or public nursing home, presumably the standards for inspection are universal. Is a distinction made, Mr. O'Brien, between private and public nursing homes?

Mr. Tony O'Brien

Not in terms of the regulatory standards. The only variation would be in regard to compliance with physical infrastructure. I think it is correct to put it this way. The public sector has been given longer to come into compliance having regard to the ability of the capital envelope to meet those costs whereas private nursing homes would already be compliant with physical infrastructure requirements. What there tends to be, and Mr. Healy can add to this, is differing requirements for many of the clients who are in some of the public sector long-term facilities whose health care needs are greater and is reflected in a different staffing mix which obviously affects cost as well.

Deputy Mary Lou McDonald

What role does HIQA play in terms of nursing homes?

Mr. Tony O'Brien

HIQA is the licensing authority under the regulations.

Deputy Mary Lou McDonald

What does that mean?

Mr. Tony O'Brien

It means that unless one is licensed by HIQA it is not lawful to provide long-term residential care.

Deputy Mary Lou McDonald

Yes.

Mr. Tony O'Brien

One can provide other types of care on a short-term basis. I think the cut-off point is 30 days.

Mr. Pat Healy

Yes.

Mr. Tony O'Brien

Thirty days. If one is providing residential care without a rehabilitative component that extends 30 days then one must be licensed in accordance with the relevant legislation by HIQA. They have the right to grant, revoke or vary such licensing. The Deputy may be aware that sometimes they do that in respect of private nursing homes. The net effect of that is that the HSE is then required to take over the management of those private nursing homes at least for an interim period.

Deputy Mary Lou McDonald

Cleary the licensing of the nursing home is a prerequisite to accessing funding. What is the relationship between the regulatory and funding pieces?

Mr. Pat Healy

One has to be licensed and under the remit of the regulator in order to secure funding under the nursing homes support scheme. One must have a long-stay bed and it must be registered with HIQA. HIQA, as well as licensing, carry out regular inspections then. They publish those reports on the website.

Deputy Mary Lou McDonald

Who would call the like of that within HIQA?

Mr. Pat Healy

They have a full team that are regularly-----

Deputy Mary Lou McDonald

Does it have a full team?

Mr. Pat Healy

Absolutely. A dedicated team to long-stay care. They visit all of the registered nursing homes, both public and private, on a regular basis. They have their own risk assessment methodologies for doing that. They obviously hear complaints from the public and so on. They respond on a consistent basis. It is fair to say that the public facilities have been well regarded in relation to care.

Deputy Mary Lou McDonald

I ask Mr. Healy to tell me the following so I have it right. Do public facilities need to be licensed in the same way with HIQA?

Mr. Pat Healy

Yes. They are registered.

Deputy Mary Lou McDonald

They are registered.

Mr. Pat Healy

And inspected fully the same as-----

Deputy Mary Lou McDonald

So they would both-----

Mr. Pat Healy

Both public and private are fully inspected and registered with HIQA in the same way. There is no difference.

Deputy Mary Lou McDonald

Do they go through the same process-----

Mr. Pat Healy

Absolutely.

Deputy Mary Lou McDonald

-----in terms of getting on to the list?

Mr. Pat Healy

Absolutely. That is one of the assurances there for the public because it is the public that chooses. Under the nursing homes support scheme, it is the public and the individual who choose which nursing home to go to. They are separately registered, separately regulated and all of those reports are up on the website to be looked at.

Deputy Mary Lou McDonald

Let us consider the division between public and private. I will be honest with the delegation that I was surprised at the balance of how things fell, the number of people in public versus private, and how the moneys went in the opposite direction but maybe that is just me. Is there a trend to move away from public nursing homes and more in the direction of private facilities?

Mr. Tony O'Brien

The total number of beds in public nursing homes has been falling as infrastructure has been brought in line with compliance. Therefore, a multi-bedded room is required to be a single bedded room.

Deputy Mary Lou McDonald

Sure.

Mr. Tony O'Brien

Typically, one is reducing the bedding or the bedage in a facility as one brings it into compliance by about a third. Consequently, the total number of public beds has fallen. The public sector would not be able to meet the needs for long-term nursing home care from its existing infrastructure. At the same time, before the economic events of 2008 and beyond there was a significant growth in private sector provision and we are beginning to see that occur again. Does Mr. Healy wish to add anything?

Mr. Pat Healy

I-----

Deputy Mary Lou McDonald

I am sorry to cut across Mr. Healy. Chairman, how many minutes have I left? Is it something like 30 seconds?

Chairman

Yes.

Deputy Mary Lou McDonald

The delegation referred to a review and a value for money analysis. The review happened in 2015. Is that correct?

Mr. Pat Healy

That is correct.

Deputy Mary Lou McDonald

Will the value for money assessment take place this year?

Mr. Pat Healy

The expectation is that it will be done in 2017.

Deputy Mary Lou McDonald

In 2017.

Mr. Pat Healy

It will be undertaken by the Department.

Deputy Mary Lou McDonald

All right. Please briefly tell me the following. Who conducted the review? Was the HSE allowed to lobby or make representations?

Mr. Pat Healy

It was the Department of Health that undertook the review. We were obviously consulted as part of the review. We made an input into it and so on. We are implementing the recommendations. There were 32 administrative recommendations-----

Deputy Mary Lou McDonald

That is fine.

Mr. Pat Healy

-----which we are implementing.

Deputy Mary Lou McDonald

The HSE was consulted. Who else was consulted? Was HIQA consulted as part of the review?

Mr. Pat Healy

I would say the whole wider stakeholder group was consulted as part of the review.

Deputy Mary Lou McDonald

What does Mr. Healy mean by the term "stakeholder group"?

Mr. Pat Healy

Nursing Homes Ireland would have been one of the bodies but also I would say Age Action and agencies like that were consulted.

Deputy Mary Lou McDonald

Can we have a list of the bodies that were consulted for the purposes of the review?

Chairman

Is there anyone here from the Department of Health who knows that information?

Deputy Mary Lou McDonald

Who is here from the Department?

Mr. Greg Dempsey

I can answer.

Mr. Tony O'Brien

It was actually a public consultation with notices placed. It was open to all potential interested parties to make submissions to the Department at the time.

Deputy Mary Lou McDonald

That is excellent. Can we get a list of who made the submissions?

Ms Angela Noonan

It is published on the Department of Health's website.

Deputy Mary Lou McDonald

Is it?

Ms Angela Noonan

Yes.

Deputy Mary Lou McDonald

Are they listed?

Ms Angela Noonan

Yes and there is a report of the submissions.

Deputy Mary Lou McDonald

Thank you.

Chairman

In case that information was not picked up on the microphone, an official has said that the list is published on the Department of Health's website.

Deputy Mary Lou McDonald

I thank the Chairman. What will the value for money review entail? Who will be involved?

Mr. Pat Healy

It is being undertaken by the Department.

Deputy Mary Lou McDonald

Yes.

Mr. Pat Healy

My colleague, Mr. Dempsey, will comment.

Mr. Greg Dempsey

It will be undertaken by the Department. We have not actually started yet. In the next couple of months we will scope it out. At this stage, we are not sure of its exact form. It will follow Department of Public Expenditure and Reform guidelines but we will be consulting. The aim is to understand the drivers behind the differential pricing between public and private. I think our expectation is that we would get it completed in 2017.

Deputy Mary Lou McDonald

Obviously the Department would have to talk to the HSE. I am trying to figure out how the review will work. I want a mechanical picture of how the review will work and who will be involved. Will the HSE and HIQA be involved?

Would Nursing Homes Ireland, or whatever the group is called, be involved or consulted?

Mr. Greg Dempsey

I am not sure yet but one would imagine most of those organisations would be involved. The first phase-----

Deputy Mary Lou McDonald

When was the value-for-money process last done on this issue?

Mr. Greg Dempsey

It has not been done on this particular topic.

Deputy Mary Lou McDonald

It has never been done. I imagine there is a standard format.

Mr. Greg Dempsey

The format and content of the value-for-money process is set out in the Department of Public Expenditure and Reform guidelines. As they are topic-specific, the initial approach to data gathering would be different for each of them. Part of the process would involve scoping the data, who we need to involve and so forth. We have not started that in the Department.

Deputy Josepha Madigan

I thank the delegation from the Health Service Executive for coming in. It is evident from the accounts that substantial public money goes through the HSE to health care providers, both public and private. We know there has been systemic elderly abuse, as well as incidents involving children, coming to light recently. I am speaking specifically about nursing homes and the fair deal scheme. We know taxpayer money has gone to supposed carers who have turned out to be abusers. I have a relevant question. What monitoring and quality assurance measures are now undertaken by the HSE for caregivers? How do we know the level of care now being provided is adequate and how are we protecting those patients from abuse?

Mr. Pat Healy

This goes back to the role of the regulator. The Health Information and Quality Authority, HIQA, independently inspects all long-stay care facilities.

Deputy Josepha Madigan

I will stop Mr. Healy there. Since 2014, HIQA has done 2,273 independent inspections. How many of those related to elderly people, as opposed to children or those with disabilities?

Mr. Pat Healy

I do not have the HIQA figures with me but they are on the HIQA website. All the 23,000 beds - 18,000 private beds and 5,000 public beds - are inspected.

Deputy Josepha Madigan

I appreciate that but I would like to be more specific because we are discussing the fair deal scheme. The role of the Committee of Public Accounts is to ensure taxpayers' money is spent prudently. I want to ascertain how many of those inspections related to the elderly. Can the witness answer that today?

Mr. Pat Healy

HIQA carries out inspections independently of us and it would be able to tell the Deputy exactly how many inspections were for long-stay care or child care.

Deputy Josepha Madigan

There are approximately 1,000 inspections per year.

Mr. Pat Healy

That is right.

Deputy Josepha Madigan

Does the witness know, even approximately, how many of those relate to the elderly?

Mr. Pat Healy

HIQA would understand that and have the figures for the Deputy.

Deputy Josepha Madigan

The witness is a representative of the HSE, so I am just wondering if it has that information.

Mr. Pat Healy

The 129 public facilities in which we provide services and all the 18,000 beds in the private sector are all inspected by HIQA. They have all been inspected consistently.

Deputy Josepha Madigan

I appreciate that but it is just not answering my question. The witness does not have the information here but perhaps he can provide it to the committee.

Mr. Pat Healy

HIQA would have that information.

Mr. Tony O'Brien

We will undertake to ask HIQA for that information and provide the Deputy with its information.

Deputy Josepha Madigan

That would be great. There have been cases of systemic abuse of the elderly. I would like to know, and I am sure the committee would like to know, how many of those independent inspections specifically related to the elderly. The fair deal scheme is on the agenda today so the information would have been helpful. Is the delegation in a position to answer how any potential neglectful or abusive caregivers are identified?

Mr. Pat Healy

Very much so. Each of the public facilities that we run and the private nursing homes would have their own management of nursing and professional caregivers overseeing the provision of care within the nursing home. Every residential facility has a person in charge who is responsible for ensuring the care is provided to the appropriate standard. It is those individuals and their teams that are inspected by HIQA when they come.

Deputy Josepha Madigan

That applies to each individual nursing home, whether it is public or private. Is Mr. Healy talking about what is essentially a human resources department that might deal with complaints?

Mr. Pat Healy

Not at all. They would have a nurse in charge with a senior nurse who is responsible for running the centre and ensuring all the nurses, care and support staff act properly.

Deputy Josepha Madigan

There is not uniform measure.

Mr. Pat Healy

It is very uniform.

Deputy Josepha Madigan

Okay.

Mr. Pat Healy

They all work to professional guidelines and HIQA standards, which are set out very clearly. HIQA inspects whether people are implementing those standards and providing care to the proper level.

Deputy Josepha Madigan

What happens if somebody is identified as a possibly neglectful person?

Mr. Pat Healy

All those are identified and any issues that arise are identified in the inspection. They are put on HIQA's report website.

Deputy Josepha Madigan

If somebody makes a complaint about a caregiver, where does it go?

Mr. Pat Healy

On the public side, it would be dealt with initially in the nursing home. It would also be dealt with in a private nursing home. Separately, the HSE has "Your Service, Your Say", a process where a person can complain. We have a confidential recipient who may receive complaints. There are a number of processes directly within a nursing home and also separately from it, so people can be heard.

Deputy Josepha Madigan

Could Mr. Healy give an assurance to the committee that the neglect and abuse we have seen towards the elderly will not occur again, particularly with regard to the measures the executive has taken?

Mr. Pat Healy

We can say the public facilities run by the HSE have a very good record in HIQA inspections, and that is well understood. Generally, across the public and private sector, there is a very high level of compliance. Where difficulties arise, they are dealt with very speedily.

Deputy Josepha Madigan

I hope so. With regard to the health repayment scheme, I note €453 million was repaid between 2007 and 2009 where charges were incorrectly imposed. I appreciate that the HSE has held its hands up in that regard. It is a substantial amount to have overcharged, so it would be very helpful for the Committee of Public Accounts to know why and how it happened. This is not a couple of cent but rather €453 million. It has been paid back but could the witnesses elaborate on the issue?

Mr. Tony O'Brien

I will ask Mr. Healy to give the detail but I have some background information. This occurred before the establishment of the HSE and it was the subject of a very detailed investigation at the time. It has been the subject of entirely new legislation that was passed to deal with the issue in 2006. Mr. Healy might give some insight into it.

Mr. Pat Healy

At the time it was identified that people had been charged who had medical cards and were entitled to inpatient services, as they were known. When that was identified, the Government passed legislation for the repayments to be made. The HSE administered it and we have a specific statutory scheme, as set out in legislation.

Deputy Josepha Madigan

How were the claims substantiated individually?

Mr. Pat Healy

That was the role of the scheme administrator. We engaged McCann FitzGerald to work with us and it was contracted to do that. It carried out the process with a set of accountants and lawyers who ran the scheme. There was a separate appeals process and the Department established an oversight group independent of both the HSE and the administrators.

Chairman

A vote has been called in the Dáil that we were not expecting. As we do not know what the vote is about we must suspend because there are no vote pairing arrangements in place.

Sitting suspended at 1 p.m. and resumed at 1.20 p.m.

Deputy Josepha Madigan

Apparently, approximately 35,000 people should have received compensation but did not. Is that correct?

Mr. Pat Healy

When we originally estimated the numbers, we were unsure of the figure. The calculation was done. It was 50% less than what was originally estimated as the maximum that might arise.

Deputy Josepha Madigan

Why was that the case? Were any efforts made to find these people?

Mr. Pat Healy

Significant efforts were made. There was a vast amount of publication. A great amount of work was done. A national communications programme was put in place to advertise it and so on. When the scheme administrator came on board, more advertising was done and so on. The vast bulk of people have been dealt with.

Deputy Josepha Madigan

Is the HSE satisfied that sufficient efforts have been made? It is seldom people refuse a refund.

Mr. Tony O'Brien

At the time, which was 11 or 12 years ago, this was probably one of the biggest public policy issues in the public domain. It was as big as any issue in terms of the level of attention it got.

Deputy Josepha Madigan

It is on the agenda today.

Mr. Tony O'Brien

Yes, but in terms of that aspect of it, as distinct from our administration of it since then, no one in the country who was potentially eligible could have failed to have been aware of it given the amount of focus that it had at the time.

This issue has significant historical origins in that it arose from a misinterpretation of the entitlements of the health boards that existed at the time and that collected this money. There was considerable public attention given to it. Therefore, in the context of anyone at the time being incorrectly charged, it is unlikely that the level of publicity and attention that attended to it would have been insufficient.

Deputy Josepha Madigan

Is the donations account still in existence?

Mr. Tony O'Brien

Yes.

Deputy Josepha Madigan

Is there any need to retain it given the level of activity?

Mr. Pat Healy

There is a requirement to maintain it as long as the Act continues in force. That is something we are reviewing now.

Deputy Josepha Madigan

Is it likely that there will be further donations?

Mr. Pat Healy

It looks unlikely.

Deputy Josepha Madigan

Claimants are aware that there is a facility to make donations. Is that correct?

Mr. Pat Healy

Absolutely. Some have been made and all of these have been paid out.

Chairman

I wish to ask a question on the exact point Deputy Madigan has raised before I call Deputy Connolly. I know of many people whose families were entitled to make a claim. However, they were happy with the service they received and they chose not to make a claim. They took the view that the family member had been looked after properly. It may be that the statutory instrument was not correctly interpreted, but that did not change the care they had received. Some families use the idea of not making a claim as their donation to the system. I have met several people who have decided not to take the money out because they were happy. Technically, they were entitled to it, but many families chose not to go down that route.

Deputy Josepha Madigan

The main point is that they were aware of it. I was keen to reiterate that today.

Chairman

Yes. It was widely known. Have you had experience of this approach, Mr. O'Brien, on the basis of your knowledge of it?

Mr. Tony O'Brien

Yes, what you are saying is exactly correct, Chairman.

Chairman

It is great that we are in agreement on something this morning.

Deputy Catherine Connolly

I thank Mr. O'Brien and all his colleagues for coming before the committee this morning. I often say that it is a good exercise in democracy and accountability. I respect that the HSE representatives are here to give replies.

I am keen to have the last point clarified. The repayments came to 50% of the expected amount. Presumably, money was put aside in the budget for double the repayment figure at the time. Is that the case?

Mr. Pat Healy

No, it was provided annually, as required.

Deputy Catherine Connolly

In the same legislation there was provision for people who did not want to take it. They could donate it. Is that right?

Mr. Pat Healy

That is the donation scheme.

Deputy Catherine Connolly

People were generous with donations. What was the figure?

Mr. Pat Healy

We have set out in the report the donations provided. The point is that all of those have been paid out. They had to be used for the specific purpose for which they were donated. All of that has been paid out.

Deputy Catherine Connolly

Could I see a record of what was done with that money? Specific criteria were set down about how the HSE could spend it. Is that right?

Mr. Pat Healy

Absolutely, we had to spend it in exactly the way the donor indicated.

Deputy Catherine Connolly

Therefore, the person who was donating determined it. Is that correct?

Mr. Pat Healy

That is it exactly. We implemented what they donated the money for.

Deputy Catherine Connolly

Can the HSE representatives come back to me with a list of where the improvements were made? Let us consider Galway, for example. The list could indicate where those donations were used.

Mr. Pat Healy

Yes. We will get those details for the committee.

Deputy Catherine Connolly

I wish to deal with the interest and the legacy in respect of the interest. I understand that €4.4 million was retained in interest by the Health Service Executive. First of all, the interest was not paid out. These are historical legacies. Is that correct? First, the money was not paid out. Then it was paid. Now the interest remains to be paid out. Has the HSE paid some of the interest?

Mr. Stephen Mulvany

Two points arise relating to the health boards and the emergence of the health service. The health services have been assisting patients and safeguarding their moneys where it was necessary to do so. That is what we term the private property of patients process. It was put on a statutory footing in 2006 but it existed prior to then. Prior to then, the legal advice for health boards was that if a person gave €100 to a health board to mind on behalf of that person, the obligation was to give €100 back.

Around 2004 or 2005 we were getting ready for the establishment of the HSE. While the issues relating to the payment scheme were coming to the fore, this was looked at again. The legal advice was that, on balance, it was more appropriate to treat it as a trustee relationship. Generally speaking, this means a trustee is obliged to safeguard €100 but also to give the person interest. The trustee can charge a reasonable administration charge.

Deputy Catherine Connolly

Did the HSE need legal advice to realise that it was holding client funds but keeping the interest?

Mr. Stephen Mulvany

There is a difference between the two legal relationships. We absolutely needed legal advice on that. The health board-----

Deputy Catherine Connolly

The HSE was holding the money in trust. The client money goes into the patient private property account. The HSE then invests that. Is that correct?

Mr. Stephen Mulvany

We do. The former health boards invested it. The advice given to the former health boards was that their relationship was technically called a bailor-bailee relationship.

Chairman

What is that phrase?

Mr. Stephen Mulvany

It is called a bailor-bailee relationship.

Chairman

Can you explain that to the layman?

Mr. Stephen Mulvany

I am a layman myself. In simple terms, the implication of the relationship is that if a body is given €100 to mind for a patient, then the obligation on that body is to keep the €100 safe and return €100 to the patient. Let us consider what happened in reality. At the time more than 170 local units were in place. The health boards used any interest they earned on that money to partly defray the cost of providing the patient private property service. We could argue whether that is right or wrong-----

Deputy Catherine Connolly

That was changed subsequently. The HSE had to change that arrangement. Is that correct?

Mr. Stephen Mulvany

Then we moved to the establishment of the HSE. We took legal advice. I was involved in this at the time. The advice was that, on balance, it was more appropriate to treat it as a trustee relationship and, therefore, the patient should get the interest, in other words, it should be given back.

Deputy Catherine Connolly

What is the status of that now? How much money does the HSE have in interest?

Mr. Stephen Mulvany

Currently, we are holding €14 million in interest in the patient private property accounts. The details are set out in the documentation before the committee. The bulk of the figure relates to the period from 2005 to 2008. Our task is to repay that money. Our task is to give that money either to the entitled next-of-kin or to the patient, where that is possible – many of the patients will have passed away.

Deputy Catherine Connolly

I understand over €2 million relates to the period before 2005. Is that correct?

Mr. Stephen Mulvany

Yes.

Deputy Catherine Connolly

That is a rather long delay. This is 2017.

Mr. Stephen Mulvany

First, our strong preference was for this exercise to be completed before now. We accept that. Second, the HSE has no desire to benefit in any way from this delay or any desire to use this money or to get access to it in any way.

Deputy Catherine Connolly

I accept that. However, at this point, what is the HSE plan in terms of the €14 million? This has gone on since before 2005. Is there any end in sight? If the HSE cannot allocate this money, what will happen? What is the HSE plan?

Mr. Stephen Mulvany

We have a plan. Let us consider the case of money earned in the four-year period between 2005 and 2008. In the middle of that period we created a central unit and we started to give everyone the proper interest into their accounts.

This is a residual issue. We have now started a project with three main phases. It is externally supported. The first phase is under way. The purpose of it is to gather sufficient data to be able to identify the clients from 2005 to 2008. Then we have to calculate an interest rate. Then we have to pay it. The first two parts of the exercise will take the remainder of the year to carry out. Then, next year, the intention is to be able to start paying the money where we can identify the clients or the entitled next-of-kin.

I will set out some information to get an understanding of the context in terms of the money involved. We are talking about interest as opposed to money given to us for safeguarding.

Deputy Catherine Connolly

I understand that.

Mr. Stephen Mulvany

We took a sample in 2015. We looked at ten care centres from a total of approximately 150.

Deputy Catherine Connolly

Okay.

Mr. Stephen Mulvany

Those centres had between 1,100 and 1,200 patient accounts. The average balance across the first quarter of those patient accounts was approximately €300.

Deputy Catherine Connolly

Okay.

Mr. Stephen Mulvany

Therefore, the average interest we have to pay back - there is no average patient because they are all individuals - is approximately €27. The average balance across the second quarter of those patient accounts was approximately €2,400. We have to pay back an average of approximately €280 for those patients. The average balance across the third quarter of those patient accounts over the four-year period was approximately €6,500. These are rough figures.

Deputy Catherine Connolly

Yes.

Mr. Stephen Mulvany

Those patients are entitled to approximately €900. The average balance across the final quarter of patient accounts is approximately €12,000. Those patients are entitled to interest payments of approximately €3,000.

Deputy Catherine Connolly

Okay.

Mr. Stephen Mulvany

That is just the scale of-----

Deputy Catherine Connolly

That is the analysis.

Mr. Stephen Mulvany

That is the analysis based on a sample of ten care centres that were selected in an effort to be representative. We have to apply this exercise to approximately 150 centres. That work is under way. The first two parts will be completed this year.

Deputy Catherine Connolly

Is any particular completion date envisaged?

Mr. Stephen Mulvany

We envisage that we will finish gathering the data and working out the amount per client by the end of this year. We believe it will take at least 12 months to do the second part of this work, which involves identifying the people to whom this money should be paid. We expect that to be difficult in some cases.

Deputy Catherine Connolly

I understand that.

Mr. Stephen Mulvany

We will not be able to identify who the next of kin is.

Deputy Catherine Connolly

A decision will have to be made in respect of such cases.

Mr. Stephen Mulvany

We will have to make a decision. We will talk to the Department. The reality is that if we cannot identify who should get some of this money, it will be paid over to the Office of the Chief State Solicitor. That is the normal course that is taken in such circumstances.

Deputy Catherine Connolly

Okay.

Mr. Stephen Mulvany

The HSE will not retain that money.

Deputy Catherine Connolly

The big issue for me is nursing homes. I was involved in a campaign in Galway that collected 24,000 signatures that remain on my floor. We had to beg the HSE not to close a public nursing home. This issue is particularly close to my heart. The Chairman is smiling.

Chairman

Yes.

Deputy Catherine Connolly

There was a similar campaign in Abbeyleix at the same time. Some 24,000 people begged the HSE not to close a public nursing home. Unfortunately, a foolish decision was made. In the same week, it was announced that we do not have enough public nursing home beds. I mention that to explain the background I am coming from. I am passionate about this issue. I note that 79% of beds are private and 21% are public. Can Mr. O'Brien explain whether the HSE is legally obliged to maintain a certain ratio of public and private beds?

Mr. Tony O'Brien

There is no such legal obligation.

Deputy Catherine Connolly

Has there ever been such an obligation?

Mr. Tony O'Brien

Not that I am aware of. I believe that has never been the case.

Deputy Catherine Connolly

Never.

Mr. Tony O'Brien

I do not believe so.

Deputy Catherine Connolly

Mr. O'Brien might check that. Are the HSE and the Department of Health operating in a vacuum in terms of public nursing home beds?

Mr. Tony O'Brien

We are operating without a legislative obligation to maintain any particular ratio of public beds to private beds.

Deputy Catherine Connolly

How has it been decided that almost 80% of beds should be private and 20% of beds should be public? How was that determined?

Mr. Tony O'Brien

There has not been a strategic decision to do that. We have the beds we have. There has been a reduction in our number of beds by virtue of the need to achieve regulatory compliance. As I was explaining to Deputy McDonald earlier, this process often results in a reduction of approximately one third in the number of beds in a given facility.

Deputy Catherine Connolly

I understand that. I do not mean to cut across Mr. O'Brien, but I have grasped that and I have heard it. I have limited time. Mr. O'Brien has already given that explanation. I am taking it to a higher level. Mr. O'Brien has said there is no obligation in this area. This means the HSE is operating in a vacuum. If it wanted to, it could decide tomorrow to pursue a policy of 100% private beds.

Mr. Tony O'Brien

No, because we have the beds we have.

Deputy Catherine Connolly

If the HSE did not have those beds, and if the public nursing beds-----

Mr. Tony O'Brien

There is no policy constraint that says we could not go 100% private.

Deputy Catherine Connolly

I thank Mr. O'Brien.

Mr. Tony O'Brien

That would require an active policy decision to move away from the status quo.

Deputy Catherine Connolly

I thank Mr. O'Brien. That is very clear. The point is that in the absence of a policy direction, the HSE has gone in a direction that has led to 79% of nursing home beds being private beds. That has happened without any policy. It has just gone in that direction. Mr. O'Brien's explanation for the reduction in the number of public nursing home beds is that HIQA has imposed limits on the number of patients in a room and demanded the provision of en suite facilities, etc. Is that right?

Mr. Tony O'Brien

That has had a reducing effect on the total number of public beds, but it cannot be used to explain the current ratio.

Deputy Catherine Connolly

Can Mr. O'Brien give me the explanation?

Mr. Tony O'Brien

It can be explained by reference to the on-the-ground position and the fact that we operate in a free market environment for the provision of these services. Obviously, the nursing home support scheme provides a mechanism for individual patients, clients or residents to exercise their choice.

Deputy Catherine Connolly

Yes.

Mr. Tony O'Brien

In effect, it enables them to take their slice of public funding and spend it in the residential facility of their choice.

Deputy Catherine Connolly

I have the greatest difficulty with that. I understand that the ratio was the subject of a legal obligation at some stage. Mr. O'Brien has told me that no such obligation exists now. I understand it was in place previously. I also have a difficulty with Mr. O'Brien's point about choice. My understanding is that when people come forward to look for beds in nursing homes, they are more or less told which nursing homes are available. I see somebody shaking their head. I am speaking on the basis of my experience on the ground in Galway.

Mr. Tony O'Brien

Sure.

Deputy Catherine Connolly

A person in Galway city might be told there is a bed 20 or 30 miles out the road in a location that is not served by public transport. He or she might be told to choose that bed or another one. Is Mr. O'Brien saying that is not happening?

Mr. Tony O'Brien

I ask Mr. Pat Marron, who administers the nursing home support scheme, to answer that question.

Deputy Catherine Connolly

Great.

Mr. Pat Marron

One of the principal features of the scheme is that it is based on choice.

Deputy Catherine Connolly

Great.

Mr. Pat Marron

People can choose where they wish to go, as long as there is a place in the nursing home they choose and the home in question can provide appropriate care, as deemed in the care needs assessment.

Deputy Catherine Connolly

An analogy can be made with the housing assistance payment. An applicant can go anywhere he or she likes. Is that correct?

Mr. Pat Marron

Correct.

Deputy Catherine Connolly

An applicant can go anywhere he or she likes as long as he or she finds a house. Is that not the same analogy?

Mr. Pat Marron

Yes, once the-----

Deputy Catherine Connolly

I understand. I will refer to Galway again. Sometimes it is easier to use a place. A person living in Galway who tries to get into a nursing home in that city, where there is public transport to enable him or her to visit loved ones, might be unable to get in because the nursing home is full. In such circumstances, he or she will have to go to Loughrea or Kilcolgan. Is that right?

Mr. Pat Marron

Yes, that is right.

Deputy Catherine Connolly

He or she will have no choice.

Mr. Pat Marron

The choice is based on-----

Deputy Catherine Connolly

What is available.

Mr. Pat Marron

-----where beds are available.

Deputy Catherine Connolly

Lovely. Okay.

Mr. Pat Marron

It is also a question of whether the nursing home can provide appropriate care.

Deputy Catherine Connolly

I thank Mr. Marron for that clarification. I do not accept that it is a choice. People cannot get public nursing home beds. They are not aware that they are entitled to choose. More publicity is needed. I would say very few people realise that there is now no difference between public and private in terms of the assessment. Mr. Marron is right when he says that one is theoretically entitled to pick any nursing home after one has been the subject of a care assessment and a financial assessment, but that is not what happens in practice. Are there any restrictions on the number of beds in Galway or anywhere else? Is it the case that applications can be made in respect of certain nursing homes only? Can applications be made in respect of all nursing homes as long as they are registered with HIQA?

Mr. Tony O'Brien

There are two criteria in the private sector.

Deputy Catherine Connolly

Yes.

Mr. Tony O'Brien

First, they must be registered-----

Deputy Catherine Connolly

With HIQA.

Mr. Tony O'Brien

-----under the terms of HIQA. Second, they must have a pricing agreement in place-----

Deputy Catherine Connolly

I see.

Mr. Tony O'Brien

-----with the NTPF.

Deputy Catherine Connolly

How many nursing homes in Galway have pricing agreements in place?

Mr. Tony O'Brien

That would be a question for the NTPF rather than for the HSE.

Deputy Catherine Connolly

No, it is a question I am asking here today.

Mr. Tony O'Brien

Yes, but we are not responsible for pricing agreements.

Deputy Catherine Connolly

That is okay, but I am entitled to ask a question. I have been told that there is choice, but now it transpires that this choice is restricted to nursing homes that have pricing agreements with the NTPF.

Mr. Tony O'Brien

Yes, that is provided for in legislation.

Deputy Catherine Connolly

I am not arguing with Mr. O'Brien or finding fault with him. I am trying to clarify the issues. The choice is very limited. The HSE is not in a position to tell me today how many nursing homes in Galway city and county have pricing agreements with the NTPF.

Mr. Tony O'Brien

As I said in response to an earlier question, I am quite happy to ask the NTPF, on behalf of the Deputy, for this information.

Deputy Catherine Connolly

Great.

Mr. Tony O'Brien

I am happy to ask the NTPF to provide that information to the committee.

Deputy Catherine Connolly

Lovely. I would also like to ask about the 7.5% contribution. After a person's care needs have been assessed, a financial assessment is carried out. A certain amount of cash in his or her bank account is disregarded. I think it is €30,000.

Mr. Tony O'Brien

It is €36,000.

Deputy Catherine Connolly

Such a person has to hand over 80% of his or her pension or other social welfare payment. His or her means are then assessed. This includes the family home. I will use myself as an example. If my family home is assessed, a 7.5% charge is imposed every year for three years. Is that correct?

Mr. Pat Healy

It is 7.5% every year for three years.

Deputy Catherine Connolly

What is the total charge that will go on the house?

Mr. Pat Healy

The way it is done is that the total income is taken into account. If one has a pension and a house, 80% of one's pension will be taken-----

Deputy Catherine Connolly

Yes.

Mr. Pat Healy

-----and 7.5% of the-----

Deputy Catherine Connolly

Up to a maximum of three years.

Mr. Pat Healy

That is it.

Deputy Catherine Connolly

Up to a maximum of 22%. Is that it?

Mr. Pat Healy

That is it.

Deputy Catherine Connolly

Is that 22% of the value of the house?

Mr. Pat Healy

Exactly.

Deputy Catherine Connolly

Can Mr. Healy explain that to me? If a person who owns a house in Galway city is going into a nursing home tomorrow, how is the 22% taken? Does the 7.5% that is taken each year change as prices increase or is the 7.5% contribution fixed?

Mr. Pat Healy

It is 7.5% of the value of the house.

Deputy Catherine Connolly

Of the value.

Chairman

At the valuation date, which is when the person entered into-----

Mr. Pat Healy

At the valuation date.

Deputy Catherine Connolly

There is just one valuation.

Mr. Pat Healy

The valuation is done at the time that the person makes the agreement.

Deputy Catherine Connolly

Lovely.

Mr. Pat Healy

A sum equivalent to 7.5% of the value of the house at that time is taken each year for a maximum of three years.

Deputy Catherine Connolly

Then there will be a charge on a person's house. Is there discretion to decide whether the house should be sold?

Mr. Pat Healy

Yes. A person can take out a loan; it is called "ancillary State support".

Deputy Catherine Connolly

That is a charge on a person's house which Revenue will collect at some stage.

Mr. Pat Healy

Yes and we pay for it in the meantime.

Deputy Catherine Connolly

How many houses have been sold to pay off the outstanding loan?

Mr. Pat Healy

We administer the charge and Revenue collects the money. It will have that information.

Deputy Catherine Connolly

Mr. Healy is great to answer blunt questions in such a straight manner. The way public services are going is frightening, especially in the way everything is compartmentalised. The expressions used, including "money following the patient", amount to open privatisation. If there are two people in a house, for example, my husband and I and we need care, is the maximum figure 22%?

Mr. Pat Healy

Yes, but provision is made in the ancillary State support system for the person receiving care to defer payment for a period. Even if the person passes on, if the spouse continues to live in the house, it can be left for longer.

Deputy Catherine Connolly

If my daughter or son is in the house, a three-year residency period applies.

Mr. Pat Healy

That is right.

Deputy Catherine Connolly

Can Revenue not state it needs the money in such cases?

Mr. Pat Healy

No; it is part of the scheme.

Deputy Catherine Connolly

If two people in a house need nursing home care, does the percentage go up?

Mr. Pat Healy

It is the same - 7.5%.

Deputy Catherine Connolly

For each person.

Mr. Pat Healy

Yes. This is where the disregard of €36,072 comes in.

Deputy Catherine Connolly

I am asking if the figure of 7.5% per year will apply to me and my husband if we both need nursing home care.

Mr. Pat Marron

As there is joint assessment, the figure of 7.5% is divided by two over a three-year period. For the husband, it would be 7.5% of the value of the house divided by two.

Deputy Catherine Connolly

By 2031 some 1 million people are expected to be over 65 years, the vast majority of whom will be healthy and not need nursing home care. Over 60% of the current budget for the provision of services for older people goes towards providing long-term residential care. Only 4% of the population are in long-term nursing home care. Most of the money is being put into private nursing homes, with less than half going into home care packages to help people to stay in their own homes. Are my figures wrong?

Mr. Pat Healy

We gave the figure to the Deputy. It is €373 million.

Deputy Catherine Connolly

What is the relevant percentage?

Mr. Pat Healy

It is one third.

Deputy Catherine Connolly

Is there a policy decision in this area and is the HSE working to change it, in recognition of the fact that most people want to stay at home?

Mr. Tony O'Brien

We want to retain the current level of public nursing home stock. We regard it as essential because some people would not receive the long-term care they need were it not for the availability of publicly provided nursing home stock. Given the demographic profile, there will be a significant increase in the demand for care services for older people. We have made submissions to the Committee on the Future Funding of Healthcare which focus on the need to provide the same assurance that the nursing homes support scheme currently provides for those for whom long-term nursing home care is the right solution in relation to home supports.

Deputy Catherine Connolly

Will Mr. O'Brien please reply in English? What is the HSE planning to do to help people to stay in their own homes? Mr. O'Brien says it wants to keep public nursing homes, but it is like CIE in that he is saying the HSE has to keep them because others are not interested in the high-dependency section.

Mr. Tony O'Brien

The HSE does not determine policy but is a policy taker. We do, however, have opportunities to advise. In this case we advise that there needs to be a very significant additional provision to meet the needs of older persons. There also needs to be a switch in provision towards those things that give certainty that people will be supported in their own homes.

Deputy David Cullinane

Mr. O'Brien described nursing home provision as a free market environment. Will he elaborate on what he meant by that?

Mr. Tony O'Brien

That is literally what I meant. Those with capital available to invest in the development of nursing homes in places where there is clearly a demand for them, provided they satisfy the requirements of the regulator, are entitled to buy land, seek planning permission, build a nursing home, staff it, gain regulation and negotiate a pricing agreement with the NTPF. From that point on, persons in the nursing homes support scheme will be entitled to services.

Deputy David Cullinane

Is it fair to say the less public provision there is the greater the need for the private sector to step in?

Mr. Tony O'Brien

An overall quantum is required.

Deputy David Cullinane

Is it fair to say the less public provision there is the greater the need for the private sector to step in?

Mr. Tony O'Brien

Yes. That is a fair and logical comment.

Deputy David Cullinane

Mr. O'Brien has also said there was a decline in the number of public beds available.

Mr. Tony O'Brien

Yes.

Deputy David Cullinane

Will he give us the figures? When did the decline start and what was the number of available beds then compared to now?

Mr. Pat Healy

In the past five years we have lost 450 beds.

Deputy David Cullinane

Were beds lost before that?

Mr. Pat Healy

Not to the same degree. Having to comply with HIQA standards and health and safety requirements meant the upper floors of old county home buildings could not be used.

Deputy David Cullinane

Did the Prospectus report not project nursing home need in the public sector over a long time period?

Mr. Pat Healy

The report which was issued in 2006 or 2007 identified the total requirement. The population figures were increasing and it was clear that, by 2015 or 2016, the numbers of beds would need to be increased.

Deputy David Cullinane

The report recommended an increase, but there was actually a decrease.

Mr. Pat Healy

As a result of the report, there was approval for additional capital funding for extra public beds, but because of the downturn in the economy the capital programme was reduced after 2009.

Deputy David Cullinane

Is that a long way of answering my question? The report looked at the level of need in the public system and called for greater bed capacity. Mr. Healy is telling me that, in the period since the report was issued, there has actually been a decrease in the number of beds available. We all know that there was a crash. I just want to make sure I am being factually correct.

Mr. Pat Healy

To be factually correct, the report identified the total need, not just public beds. As a result, capital investment was identified for a range of public beds. As the director general said, the scheme also provides for people to supply private beds. The report identified the total need across the country, including the need for additional public beds in certain locations.

What we have included in the report today is the capital investment of €500 million that is identified to maintain the current stock.

Deputy David Cullinane

Earlier, Mr. O'Brien said that when comparing public service provision with the private sector in terms of nursing home settings and infrastructure, the quality of the buildings was not as good in the public sector.

Mr. Tony O'Brien

That is correct. That is the very reason for the investment programme. It is to bring that stock up to date. There are many present day nursing homes which are operating in facilities which are little changed, in truth, from when they were workhouses.

Deputy David Cullinane

I will come to that. That is my point. What we had over a sustained period was, possibly, a lack of investment to build new buildings or improve the existing ones to make them fit for purpose. HIQA then comes onto the scene. Examples were given where HIQA, doing its job to which no one can object, recommended closing a number of nursing units and wards within certain care facilities. On the back of the quality of the buildings, is it fair to say that because of a lack of investment, HIQA recommended that either nursing homes close completely or that units be closed?

Mr. Tony O'Brien

It is a little more subtle than that. The public sector was given a longer time to come into compliance. That has been extended further again on the basis that-----

Deputy David Cullinane

It may well have been. To give an example, I refer to St. Brigid's ward in St. Patrick's Hospital in Waterford. That was closed at the behest of HIQA, was it not?

Mr. Pat Healy

It was closed for health and safety reasons, principally.

Deputy David Cullinane

Who made the recommendation?

Mr. Pat Healy

The fire safety people were the key people who decided.

Deputy David Cullinane

Is Mr. Healy saying that HIQA had no role in that? My understanding is that HIQA made the recommendation.

Mr. Pat Healy

Of course, HIQA had to take-----

Deputy David Cullinane

Look at what I am asking. HIQA made a recommendation that the unit be closed.

Mr. Tony O'Brien

It is fair to say that with or without HIQA, it was not compliant with fire safety. Obviously, in order to provide an all-encompassing regulatory framework, HIQA takes account of fire safety.

Deputy David Cullinane

I understand that but my point is that the body with responsibility for examining whether or not units are fit for purpose is HIQA. It must go in, examine and do all its work and then make a proposal. Notwithstanding what any other agency does, HIQA makes a proposal. My point is that because of the poor quality of stock and buildings, HIQA has recommended, and it has been a consequence of its recommendations, that nursing home units close.

Mr. Tony O'Brien

They have been both closed and reduced in size. The overall number of beds has reduced for a variety of reasons in different places. Sections of nursing homes have no longer been approved and reductions have also happened to achieve ongoing registration in respect of the number of beds where rooms were remodelled into single, en suite rooms.

Deputy David Cullinane

They have been closed with a resultant lack of capacity. Notwithstanding its size, Waterford has one hospital, St. Patrick's, trying to cover an entire city. Deputy Connolly stated earlier that people have no choice when they are told where to go and Mr. Marron came back, correctly, and said they did. In reality, they do not have a choice. I put that to him. It is a bit disingenuous to say that because, in reality, all public nursing home units are at full capacity. Trying to get a bed in St. Patrick's is like trying to find hens' teeth. The only option for people in that case is the private sector. If there are capacity problems in cities, people are being told the only places are ten, 20 and 30 miles from where they live with all the problems associated with that. That is the reality for families of patients because of a lack of capacity in the public system. While one can point to a technical choice, there is no choice if there are no available beds. The only option is outside people's environs.

My next question is to Mr. O'Brien and it relates to the cost of a bed in the public system versus the private system. We hear a great deal from private providers that the private system is cheaper. Can Mr. O'Brien elaborate on the level of care? He said earlier that the cost of the service was based on nursing and care. Is a different level of care provided in public facilities?

Mr. Tony O'Brien

There is an inherent cost differential on a like-for-like basis but it is also the case that many of those with the greatest levels of medical and care need are accommodated in the public sector. Mr. Healy would be able to provide Deputy Cullinane with more detail on that.

Deputy David Cullinane

Before he comes in, I note that the private providers are at pains to point out to the committee that they provide a better quality and cheaper service. The committee received an invitation to visit a private facility also. I am not saying that is correct. I am asking about the difference between the service provided by a public nursing home as opposed to a private one in terms of quality and services and whether that relates to the actual cost.

Mr. Pat Healy

The best assessment of that is HIQA inspection reports because that is independent across public and private. As I said earlier, the public service facilities fare very well in those reports as do many private facilities. We mention in section 5.3 of the report to the committee that in the review it was confirmed that a higher proportion of maximum dependent older people are catered for in public facilities. It is 60% versus perhaps 30% in the private sector. That is the figure. If one asks the acute hospital system, geriatricians who refer patients out will tell one that there is a higher level of dependency.

Deputy David Cullinane

There is a higher level of care.

Mr. Pat Healy

There is a higher level of need which means one needs more nurses than one would in the private sector. That feeds into cost.

Deputy David Cullinane

It is not a like-for-like comparison.

Mr. Pat Healy

Not always. It is fair to say that there are private facilities which deal with high-dependency people, but we are talking about the average across the system.

Deputy David Cullinane

The setting of the rate was referred to earlier by Deputy McDonald. Mr. O'Brien said that the HSE had no function in regard to cost, which was addressed by the NTPF. Mr. O'Brien is the Accounting Officer and as such he is the person who is accountable to us in terms of cost. That is one of the reasons he is here. This happens very often, as the Chairman has said, in other contexts. We bring in a chief Accounting Officer and ask about costs only to be told "That is not for me, it is for somebody else". In advance of and anticipating that in future, we should be informed that even though he is the Accounting Officer, Mr. O'Brien does not set the actual rate and that we need the NTPF in here. We do not have it today but we need to hear from it at some point. If the NTPF is setting the cost, we need to talk to it. Mr. O'Brien can correct me if I am wrong, but he said he had no function and simply signed the cheques. In terms of the fair deal scheme, he is told what the cost is and signs the cheque. Is that accurate?

Mr. Tony O'Brien

If we have approved an individual to avail of the fair deal scheme and if he or she avails of a bed under an NTPF agreement with a private nursing home, we pay that weekly fee per bed. We do not pay it on a weekly basis, but it is the equivalent of that.

Deputy David Cullinane

However, the HSE does not set that rate.

Mr. Tony O'Brien

No.

Deputy David Cullinane

I just want to be fair.

Mr. Tony O'Brien

It was the express intent of policy and legislation at the time to disaggregate those two functions. In other words, there was an express decision by the Oireachtas to ensure that it was not the HSE that set the rate. That was the primary reason the function was given to the NTPF.

Deputy David Cullinane

Why was that? Why would there be a conflict?

Mr. Tony O'Brien

I would have to go back and read the debates but I suspect it was in order to provide a sense of assurance to the private sector that it would be treated fairly by an organisation with which it was otherwise competing.

Deputy David Cullinane

I accept that. While that may well be the right thing, albeit I do not know, we have the chief Accounting Officer who is saying there is a huge cost on which the HSE signs off but which it does not set. When that situation arises, it would be better to have the NTPF here as well. We do not, which is unfortunate.

Chairman

There is a gap.

Deputy David Cullinane

There is a gap there in terms of accountability. To be fair, having regard to the time, I will leave it at that.

Chairman

I have one very quick question. When the rate is set by the NTPF for a nursing home and the subvention is agreed, can there be top-up fees? I am not talking about the little ancillary extras, but can the HSE approve someone for €1,000 per week with the family paying €200 on top of that?

Mr. Tony O'Brien

No. There are not supposed to be top-up fees.

Chairman

There will be extra ancillary bits. We understand the smaller bits. I am talking about the basic weekly or monthly fee.

Mr. Pat Healy

It is not a matter of top-ups.

Therefore the price will cover what is funded under the nursing homes support scheme which, as I said, is bed and board, laundry and so on. Apart from that, if one gets hairdos and so on, they will be charged separately.

Chairman

In other words, the private nursing home cannot charge an additional fee for the basic items covered.

Mr. Pat Healy

That is right, for what is covered in the fair deal scheme.

Deputy Bobby Aylward

They do charge extra, though, for extras like hairdressers.

Chairman

They do for hairdressing and entertainment.

Mr. Pat Healy

Exactly. They can charge separately for things that are outside the scheme. We do not do so in the public side.

Chairman

You do not charge for looking after people.

Mr. Tony O'Brien

If they charge, or seek to charge, a top-up for the core provision of the nursing homes support scheme, NHSS, they would be in breach of their pricing agreement with the NTPF.

Chairman

Who checks that?

Mr. Tony O'Brien

The NTPF has a function in that regard.

Chairman

We will have to write to the NTPF to give us some information. It would have been helpful had we invited them in today.

Deputy Bobby Aylward

Can we bring them in some other day?

Chairman

We will write to them first. We have a big list of people to see. We will take the written response and then decide what to do, so we will follow this up.

Deputy Catherine Murphy

Obviously standards have changed and a lot of that is welcome as regards people sharing and so on. We can see the 80:20 ratio between private and public and Mr. Healy has told us that there is a loss of beds. He has also identified capital needs for the 20% to bring them up to standard. Has the HSE actually opened any new beds or are there proposals to open any new beds under the public system?

Mr. Pat Healy

As we are doing the redevelopment, details of which we have given to the committee, there are some new beds in that. If we were redeveloping a 100-bed unit we might open 110 beds, but there are not significant plans for 100-bed units or the like. The last public facility we opened was in Mount Carmel here in Dublin, which is not in the fair deal scheme. It is a short-stay, transitional care facility. However, with the capital programme we have to 2021, we are focused on bringing our own facilities up to standard in order that we will be compliant with HIQA's standards by then.

Deputy Catherine Murphy

There are some good examples in both the public and private sectors. However, the private sector may determine the location of nursing homes. In my own area, for example, there are quite a lot of nursing home facilities and people from Dublin will be located in County Kildare because of that. Some of that has to do with the availability of land. Some of the facilities tend to be on the periphery of towns and are isolated. Without predetermining or setting a set of standards for the quality of life of somebody interacting with the community, does that come into play at all in terms of the policy approach to this? Or is it very much the offering from the private sector?

Mr. Pat Healy

The idea of choice was that, over time, the system would be responsive to where people wanted to be accommodated. It does of course take account of the availability of planning land. The other significant thing is that outside the greater Dublin area there is a long tradition of community hospitals and public facilities that provide long-stay care but they will be mental health facilities, primary care centres and so on. They are geographically spread around the country. The greater Dublin area did not have a history of such community hospitals.

Deputy Catherine Murphy

The HSE will scope out a value-for-money audit of the fair deal scheme. What will be included in that audit? Is it only a value-for-money audit or is there a quality-of-life element? There is a demand in that regard. For example, nursing home care has been identified as inappropriate for approximately 2,500 people, but there is no alternative. Is the HSE looking at a statutory element for home care, as opposed to nursing home care in that context or is it just about value for money for what is there at the moment?

Mr. Greg Dempsey

I will answer that question in two parts. We have not determined the final scope of the value-for-money audit but at the moment it is simply limited to asking why public hospitals cost more than private ones. That is the particular exercise.

In respect of some of the other policy initiatives, there is some work going on in the Department to examine the long-term demand and challenges arising from the change in population, as well as considering a policy response in respect of, for example, providing more home care in order that people can stay at home longer.

Ms Angela Noonan

The Department has recently commissioned a report on home care, looking at four other countries. The Minister intends to launch a public consultation process by May concerning a home care scheme.

Deputy Catherine Murphy

I thank the officials for those replies. I wish to go back over some of the questions that were asked earlier about the fair deal scheme. When the scheme was initiated, property values were very different. Later on, the economic crash changed the potential income so the scheme varied a bit. If I remember rightly, a more forensic approach was then taken to people qualifying. In his opening remarks Mr. O'Brien noted it was on a named resident basis whereby people are individually evaluated as to whether they qualify for the scheme. Therefore, they probably are in greater medical need than they would have been when the scheme was originally considered.

As regards the length of time involved, dementia cases are probably at a more advanced stage than would have been the case when the scheme was initially devised. When people go into the scheme, my understanding is that the 7.5% rate is for up to three years. Are a significant number of people at a more advanced stage medically? Does Mr. Healy know how many people would be in the scheme for six months, a year, or less than three years? How is that handled?

Mr. Pat Healy

We set it out in table 5 at paragraph 3.6. The average at this stage is three years and it is going down. Under the older subvention scheme there were contracted beds, as they were called. One can clearly see that we still have people in the system who are contracted. Some of them have highly complex needs but they are living a lot longer.

The new scheme, which came in in 2009, includes a care needs assessment and a financial assessment. When one does the care needs assessment, one also has a local placement forum which would generally have a geriatrician and a multidisciplinary team. That is a good protector or oversight to ensure that only those who require it will go into long-stay care. The figures bear out the fact that the number of years for which people are staying in long-stay care is reducing. That means that they are older and closer to end-of-life care as they go into nursing homes.

Deputy Catherine Murphy

If somebody qualifies for the fair deal scheme and goes in for six months or a year, how is that calculated?

Mr. Pat Healy

It is just 7.5% if the person is there for one year and that will be it.

Deputy Catherine Murphy

There is no advantage to the HSE?

Mr. Pat Healy

No. They are not double or treble functions.

Deputy Catherine Murphy

I just wanted to be sure about that. As regards people who are funded, St. Raphael's is in my constituency and people are in residential places there, but it is a different thing entirely. I wish to ask about the adequacy of funds in this regard. I have come across situations where people have been asked to provide money for a new mattress. How does Mr. Healy measure the adequacy of the money provided for those kind of scenarios?

Mr. Pat Healy

That does not happen at all in the nursing homes support scheme. There is no question of that. As I said earlier, the fund on the public side is for the cost of care.

On the private side, the price is for a very specific set of services to be provided, including bed, board, a certain number of aids and appliances and laundry. That is the cost and that is what is to be delivered. There is no question of paying more for those services. Obviously, as we said earlier, there are additional elements if people, for example, get their hair done. They might have to pay for that but there is no specific extra cost or charge for the core services.

Deputy Catherine Murphy

As I understand it, 18 of the 32 administrative recommendations on financial assessments have been finalised. Have they been implemented at this stage?

Mr. Pat Healy

They are being implemented. Many of them were technical guidelines and issues of that nature and they are being implemented. One of the bigger recommendations is to streamline the scheme and its operation. There are two purposes behind that. The first is that we are moving to regional locations now but we will centralise the expertise. The important issue, as set out in the report, is to make this simpler. We have easy-read versions but clearly people still find the scheme complicated. We are doing more work on this and in a number of weeks we will have a new, up-to-date easy-read version and simpler, easier to understand guidelines. In the new documentation we are also going to provide examples relating to some of the issues we have discussed today, like the 7% issue. We will provide examples of how the financial element is calculated, how care needs are determined and so forth so that people will understand it better.

Deputy Catherine Murphy

The recommendations that have not been-----

Mr. Pat Healy

They are all in the process of being implemented. The 18 that were finalised have been fully implemented. Some of the ones I have just referred to, like the one on regional offices, are not fully implemented yet but are under way.

Deputy Catherine Murphy

Does Mr. Healy have a timeline for the completion of that work?

Mr. Pat Healy

We are aiming to do most of that work this year.

Deputy Catherine Murphy

Obviously, there is a choice within a choice here in terms of the availability of beds. However, real choice is about having a policy position relating to older people and people with high dependency. It is all very well giving people a choice but not if they do not want that choice. At what point do those two things converge, in terms of policy? In terms of the public consultation process to which Mr. Healy referred, has consideration been given to the financial implications involved in providing the deal? Is the HSE looking at the issue of the care that should be provided separate to the financial aspects?

Ms Angela Noonan

I do not think it is possible to look at those two issues in isolation. The report that has examined the four countries, on which the consultation process will be based, looked at the financing of home care in those countries. It was not just an examination of the level of care or the regulation of that care but also of the financing of that care.

Deputy Catherine Murphy

Does the HSE look at geographic locations? The ideal is for someone to be able to get out, to potter around, get to the shops and so forth rather than being isolated. Are such issues taken into consideration? Does the HSE look at integration within communities and enabling people to live, as opposed to just existing?

Ms Angela Noonan

That might come back from the consultation process but currently, it would not be something that the home care provisions would take into account. There are other policy initiatives that are relevant, like the positive ageing strategy, and which do consider issues like integration, social isolation and so forth but they would not be considered within the home care package as we know it.

Chairman

I am sorry to interrupt but a vote has been called in the Dáil. We must suspend the meeting because there are no pairing arrangements in place. I am not sure how long the voting will take-----

Deputy Catherine Connolly

Could we tie in some lunch, for ourselves and the witnesses?

Chairman

Yes. We will suspend for one hour, from 2.15 p.m. until 3.15 p.m. That will give Deputies time to vote and allow the witnesses to get a cup of tea or some lunch.

Sitting suspended at 2.15 p.m. and resumed at 3.23 p.m.

Chairman

We are back in public session and are resuming our discussion with the HSE. The next speaker is Deputy Aylward.

Deputy Bobby Aylward

I thank the Chairman. It is an odd day. We are in and out like yo-yos but that is the way it is. We had a good start this morning, I suppose.

I want to go back to the private property accounts. Could Mr. Mulvany tell me briefly why these accounts came into existence? Is this the patients' money? Is it the case that they had private savings all along or was money accumulated through social welfare payments? Would most patients have family situations where they would have accounts with their own banks? How did the HSE have control of these private accounts? How come it has to repay money? If something in the system was wrong for so long, why was the correct system not in place always?

Mr. Stephen Mulvany

In a way, the HSE is providing a service of last resort here. There are some patients who have capacity and neither need nor want us to mind their private property - their own funds. That is entirely okay with the HSE; it is not a service that we seek to provide. It is, however, one that we have to provide for some patients and families. It is quite an extensive service. We seek to safeguard patients' moneys when they are in our care, particularly those who would not have capacity. We provide a service which effectively allows them to have their bills paid, have their social welfare money collected, where applicable, and which discharges the contribution that the State requires them to give to the provider, as well as providing their own "for patient comfort" moneys or moneys for their own use. Our guidelines are very explicit. We make it very clear that this is the patient's money. If patients want to manage their money themselves and have capacity, that is entirely at their discretion. Our assumption is that people do have capacity unless there is a reason to doubt it. That is the why. We only do it where it is necessary or asked for. It is not something we insist on.

In terms of why we have to pay interest now, in the health board days, the advice the health boards had was that, when they were doing this patients' private property service as a service of last resort, their legal relationship to the patient was such that the patient would give the health board some money, and the health board minded the money and gave it back to the patient. The advice was that the health boards did not have to give interest. The interest was retained by the health boards to partly offset the costs of providing what is quite an extensive service. At the time, it was offered in over 170 centres.

In around 2004 or 2005, these issues were becoming very topical. The HSE was on the way in. As part of the overall preparation for that change, we got further legal advice which said actually, on balance, the relationship is more likely to be that of a trustee. Trustees are obliged, not just to give back the €100 that was given to them for safekeeping, but also to give interest if it is earned. We set about putting that in place. We established a central patients' private property unit for data gathering and a repayment scheme. We have a backlog, in this first instance, of approximately four years' worth of interest, from 2005 to 2008. We now need to repay this money to patients or, in most cases, to their entitled next of kin. That is a big logistical exercise and, unfortunately, in many cases we will struggle to find an entitled next of kin. There is a large piece of work under way to achieve the first two parts of that, namely, the data gathering and calculating the interest. That is to be undertaken this year, I believe. It will take at least to the end of next year or possibly longer to figure out whom can we pay the money back to.

Deputy Bobby Aylward

The €14.4 million in interest sounds like an awful lot of money. The pre-2005 interest was €2.368 million. We are talking about 12 years ago. How is it taking this length of time to sort all this out?

Mr. Stephen Mulvany

Agreed. As I said, our intent is to get this paid. The HSE does not want to hold this money. Our preference would have been to have got to it earlier. In terms of the amount, in December 2004, the long-stay charges or contribution of the time were suspended, in what eventually became the repayment scheme issue. Over the 29 years from 1976 until then, the average interest across all these accounts - remember there are about 18,000 to 20,000 accounts - was less than €1 million per year. As soon as the charge was suspended in December 2004, patients no longer were making contributions to the cost of their care and the value of money in their accounts went up significantly. Part of our response was to try to reduce any risk, by bringing money from the local centres into a central point where we could better manage it and give better support to the 170 local centres. To do something well across 170 centres with all the complexities, particularly when we are talking about deceased patients and probate - it is much better to do the complex stuff centrally. We established a system in that central unit that gives interest to the accounts automatically when it is earned. It is a very robust system and is separate from the HSE's accounts. This is a legacy issue which has taken us longer than we would like to sort out, that is, to give the four years' worth of interest, which is in the region of €12.5 million, to those patients.

Prior to 2005, health boards were mainly not returning interest. They had a different legal relationship. In the few years up to that date, a number of health boards in the west had retained interest. That is the €2 million figure. Based on what we learned from completing the 2005-08 interest payment, we will have to make a decision, one that will undoubtedly involve engagement with the Department, on whether to pay the interest dating from the earlier period. If the decision is "No", the money will not be retained by the HSE.

Deputy Bobby Aylward

I imagine that many of the patients have died in the past 12 years, but the money is still there. Who will get it? Will it be the family? Many legalities must be involved. If a will has been made, that is fine, but if a person dies intestate, the family have a claim. I understand they get the money. Must the HSE divide it up or to whom does it give the money? What about a ward of court who has no family? Where does the money go to if his or her family have died and he or she is last in line? What are the legalities involved?

Mr. Stephen Mulvany

This is complex. We have used the expression "to the entitled next of kin", but the more correct legal term is "to the legal personal representatives". That is the person we must seek. In the case of a ward of court who is alive, the money will be put into his or her patients' private property account. The wards of court office has the usual supervisory role. Often, a committee of the ward involves family members. I will have to check the details, but if the ward of court is deceased, we will either repay the money to the wards of court office or, through it, the Chief State Solicitor's office. In no case does the HSE keep the money indefinitely.

Deputy Bobby Aylward

The money goes back to the State.

Mr. Stephen Mulvany

Generally, the legislation on people who die intestate and where a valid legal personal representative or next of kin cannot be identified indicates that the money should be paid to the Chief State Solicitor's office, which means that it goes back to the State.

Deputy Bobby Aylward

Given what has happened, there seems to be weak control in the system. Was there any misappropriation of funds? There are many areas in Ireland. Has the HSE proved that there were no misappropriations? Has the Garda ever had to be called in to investigate a case?

Mr. Stephen Mulvany

The interest issue is separate from that of control breaches. In terms of the 2015 accounts which are before us, control breaches were identified. A programme is in place to address them.

Deputy Bobby Aylward

Were there repercussions for the identified breaches?

Mr. Stephen Mulvany

One should consider the nature of some of the control breaches. I am unaware of any finding in the audits in recent years to the effect that any patient's money was misappropriated or that there was fraud. The issue is not fully complying with controls. I cited the example of bank reconciliations. That is a key control. In 14 of the 150 or so centres, it is not that bank reconciliations were not made but that the centres were not able to complete them because they entailed historical reconciliations of differences. If we exclude the historical issues, the difference at the end of the bank reconciliations in four of the 150 or so areas was less than €100.

Deputy Mary Lou McDonald asked me for the figure for differences in bank reconciliations. I stated that it was in the region of €100,000, but I can provide the actual figure. In the 2015 accounts it is €58,941.

The work we are undertaking on these two issues is approximately 70% finished. We are examining each reconciliation and assisting the local centres with external support so as to ensure we close out the difference in reconciliations. Where we cannot close them out, it is not because people have not tried or anything untoward is happening, rather they simply have not been able to do it. The HSE will make good the difference. We will not leave a difference that has an impact on the patients' private property accounts because we treat that money as separate and belonging to the patients.

Deputy Mary Lou McDonald also asked about the likely 2016 balance. At the end of 2015 it was €129 million in these accounts. The early draft 2016 closing figure is approximately €116 million; therefore, it is decreasing. Does that answer Deputy Aylward's question?

Deputy Bobby Aylward

In hindsight, should there have been more scrutiny? Is there a need to have more regular internal audits?

Mr. Stephen Mulvany

Since the 2004-06 period, the HSE's patient private property working group and the guidance it has issued have substantially improved controls in this regard. There are many vulnerable elements and staff who are trying to deal with complex issues, patients and families. Fundamentally, this is a service for patients and their families. A system has been in place for years. An external firm is contracted every year separate from the HSE to audit all 150 or so centres. It physically attends a large sample and produces a financial statement. It gives us a list of control breaches. It also prepares the overall patients' private property account which is audited by the Comptroller and Auditor General. Having gone through approximately 70% of the work on the control breaches, my sense is that there are strong controls in place. No system of control is perfect and cannot be improved, but this one is strong, given how dispersed it is. More than 90% of the money in question is not in local centres where it is more difficult to exercise control, rather it is in the central unit, the audits of which have never raised a significant issue. The system is relatively well managed, but we do not want to be complacent.

Deputy Bobby Aylward

I will move on to the fair deal scheme. What is the normal time involved? One or two years ago there was a lack of available financing, but the scheme seems to have improved since. I know this because I have been making representations on behalf of constituents. What is the timescale from the start to when a patient joins?

Mr. Pat Healy

No longer than four weeks. Sometimes the timescale is three weeks.

Deputy Bobby Aylward

That is good to hear.

Mr. Pat Healy

Since additional funding was provided two years ago, the system has stabilised.

Deputy Bobby Aylward

Is there enough money available to cover everyone who applies?

Mr. Pat Healy

Absolutely.

Deputy Bobby Aylward

It is covered in total.

Mr. Pat Healy

Yes.

Deputy Bobby Aylward

The subvention to private and public services has been covered and I do not want to go back over old topics, but it is difficult to square the situation. In most private homes the subvention is €800 to €1,000 per month. In public homes the figure is €1,400. That is a lot of money and sounds extraordinary. During the by-election a few years ago I visited many private nursing homes. That the residents were receiving less than patients in public homes was one of their complaints. It is a discrepancy in the system. I cannot understand why there is a difference of €300 or €400 per month. It is a lot of money. Why is there such a discrepancy?

Mr. Tony O'Brien

Beyond basic pay, there are significant cost drivers of differences in terms and conditions between the public and private sectors. That must be acknowledged.

Deputy Bobby Aylward

Why is there such a difference?

Mr. Tony O'Brien

Public policy, as determined by the relevant Ministers, sets out the terms and conditions of employment for public employees, whereas private operators determine their own terms and conditions.

Deputy Bobby Aylward

Is Mr. O'Brien referring to cheaper labour - cheaper nurses and doctors?

Mr. Tony O'Brien

The basic hourly rates are typically the same. Whereas public employees - those in HSE-run facilities - typically receive full pay maternity leave, sick leave and so on, it would be more normal for individuals employed in the private sector to be reliant on the allowances available from the Department of Social Protection. The cost of their employment is lower in these facilities. That is one part of the equation. The other part that adds to the difference is the relative complexity of the needs of patients in public nursing homes, where there tends to be a more dependent blend of high to low acuity. That is not to say some private nursing homes do not also provide for high needs, but typically there is more of that blend in a public nursing home. That influences the blend of staffing provided. Typically, there is a richer blend of nursing staff and so on in high-dependency public nursing homes which drives cost. Mr. Healy might like to add something.

Mr. Pat Healy

It is not just the HSE saying that. I mentioned this morning that the acute hospital sector, which is discharging high dependency patients, relies very heavily on the public system. More important, the review published in May 2015 acknowledged that in the public system, higher dependency was around 60% compared with 30% in the private system. It is not just the HSE saying that; there is good evidence to support it. With the capital programme only just under way, the older stock such as the large old county homes can have infrastructural issues that require more staff because of the way the building is developed, whereas modern private facilities are more modern and more easily managed. As we complete the work that is under way in the capital programme, that will improve.

Deputy Bobby Aylward

I am from an agricultural background. Mr. Healy gave the figures on the domestic house - the 7% and 7.5% over three years. I have concerns about farmers who may be asset rich but cash poor. Such farmers probably have inherited assets and want to pass them on. There were changes in the budget. Can Mr. Healy give a brief outline on the agriculture end of it, from a farming point of view?

Mr. Pat Healy

That has been acknowledged. For farmers, the private residence is dealt with the same as everyone else but the farm is dealt with as income. That has proven to be a challenge in some agricultural situations. It is being taken account of and the Minister of State, Deputy McEntee, has spoken about that. It was mentioned in the budget. Work is being done on that to look at how it might be addressed. It is a policy issue that will be addressed in due course.

Deputy Bobby Aylward

What way is it assessed now? What happens in the case of two brothers who are not married? They may or may not have wills. If the owner of the land is incapacitated and is sick and brought to hospital, they are left frightened out of their lives that they will lose everything. I had one on to me yesterday.

Mr. Pat Healy

It is the case that the farm is treated as income at present. The income generated out of the farm------

Deputy Bobby Aylward

Is it based on accounts or on the amount of land?

Mr. Pat Healy

It is based on the income it generates. It is based on accounts.

Deputy Bobby Aylward

It is based on accounts.

Mr. Pat Healy

Yes. The income it generates is treated as income to be considered for the scheme. The house is taken as the private residence so the 7.5% rate applies to it. Whatever income the rest of the enterprise generates is taken into account as income.

Deputy Bobby Aylward

I am glad to hear it is all based on income. I did not realise that. It is all based on income so the land has no bearing on it.

Ms Angela Noonan

The farm asset is taken into account at 7.5%.

Deputy Bobby Aylward

So if the land is worth €500,000, is it taken at 7% over three years?

Ms Angela Noonan

It is 7.5% per annum.

Deputy Bobby Aylward

That means that most farmers could have to sell land just to pay for it.

Ms Angela Noonan

They might have to sell a portion of the land.

Chairman

Is there a three-year cap for the farmer?

Ms Angela Noonan

There is a three-year cap on the principal private residence.

Chairman

Listen to this, Deputy Aylward.

Ms Angela Noonan

The idea, when the fair deal scheme was introduced, was that nobody would have to sell their home to pay for their nursing home care so the three-year cap only applies to the principal private residence, that is, the family home. It does not apply to the farm unless there are specific circumstances, one of which is a sudden illness in the family. In that case, the three-year cap will apply to the farm.

Chairman

Is Ms Noonan saying that if somebody from a farming background survives ten years in a nursing home, under the fair deal scheme, 70% of their farm is gone on debt? I understand that. People talked about the three-year cap but it is only very specific. That is the point Deputy Aylward is getting very concerned about. Is there double counting in the farming community if their income is being taken into account and on top of that, the HSE is taking 7.5% of the value of their land for every year?

Ms Angela Noonan

The income is being taken into account if the person is making an income from it. If, for example, their son is running the farm, it is the son's income. The income would not be considered if the son is earning it. However, if the asset was still in the father's name, the 7.5% per annum would be charged to it. It is currently being looked at in the Department. It was a recommendation contained in the review of fair deal in 2015 and there is also a commitment in the programme for Government to remove any discrimination against farmers so it is being looked at at the moment.

Chairman

We want to clarify this situation. Is Ms Noonan saying that in a farm situation in which there is an elderly farmer whose son is working the farm, earning the income and supporting his generation, who will inherit the farm, if the father has not signed it over at this point-----

Deputy Bobby Aylward

It is over three years, I think; there is a length of time mentioned.

Chairman

They look at recent transfers. When the father passes away in the nursing home after ten years, his farm is gone and has been taken out from under the son who has been farming it.

Ms Angela Noonan

As it currently stands, it is the case if somebody survived in a nursing home for ten years and the farm asset was one of the assets and was in the name of the person in the nursing home.

Deputy Bobby Aylward

Why is it not capped at three years like a domestic house with a three-year cap at a maximum of 7%? Why is the land not capped at three years?

Ms Angela Noonan

Prior to the introduction of fair deal in 2009, people had to sell their family homes to pay for their nursing home care. One of the key provisions in introducing fair deal was to stop the family home having to be sold to pay for nursing home care. That is why there was a three-year cap introduced for the family home.

Deputy Bobby Aylward

That is a reason why farmers should be treated like that. The phrase, "fair deal" contains two nice words. It is a reason why a farm should not be sold off on the son to pay for it. It should be capped at three years. There should be the same fair deal for everyone and everyone should be treated equally.

Ms Angela Noonan

The Department is looking at it. I hear what the Deputy is saying about introducing a three-year cap for the farm asset. We will take it on board when we are considering it.

Deputy Bobby Aylward

When will the review take place?

Ms Angela Noonan

It is being considered at present.

Deputy Bobby Aylward

When will the same rules apply to farms as to domestic houses?

Ms Angela Noonan

If a decision is made, for example, to introduce a three-year cap to the farm, it will require a change in the 2009 Act. Who knows how long that will take? The Government no longer controls legislation. It would have to go through the Oireachtas.

Chairman

The Department has been doing a review. Ms Noonan talked about what is ultimately handed over. The value of the house is handed over for Revenue to ultimately collect. Can Ms Noonan give us a breakdown of what is handed over to Revenue to collect in respect of family homes and separately in respect of other assets such as farm assets? How much has been handed over to Revenue to collect down the road? The Department must have a breakdown of those figures because applications and people qualifying have to specify the value of their assets and income. That is all on the application form for the fair deal scheme. The information must be in the system. What breakdown can Ms Noonan give us on how many farm families have been affected by this to date?

Ms Angela Noonan

We do not have information on the number of farms that have been affected by this to date. We have information on the number of people with farms who are being supported by the scheme at the moment. Of the 23,000 people being supported by the scheme, 648 have farm assets.

Deputy Bobby Aylward

Is the loan system the same for the farm as for the domestic house in that whoever inherits has to pay the loan off when the person dies?

Ms Angela Noonan

If the asset is registered in the State, the charge based on the asset can be deferred and the loan availed of.

Deputy Bobby Aylward

It is treated the same as a domestic house.

Ms Angela Noonan

Yes.

Deputy Bobby Aylward

I have some more questions. Perhaps my first is a question for HIQA rather than the Department. There were investigations that uncovered bad things happening in nursing homes, in Galway etc. Does the Department have any input or anything to say on those discoveries?

Mr. Tony O'Brien

Is the Deputy referring to Áras Attracta?

Deputy Bobby Aylward

Yes. It is one but there are others.

Mr. Pat Healy

Áras Attracta is for adults with disabilities; it is not part of the nursing home scheme. HIQA also regulates it. We have a comprehensive programme under way to implement the recommendations made by HIQA. We separately carried out a specific assurance review there.

Deputy Bobby Aylward

Does the HSE play a role in making sure this is not happening anywhere else?

Mr. Pat Healy

Absolutely. We have a comprehensive set of plans. There will be people moving from the centre this year into community living and HIQA has returned and continued to inspect it since we started to implement our plan. It is progressing well.

Deputy Bobby Aylward

My final points are local. Thomastown has a nursing home in Kilkenny and for years HIQA has told us it is not up to scratch because, as the witness referenced, it is an old building and there are fire hazards. There are supposed to be plans in place to build a new hospital and there is land on a greenfield site. I wonder how advanced that is as I am told HIQA has warned the HSE on numerous occasions that if it does not do something soon, it will close the Thomastown facility. We cannot lose that important service in south Kilkenny, as it is most important for older people in nursing care in the area.

Mr. Pat Healy

That is St. Columba's. The project is on the capital plan and referenced in the pack we distributed on page 29.

Deputy Bobby Aylward

What is the timescale?

Mr. Pat Healy

It will be 2021.

Deputy Bobby Aylward

That is for the building of the new hospital.

Mr. Pat Healy

Yes.

Deputy Bobby Aylward

I am told the existing building is a fire hazard. My sister works there and I have been told by nurses that if there was a serious fire in the morning, God forbid, I do not know what would happen.

Mr. Pat Healy

We have prioritised it and there is €18.9 million earmarked to develop that.

Deputy Bobby Aylward

It will be 2021.

Chairman

Members may want to ask more questions. The breakdown of people being provided for under the scheme has 80% in private institutions and 20% in HSE institutions. In the past couple of years, a couple of hundred beds have come out of the system and there is no great plan to increase numbers dramatically; there may even be a few more restrictions, depending on the refurbishments that must take place. With the increasing population, it seems as if the 80:20 split will head to 90% private and 10% public. The HSE must have done some projections on that. The executive is not increasing its capacity but the population is increasing. If the HSE is not providing the extra capacity, it will go to the private sector. Where does the delegation see the split going if it is now at 80:20?

Mr. Tony O'Brien

There are two components to the issue. The first is a slightly bigger discussion that we have touched on, which is that we need, over time, to provide for a wider and more sustainable scheme aimed at providing the supports to which many people would prefer to have access to remain living in their own homes and communities rather than in residential nursing care. This is a discussion we have had with the committee discussing the future of health care. We also spoke to that committee about the overall capital envelope for the health sector. As was referenced, a little tangentially, in 2008, before the music stopped, so to speak, we were on track for a level of capital infrastructure development that was double the rate that has occurred in the mean time due to the inability to fund it. We have put forward very strongly the notion that we must get back to that earlier trajectory, and if we did so we would certainly be looking at the blend of public-private nursing home facilities.

There are two reasons for this. The first is the figure of 21% for public facilities, which is probably as low as we would wish it to go. There is a requirement for the particular type of care that those facilities can provide that is not as well provided elsewhere. Additionally, we are the provider of last resort, called upon in circumstances where the regulator is effectively revoking the licence of private providers. In order to be able to do that, we need to retain a certain core ability from which to call upon to manage those facilities. Those combined factors, combined with demographic change, mean we are of the view that the total bed stock would need to change. Under the Department of Health, led by the Minister, Deputy Simon Harris, there is an overall capacity review being undertaken this year. It is often referred to as a hospital capacity review but it is not; it is a system capacity review that will examine bed capability in all sectors. Our view is we need more beds outside the acute sector. We may need some in the acute sector but the preponderance should be outside the acute sector.

Chairman

I get the point. The witnesses have referred to people living in their own property and payments ultimately being made to the Chief State Solicitor if nobody can be found. How much has been transferred to the Chief State Solicitor's account from the patient property fund? The witnesses have twice mentioned where this goes if we cannot track anyone, saying that as a last resort, it is handed to the Chief State Solicitor.

Mr. Stephen Mulvany

One of my colleagues has the figure. None of the interest as retained, the €14 million, has yet been paid to the Chief State Solicitor. From time to time, we pay over money in accordance with legislation. I will see before we finish if we can get those figures.

Mr. James Gorman

We do not have the figures but once local care centres can confirm a person has passed away with no known next-of-kin available, it can draw a cheque locally, which they do periodically, and pass that the Chief State Solicitor's office.

Chairman

It does not go through the HSE and it would not necessarily know about it.

Mr. James Gorman

We would not but we could seek to get figures on payments to the Chief State Solicitor's office. The kinds of accounts we have centrally held are called inactive accounts. They are dormant accounts where we cannot confirm that the person has passed away. We know those in care centres who have passed away but we would not have next-of-kin details. In that case it is an inactive account. The Chief State Solicitor's office will only take moneys where it can be confirmed the patient has passed away with no known next of kin.

Chairman

The witnesses might send us a note on that. They might have to consult with the Chief State Solicitor.

Mr. Seamus McCarthy

There is legislation around intestate estates and there is an account that I audit and which comes before the Oireachtas. It is managed by the Department of Finance.

Chairman

Okay.

Mr. Seamus McCarthy

Basically, it receives the funds from the Chief State Solicitor.

Chairman

There would be more than the HSE in that.

Mr. Seamus McCarthy

Yes.

Chairman

What is the name of the account?

Mr. Seamus McCarthy

It is the intestate estates fund account.

Chairman

If it is laid before the Oireachtas we will ask for it to be circulated to members during the week so we can have a look at it.

Mr. James Gorman

Where it cannot be confirmed that the person has passed away, the account itself is in a form of limbo and the Chief State Solicitor's office will not take those kinds of payments from us. We would be looking at some form of legislation allowing for the passing of those funds to the State.

Mr. Seamus McCarthy

The dormant accounts process only relates to financial institutions and probably does not provide for that.

Chairman

It does not cover it.

Mr. Seamus McCarthy

Perhaps it is a lacuna.

Chairman

We will get a copy of the information. Another point has been mentioned in passing regarding people in long-term care. There are many people in long-term care in the disabilities sector or psychiatric services. They may not come under the scheme we are discussing. Will the witnesses comment on the people in the care of the HSE not covered by the nursing home support scheme? There must be a number of those institutions that have people with long-term disabilities or psychiatric care requirements. Are they included in what we are discussing?

Mr. Tony O'Brien

Is the Chairman referring to public-private partnerships?

Chairman

No, I am talking about the nursing home support scheme.

Mr. Tony O'Brien

No. It is only those who come within the scope of the nursing home support scheme. There could be some with disabilities or complex needs but, typically, there are not.

Chairman

The public might think we are covering the entire population of people in long-term, permanent HSE accommodation. We will probably ask the witnesses to send us a note on what other categories of people are not included in this scheme. We seem to have missed out on that. I know it is outside the nursing home scheme but there are people in long-term care in institutions. How is the HSE funded for that if it is not through this scheme?

Mr. Tony O'Brien

That would be through our overall funding. This is a specific subhead in the Vote. In our general fund as set out in the service plan, there would be sums for covering care of those with intellectual and physical disability, as well as mental health services.

Mr. Pat Healy

There is €1.5 billion spent on people with disabilities and just under €1 billion of that relates to residential care and so on.

Chairman

That is probably from where I am coming. How much relates to residential care?

Mr. Pat Healy

It is just under €1 billion. Approximately €900 million would be tied up in residential care.

Chairman

How much is being spent on nursing home support?

Mr. Pat Healy

That is €940 million.

Chairman

There is as much money allocated for long-term residential care of those with disabilities as for nursing home support.

Mr. Pat Healy

It relates to full-time residential care. Some of these people could be children and some are young adults.

Some of them are ageing in disability but one would not have a significant number of people in this older age group. They are often being provided with lifelong care so they would be people with moderate, severe or profound disability in residential care. Their age profile would be younger than this age profile.

Chairman

I ask Mr. Healy to provide a detailed note on this issue because when a committee such as the Committee of Public Accounts examines these issues we often mistakenly believe we are capturing the full picture. The amount spent on long-term residential care for disabled people may be similar to the amount spent on the fair deal scheme. We do not often discuss this topic, which is probably neglected. I am not saying there is an issue but the subject does not attract much public discourse. I ask for a note to give the committee a fuller picture.

The HSE sometimes pays private providers to care for some of those who are in this category. Are these payments included in the budget? How much of this care is provided through HSE facilities? I have heard of one difficult case which would cost up to €200,000 per annum in the private sector. I ask for a detailed note on the numbers, maximum costs, etc.

Mr. Pat Healy

We can provide a detailed note. We have a national database that identifies people with disabilities who are in residential and day care, receiving home support and so on. We can give the committee the detail on that. In terms of the private side, our operational plan for disability lists all of the agencies, including the large private providers, with which we have contracts. All of that is provided for.

Chairman

Typically, what would be the cost of a complex case in the private sector? Is the figure to which I alluded out of the ordinary?

Mr. Pat Healy

It can vary depending on the needs of the individual, but €200,000 is not an unusual cost for an emergency case where one would have complex needs, a significant level of disability and perhaps challenging behaviour or maybe a mix of disability needs and mental health needs. That type of cost is not unusual in the types of emergency cases that are dealt with.

Chairman

Mr. Healy will understand that this includes an important group of people who have not come on to the committee's radar. While other committees are probably examining the issue, it is important that we have an understanding of the full picture. That is all I am suggesting in this regard.

On the nursing home support scheme, the document provided refers at paragraph 4.3 to the determination of the costs of care. Services not funded under the nursing home support scheme include incontinence wear, chiropody, ophthalmic and dental services. Surely old people are entitled to have incontinence wear and chiropody covered under the scheme? Their nails grow and if they are being looked after in an institution, they are entitled to chiropody services. If an old person needs a new set of false teeth, the cost is not covered. I will link that issue with people in the institutions who are on medical cards because some of these services are covered by medical cards when the person is living at home. The medical cards of persons who move into a residential institution become almost redundant. They are given bed, board and care and nothing else is readily available from the private providers. Some things that should be covered under a medical card do not seem to be covered. I ask Mr. Healy to talk me through that issue.

Mr. Pat Healy

The key thing, as set out earlier, is that we are implementing a statutory scheme which is set out very clearly in a law passed by the Oireachtas in 2009. The scheme sets out clearly what is funded under the nursing homes support scheme and we are prohibited from charging anything else into it. What we are allowed to charge and what can be funded properly under the scheme are bed and board, the nursing and personal care appropriate to that, basic aids and appliances and laundry. The list of other things is separate from that. In the public side, we would not charge for additional components like that but we-----

Chairman

The HSE cannot pay the private provider for them.

Mr. Pat Healy

No.

Chairman

Ms Noonan indicated the HSE is carrying out a review of the fair deal scheme. It is fine to talk about the assets but let us talk about the people in nursing homes who do not have incontinence wear covered. I am sure that is top of the list of the review. What is Ms Noonan's view on the matter?

Ms Angela Noonan

The reason these items are not covered in the fair deal scheme is that they are covered under the medical card scheme. This has been done to ensure the taxpayer does not pay for the same services twice because if we were paying for them under the nursing home support scheme, they are also covered under the medical scheme. That is why they are covered under the fair deal scheme. When we place somebody in long-term residential care - a nursing home - we consider it as being the same as being in their own home except with different supports, so that whatever they are entitled to in their own home, they are also entitled to in the nursing home.

Chairman

As the witnesses will understand, I specifically linked the question to medical cards. All elderly people aged over 70 years are entitled to a medical card. My impression is that when people in private nursing homes seek some of these items or services, the operator will say they cost extra as they are not covered under the fair deal scheme. Do the witnesses get my point? These items are not covered under the fair deal scheme. People who have a legitimate medical card are not getting the use of the services to which they are entitled. They tend to be told that dental services are not covered under the fair deal scheme and they tend to leave it at that and suffer in silence. Maybe the family or someone else will pay the cost but the medical card does not seem to come into play very much. The witnesses are arguing that theoretically the medical card should come into play. Do they understand my concern for elderly people?

Mr. Pat Healy

In relation to incontinence wear, a very substantial amount of incontinence wear is drawn on the medical cards.

Chairman

Is that through nursing homes?

Mr. Pat Healy

Yes.

Chairman

Mr. Healy knows which nursing home is the most expensive and it is Abbeyleix. Most nursing homes cost between €1,000 and €1,800 per week per resident, with a couple of them costing more than €2,000. In my home county, however, the facility in Abbeyleix costs €4,082 per patient per week and St. Brigid's nursing home, Shaen, €2,584. The witnesses are no doubt aware that the costs in these two facilities are utterly out of sync with those of the others. The cases in St. Brigid's nursing home are more complex in nature. Some years ago, the HSE announced it was closing the Abbeyleix facility but was prevented from doing so by some of the patients who were found by the courts to have a right to stay in the home. The number of long-term patients has since declined from more than 30 to perhaps three or four. I am aware that the HSE also provides some respite care services at the facility. Will Mr. Healy explain the reason the weekly cost of care in one nursing home is almost four times higher than in almost all other nursing homes?

Mr. Pat Healy

For completeness, we included the facility in the list because there are two long-stay patients left in Abbeyleix. The whole purpose of what we are doing in Abbeyleix is to reconfigure it into short-stay community hospital for the area.

Chairman

Mr. Healy is confirming that it is the HSE's long-term intention to close the facility as a long-term care facility.

Mr. Pat Healy

No, it is because it is-----

Chairman

He said it is short-stay and has two patients left in it. That has never been said before. The HSE pulled back from that in the High Court.

Mr. Pat Healy

It is a community hospital which also provides rehabilitation and the facility will be further developed. It will have a rehabilitation component and a community hospital type of component, which is why the costs will be higher. However, the costs will not be included as part of the fair deal scheme as time goes on because the focus will be on the community hospital type of approach in relation to more high dependent people who need rehabilitation and step-down care linked to Portlaoise hospital and so on. There will be step-down out of Portlaoise hospital. This is a positive thing in terms of Abbeyleix into the future.

Chairman

It will provide respite and short-term care.

Mr. Pat Healy

It will provide short-term care, step-down care and rehabilitation. It is a positive thing for Abbeyleix. In terms of Shaen, it is important, as the Chairman said, that there are high dependent, particularly complex cases there and the really positive thing is that there will be three units together. There will be whole new development of 130 beds at St. Vincent's in Mountmellick and that will work as a continuum of care across the three institutions linked to Portlaoise hospital.

Chairman

Essentially, Mr. Healy is saying the long-term future for Abbeyleix is not to provide long-term residential care.

Mr. Pat Healy

It will be a community hospital for the area and will provide step-down rehabilitation so it has a very positive and secure future.

Chairman

Could Mr. Healy confirm that it will not be for long-term residential care?

Mr. Pat Healy

There are still some long-term patients.

Chairman

There are two left.

Mr. Pat Healy

The intention is that it would be a community hospital in the future.

Chairman

For short-term care?

Mr. Pat Healy

For short-term rehabilitation.

Chairman

I cannot get Mr. Healy to say it.

Deputy Bobby Aylward

Are you thinking ahead, Chairman, for yourself?

Chairman

I am trying to get a direct answer. There were more than 30 patients and the number is now down to two. I hope the two people there live a long time, given the great care that is provided. Mr. Healy has said there will be no more long-term nursing care beds.

Mr. Pat Healy

It will be a community hospital in the future.

Chairman

That is still not saying it. That is what creates public angst. It is black and white what Mr. Healy means to say. He has said it six times without saying it.

Mr. Tony O'Brien

I think it is a case of two people being divided by a common language. Let us be clear; those residents can continue to live out their lives there for as long as they like. We hope they will have long and happy lives there. Beyond that, the future use is as Mr. Healy has outlined.

Chairman

Okay, I think that is abundantly clear. One can understand why the question was asked.

Deputy Catherine Connolly

I wish to clarify a few things. I had that page marked in regard to the therapies that were excluded in 4.3. They are not counted in. The service is not funded. The Chairman has referred to them. To clarify, all therapies are not covered and social programmes are not covered. Are they covered somewhere else then?

Mr. Tony O'Brien

They are not part of the nursing homes support scheme. There are eligibilities, depending on the eligibility of the individual for some of those services for the medical card scheme, and if a patient is in a public nursing home while there are one or two things-----

Deputy Catherine Connolly

I do not understand that. If I was talking to somebody who was going into unit six or seven in Merlin Park in Galway-----

Mr. Tony O'Brien

That is a public facility.

Deputy Catherine Connolly

Yes that is a public service. The cost of care is determined in the following way.

Mr. Tony O'Brien

Yes, this is a mathematical process. In order to tell one what the cost of care under the nursing homes support scheme is, we have to exclude things that are not covered under the scheme. That is not to say they are not provided.

Deputy Catherine Connolly

That is okay, but when it comes to private nursing homes, are they excluded or are they taken into account?

Mr. Tony O'Brien

They are not part of the subvention paid to the nursing home.

Deputy Catherine Connolly

So a person, as well as paying for everything we have outlined so far such as giving up 80% of his or her pension and whatever else, will also have to pay for therapies.

Mr. Tony O'Brien

If they are eligible by virtue of having a medical card-----

Deputy Catherine Connolly

But if they are not?

Mr. Tony O'Brien

If they are not eligible for publicly provided services under the medical card scheme, or otherwise eligible, then the likelihood is that they are paying for those services.

Deputy Catherine Connolly

I thank Mr. O'Brien. I have a few quick questions about the 22%. To clarify the issue on the basis of my being assessed today, for example, if the economy is booming and prices are rising, one is left with a big charge on one's house.

Chairman

It is based on today's evaluation.

Deputy Catherine Connolly

If I happened to need nursing care when the bottom fell out of the market the 22% would be much less than 22% of my house today so the 22% is utterly dependent on a fluctuating market. That seems most unfair. I am 22% at one stage but my neighbour would be much higher five years later because the economy has picked up or vice versa. Is that not right? I just want to clarify the issue.

I also have a few more issues to clarify. Age Action has come up with a figure of approximately 35%. It maintains that people are in nursing homes who really should be at home and would prefer to be at home but the home care packages and home help are not available so they end up in nursing homes. What is Mr. O'Brien's reaction to that?

Mr. Tony O'Brien

Because of the scheme of assessment nobody is being approved for the nursing homes support scheme who does not have needs consistent with the scheme. However, there are people who have needs consistent with the scheme whose preference may well be to stay at home and who would stay at home if they had the same level of psychological assurance that all the supports they need would be provided at home to the same extent they can have it with the nursing homes support scheme. As part of the review the Department is undertaking, which has been discussed, we have a view, which we said to the Committee on the Future of Healthcare, that we need a scheme similar to the fair deal scheme for home care.

Deputy Catherine Connolly

I do not agree with Mr. O'Brien on that but I agree that services are needed to keep people out of nursing homes.

Mr. Tony O'Brien

That is okay.

Deputy Catherine Connolly

What percentage of HSE staff in nursing homes are agency staff? I saw the information in the briefing document.

Mr. Pat Healy

I do not have the percentage with me but I can send the information to Deputy Connolly. What we have said is that in some locations we are using a considerable number of agency staff and we have been seeking to reduce that, for two reasons, the first is cost and the second is that a permanent workforce on a full-time-----

Deputy Catherine Connolly

I understand that. I am 17 years working as a local representative. I am fully familiar with the situation. I am tired hearing about it, although I am not referring to the witnesses. Agency staff is a major issue. The situation has come about as a result of Government policy and not employing people. I would like the percentage-----

Mr. Tony O'Brien

The reason for dependency on agency staff is our inability to recruit staff.

Deputy Catherine Connolly

That may well be true at this point but I have spent some time on a health forum and I know there was an embargo, that staff were not employed and the HSE went down the route of taking agency staff at a great cost. My specific question is what percentage of staff in nursing homes are agency staff? It is okay if the witnesses do not have the information. They can get it.

Mr. Pat Healy

We will send that on.

Deputy Catherine Connolly

Áras Attracta was not covered today. The reference to it just arose out of a question. Is that right?

Mr. Tony O'Brien

It is not part of the nursing homes support scheme.

Deputy Catherine Connolly

As it has been raised, could the witnesses clarify the position on the review?

Mr. Pat Healy

The review is complete. We published it earlier this year. It is known as the McCoy review. One part of it was to look at Áras Attracta and issues relating to it but, equally important, was the review of system-wide issues. There was a very positive launch of the report and its recommendations are being implemented.

Deputy Catherine Connolly

I will finish on this point. In terms of bringing the fair deal scheme approach to homes-----

Mr. Tony O'Brien

We are only talking about the same psychological assurance.

Deputy Catherine Connolly

Yes, but if Mr. O'Brien was talking about such a mechanism I would not agree because people in their homes would be told they would be charged for being minded at home, after paying taxes all their lives.

To return to what was raised by my colleague, which I also raised, one cannot have a system where one talks about choice where there is no choice, and one cannot have a review without looking at quality of life and all the other services such as smart cities, smart travel and all the wonderful smart documents we have got and then tell someone in Galway city that one must go from Barna to Kilcolgan, Oranmore or somewhere else. That is not a smart policy. Any review should examine that so people can visit their loved ones in a nursing home and that they can go out and stroll around. If a review involving value for money is to mean anything then it must include that.

Deputy Bobby Aylward

Even within counties there is a discrepancy with the subvention being paid to private nursing homes. I am just talking about Carlow and Kilkenny, which is one constituency, where different rates are being paid in different areas that are not far apart. I refer to the monthly subvention. How come one private nursing home is getting more per patient than another? That has been pointed out to me by several individuals.

Mr. Tony O'Brien

I understand the committee intends to write to the National Treatment Purchase Fund, NTPF, to suggest that issue might be included.

Chairman

The NTPF sets the price with the nursing homes individually. The HSE's sole duty is to write the cheque.

Deputy Bobby Aylward

I understand that.

Chairman

We might have been better off had we invited the NTPF here today as it carries out the negotiation. We will write directly to it on the issue.

Deputy Bobby Aylward

It is discrimination within the one county or constituency where one subvention is bigger than another when they should be all the same.

Chairman

We will get an answer for the Deputy. Is it agreed that the committee disposes of the HSE's patients' private property accounts 2015, the HSE financial statement 2015, note 13, specifically in regard to the fair deal scheme; and the health repayments scheme donations fund 2015? Agreed.

On behalf of the Committee of Public Accounts I thank all the witnesses from the HSE and the Department of Health and the Comptroller and Auditor General and his staff for participating in the meeting today, and for the material they supplied to the committee. We look forward to receiving the other information as soon as possible. There being no other business the meeting is adjourned.

The witnesses withdrew.

The committee adjourned at 4.20 p.m. until 9 a.m. on Thursday, 23 March 2017.