COMMITTEE OF PUBLIC ACCOUNTS debate -
Thursday, 1 Oct 2020

Special Report of the Comptroller and Auditor General on the Nursing Homes Support Scheme: Discussion

Mr. Colm O'Reardon (Acting Secretary General, Department of Health) and Mr. Paul Reid (Chief Executive Officer, Health Service Executive) called and examined.

Chairman

This morning we have our first public engagement with witnesses from the Department of Health and the Health Service Executive. I would like to warmly welcome our witnesses. I look forward to working productively with both bodies in the months ahead.

The focus of today's meeting is the Comptroller and Auditor General's special report No. 110 on the nursing homes support scheme, also known as the fair deal scheme. The scheme has now been in operation for ten years. On foot of the Comptroller and Auditor General's report, this is an appropriate time for the committee to examine it. To assist us in our examination of the report, we are joined by witnesses remotely and in person, in compliance with public health guidelines.

From the Department of Health, we are joined in person by Dr. Colm O'Reardon, acting Secretary General, and Dr. Kathleen MacLellan, assistant secretary at the social care division. We are joined remotely by Mr. Niall Redmond, principal officer at the social care division, and in support, Ms Pamela Carter, principal officer at the parliamentary division.

From the Health Service Executive, we are joined in person by Mr. Paul Reid, CEO, and Ms Anne O'Connor, chief operations officer. We are joined remotely by Mr. Stephen Mulvany, chief financial officer, Mr. Ultan Hynes, head of service for the nursing homes support scheme, and in support, Mr. Ray Mitchell, of parliamentary affairs.

The witnesses are very welcome. I know that the HSE in particular is going through a particularly busy and difficult period at the moment. I remind members, witnesses and those in the Public Gallery that all mobile telephones must be switched off. I also ask members and witnesses to remove their masks when speaking as they interfere with broadcast sound.

I draw the attention of witnesses to the fact 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 the committee. However, if they are directed by the committee to cease giving evidence on 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 or 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 long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the House or an official either by name or in such a way as to make him or her identifiable.

Members are reminded of the provisions of Standing Order 218 to the effect 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. While we expect witnesses to answer questions asked by the committee clearly and with candour, they can and should expect to be treated fairly and with respect and consideration at all times in accordance with the witness protocol.

Mr. Seamus McCarthy

The special report for consideration by the committee today presents the findings of an examination by my office of the nursing homes support scheme, generally referred to as the fair deal scheme. Members are probably already aware that it is a complex means-tested scheme, and one that is vital to many members of our communities. I wanted to look at how the scheme was operating about ten years on from its establishment.

I should first make a couple of points about the scope of the examination. Nursing homes are regulated by the Health Information and Quality Authority, HIQA, where standards of care are concerned. We decided not to look at issues in that area and to focus instead on the financial and administrative aspects. The year, 2018, was the latest available period of account when we were doing our fieldwork and drawing up the report.

Where we could, we have provided relevant later data.

Finally, we completed the report in the first weeks of the Covid-19 lockdown. It was already evident that the pandemic was impacting enormously on residents of nursing homes and that it might impact significantly upon the nursing home sector as a whole. I decided that it would nevertheless be useful to publish the report as an input to the debate about how the sector should operate in the future.

In 2018, some 23,300 residents of nursing homes were being provided with financial support under the scheme at a cost of €969 million to the HSE. This included €51 million worth of loans provided to help residents pay their contributions to the cost of their care. The HSE estimates that residents paid an additional €343 million directly to nursing homes. Approximately 550 nursing homes participate in the scheme, with the majority, 80%, being privately run, for-profit and not-for-profit operations. The remainder are public nursing homes run by the HSE.

The types of goods and services provided under the scheme were set out by the Department of Health and the HSE in 2009. They comprise accommodation, bedding, food, nursing and personal care, laundry and standard aids and appliances to assist with day-to-day living. No review of these components has taken place since 2009. Nursing homes also provide other services not covered by the scheme, such as access to social programmes and transport and assistance for residents who need to attend medical appointments. These additional services may result in additional charges for the resident. From a review of nursing home contracts, the examination found that the level of detail on additional fees charged by nursing homes varied. In addition, it appears residents of private nursing homes are more likely to incur additional charges for those services than those in public homes.

The way in which the weekly charge rates are determined for individual nursing homes is prescribed in the scheme legislation. For public homes, the cost of care method must be used. For private nursing homes, the agreed maximum price method must be used. In 2018, the average charge for public nursing homes was €1,564 a week, while the average charge for private homes was €968 a week. Since the methods used to determine these rates differ, a meaningful comparison cannot be drawn. The weekly rates are the same for each resident supported by the scheme regardless of his or her care needs, including his or her level of dependency. By law, the weekly charge for public nursing homes must not exceed the cost incurred by the HSE in providing care. The HSE calculates the rates it charges by reference to prior period scheme costs and an expected 95% bed occupancy. As the HSE does not currently have a single financial system, the process to identify and isolate these costs is not a straightforward one. This creates risks around the completeness and accuracy of the weekly charges calculated and published by the HSE.

Funding shortfalls occur in public homes where current operating costs run at a higher rate than the prior period or where bed occupancy is less than anticipated. In 2018, additional funding of €23 million was allocated to public homes by the HSE from other Exchequer resources to cover such shortfalls.

The National Treatment Purchase Fund, NTPF, is responsible for negotiating the prices to be charged by private nursing homes. The NTPF has outlined the many factors it takes into account in arriving at the weekly charge rate it is prepared to allow for a nursing home. However, it has not provided to the examination team a model explaining how the various criteria are weighed and combined, stating that all the criteria are considered in the aggregate. Consequently, it is unclear how these criteria influence the negotiation. I will explain more about this when representatives from the NTPF appear before the committee in two weeks.

The scheme is a cash-limited one, meaning that an individual will only receive financial support once funding becomes available. A placement list is used by the HSE to manage access to the scheme. The examination found that the HSE's target waiting time of four weeks was generally met.

For individuals in an acute hospital setting awaiting access to scheme funding, the HSE also has in place short-term transitional care arrangements to facilitate discharge from the acute setting to a residential care setting. Payments of approximately €12 million were made to private nursing homes in 2018 for transitional care. The cost of transitional care in public homes is not known, and transitional care payments are not counted as part of the scheme cost. Resident contributions are also not collected while transitional care is being provided.

The scheme's optional loan element is to ensure that an individual does not have to sell his or her home or other property assets in order to pay for long-term care. By the end of 2018, just over 10,600 individuals had availed of this facility with loans advanced totalling €239 million. The loan normally falls due for repayment upon an individual's death and Revenue has statutory responsibility for collection. By the end of December 2018, the HSE had notified Revenue of 5,650 loans worth €114.1 million that could be collected. We found that 94% of the debt had been recovered by the end of February 2020.

Chairman

I thank Mr. McCarthy. I now ask Dr. O'Reardon for his opening statement on behalf of the Department.

Dr. Colm O'Reardon

Good morning, Chairman and members of the committee. Before I begin, I congratulate the Chairman on his appointment and wish him and the members of the committee every success in their work. The Department is obviously pleased to work with the committee. We see this engagement as important and helping us in our role.

In talking about nursing homes, it is important to record again the serious impact that Covid-19 has had on residents of nursing homes this year and to again express our condolences to the families of those who lost their lives in nursing home settings. It is equally important to commend all of those who worked tirelessly to protect nursing home residents and prevent the spread of the Covid-19 virus in those settings.

The nursing homes support scheme, or fair deal scheme, is a system of financial support for people who require long-term residential care. The scheme, established by the Nursing Homes Support Scheme Act 2009, has been in place for more than ten years. It aims to ensure that nursing home care, when needed, is both accessible and affordable.

Participants contribute to the cost of their care according to their means while the State pays the balance of the cost. This helps to safeguard equity of access and the sustainability of the scheme, ensuring that resources are targeted at those most in need.

When an applicant to the scheme is approved, following both the care needs and financial assessment, he or she can choose his or her preferred nursing home regardless of whether it is public, private or voluntary once that nursing home has an available bed and can cater for the care needs. Applicants' level of contribution is unaffected by their choice of nursing home and all registered nursing homes are regulated by HIQA against the same set of standards for safety and quality.

In 2019, almost 23,000 residents were supported by the fair deal scheme. For 2020, additional investment of over €70 million to the scheme brought its annual budget to over €1 billion for the first time, to support over 24,000 residents. The Government has also made €90 million available this year through a temporary financial scheme to support private and voluntary nursing homes to prepare for and manage Covid-19 outbreaks. Funding for the fair deal scheme represents 6% of the current health vote.

The Department welcomes the Comptroller and Auditor General's report, which provides an overview of the scheme after its first ten years in operation. The report acknowledges the complexity of the scheme and recognises its cash-limited nature, which can create challenges with regard to waiting times for access and timely discharge from acute care.

The Department fully supports the report and its findings and has commenced engagement with the HSE and the NTPF regarding the report's recommendations. This includes initial consultation with the HSE on the recommendation for the Department to review the cost components of the scheme.

The principles underlying the fair deal scheme remain essential in our planning for services that can meet the diverse needs of our older citizens.

To ensure fairness, value for money and equity of access, the Department is committed to the development of a standard assessment tool for care needs assessment, a safe staffing framework and new care models.

I thank the Comptroller and Auditor General for his comprehensive examination of the scheme, which will lead to its further development and improvement.

Chairman

We now move to Mr. Paul Reid on behalf of the HSE. I invite him to make his opening statement.

Mr. Paul Reid

Like Dr. O'Reardon, I wish to pass on deepest sympathies on behalf of the HSE to the families and friends who have lost loved ones in nursing homes during the pandemic.

I thank the committee for the invitation to attend this meeting to discuss the Comptroller and Auditor General's special report No. 110 on the nursing homes support scheme, also known as the fair deal scheme. As this is our first meeting with the incoming committee, I would like on behalf of the HSE to wish the committee well in its important work and to assure it that the HSE will assist it in every way we can. I also wish the Chairman the very best.

As we submitted in advance of the meeting, as requested, a briefing paper on the nursing homes support scheme, I will confine my opening remarks to the following. The nursing homes support scheme is a scheme of financial support for clients who are deemed to require long-term residential care. The scheme was established under the Nursing Homes Support Schemes Act 2009 and currently supports more than 22,572 residents at HIQA-registered older persons’ residential settings. In 2020, more than €1 billion is assigned to the scheme to support those clients. The HSE provides residential care for some 20% of those funded under the scheme.

As well as being a service provider, the HSE administers the scheme, which was the primary focus of the Comptroller and Auditor General's special report. Although the HSE administers the scheme, the NTPF agrees the weekly maximum price for private nursing homes. The cost of care for public nursing homes is calculated by the HSE and does not exceed the cost to the HSE of providing such services. The HSE acknowledges that there is a variance in the average cost of care paid to public versus private nursing homes, with HSE centres generally having a higher cost of care. There are a number of key factors driving this variance, including pay-related issues, with generally higher staff pay rates and conditions at public nursing homes, as well as higher staffing ratios. The physical build at a number of older HSE centres adds costs due to the extra staffing levels required to manage clients in such circumstances. There was also a requirement for a reduction in the number of long-stay beds to comply with health and safety, fire regulations and HIQA compliance with residential care standards. Finally, the HSE provides residential care services in locations that are not viable for private providers. The HSE has inputted to the ongoing Department of Health value for money review of nursing home costs.

The administration of the nursing homes support scheme requires significant resource input by the HSE for the application process and the financial administration of the scheme, including the oversight of a process to manage payments of €1 billion annually to public and private nursing homes. I welcome the nine HSE-specific recommendations of the Comptroller and Auditor General's special report and note that the HSE has designed a management action plan that assigned responsibility for the implementation of all the HSE recommendations, the majority of which are now implemented. The HSE is committed to working proactively with all other identified stakeholders noted in the special report, including the Department of Health.

Chairman

We now move to members for questions. The lead speaker this morning is Deputy Catherine Murphy, to be followed by Deputy Munster, who has been called to the Dáil Chamber for Priority Questions but will join us soon. Deputy Catherine Murphy has 15 minutes.

Deputy Catherine Murphy

The witnesses are very welcome. There is a degree of normality in having a hearing such as this at the Committee of Public Accounts, even though it is a busy time for the witnesses for other reasons. As the Chairman pointed out, my time is limited. I have 15 minutes for my questions and the witnesses' answers. I will try to get as much in as possible and I would appreciate if I could have fairly short responses.

The previous Committee of Public Accounts sought a value for money review.

That related to a period before Covid-19, and the review was to look at the value for money in respect of public and private nursing homes. We had an expectation that was going to be produced in 2019, originally in March, and then we were told it would be the fourth quarter of 2019. We were given those assurances. Dr. O'Reardon might tell us why it has not been published to date. I will start with that question.

Dr. Colm O'Reardon

I thank the Deputy. We share the Deputy's frustration about that issue. It is an important piece of work. I believe the value for money group was set up in March 2018. It is an interdepartmental arrangement and ran into serious difficulties in getting data. The original plan was to go to the NTPF and use its data sources and that ran into data protection issues, legal discussions, etc. Subsequently, there were discussions with Nursing Homes Ireland and eventually an agreement was reached to access data via that group. Things had been paused because of the scale of the data problems but it got back up and running in March, and then immediately Covid-19 struck.

Deputy Catherine Murphy

Is there a date for publication at this stage and are there still issues regarding data? What is the up-to-date scenario?

Dr. Colm O'Reardon

As far as I understand it, the data issues have been resolved in the sense that there is now an agreement with Nursing Homes Ireland to supply those data. That agreement was not arrived at easily. The group is now back meeting, but I do not have a date to give to the Deputy for the completion of the report.

Deputy Catherine Murphy

Is there even an estimated date?

Dr. Colm O'Reardon

I cannot give that to the Deputy, but we are equally as frustrated as she is because this is an important piece of work and we want to get it done.

Deputy Catherine Murphy

This work has been going on for years now, and we cannot even be given an estimated date as to when the review is likely to be published. This matter concerns value for money and it is an important report, as Dr. O'Reardon acknowledged. What roadblocks are preventing the report from being published?

Dr. Colm O'Reardon

I am not aware of any such roadblocks, but the work was effectively paused until people could find a source of data they could use. They had got to the point in March this year where they were able to recommence work and then we were hit by the onset of the Covid-19 pandemic. That has knocked us back by many months, but work is recommencing now on the report.

Deputy Catherine Murphy

How many people are working on it?

Dr. Colm O'Reardon

It is an interdepartmental group. There are representatives from the Departments of Health and Public Expenditure and Reform. There is also a very experienced independent chairperson, who has done several of these types of reports, as well as input from the ESRI and the HSE. It is managed through that process and that is a standard process, which works.

Deputy Catherine Murphy

I presume that Dr. O'Reardon finds it unsatisfactory, or more than unsatisfactory, that this work commenced in 2018 and there is still not even an estimated date for completion.

Dr. Colm O'Reardon

We, and the staff in the Department, found it very frustrating that we could not get data to allow us to do the work. Such things happen, but it is particularly unfortunate because this is an important piece of work and we were not able to get the relevant information to be able to get off the ground with it. As I said, however, this is a priority for us and it is something we need to get done.

Deputy Catherine Murphy

It is certainly a priority for this committee as well.

Dr. Colm O'Reardon

Absolutely.

Deputy Catherine Murphy

In 2015, the HSE committed to publishing the weekly cost of care-based charge rates for public nursing homes. It did not publish the rate for 2017 and produced an incorrect rate for 2018. The average weekly rate increased by 26% in public nursing homes between 2010 and 2018, and by 11% in private nursing homes.

Deputy Catherine Murphy: In 2015, the HSE commited to publishing the weekly cost of care-based charge rates for public nursing homes. It did not publish the rate for 2017, and produced an incorrect rate for 2018

Why did the HSE commit to publishing those rates in 2015 and then not do so? The executive uses rates internally for pay adjustments, for example. Perhaps Mr. Reid will address that. Does the HSE have the information? Why is it not published? What is going on in that regard?

Mr. Paul Reid

I will make a few brief comments and then I will call on our chief financial officer, Mr. Mulvany, to follow up. On the previous commitment in 2015, much work was done to try to collate the data. We reflected, and I believe the Comptroller and Auditor General reflected in his report, some of the frustrations around not having a single integrated financial system, which is what we are currently working on and deploying. We have put processes in place to collate the data much better and we have made some progress on the production of it. I will ask Mr. Mulvany, who is in the other room, to make a comment also.

Chairman

There is an technical difficulty so we will come back to Mr. Mulvany. Could the Deputy move on to another question?

Deputy Catherine Murphy

Will Mr. Reid address the integrated financial system and the impact? At our previous meeting we, discussed the deficiency in not having an integrated system. How is this impacting that work, given that the HSE knows the pay rates internally and knows the pay adjustments? How would that not be reflected? Is this a reason? It seems obvious that the HSE knows these pay adjustments.

Mr. Paul Reid

I am not quite sure if there is a lost connection with the audio.

On the integrated financial management system, it is a frustration across a range of cost appropriations for us in the HSE. Significant investment, which has been approved by our board, and which is Government funded, has put in a deployment process for us that we are now on track to roll out. Perhaps Mr. Hynes could comment on the cost elements while we try to get Mr. Mulvany into the room.

Chairman

There is an audio difficulty. Unfortunately, we are having technical problems. Do the witnesses wish to continue while we sort that out?

Mr. Paul Reid

Yes, of course.

Chairman

Would the Deputy like to ask a further question?

Deputy Catherine Murphy

It is quite difficult to have a flow of questioning.

Chairman

There are some technical difficulties. We will deal as much as possible with the four witnesses in the room. We are aware that the numbers are restricted here. The committee is trying to operate within the guidelines. In fairness to committee members, there are a number of questions, and if the witnesses present could deal with them, that would be good.

Ms Anne O'Connor

While we are waiting to connect to the other witnesses, I will continue. We have published the 2020 cost of care. The important thing about cost of care is that it does not impact on the contribution from residents. Sometimes there is a perception that the cost of care can affect the payment by residents in nursing homes, but it does not. That is calculated in a different way.

On the challenge around the system, the cost of care is calculated on a range of different factors. In the absence of a single integrated financial system, we are reliant, as we are in many other areas in the HSE, on gathering through all sorts of different mechanisms the costs of specific things in different locations, even the costs in different geographies. We do not have a single system across the country. Capturing costs on a geographical basis on a single national rate can be very challenging for us. The integrated system can impact on our ability to give a standardised view of cost in relation to everything, including this.

Deputy Catherine Murphy

Is it a postcode lottery?

How uneven are the data on which the HSE relies? I appreciate that there is a method of calculating for individuals, such as 80% of their income and so on. We know the calculations for those people's personal contributions but how uneven is it around the country and what data sets is the HSE using? Is it looking for other sources of data to have a more even calculation?

Ms Anne O'Connor

Unfortunately, the technical experts on this matter are in the other room. As regards the data sets and calculating costs, the actual costs are different between the east and the west, so there are geographical variances.

Deputy Catherine Murphy

What kind of difference are we talking about?

Ms Anne O'Connor

The cost of care is dependent on all sorts of factors, including staffing costs. From the HSE perspective, we have significant challenges in those differences, such as a higher dependency on agency staff, etc. We would have to get the data sets that underpin the gathering of the cost of care.

Deputy Catherine Murphy

Would agency staff be more likely to be used on the east coast?

Ms Anne O'Connor

In general, in all of our services, yes.

Deputy Catherine Murphy

What is the difference between the highest and lowest figures?

Ms Anne O'Connor

I do not have those figures, unfortunately. Mr. Hynes has the specifics of the actual costs.

Mr. Seamus McCarthy

Diagram 2.5 on page 27 of the report shows the spread of charges for both public and private sectors. I will explain the diagram to the Deputy. If she looks at the width of the graphic rather than its height, the lighter green colour shows figures from about €800 to about €1,400, which is the spread of weekly charges for private nursing homes. The lower graphic goes from about €1,200 to €1,800. There are also some much higher figures going up to as much as almost €2,500 for some nursing homes. There is a much wider spread for the public nursing homes than for the private ones.

Deputy Catherine Murphy

Is that based on geography or dependency?

Mr. Seamus McCarthy

We have the detail behind that graphic and the figures are published. There is an element of geography but it could also relate to the newness or age of the nursing home. There are many factors.

Ms Anne O'Connor

It is not really related to dependency.

Chairman

I have added on two extra minutes for the Deputy because of the interruptions.

Deputy Catherine Murphy

I am not even able to-----

Chairman

She now has three minutes left.

Deputy Catherine Murphy

Okay, it is just-----

Mr. Paul Reid

If we could get one of the technical team in the room, it would make the flow better.

Chairman

We are still working on it. We do not have that connection yet.

Deputy Catherine Murphy

Ms O'Connor said that the cost of staffing in public nursing homes is due to conditions and because the ratio of staff to the people for whom they are caring is higher. Has the HSE published documentation on that?

Ms Anne O'Connor

We do not have a breakdown of staffing in private nursing homes. This has been a challenge for us, so HIQA would have a view-----

Deputy Catherine Murphy

How does the HSE make the comparison then?

Ms Anne O'Connor

We do that through the cost of care calculations. The NTPF sets the cost of care. I do not know how it does that. Unfortunately, we need Mr. Hynes to answer that question. From our perspective, we do not have any visibility. The only time we had any general confirmed inputs into private nursing homes was as a result of Covid. They work as entities with the NTPF in terms of the cost of care.

We do not set the cost of care. That is done through the NTPF. The HSE's role is in relation to the administration of the payments for the nursing homes support scheme.

Dr. Kathleen MacLellan

The staffing framework has been committed through the Department. The Deputy may know that this has been completed in the acute hospitals and the emergency departments. The next phase of that is with the long-term residential care. The evidence review is under way on that and guidance has been developed, which will be worked through across the nursing homes to test it in the coming period. In addition, the nursing home expert panel report has recommended an audit of staffing levels across all nursing homes and that HIQA would conduct that.

Deputy Catherine Murphy

When will that expert panel report be finalised?

Dr. Kathleen MacLellan

It is published but is yet to go to the Government. We are fully committed to its recommendations and have established the implementation framework. An implementation oversight team and a reference group are in place. Both groups have met and are looking through the priority recommendations. It is a cross-agency group across HIQA, the HSE, the NTPF and the Department of Health.

Deputy Catherine Murphy

That will contain a lot of information. Is it likely to assist with the value for money audit?

Dr. Colm O'Reardon

I am not sure they are definitely connected but I cannot see how it would hurt. The value for money review is looking at cost components. One important thing in all this is that we also start to develop measures of dependency or acuity so that we can better relate where resources go within the structure to the dependency and acuity of the residents. That is something that on which we will work.

Chairman

If members are happy, when we are reconnected with the other witnesses again, we will get an answer to the question.

Deputy Catherine Murphy

That is okay.

Chairman

The next speaker is from Fianna Fáil. There are five minutes and I will signal after four. I ask the questioners to keep their questions concise and for the witnesses to try to give direct and straight answers. They will appreciate that we are trying to do our work within a two-hour meeting and we are trying to make the best we can of it.

Deputy Marc MacSharry

I welcome everyone and offer good wishes to Dr. O'Reardon in his new role. I thank Mr. Reid and everyone from the HSE for giving their time at this most difficult time for themselves. As someone who is mercilessly critical at times, I want to take the opportunity to thank the HSE and the Department of Health and all associated with them for their mountain-moving heroics over recent months in terms of Covid. It is important to say that and that I, as someone who is often very critical, would say it.

If technical difficulties interfere, rather than hold up the meeting, I ask that Mr. Ray Butler would reply to the meeting in writing this evening. I do not want an answer here, but I have an important question on public expenditure to ask now, which Mr. Butler might answer on behalf of the HSE or the Department of Health jointly, if necessary.

In the context of Covid, where there is very substantial expenditure, it would be useful for the committee to know if the National Public Health Emergency Team, NPHET, uses any formula similar to that of the National Centre for Pharmacoeconomics when a breakthrough drug comes on board such as ipilimumab or Orkambi, which are very expensive. Apart from the health technical assessment and the other medical criteria that it applies, it also considers the formula cost per year per life saved. As Mr. Reid has said, this could be with us for a great deal of time. I am conscious that responding to a question from a colleague yesterday, NPHET replied that the average age of those deceased, with whose families we sympathise, was 89 years with underlying conditions. Is a similar formula or methodology applied in the sorts of restrictions and expenditure we must enter into for measures for Covid?

If there is, will Mr. Reid let us know what it is? If not, why is that the case? The witnesses have acknowledged this disease will be with us for some considerable time so will the HSE or the Department consider implementing such measures and informing us of the criteria? That is not for the here and now but a detailed paper or note for the committee would be very useful for us, considering the vast expenditure that is, quite rightly, being applied to fighting this terrible disease.

Mr. Paul Reid

My colleague, Dr. O'Reardon, may wish to comment on this as well. Our response to date has been primarily driven by the public health advice given by NPHET and Government decisions. From a HSE perspective, we implement those decisions. I am very familiar with the process outlined by the Deputy from the National Centre for Pharmacoeconomics and the financial economics process behind that. It is a very good benchmark. However, in the context of the pandemic, our response has generally been driven by public health measures to protect and save lives. Many of the measures we have implemented come from a range of perspectives, including the impact on the economy, society or the health service and costs. Examples include PPE and testing and tracing, which have been a big cost for us this year.

Deputy Marc MacSharry

I am conscious that the witnesses have not come here to discuss that matter so it is why I asked for a written note. I have a minute of my time left.

Mr. Paul Reid

As a final point, the new oversight group that has been established and is chaired by the Secretary General at the Department of the Taoiseach has set out to try to understand some of the wider societal and economic impacts.

Deputy Marc MacSharry

Sure. I totally understand that speed trumps accuracy now and there is a need for this. However, based on the predicted unfortunate longevity of this disease, we could usefully carry out that exercise. We should do it. I will leave it at that.

There is a lack of data provided to help the value for money report. Who is not providing those data?

Dr. Colm O'Reardon

We had a lengthy engagement with the NTPF and it went to discussions with its legal advisers about data protection matters. At the very end, it proved impossible.

Deputy Marc MacSharry

Is GDPR hanging us on this or is it a convenient life jacket?

Dr. Colm O'Reardon

As I understand it, this is a data protection issue.

Deputy Marc MacSharry

Okay. Will the witnesses provide us with a note on that from the legal advisers indicating the reasons the information cannot be gathered? In the Comptroller and Auditor General's experience of private accountancy, if a company sought a value for money report, what would be the typical timeframe within which a result would be expected?

Mr. Seamus McCarthy

I am sorry, but I am not clear about the question.

Deputy Marc MacSharry

If I asked somebody to undertake a value for money report for a company, agency or Department, notwithstanding the huge nature of this topic, what would be the typical timeframe in the private or public sector for it to be completed?

Mr. Seamus McCarthy

It can be a lengthy process, depending on the complexity of the matters.

Deputy Marc MacSharry

Sure. Could Mr. McCarthy define "lengthy" in this case? What would be a ballpark time?

Mr. Seamus McCarthy

One could be looking at a couple of years.

Deputy Marc MacSharry

Right. How long are we into this process now?

Dr. Colm O'Reardon

As I understand it, this began in March 2018.

Deputy Marc MacSharry

It is a couple of years. We are talking Unilever proportions.

Mr. Seamus McCarthy

It is a complex process.

Deputy Marc MacSharry

The GDPR aspect or the lack of data is difficult but it will not wash with the public. If blame is be apportioned, we do not want to inadvertently point it at the Department, the HSE or any individual. If there is a flaw in the legislation, the committee needs to know in order that we can make recommendations accordingly.

Deputy Alan Dillon

Good morning to everyone. I hope to focus on two points, specifically overall spend and the NTPF. I also echo Deputy MacSharry's acknowledgement of the ongoing efforts in the fight against Covid-19 and tremendous work that is being done. It must be appreciated by everyone.

On the report, 33% of the entire fair deal budget for 2018 was given to HSE-funded nursing homes, which support only 20% of residents in long-term care. How is that justified? Mr. Reid has stated the entire budget has amounted to more than €1 billion to date.

However, we only reflect 20% of that in the public interest.

Mr. Paul Reid

I thank the Deputies for their comments. Unfortunately, we do not have our financial team connected yet but as we have said in the report, the breakdown of cost elements are very different. The calculation methods of the NTPF and the public sector are very different and the cost drivers can be very different between public and private. The report has reflected those differences and the two different calculation costs so the distribution of the costs is done on that basis.

Deputy Alan Dillon

There are concerns and findings with the NTPF's model for determining where the fees are set, as there are no internal written procedures or guidance for staff. Is this about funding for the most vulnerable to avail of specialist care or do we need to determine the practices and how the NTPF engages in this?

Ms Anne O'Connor

As regards the calculations of the cost, I cannot speak for the NTPF but from our perspective the costs are higher in public centres for a number of reasons and that has been the case historically. I mentioned the staff already, as staff rates and conditions in public nursing homes lead to a higher charge. The conditions and physical build of many HSE facilities would also be poorer than those in the private nursing home sector. There have been incentives for the development of private nursing homes. We have an improvement programme but the environment would require us to have different costs associated with older buildings.

As regards occupancy, the reality for some HSE units is that we are the provider of last resort in some areas. Our cost of care is calculated by occupancy rates and in some of our units we are not filling all of our beds. However, we have to maintain a unit. That would not necessarily be the case in a private nursing home. The costs have to capture all of that and so they are higher. We are looking at the different supports and I know concerns have been expressed about the range of supports provided in public and private homes and so on. The expert review group and the work that would be undertaken was mentioned earlier. That is what underpins the higher cost in public units and it is on that basis that the cost of care is set by the NTPF.

Deputy Alan Dillon

When means testing, the HSE looks at details of a person's income and assets and presents them with supporting documentation. Resident contributions to the cost of care are based on a maximum of 80% of their weekly incomes, or 7.5% of the value of their homes, subject to a three-year cap. That could be changed to six years with new legislation coming in for farms and businesses.

Chairman

The Deputy has less than a minute left.

Deputy Alan Dillon

Similarly to the medical care scheme, can the HSE ensure that the information being supplied is accurate in each of the locations assessing these applications, given the lack of a financial management system and how they are being reviewed?

Ms Anne O'Connor

A significant amount of work goes on in determining those assets, but our experts are in the other room. In terms of determining people's assets as part of the fair deal assessment process, there are quite robust systems in place for how we work through that process with people. There is a financial system there that is set to be updated. We are working in the most standardised way we can in the units around the country, given the infrastructure available to us. The fair deal scheme and the work of the HSE is standardised in how we go through that process with people. It is bound by the rules set in the legislation around it.

Chairman

The time is up but Mr. Reid may come in briefly.

Mr. Paul Reid

I just wanted to make this point because it was one of the findings from the Comptroller and Auditor General's report. I would not like to give the impression that just because we did not have an integrated financial management system, we did not go about putting in a standardised process. Some of the actions we have taken under the report included standardisation across all the offices, standardisation of training and data capture and a more user-friendly application process to guide the client through.

Chairman

I understand Deputy Carthy has changed slots.

Deputy Matt Carthy

Yes, and I thank Deputy Devlin for facilitating me. I have an oral parliamentary question that I hope to ask in the House.

I thank the witnesses for attending. I know this is Mr. Reid’s second time at an Oireachtas committee that I am aware of this week, and the same goes for Ms O'Connor. I am sure they need it like a hole in the head considering the work they have to do, so we appreciate that. However, parliamentary oversight is important, and arguably more important at this time than ever.

I want to go back to the issue regarding the differential in fees between the publicly and privately provided care facilities. Notwithstanding all of the other understandable issues Ms O'Connor has mentioned, I gather from Mr. Reid’s opening remarks that salary differentials are a big factor. Is that fair to say?

Mr. Paul Reid

Yes, they are a factor. It is one of the few factors that are in there.

Deputy Matt Carthy

We know that, during the Covid period, particularly in the early stages when the prevalence of Covid in nursing homes had a very tragic outcome in some instances, the issue of agency staff being used in private nursing homes in particular was again a factor. Many private nursing home operators have told me that they had difficulty in that their staff were applying for HSE positions. Is there a problem with the negotiated rate paid by the NTPF? Does that encourage private nursing homes to pay their staff less? Will Mr. Reid comment?

Mr. Paul Reid

I will give a quick answer and my colleague might also answer. First, I am more than happy to be before the committee or any number of committees. We fully respect the oversight role of the Oireachtas.

Second, with regard to the issue of agency staff and private versus public costs, certainly during Covid the movement of agency staff between nursing homes was a primary factor, although we are not going into it today. We worked very closely with Nursing Homes Ireland, which is private, on reducing the movement of agency staff between multiple sites. That was one of the areas we wanted to address.

I will make a brief comment on the second point on staff applying to go from private nursing homes into the HSE. This is something we are always cognisant of in that we do not want to cannibalise the sector. Certainly, during Covid, we put very clear communications out into the system that we should not draw our resources from private nursing homes.

Deputy Matt Carthy

I do not blame staff who want to get more secure or better conditions. My point is that perhaps they should have better conditions in the private sector in the first instance.

Mr. Paul Reid

One of the findings from the expert panel review was in regard to the stability and resourcing of the sector, which are factors.

Deputy Matt Carthy

I know the HSE is dealing with a wide range of cases. If we say the average public cost for nursing home care is €1,564 and for private it is €968, what is the associated average cost of home care packages if we were to extrapolate for the patients who are in nursing homes? We would be talking about a substantial number of home care packages being required. Does the HSE have a cost as to what that would average out at?

Ms Anne O'Connor

No. Perhaps Dr. Kathleen MacLellan would know more about this. In terms of where we are at with the introduction of the interRAI system, we would have a standardised assessment. The Deputy is right that part of the challenge heretofore has been that the cost of having sufficient home care for one individual has often been such that we have not been able to pay that, and it has sometimes been more straightforward for people to go into long-term residential care. The new statutory scheme will help with that and there will be a standardised assessment that will be used to guide whether people should go into home support or into residential care. I know the Department of Health has been very involved in that.

Dr. Kathleen MacLellan

We are doing some work with the ESRI on demand and financing models across home care as part of the preparation for the statutory home care scheme. That will give us a much stronger sense of the demand and the type of finance model, and linked with that has been the standard assessment tool. This means we will be able to link that with the kind of care needs across our older people, hopefully guiding people towards the different types of care.

Deputy Matt Carthy

I am sorry but I only have nine seconds left and would appreciate "Yes" or "No" answers. I take it that everyone agrees that we should move towards a more home care-based model. Regarding how this is relevant to the work of this committee, can our guests give a commitment that there is nothing, contractual or otherwise, that will result in a cost to the State from this? Private nursing homes, some of which are new, had an expectation of fair deal scheme revenue but that might be removed if our home care strategy is successful. Can we be assured that there will not be a cost to the Exchequer if that strategy succeeds?

Dr. Colm O'Reardon

I cannot see how that could happen. If we look at the demographics in our country, it is clear that we are going to have significant increases in the numbers of older people that we are going to have to care for into the future. We are going to need every service that is available to us, whether that is residential or home care.

Deputy Matt Carthy

Thanks for that. My apologies, but I have to go now.

Chairman

We will move on to the second Fianna Fáil speaker, Deputy Devlin, who has cúig nóiméad.

Deputy Cormac Devlin

I welcome all of the witnesses and thank them for their attendance and for their ongoing co-operation with the various Oireachtas committees, which is greatly appreciated. I also thank all of the staff of the HSE and the Department of Health for their efforts in the fight against Covid-19.

I wish to take up some of the points made earlier on costs. The breakdown of the 550 nursing homes involved is that 80% are private and 20% are public. Of the millions of euro that are spent, is there a disparity between the care and ancillary costs for people in public nursing homes as opposed to private homes? I refer to care, equipment and activities. Are those costs covered if a person is in a public nursing home as opposed to a private one? My understanding is that all of the ancillary costs in private nursing homes are paid for by residents or their families.

Ms Anne O'Connor

The Deputy is correct in terms of some costs. There is a concern, and there is some legitimacy in that concern, that people in public nursing homes may receive ancillary services. This relates, in particular, to some of the social and therapeutic activities as well as to other equipment, aids and appliances that are probably more readily available. This is not true in all cases and it is important to note that there is a perception that people in public homes receive significant amounts of therapy, which is not actually the case. Anyone awaiting a therapy appointment will be aware of the significant waiting times, regardless of where a person lives. We also know that, in some private nursing homes, people are charged for a range of different ancillary supports. I am not familiar with the situation in every nursing home because, as the Deputy said, there are more than 500 of them but there is a perceived inequity there. The expert group is looking at that issue. We are looking at the range of supports available. Some supports are available to everybody regardless of where they live. For example, GP and pharmacy supports funded under the scheme are available to people regardless of where they are living. There may be some inequity but it is not necessarily as pronounced as may be perceived in some areas. A lot is dependent on resources.

The development of services for older people in general as part of our model around integrated care and community-based networks will, hopefully, support everybody in a better way and that is the direction of travel for us.

Deputy Cormac Devlin

Is Ms O'Connor saying that the value for money group is going to examine that issue, along with other issues in terms of the disbursement of the NTPF money? I invite Dr. O'Reardon to come in on this as well. Nursing Homes Ireland has called for an independent appeals mechanism to be introduced within the fair deal negotiation process. Is that going to be considered by the value for money group?

Dr. Colm O'Reardon

A number of different pieces of work are going on simultaneously. The value for money review is a formal process run under the auspices of the Department of Public Expenditure and Reform. There is a commitment under the programme for Government to examine the issue of additional charges in nursing homes. The issue was looked at recently in collaboration with the Competition and Consumer Protection Commission, CCPC, but there is a further commitment to go back to it under the programme for Government, so we will be moving on with that work.

Finally, the NTPF has statutory responsibility for dealing with the negotiation of charges. That is its role. A review of the pricing negotiation mechanism was recently completed and we are hoping to publish it shortly.

Deputy Cormac Devlin

Did Dr. O'Reardon say that the review has been completed?

Dr. Colm O'Reardon

Yes.

Deputy Cormac Devlin

In regard to the expenditure of €969 million, Dr. O'Reardon indicated that, with 24,000 residents this year, that figure would hit more than €1 billion. I acknowledge the comments by the HSE witnesses regarding the 80:20 split as between public versus private provision. In terms of agency staff costs for the HSE, there seems to be an inequality - if one wants to call it that; disparity might be a better word - between public and private nursing homes. I hope that will be addressed within the work of the value for money group or in any of the other reports that are being done. There is a perceived inequality in this area and that needs to be addressed. Certainly, in terms of the staffing costs detailed in the report of the audit by the Comptroller and Auditor General, the sheer volume of agency staff being used needs to be addressed because it is going to drag up those costs. Ultimately, the public is paying for it.

Deputy Jennifer Carroll MacNeill

I thank the witnesses for attending the meeting and for the work they have been doing over the summer. I have seen some of them at meetings of the Special Committee on Covid-19 Response. It is very good to see Dr. O'Reardon at this meeting today.

I want to focus on the cost of providing nursing home and long-term residential care services to people with dementia. Some 7,500 people are diagnosed with the condition every year and that number is increasing as a result of better detection and awareness and also because people are living longer. Dementia is a terminal illness and some 25% of people admitted to hospital have the condition as part of their presentation. While we want people to be cared for in their homes in the long term as far as that is possible, we recognise that residential care is an important part of dementia care at different stages of the treatment of the illness. It is a very particular and more expensive type of care because of the nature of the additional social care that must be provided and the different presentation and profile of people in residential care focused on dementia compared with other forms of residential care. I would like to hear the witnesses' thoughts on that before we discuss more specific issues. What is the cost of providing long-term residential care for those with dementia as his or her primary illness compared with the cost of care for other people in long-term residential care?

Ms Anne O'Connor

I do not know whether the Department has a specific cost breakdown for residential care of people with dementia. When it comes to dementia, the cost of care does not necessarily reflect dependency rates. We know that many people in long-term residential care have dementia and it has become a much more prevalent condition courtesy of the ageing population, etc. Caring for people with dementia has become more of a business as usual thing. As the Deputy correctly said, the dependency level of those residents is higher.

Deputy Jennifer Carroll MacNeill

What does Ms O'Connor mean by "more of a business as usual" thing?

Ms Anne O'Connor

Many years ago, people with dementia were viewed as being very complex cases and were often harder to place in residential care whereas now, given the population profile, all nursing homes cater for people with dementia. There are people who present with very challenging behaviours associated with dementia and not all nursing homes can cater for them. In addition, there may be higher staffing ratios associated with residents who have more complex needs. I do not have a breakdown of costs relating specifically to people with dementia in residential care.

Deputy Jennifer Carroll MacNeill

It is not just about challenging behaviours. The provision of good care for people with dementia is about providing a more proactive, socially focused form of care. Such provision is necessarily more expensive because it requires more day-to-day attention than in the case of somebody with a long-term illness who may be bedridden for a long period. It is not just about challenging behaviours or complexity. How is the HSE anticipating the cost of caring for people with dementia in residential care and why can that specific cost not be distinguished? Some residential care centres are devoted to dementia patients. Why can a distinction not be made as to the particular costs associated with the provision of dementia care?

Ms Anne O'Connor

We do not have a breakdown of costs based on dependency within nursing homes as part of the overall cost figures. The departmental officials might have some information in this regard.

Deputy Jennifer Carroll MacNeill

Do the departmental witnesses have any information on this point?

Dr. Kathleen MacLellan

We do not have a breakdown of those costs. The standard assessment tool, which we already referred to, might be helpful in this regard. It will provide us with a much better and more structured and objective approach in the assessment of care.

The Deputy is absolutely right that people with dementia have very specific, bespoke needs and need a person-centred approach. The standard assessment tool involves a number of assessments including frailty, cognitive assessment and the ability to live at home with certain supports or to have to go into longer term care. Once we start moving with that, and there are commitments in the winter plan as we move into 2021, it will really help us provide much stronger, focused care for those with dementia.

Deputy Jennifer Carroll MacNeill

Am I correct in understanding that the Department and the HSE recognise that the cost of providing dementia care is different from that relating to other forms of residential care, partly because of the social presentation of someone with dementia?

Dr. Kathleen MacLellan

It is very difficult to make a general statement. We recognise that the care needs of those with dementia vary because people are at different stages and have different types of dementia. Their care needs will change the type of dependency model needed. We have a dementia strategy-----

Deputy Jennifer Carroll MacNeill

I am aware of that and of the recent improvements, which I acknowledge. However, take St. Joseph's in Shankill in my area, which is facing significant funding issues. That is my concern. It is linked to the overall funding structure, the NTPF and the nursing homes support scheme process, and the appeals mechanism relating thereto. In the 17 seconds I have left, I want to distinguish this as a particularly significant issue, given the profile of people and the presentation and increasing diagnosis. I would ask that particular attention be paid to this matter.

Mr. Seamus McCarthy

When we looked at the negotiation process with private nursing homes, we saw some evidence that dependency was a feature of the negotiation process but we were unable to identify the specific contribution that made to the price that was finalised. There will probably be an opportunity to discuss this with the NTPF when its representatives come before the committee in two weeks.

Deputy Jennifer Carroll MacNeill

I am looking forward to it.

Chairman

We are awaiting some replies to questions from Deputy Catherine Murphy whenever the witnesses in the other room are able to provide them. In the interim, we will continue with Deputy Verona Murphy.

Deputy Verona Murphy

I reiterate everyone's appreciation for how the HSE has acted throughout Covid. From what I hear and have read, it is clear that the NTPF does not have an appropriate model or process in place to determine fees or compare costs relating to nursing home care. Ms O'Connor said that the costing disparity depended on a number of factors. She referred, in particular, to the east-west costings and the fact that it costs more depending on the part of the country. Is that correct?

Ms Anne O'Connor

The cost of care is set on the basis of staffing costs and environmental and infrastructural challenges relating to staffing or other factors, such as cleaning. There is a difference between east and west in those costs.

Deputy Verona Murphy

I come from County Wexford, which has a significant amount of private provision compared with public. I do not understand how a public bed in Wexford that is within 15 km of the closest private bed costs a little short of €1,600 where the private bed costs €910 under the fair deal scheme. There should not be any disparity in the calculation of the cost of providing the service. The facilities in question are within 15 km of each other and the staffing issues relating to both are similar. It is not easy to get staff in the sector.

Ms Anne O'Connor

There is also the occupancy rate of the units.

Deputy Verona Murphy

The occupancy rate is relevant. I have looked at that because I am personally in touch with all of the nursing homes, private and public, particularly in the context of the Covid-19 pandemic. I am greatly concerned that the Comptroller and Auditor General, over a period of time, has highlighted the issues with the regard to funding and support for nursing home residents. There seems to be a dire need for scrutiny because the disparity in care provision is growing.

With respect to Deputy Carthy and the point that there may be an inclination to move to care at home, I am one of a family of 11 looking after my 83-year-old mother in a home environment. I can say that that is not a model that anybody will be moving to because 24-hour care in a home setting involves almost 20 people in the course of a week. I cannot see how that model would be suitable for many. Much of the equipment used in home care requires two people to operate it, so I do not want people in this country to be under the illusion that funding will be provided or that value for money will be delivered in providing care in a home setting. I do not believe that and it should not be intimated.

The review of the fair deal scheme was published in 2015. Can Dr. O'Reardon provide the committee with an update on the status of the pricing review? It was previously stated that the review would take 18 months to complete. Are we any closer to completion of the pricing review?

Dr. Colm O'Reardon

We recently completed the pricing review. It is now with the Department and we are looking at it. I have a couple of things to say. The difference between the public setting and the-----

Deputy Verona Murphy

Sorry, but before Dr. O'Reardon moves on, I wish to clarify something. When he says the Department is looking at it, does he mean the review is complete?

Dr. Colm O'Reardon

The review is complete and we need to analyse it and bring it to-----

Deputy Verona Murphy

What does the analysis involve? If the review is complete, has the analysis not also been completed?

Dr. Colm O'Reardon

The review is quite a technical piece of work, so the Department needs to look at it and brief the Minister on it and take him through it.

The difference between the price in the public and private care settings is long established and has been there since the scheme was introduced.

In terms of the direction of policy, it has been the policy for a long time to work to develop a statutory home care scheme. The two things are not mutually exclusive. We think we will have to continue to provide residential care into the future and it will always be part of the suite of policies that exist in this area. However, there is an urgent need to work ahead and develop the statutory home care scheme to ensure we are providing the maximum amount of care with the maximum value for money.

Deputy Verona Murphy

The maximum value-----

Chairman

Sorry, Mr. Paul Reid wishes to make a point.

Mr. Paul Reid

I will be brief. Every circumstance is different and obviously I cannot comment on the case of the Deputy's family. However, the direction that we see ourselves going in is home care. It is much more beneficial, with the right supports and enablement in place. From our perspective, long-term care settings provide a good service, but our experience is that providing the service at home for as long as possible is the right thing to do. That is the line of flight we are heading towards with Sláíntecare, and it is where we want to provide more support in the future.

Deputy Verona Murphy

I appreciate what Mr. Reid is saying. However, when one looks at the issue from a public purse perspective, as the committee is doing here, it has taken a long time to develop a strategy that deals with the disparity in care provision. For example, €23 million of extra funding was provided in 2018, as the Comptroller and Auditor General may wish to confirm. There was an increase in funding of 26%, whereas the costs in the private sector in the same year increased by 11%.

Mr. Paul Reid

I was merely commenting on the strategy around home care.

Deputy Verona Murphy

I appreciate that the review has been completed. Is there any indication of a timeline within which we will see that review in the public domain?

Chairman

I ask the witness to answer briefly, as we are out of time.

Dr. Colm O'Reardon

We will bring it to the Minister. We need to be cognisant of the fact that the negotiations between private nursing homes and the NTPF are commercial negotiations between commercial operators on the one hand and the NTPF on the other.

It is a technical arena but is also an intensely commercial arena. We would have to be extremely careful about introducing changes into that process because we have to be mindful of value for money for the taxpayer.

Chairman

I thank Dr. O'Reardon. At this point, I will bring in our remote witnesses, Mr. Stephen Mulvany and Mr. Ultan Hynes, to answer questions asked by Deputy Catherine Murphy earlier. I hope we have the audio connection now. I ask the witnesses to try to keep their answers concise and defined.

Mr. Stephen Mulvany

I apologise if the committee has already covered some of the Deputy's questions. She asked about the value for money review and the publication date. I believe the Secretary General dealt with that question. The Deputy also asked about publication of the public cost-of-care rates. The HSE published in 2018, 2019 and in February 2020. There was an issue in 2018, as referenced in the report, when there was a 3% difference caused by pay rates. The rate that was being used was different from the rate that was published. The key point, which is set out clearly in the Comptroller and Auditor General's report, is that this had no bearing on the actual contribution that individuals had to pay. They were not impacted by that.

Reference was made to a single financial system. I think there is some confusion there. There is a system that our nursing home support officers use to gather and process applications and payments for the fair deal scheme. That is a single system, although we are working to make improvements to it and we have made some improvements to it and the processes. Separate from that, there is a reference in the report to the HSE's own finance and procurement system. The HSE is implementing a single national system and that will take some years. We would expect 80% of the entire public health system, including large voluntary organisations, to be covered by 2024. These are two separate but related elements. While this is, as the report states, causing some additional complexity in calculating costs of care, it does not impact on the rates that individuals are contributing to their care. We have implemented processes to try to improve that, pending the single national financial system. That will make it more straightforward but there are other issues that my colleagues have referred to, including the safe staffing framework and the assessment of complexity, which are as important as the issue of the cost piece of it. The value for money report will provide an opportunity to bring those matters together and to see what the structural reasons are public and private might be different. The issue of the rural piece has a relevance, but staffing related issues and the complexity of care will be the predominant factors.

We make no apologies for the fact that we have public servants running these units. They are on public sector terms and conditions. In some cases, we have a different ratio of staff to patients than in private centres. In some cases, this is clearly appropriate, given the dependency levels. We also have different ratios of qualified nursing personnel to unqualified healthcare assistant personnel. Typically, we have different clinical supervision at nurse management levels, which is also important.

The value for money report is the best opportunity to use real data to say which of those disparities are justifiable and should continue, and if there are any on either side that need to be worked on.

I will leave it there unless there are obvious points I have missed.

Chairman

Does the Deputy wish to make a further comment?

Deputy Catherine Murphy

I have absolutely no issue with people being employed on good terms and conditions but we have already heard that there is a deficiency of information for making a comparison. Can Mr. Mulvany honestly say that a comparison can be made when we do not have the full information on conditions and the ratio of staff? How can that comparison be made when we do not have the information and how can Mr. Mulvany be sure of what he is saying?

Mr. Stephen Mulvany

That is the purpose of the value for money review. The Secretary General has addressed the information issue. There was difficulty in getting information. The HSE has certainly provided all the information it has been asked for, as far as I am aware.

The HSE understands that an agreement has been reached with Nursing Homes Ireland about private nursing home data. Deputy Catherine Murphy is absolutely correct that it is only when comparable, quality data are compared to a process that has an independent chair, which this process does, that we will end up getting real understandings as to which of the differences are appropriate and which may need to be adjusted over time.

Chairman

Deputy Munster has joined us. She is very welcome.

Deputy Imelda Munster

I want to touch on the scope of care that is to be provided under the scheme. The legislation states that all nursing homes participating in the scheme, whether public, private or voluntary, must provide the specified services within the contract payment amount and at no additional cost to the care recipient. The services included are outlined on page 25. One of these is nursing and personal care appropriate to care needs, along with standard appliances needed to assist with daily living. I wish to raise the issue of private nursing homes charging for incontinence wear. In the report that was furnished to the committee, the sample of contracts stated that one of the nursing homes was charging €61 per box. The HSE supplies these free of charge. If additional wear is needed, that would normally be provided. Residents are actually being charged twice for the same thing. These charges appear to involve breaking the law. Would I be right in saying that?

Mr. Paul Reid

I will make a few general comments. The report clearly brought out the scope of services, where they differentiate and what happens in the public services. Ms O'Connor has-----

Deputy Imelda Munster

On the issue of incontinence wear, they appear to be breaking the law.

Mr. Paul Reid

Not in terms of policy.

Dr. Kathleen MacLellan

I cannot comment on breaking the law, but our residents are entitled to a certain supply of medical products for those who are medical card holders. It would certainly be our expectation that this would be provided-----

Deputy Imelda Munster

If nursing homes are charging residents for the same thing twice, it is in breach of the contract of care and the provision of care and it clearly involves breaking the law.

Mr. Paul Reid

For completeness, Mr. Hynes is on camera now and he deals with this specifically. Perhaps he will comment.

Chairman

We cannot hear Mr. Hynes due to audio issues.

Deputy Imelda Munster

Am I correct in stating that the Nursing Homes Support Scheme Act is law and places matters on a statutory footing?

Dr. Kathleen MacLellan

Perhaps these are issues for the Competition and Consumer Protection Commission if people are being charged for costs that have----

Deputy Imelda Munster

On the issue I have outlined, if the Nursing Homes Support Scheme Act is law and places matters on a statutory footing and if a home is breaking the terms of the Act by charging a person twice for the same thing, is that not illegal?

Dr. Kathleen MacLellan

If somebody is being charged twice-----

Mr. Stephen Mulvany

Perhaps I could comment. What is outlined on page 25 of the Comptroller and Auditor General's report is clear in that it is standard aids and appliances to assist with daily living. Incontinence wear is part of that. The HSE provides standard levels of assessed need for incontinence wear to residents in public and private nursing homes. The issue is when additional incontinence wear may be required and whether this is charged for. It is charged for on the public side. Making it an additional charge for something that is not covered under the contract is not a breach of the contract. The question is whether the HSE charges for such additional incontinence wear over and above the standard.

In some or most cases, it does not. As colleagues noted earlier, that needs further examination. I do not believe the private nursing homes are breaking the law by levying a charge for something that a standard contract does not require them to provide. Were they charging for something that a standard contract did require, that would certainly be a breach of the contract. I hope that is clear.

Deputy Imelda Munster

Would Mr. Mulvany not consider incontinence wear part of personal care? The HSE clearly does so in the public nursing homes and if it is provided free by the HSE to both private and public homes, why are private nursing homes charging additional costs? Is that not a breach of the Nursing Homes Support Scheme Act?

Mr. Stephen Mulvany

Maybe I have not made myself clear. The report states that a standard assessment is carried out. As I understand it, though colleagues may have better information on this, that assessment looks at the incontinence wear requirements of residents in both public and private nursing homes and the HSE provides that free of charge. From time to time, there may be an additional requirement for incontinence wear. That is outside the normal contract and therefore a charge may be levied by the private hospital. In practice, I understand the HSE does not levy an additional charge in most cases. That is the issue. It is one of disparity as opposed to breach of contract.

Deputy Imelda Munster

On page 39 of the report, there is no reference to the charge for incontinence wear only being for additional incontinence wear, where it is needed. There is a charge of €61 per box. If the incontinence wear is being supplied free of charge right across the board, then that charge is in breach of the Act.

I will move on to-----

Mr. Seamus McCarthy

To be clear, the representative of the HSE has explained that the charge is for an additional requirement for incontinence wear.

Deputy Imelda Munster

Does it state that specifically in the samples of contracts that were examined? I refer to the charge of €61.

Mr. Seamus McCarthy

The provision of incontinence wear is not actually part of the contract for care. It is a separate provision by the HSE.

Ms Anne O'Connor

It is based on assessed need. The contract provides for incontinence wear in line with the assessed needs, which are set by the HSE. If it goes above the perceived or actual assessed need, a charge is applied by nursing homes.

Deputy Imelda Munster

It is €61 per box.

Mr. Seamus McCarthy

That is what was specified on the particular contract we looked at.

Deputy Imelda Munster

I refer again to the contracts of care. The report states: "Additional fees for increased dependency are therefore not allowed for Scheme-supported residents" and that "five of the six private nursing homes’ contracts of care reviewed included provisions for possible increases in charges if the resident’s level of dependency changed". Is this something that is clearly being flouted?

Ms Anne O'Connor

Is the Deputy referring to the dependency levels?

Deputy Imelda Munster

The report stated that five of the six sample contracts examined included a reference to a change in fees if a resident's dependency level changed but under the actual Act, additional fees for increased dependency are not allowed for scheme-supported residents.

Ms Anne O'Connor

Again, I do not-----

Deputy Imelda Munster

That is clearly flouting the Act. I am asking about this because we are paying these private nursing homes €649 million per year and it is clear that people are being charged when they should not be. I could cite incidents of charges right across the board, from bedsore creams to prescription painkillers to wound dressing. All of these charges are being made. Where is the oversight? We are paying €649 million of public funding per year and it is clear in this case that additional fees for increased dependency are not allowed. Five of the six contracts examined stated that there was room to change those fees. Where is the oversight?

Dr. Kathleen MacLellan

It might be worth clarifying that the negotiation of the fees is between the NTPF and the individual provider and those contracts are under an ongoing-----

Deputy Imelda Munster

That is fair enough.

Dr. Kathleen MacLellan

That is where that type of change is made.

Deputy Imelda Munster

It is in breach of the Act if the costs are changing based on the patient's level of dependency. Whether that is the NTPF or whoever else, public moneys are being paid and the Act is not being adhered to.

Are laws being broken here?

Mr. Seamus McCarthy

The contract has a clause stating that there may be additional charges. Nursing homes may be using a single form of contract for both scheme and non-scheme patients. For a non-scheme patient, if the dependency rate increases then the charge may be increased. The difficulty we had with it is that that is not allowed for a scheme patient but there is some confusion because the contract a scheme patient has with a nursing home actually states that there may be additional charges. It is confusing and that kind of confusion is unnecessary. It should not be a great onus on a nursing home to produce two different kinds of contracts, one of which states quite clearly that there will not be additional charges. That is the point to which we were trying to draw attention.

Deputy Imelda Munster

There is no oversight. A family may not know that they are signing a contract stating that the charges could be changed depending on the level of dependency.

Mr. Seamus McCarthy

Exactly, and because it is in the contract, if there is a change in dependency the nursing home might say that it is clearly there and try to collect extra fees. It is unsatisfactory-----

Deputy Imelda Munster

To say the least.

Mr. Seamus McCarthy

-----that there is that kind of confusion.

Deputy Imelda Munster

From a systems, practices and procedures point of view, this is wholly unacceptable. Can the witnesses provide a breakdown of the number of high-dependency residents in private nursing homes versus public ones? Do they keep a record of that at all?

I refer to medical card charges. Pensioners have an entitlement to a medical card whether they are in a private or public nursing home, though people predominantly raise the private ones with us. If a pensioner is ordinarily resident in the community, he or she is entitled under the medical card to get-----

Chairman

The Deputy has gone over time.

Deputy Imelda Munster

-----free wound dressings, prescription painkillers, incontinence wear and so on, and even physiotherapy or speech and language therapy. However, if the pensioner is in a nursing home, he or she is not entitled to those things. Where is the breach there? These people are ordinarily entitled to such things-----

Chairman

We have gone over time.

Deputy Imelda Munster

-----under the medical card but as soon as they go into a nursing home, they are charged for those basic things.

Chairman

I ask that the HSE and the Department reply to Deputy Munster's final two questions in writing.

Deputy Imelda Munster

The last question requires a longer response because the issue has not been addressed and has been allowed to continue for years.

Chairman

I understand that.

Deputy Imelda Munster

Briefly, are the witnesses aware of the breakdown of high-dependency residents in public or private nursing homes?

Chairman

With respect to Deputy Munster, I have to be fair to the rest of the members present. I ask that those two questions be replied to in writing, by the HSE and the Department's Secretary General. I call Deputy McAuliffe.

Deputy Paul McAuliffe

I welcome the witnesses, particularly those I saw only a few days ago.

I ask the HSE and the Comptroller and Auditor General to comment on the differential between the value placed on a property and its sale price. Often, the value is set when a placement is made, but at the time of settlement or after the person has passed away, the value may have changed. Has the HSE lost out in some cases because there has been an uplift in the market since the value of a property was originally set? Equally, are there collection issues for properties where the market has gone the other way? Many families feel they are paying a far higher percentage than the 15% outlined in the scheme because their properties were valued at higher rates and then sold at lower ones.

Mr. Seamus McCarthy

The representatives of the HSE might want to comment on that first.

Mr. Paul Reid

There is a period of time for the settlement. That is set out in the Act and is what we would progress. There are swings and roundabouts when it comes to valuations.

Deputy Paul McAuliffe

I refer to cases where the sale value might have been settled in 2007 or 2008 and when the property was sold in 2011 or 2012, it would have realised a price substantially lower than the value which had been put on it. In that case, the person would pay much more than the 15% of the value when the property was sold. Equally, if there is a significant uplift in the market the HSE may be losing out, getting a lower percentage of the final sale price.

Mr. Paul Reid

There are fluctuations, variations and swings and roundabouts in different scenarios. Unfortunately, we cannot call to the meeting Mr. Hynes, who deals specifically with this.

Deputy Paul McAuliffe

Perhaps Mr. Hynes would come back to me.

Mr. Ultan Hynes

After a valuation is made of a property, we do not make further adjustments to it for financial contributions. On the sale price -----

Chairman

The quality of the sound from the other room is very poor.

Deputy Paul McAuliffe

I am happy to receive a written reply. It unlocks my second point, that is, if we are dependent on the market, is there a need to review the scheme to see if settlement can be made far earlier? I suggest this because there is a difficulty with housing. Selling the home at any point is an emotional issue but it often happens when the person passes away. Is there any way that, if the scheme is being reviewed, financial incentives to promote the sale of the home while the person is alive could be put into the contract?

Mr. Paul Reid

A review would be a policy issue.

Mr. Seamus McCarthy

There is an option for the person who takes the loan to settle it at any time. He or she can move and opt for that. It could be that, when people go into a nursing home, they want the security that their homes are still there for them, but two or three years on they might decide to go ahead with the sale. At that point they can settle the loan that is outstanding.

Deputy Paul McAuliffe

Many people are fearful of the fair deal scheme and its legal complexities. I do not think it is easily understood and there is no incentive to sell earlier.

I referred to the financial products that are often called life loans. They are sold by banks that provide a lump sum but there is no capital or interest repayment during a person's lifetime. It is a punitive product that often results in very significant repayments. I have seen the HSE view that differently for different people in the fair deal scheme. In some cases, it has been taken into account in the calculation of the 15% and not in others. I believe it is equivalent to a mortgage and should be taken into account.

Mr. Paul Reid

This is a matter that might be answered by Mr. Hynes, who is in the other room, if we might bring him in here. It would help the committee.

Chairman

The connection is not good enough. We would like Mr. Hynes to join the meeting physically in this committee room.

Deputy Paul McAuliffe

I am happy to wait for an answer, as Deputy Catherine Murphy did.

Deputy Colm Burke

I thank the witnesses for their submissions and the work they are doing on these cost-benefit and value for money analyses. There have been questions comparing public and private provision already. Between 2010 and 2018, the cost of public nursing home provision increased by 26% while the private sector increased by 11%. The 2018 figure was €1,564 in public and €968 in private. The €1,564 is to cover the day-to-day running costs of a public nursing home whereas the €968 that the private nursing home collects includes part of the repayment for the capital cost. It is only a small part but the private sector has to pay for the cost of providing the building whereas in the public sector, that is absorbed into the HSE budget. Therefore the discrepancy is far higher. Why was there a 26% increase in public sector costs in the eight-year period and an 11% increase in private sector costs?

From the report, the HSE indicates that the total operating cost of public nursing homes for 2018 was around €590 million. A total of €320 million was from the fair deal scheme and €68 million from residents' contributions. Can I get clarification on that?

Another member raised the matter of dependency. When someone goes into a private nursing home, he or she may be able to get up and walk around, but as the years pass, the person's dependency increases. Is there a review of that dependency and is it built into the cost that the private nursing home must accommodate? There is a change from the first day a person arrives in and, say, three years later.

Can we get a better system for step-down facilities? If we want to develop home care, we must have step-down facilities. We find time and again that someone who is in a hospital and ready for discharge after five days is still occupying a bed six weeks later in the same hospital. What is being done to develop step-down facilities? What can be done immediately to do that? It is the biggest cost factor in the HSE. Recently, I dealt with someone who had a stroke and was still occupying a hospital bed 16 weeks later despite being ready for discharge.

Mr. Paul Reid

I will respond to the first and last questions. On the difference in increases between public and private costs, we are very anxious that the value for money process helps to address that and brings out the different drivers of costs. That will be one of its valuable outcomes. We summarised what we believed were the significant variations - staff related, which can be significant and involve the different mix of staff allocated between the two; the complexity of care, which can differ across public and private providers; and similarly the dependency level.

Deputy Colm Burke

It is 26% and 11%. They are two very different figures.

Mr. Paul Reid

That is why we undertake value for money analyses. I will ask my colleague to speak on the increased dependency and progression. On the final question on step-down care, that is something we value greatly. We see huge benefit in it as part of the Covid and winter plans. We invest significantly in it. It does help reduce costs and the burden.

It is part of Sláintecare and part of the direction in which we want to go, and we are investing more money in step-down beds.

Deputy Colm Burke

Could I get a written reply on where we are now and where we hope to be in 12 months' time regarding step-down facilities?

Mr. Paul Reid

We will be very happy to share details of what we are doing now and what we hope to do. I ask Mr. Hynes to comment on increased dependency.

Mr. Ultan Hynes

Basically, the cost of care that is agreed is for the lifetime of the person in the nursing home. I presume that is on the basis that groups of people in the nursing home have different levels of care and requirements. One person might be ready to move along, but other residents would be coming in as well. There clearly will be an assessment of a client's medical and nursing needs, but in respect of finance there is a fixed price and that is the rate.

Chairman

I thank Mr. Hynes for that reply. Deputy McAuliffe had asked questions, so we will move back two or three minutes because there were difficulties hearing the replies.

Deputy Paul McAuliffe

That was with both questions. One was on life loans.

Mr. Ultan Hynes

Life loans are potentially allowable as a deduction. If the life loan was taken out, for example, to build a conservatory onto a house, that would add value to the house and be included. If the life loan were used for a world cruise or something like that, it would not be allowable.

Deputy Paul McAuliffe

I might contact the HSE regarding the details of the cases I dealt with and then we can look at those.

I turn now to the idea that the value of the property is set at the time of placement, in the context of the realised value when the property is sold and the differential in the market value. Given that it is set in stone that it is the value at the point of placement, does that automatically allow us to put in place some incentive to allow people to settle matters early and release housing stock back into the market?

Mr. Ultan Hynes

I confirm that the valuation of a property is taken at the time of application and there is no further valuation or revaluation of the property for the lifetime of the person in care. Regarding selling the property, we need to separate out the issue of ancillary State support. People who take out a loan on a property do not have to sell their property. They can pay back that loan at any time if they wish to do so. People generally do not wish to do that because the situation usually occurs after someone passes away. There may even be a deferral. I do not think it is appropriate for me to comment on the issue of selling property.

Deputy Paul McAuliffe

Let me put it differently. Given that the valuation is set at the point of placement,-----

Mr. Ultan Hynes

Yes.

Deputy Paul McAuliffe

-----there would not be any financial loss to the HSE as a result of the loan being settled earlier rather than later.

Mr. Ultan Hynes

No, there would be none whatsoever.

Deputy Paul McAuliffe

That is great. I thank Mr. Hynes.

Chairman

We have about six or seven minutes left. I have some questions regarding-----

Deputy Colm Burke

Could I ask-----

Chairman

Yes, but very briefly.

Deputy Colm Burke

I asked about the €590 million spent in 2018, but I did not get clarification on that topic. Some €320 million comes from the fair deal scheme and €68 million from the residents in the public nursing homes, but there is a gap. Could I get a reply in writing regarding how that gap arose?

Chairman

I request that a written reply be sent to the Deputy. Regarding the costs of private-----

Mr. Stephen Mulvany

Page 29 of the report of the Comptroller and Auditor General deals with that difference, which is referred to as approximately €200 million. The largest single element of that difference is the €125 million that is the cost of our care that is not long term. Similar to the private system, our public nursing units provide long-term care, which is the subject of the fair deal scheme that we are discussing, and care for short stays, such as for rehabilitation, convalescence, etc. The fair deal scheme does not deal with those aspects, so €125 million of that figure arises from those short-stay beds.

The figure of €54 million arises from the different supports that might be provided in the public system rather than the private system, and the last portion concerns instances where units do not obtain the necessary occupancy level. We are then effectively spreading the total cost over a smaller number of beds. We do not allow that cost to hit the fair deal scheme, because that would contract the total funding available for patients and for the private sector. That is an internal matter which is managed.

The 26% referred to by the Deputy concerns the movement over time, from 2012 to 2018, in the cost of public care. That has been largely driven by changes in standards and our need to reduce the number of beds across the public system, particularly given the age of some of our units. When the number of beds is reduced, an element of the costs is fixed and that is spread over a smaller number of beds and that in turn drives up the cost.

Chairman

I have some questions on private nursing homes and the cost differential. Reference was made to geography. There is also the issue of staffing ratios. I ask the witnesses to keep their answers concise. The staff-to-patient ratio in the public nursing homes with which I am familiar is higher than that in private nursing homes. Does Mr. Reid believe the level of care is also a factor? I refer to the variation in cost around the level of care, patients being higher dependency and staffing ratios. Are those issues, along with the fact that staff having better rates of pay, major drivers of public nursing homes being more expensive?

Mr. Paul Reid

One of the elements of it is the fact that the staff are in permanent pensionable employment. The cost of pensions must be taken into account. In addition, the staffing ratios are different and the clinical mix of staff probably is too.

Chairman

Would it be fair to say that, in general, patients in public nursing homes tend to be higher dependency and have more complex needs?

Mr. Paul Reid

The four factors I summarised are staff-related costs. The fact that staff are permanent pensionable employees, the complexity of care, the higher dependency and the different skill mix among the staff explain some of the variances in costs.

Chairman

The HIQA accommodation standards were extended to 2021. They will have significant implications in terms of nursing home capacity. The stipulation in those guidelines relating to single-room occupancy will affect nursing homes in my area, such as those in Abbeyleix, Mountmellick and Shaen, as well as many private nursing homes. How many beds will be lost from the system as a result? Has that been estimated by the Department or the HSE? In some nursing homes, capacity could be reduced by 30% or 40%. Is there an overall figure for the number of beds that will be lost?

Mr. Paul Reid

We have been working with HIQA on the terms of the capital funding plan we will commit to in the coming years to get us to where we wish to be. It will have implications for us. I am sure we have worked out the bed differential but I do not have it before me. I can get it for the Chairman. One of my colleagues might have the figure.

Ms Anne O'Connor

I do not have the specific numbers but it will have a significant impact on us.

Chairman

What percentage reduction is involved across public and private nursing homes?

Ms Anne O'Connor

I do not have that figure. I will get it and revert to the Chairman.

Chairman

I would appreciate that because it is a real issue. It was a real issue four or five years ago and then it was pushed out to 2021. It will have implications for nursing homes such as those in Abbeyleix and Mountmellick.

On the component costs, they incorporate what are referred to as additional services in private nursing homes. There is an issue around access to allied staff in public nursing homes. Typically, patients would have access to chiropodists, physiotherapists, occupational therapists and speech and language therapists. Some residents of private nursing homes have to pay for such services whereas they are available free of charge to residents in public nursing homes. What is the situation in that regard?

Ms Anne O'Connor

Some of our units provide such services. For example, residents of St. Mary's Hospital in the Phoenix Park have access to all therapies, but it is more than just a long-term stay facility. Not all public nursing homes have access to all the therapies. I mentioned earlier that there were challenges in terms of waiting times in certain areas for those awaiting any of the core therapies, namely, physiotherapy, occupational therapy and speech and language therapy. However, we know that there is a difference. In some areas there is no doubt that there is a difference between public and private nursing homes in terms of access to therapies. It is a piece of work that we are undertaking as part of the-----

Chairman

I also raised the issue of patients having to pay for access to the therapies. A patient in a private nursing home who may be of limited means may have to pay for the therapies whereas the services are available to those in public nursing homes, which have allied staff who provide physiotherapy, occupational therapy and chiropody. That is a serious issue.

Ms Anne O'Connor

It is.

Chairman

The operators of private nursing homes also believe it is a serious concern.

Ms Anne O'Connor

It is. I would not want people to think that people in public nursing homes have ready access to all of these therapies either because that is not the case nationally. There is a significant difference in different areas depending on the resource available. I would say, though, that as part of our development of our community health networks and our integrated care teams for older persons, and certainly based on the learning we have had from Covid with our Covid response teams, we are developing that view. Certainly, as part of the implementation of the expert group, it is something that we are going to prioritise in terms of examining what is available and how we can support populations regardless of where they live.

Chairman

We are up against the finishing line, unfortunately, but I would appreciate a reply in relation to the estimated reduction in capacity. The number of elderly people in the country is increasing. If the regulations result in a reduction in capacity of 35% by 2030, that will have huge implications for nursing homes and the care of the elderly. We need to be on top of that.

Dr. Kathleen MacLellan

In relation to the capital programme and our ongoing considerations, it is very important to recognise as well that we need to look at the impact of Covid and the additional requirements that we would not have had a year or two years ago in relation to infection prevention and control. That is also going to have an impact on our capital programme as we move forward on our deadlines around 2021.

Deputy Verona Murphy

Is it the witnesses' opinion that the review, which Dr. O'Reardon indicated had been completed, should be looked at as a matter of urgency as opposed to taking the position that having completed the review, we will get to it?

Chairman

That is a "Yes"-"No" answer.

Deputy Verona Murphy

Yes. I put it to the Comptroller and Auditor General as well.

Mr. Seamus McCarthy

I am not clear on the question.

Deputy Verona Murphy

A review was carried out, supposedly, from 2015. Dr. O'Reardon said it has been completed and is waiting for the Minister. Is it the witnesses' view that the review should be looked at?

Dr. Colm O'Reardon

There is a huge volume of work in all of this area. As the Deputy can understand, people have been working incredibly hard on a whole range of things in the area of nursing home residences. There is a huge volume of work that comes out of the expert panel review. This is one of those things that we look at but - I am sorry for taking up the Chair's time - we expect the NTPF to engage in a commercial way with the commercial nursing homes to drive value for money for the taxpayer. We are broadly satisfied that it is doing that.

If I am permitted one more comment, for all of us to get to a better place on this whole issue, it is important that we develop the standardised assessment tool so that we have a better understanding of the level of need in the community and dependency of nursing home residents in whatever setting they are in. That is a fundamental piece of work that we have to do, both in terms of public and private nursing homes and also the statutory home care scheme. If I was to identify one important piece, I would say that is the thing that will help us to get to a better place in this conversation.

Deputy Verona Murphy

I thank Dr. O'Reardon.

Chairman

We are up to the finishing line. I thank our witnesses for joining us and the information they provided for today's meeting. I sincerely wish them the very best in dealing with the unprecedented challenges in the months ahead. We experienced the effects of some of those challenges today with the technology and our apologies for that. We will seek to improve that. I also thank the Comptroller and Auditor General and his staff for attending and assisting the committee today. It is proposed that members request the clerk to the committee to seek follow-up information and carry out any agreed actions arising from this meeting. Is that agreed? Agreed.

The witnesses withdrew.

The committee adjourned at 12.14 p.m. until 4.30 p.m. on Wednesday, 7 October 2020.