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Dáil Éireann debate -
Thursday, 9 Nov 1989

Vol. 392 No. 9

Health (Nursing Homes) Bill, 1989: Second Stage (Resumed).

Question again proposed: "That the Bill be read a Second Time".

Deputy Wyse is in possession.

Before we adjourned for lunch I was dealing with the legal aspect of section 5. I am worried about this section and would ask the Minister to consult his legal advisers on it. It will certainly help the people running nursing homes who are not prepared to comply with regulations, so that old people could be living in danger. We all know how long appeals take, and for that reason I would ask the Minister to have another look at that section. I have consulted with a number of people who are of the same opinion, that this section should be looked at again. The Irish Private Nursing Homes Association run a good service and they are anxious about the word "licence". Because of the trouble in recent times, "licence" might not be the best word to use. I do not know why this organisation are opposing the word "licence", but if the word "registration" could be used I am sure it would satisfy the people concerned.

I do not wish to detain the House and I know a number of Deputies wish to make a contribution to this very important Bill. This is the first positive move towards regulating the position of nursing homes. I have no doubt that on Committee Stage perfection will be reached.

There are many excellent nursing homes in this country run by very honourable people providing a worthwhile service to the community. I want to pay special tribute to a number of excellent, well run, well managed homes in my health board area, which are a joy and comfort to old folk who have to be accommodated in them. The only lack there are recreational facilities. I appeal to these nursing homes as far as possible to link up with community associations. After all, to see old people sitting in a nursing home even surrounded by every comfort, but not getting the necessary recreation, is sad.

We should not be complacent. Every effort should be made to improve standards generally. Private nursing homes undoubtedly can continue to provide a very valuable service. The provisions in this Bill can go a long way towards improving the standards, and the provisions for proper licensing, proper regulations and proper management are to be welcomed. However, a word of warning. It is important that health boards should not become over-dependent on private nursing homes for the discharge of their own statutory obligations especially to the elderly who are financially vulnerable and in need of continuing nursing care.

Again I compliment the Minister and I support the passage of this Bill. I hope many of the fears and anxieties I and other Deputies have had in the past will be relieved by the Bill's enactment. I may have other contributions to make on a few aspects of the Bill on Committee Stage.

Private and voluntary nursing homes offering care for elderly persons have a long tradition in Irish society. In recent years there has been a rapid increase in the number of private homes and there is a growing demand for the kind of care they provide. As the elderly population increases the demand seems certain to rise, even allowing for better community support for elderly people at home.

It would appear from the recent report of the Commission on Health Funding that the number of beds in private nursing homes has increased from 4,700 in 1980 to 6,422 in 1986. I understand some private nursing homes do not respond to the Department of Health survey on which this data is based, so in reality the figure might be much higher.

Although not part of the State's provision for the elderly, private and voluntary nursing homes cannot be considered in isolation from public organised services. The State has a statutory responsibility to ensure a minimum standard of care in private nursing homes. This statutory obligation is provided for in the Health (Homes for Incapacitated Persons) Act, 1964, and subsequent regulations. The first set of regulations made under the Act were introduced in April 1966 but there was dissatisfaction with them and it led to the introduction of new regulations in 1985. These regulations are very comprehensive. In addition to laying down minimum standards for accommodation, food and care in the home, the new regulations have introduced stricter standards in relation to patients' records, staff qualifications, fire safety and equipment. Health boards have the power to inspect the homes regularly. In enforcing the regulations, the health boards have carried out a policy to allow time to homes in which to raise the standards as required by law and we have seen a considerable improvement in the standards of nursing homes as a result of the regulations introduced in 1985.

The report of the Working Party on the Services for the Elderly, The Years Ahead — A Policy for the Elderly, recommended that the requirement that nursing homes notify the health board one month in advance of opening should be replaced by obligations on homes to hold a licence from the health board as a precondition for accepting patients. As a result of this recommendation, we have this Bill before us today. Until now private and voluntary nursing homes can be approved by the Minister for Health for the provision of nursing services under section 54 of the Health Act, 1970.

The significance of approved status for nursing homes is that it allows the residents to claim as a right a subvention from the Minister for Health towards the expenses of living in these homes. Residents of approved homes can also claim contributions from the VHI board towards their nursing expenses. The cost of living in an approved home is also allowable against tax if the residents can benefit from a taxable income. No home is required by statute to seek approval, though it is clearly an advantage to do so because of the great financial flexibility which it confers on residents. This is reflected in the fact that over three-quarters of the homes interviewed in the study carried out by the National Council for the Aged in 1986, report No. 13, had applied for approval. It is notable that private homes are more likely to seek approval than voluntary homes. This can be explained by the fact that 93 per cent of the voluntary homes which did not seek approval do not classify themselves as nursing homes but rather residential or retirement homes.

Not all the homes which sought approval for the provision of nursing care under section 54 of the 1970 Act had been successful in gaining approval. That is not a direct result of any concern about the standards of nursing care in the homes seeking approval but rather a reflection on the State's financial restraints. Approval of homes led to increased demand for State subvention which, in the current climate of cutbacks and financial rectitude, cannot be met by the health boards. As a result, no new approvals have been made by the Minister for Health since 1980. The refusal of the Minister to approve any new homes is unfair to elderly persons who require a subsidy but are unable to find a place in an approved home.

The daily rate of subsidy for patients in approved homes on 1 July 1989 was £6.78 per day. While people are entitled to this subsidy under the law, in reality, they do not always get it. The Eastern Health Board carry out a means test on an applicant for the subsidy, and I understand they have run out of funding for such subsidies. The principle of subsidisation of elderly patients in private nursing homes is justifiable, I believe. The existence of a subsidy enables those with some private means to avail of nursing home care and is, therefore, cost effective as it relieves the State of the greater expenditure which would be required if it had to provide additional public facilities.

The Commission on Health Funding were of the view that the present arrangements for subsidisation of patients was neither equitable nor efficient. I support the working party's recommendation that section 54 of the Health Act, 1970, be amended to enable health boards to subvent the care of elderly patients having complied with specified assessment procedures in nursing homes licensed by the board and to enable the boards to vary the level of subvention according to individual means. They concurred with the view of the working party that a subsidy should be paid only in respect of patients who had been assessed as being in need of residential care and that there should be scope for varying the level of subsidy to take account of the degree of financial and medical dependency of the patient. In this Bill the Minister has taken on board this recommendation and will, by ministerial order, determine the amount payable.

From time to time public representatives are approached by relatives of people who are patients in acute beds and who are under tremendous pressure, to have the patient — a parent, perhaps — removed from the hospital. Often, due to the circumstances of the case, the relatives are not capable of looking after the patient because of the medical care required and they have no option but to place him or her in a private nursing home. I hope that when the Minister is making the regulations he will set out guidelines — similar to those for a medical card — as to entitlement under the subvention. I see a difficulty here because it is not only the financial circumstances of the patient that have to be assessed but also the patient's dependency. I note from the Minister's speech that he is proposing a payment for three categories of physical dependency. While I accept fully that the Minister is endorsing the working party's report and also the report of the Commission on Health funding, a case can be made for having both types of subvention, namely where a fixed subsidy would be paid to people, with some private means, to allow them to avail of nursing care. In that way the State would be relieved of the great expenditure that would be required if it had to provide the additional facilities.

The National Council for the Aged have recommended that all applicants for nursing homes should be thoroughly assessed before admission. I am pleased to note that the working party did not accept that recommendation. They did, however, say that individuals who wished to pay the full cost of nursing care are entitled to do so and should not be obliged to avail of assessment or other services. They considered that the independence of individuals and their families must be respected. While families may not be able to pay the full amount involved, they may be able to go very near to paying it and in these cases I am asking that a direct subvention be paid towards the cost as distinct from people who would have very little means and who would not be able to pay for the services of a nursing home. There is also the question of the dependency of a patient. When admitted they might have a very moderate sense of dependency but after a number of months in hospital that dependency might grow. If agreement could be reached with the relatives at an early stage for a direct payment per day it might cost the Exchequer far less.

The elderly who are unable to maintain an independent life in the community are a particularly vulnerable section of the population. The quality of their life is dependent on the nature and quality of the care provided by those who run nursing homes. While I have no knowledge of any proprietor of a nursing home taking advantage of elderly people, I welcome the licensing system which will serve to strengthen the safeguards of patients cared for in nursing homes.

In his contribution this morning Deputy Ferris referred to the cost of the licence. The Minister will, by regulation, fix that cost. I would ask him to take on board many of the recommendations contained in The Years Ahead — A Policy for the Elderly and also the report of the Commission on Health Funding. The policy for the elderly recommends that the licence should cost no more than £10 per year. I would ask the Minister to take that recommendation on board also.

I welcome also that part of the Bill which makes statutory provision for the boarding out of patients to private homes. It is the reverse of that I would like to bring to the Minister's attention. There are many old people in our society who have gone beyond the stage of independent living, people living on their own, probably an elderly father or mother, who are a cause of concern to their families. They want to remain in their own homes but need constant daily care. There are others, mostly people who have worked as domestic servants, who find they have nowhere to go when their employers sell their houses and retire to residential homes. I understand there are families who are prepared to take such persons into their homes and look after them for a certain payment. While a voluntary organisation is operating that system at present it is a proposition that should be taken on board by the health boards. They should carry a register of people who would be capable of doing this work. I am not asking the State to put any funding into this but they could have a list of people to whom people with elderly relatives needing care could refer to.

Finally, there is a number of issues in the Bill which we can deal with on Committee Stage. The matter of appeal is one of the most important. I am glad this Bill has come before the House. The care of the elderly affects the majority of people in society at some stage. We will all be old in due course. I accept the Bill in principle and I recommend it to the House.

I, too, welcome this Bill as indeed many Deputies have done in the course of this debate. It is very encouraging to see that the language and terminology used in the Bill has changed dramatically since 1964 when we were talking about incapacitated persons. Now we are talking about dependent persons. That is the first point that must be made. The phraseology used here takes account of the dignity of the individual and deals with this problem in a most humane way. It is a new beginning. It will be a bench-mark in this whole debate on the care of the elderly and it is most timely. Most speakers from across the Floor have said that the Minister was very quick to produce this Bill. Some people even said they did not expect it as early.

I look on this Bill as a new framework for nursing homes. It is part of greater debate which is taking place on how we care for the elderly and not just those who are dependent. As soon as we pass this Bill we should move from it and develop in other areas also. We are improving standards of care in the private and voluntary nursing homes. We are also opening the doors of our nursing homes.

Many speakers today referred to individual problems in their own constituencies. Everybody was very careful to say that in 99 per cent of our nursing homes excellent care service is provided. The Minister told us that 5 per cent of our elederly are in residential care while 17 per cent are being cared for at home. This gives an indication of the contribution made by the family. In talking about what is an institutional type of problem it must be pointed out that in our country families provide a very comprehensive backup structure and support for our elderly.

The important messages from the Minister's speech is in terms of the figures he gave in relation to our population projections and in particular the demographic trend in relation to Dublin. Any of us who is involved in local politics, as well as being Members of Dáil Éireann in the Dublin area would be aware of the growing numbers of elderly people in the greater Dublin region. The Minister has given us the projected increase in this respect as 30 per cent by the year 2000. That is a tremendous challenge to us as legislators and it is important to have these figures. The Minister pointed out in referring to the census figures that in other parts of the country, particularly along the western seaboard, the numbers will decrease by 12 per cent.

The Eastern Health Board are carrying out surveys as to where the precise needs will be. They should work closely with the housing authorities in the Dublin area in this matter. The fact that people are living longer has major social implications. There is a broader apsect which relates not just to health care and there is a need to co-ordinate the role of the health boards, housing authorities and the Department of Social Welfare.

At Rathfarnham, in my constituency, we have built some accommodation for the elderly. A number of the elderly people living in this cluster of apartments asked that their residential caretaker, who was being asked to leave because of local authority cutbacks, should be retained. The new system will involve a community warden who will check on the elderly residents in various residential locations. We have a tradition of caring for the elderly. It has a different aspect in urban as compared with rural Ireland and we should maintain our high standards. Elderly people in Dublin like care, companionship and personal attention. This could be provided by a residential warden who might get the newspaper and help to light the fire. I appreciate that there are constraints on resources but as finances improve we should ensure that this kind of personal service is provided. It would be sad if we were to eliminate that kind of assistance. I am a member of Dublin County Council and my colleagues in Dublin Corporation would be more familiar with the community warden system which is to be introduced and which will have a back-up alarm system monitored from a central location. We must also consider carefully the location of new schemes. Some very attractive schemes exist in the county area.

The Minister has referred to the need for a register but if we can provide health care services and more community housing projects many more people will be looked after in their own communities. That must be the ultimate aim. I would stress that the Departments of Health, Social Welfare and the Environment should address these issues together. At the end of the day family support and care in the home is the best possible system. The Department of Social Welfare are very supportive and the Minister's predecessors have many achievements to their credit. We will not know the cost of these plans until we identify where the real needs exist. This must be established by co-ordinating the agencies involved and devising a fair system. The public will be quite happy to ensure that resources are directed towards the elderly.

We must acknowledge the contribution made by the working party report, The Years Ahead. Much background work was done on this subject and the licensing system for nursing homes was recommended. The setting up of a register is a key aspect so that we will know where all these facilities are available and what is going on behind closed doors. This information will be available to the public and we will have a review system to ensure the maintenance of high standards.

The health boards are subventing the care of people in nursing homes and the Minister is co-ordinating the work of the public and private sectors in caring for the elderly. Much has been said about the growth in the number of nursing homes. There are 332 private nursing homes throughout the country and 20 have been opened during the past year. I presume these are primarily in the Dublin area.

The Workers' Party referred to the growth in the number of private nursing homes as a worrying trend. My view is that they are meeting a demand. I presume people who are involved in property look at the demographic trend and see this as a growth area. That is a reality. The numbers of elderly people in need of care are increasing. In caring for those who are in a position to pay, the private nursing homes are ensuring that health boards will be able to care for those who are less fortunate.

I find it hard to accept the views expressed by The Workers' Party who seem to begrudge people the profits they earn by providing this service. In co-ordinating the operation of private nursing homes, voluntary nursing homes and the role of the health boards we are providing controls and a register which will ensure high standards. We should be delighted to be involved in this. That is something in which we should be delighted to get involved instead of criticising it. After all, the health boards are charging a fee for the licence to cover the cost of inspection so, in a way, it is self-financing. At present there is no system of licence or registration. The Minister rightly said today that he is not putting any obstacles in the way of anyone who wants to set up a new nursing home. The demand is there and I am sure it will increase.

We need to ensure that the development of these homes is monitored so that we are prepared to provide the resources to the proper areas. We are all in agreement that help should be given to those in greatest need. The tiered system is mentioned in the Bill and I will refer to it later. It means getting the resources to those in need. We will not find out where the area of greatest need is unless we establish a register containing information. Clearly the census figures were very helpful in letting us know where these needs are. Regulations will be laid down to govern the standards of care and the Minister covered this adequately in relation to accommodation, food and the number and qualifications of staff, which are obviously very important. I am concerned that at present somebody starting up a new home might not know how to organise the proper diet for patients under their care, having the right kind of staff and so on. This at least dispels our fears on that score.

At present the Eastern Health Board have arrangements with some private and voluntary homes under section 26 of the 1970 Act to subvent the care of the elderly. Under the present Bill all health boards can become involved in this process and those setting up nursing homes will get it right from the first day. Those running such homes will have to have a licence before they open which will have to be renewed every two years.

The Bill also provides that if a crisis arises the health board can take over the management of the nursing home. I hope that this mechanism will never have to be used but one can imagine the problems of 20 or 30 people in a home which is unsuitable if the health board could not intervene. It is provided in the Bill that they can come in with the consent of the owner and, if not, they can apply to the courts until the problem is resolved.

I referred earlier to the terminology in regard to dependent persons. Most people covered by the Bill are elderly but it also covers other dependent people in younger age groups. The key word is "dependent".

The public will be fully informed under the licensing process because licensed homes will be included on a health board register of all the homes in the area. Many people would not be aware of the location of these homes so that is a step forward. Earlier, a Deputy referred to the possibility of having the register available in the local library. I support that view because this Bill is very informative and, if it is desired that the public should be aware of its contents, the obvious place to put the register is in the public library.

The Minister talked about a partnership between the health boards and the nursing homes which is very realistic and honest. He also referred to the constant learning process for the boards and the authorities of the homes. He is basically saying that this is a new beginning, that he is willing to listen to the views of the authorities of these homes and the health boards and to monitor developments. He has been very open about the manner in which he wishes to proceed. The boards will, in some cases, provide training for nursing home staff and constant communications between health boards and the homes is a very good idea. The inspectors will ensure regular contact with the homes. The nursing home will have to be of the highest standard if they are to be granted a renewal of their licence. Expert advice will be available and this is very important to somebody setting up a home for the first time. The bottom line is to cater for the needs of the residents so that from the first day they are adequately catered for.

If a nursing home is sold and the licence expires there is the possibility of a new owner coming in who would not be very experienced. The Bill ensures that personal attention will continue, which is very welcome. The health boards can also lay down strict controls in applying conditions to a licence, particularly in regard to the need to carry out improvements to a home. Heavy penalties will be imposed on those who are found guilty of running a home without a licence but I cannot imagine anyone trying to do that. However, it was important to include this provision in case anybody tries it.

The anomalies will be cleared up in relation to a dependent person who is not able to pay for the cost of nursing care. He can now apply to the health board for subvention and the health board will assess the needs of the individual. The Minister said that the boards may arrange for support in the home and in any case there is access to any licensed nursing home for the individual if this is required. The subvention will be based on the needs of the individual. The tiered system is also welcome; there are three categories for physical dependency, light, moderate and heavy. This is why the Minister referred to the need to cater for the individual because the more dependent the person, the more costly will be the assistance.

The Minister should look at one aspect of the subvention. The Bill says that any person receiving subvention at present under section 54 will not be affected. This subvention of £6.50 per day will continue to be paid. Under the new arrangements people's entitlement might increase and, therefore they should be allowed to apply under the new system. This should be more clearly explained to them as at present it implies that they are all right and that we want to cater for others. It is important that those receiving the £6.50 per day should be encouraged to participate in the new system.

This morning I received submissions — as no doubt many other Members did — from the Irish Private Nursing Homes' Association regarding their concerns about the register and the licence system. I do not see any problem, in this area but perhaps we will put down amendments on Committee Stage. Whatever term is used — licence or register — we are talking about a greater awareness of what is happening in the private sector. We will be more aware of their contribution. I foresee the public and private sectors working hand in hand. I cannot understand why anybody in the private sector would have anything to fear.

The Minister should examine these detailed amendments because they may contain some useful proposals. No doubt his officials have had time to look at them. A learning process will be involved. I would ask the Minister to include in his consultations the Irish Private Nursing Home Association and to work closely with them. No doubt he is already doing so.

Boarding out was referred to. This is a facility catering for frail, elderly persons who do not need nursing services but who require care and companionship, which illustrates that the provisions of the Bill cover all aspects of this type of care. They widen the choice of home to those entitled to subvention. It is my belief that this Bill heralds the beginning of better care in this area.

The Minister referred also to the need for a code of practice in nursing home care and said that this would be agreed in consultation with health boards and nursing homes. He also agreed to circulate such code of practice with the regulations to be made under this Bill.

This is an enlightened Bill based on many submissions, much preparatory work, in particular that of the working party, and will constitute a bench-mark in the area of care for the elderly. Its provisions are positive in that they point in the right direction, emphasising a new attitude in this important area while allowing adequate scope for further development. In the overall area of care for the elderly I would hope that the Departments of Health, Social Welfare and indeed the Environment, through their involvement in housing, would examine closely what has been said in this House today and bear it in mind. We can be proud of what has been achieved in this area. We are now involved in an in-depth analysis, using census figures, demographic trends and so on. We must all ensure that urgent action is taken in this area within the next ten years which is what the provisions of this Bill are all about.

I welcome this Bill whose purpose, as the Minister said in his introductory remarks, is to promote the highest standards of care for dependent persons in nursing homes and so on. Its provisions provide for the proper care of dependent elderly, many of whom are disadvantaged and poor.

Yesterday The Workers' Party spent practically the whole morning calling for quorums. I notice now that, in an area in which they should have a special interest, their benches are surprisingly empty.

I do not know whether you, a Cheann Comhairle, are aware that the Minister is a neighbour of mine. I want to commend him on the initiative and caring attitude responsible for his introducing this Bill. I am very much in favour of as much participation as possible by private enterprise in the delivery of services wherever appropriate. Our experiences since the beginning of this decade should have taught us the lesson that withdrawal by the State from delivery of a particular service can be a traumatic experience for many. The Minister himself will vouch for that because, in the course of the last General Election, he was subjected to a fair degree of abuse as a result of his efforts to curtail the expenditure of his Department. Henceforth, whenever any new service is being examined with a view to its introduction perhaps the Government should be thinking in terms of diverting it to the private sector, thereby lessening Government input into people's lives which I believe to be desirable.

The private sector has responded to the remarkable demand there has been in this area in recent years. There has been a proliferation of nursing homes countrywide. The Minister said in the course of his remarks that there were 332, with something like 20 new nursing homes having been established in the past year which did not include a number looking after the elderly that might not necessarily be operating or described as nursing homes. Naturally their clientele are extremely vulnerable by the very nature of the health problems they experience and are open to exploitation. Therefore it is only correct that the Minister intervene in this area. I am not suggesting that there is widespread exploitation. Nonetheless it is correct that the Minister has intervened to ensure that their clientele are protected.

The sustained growth of private nursing homes would suggest a number of things, one being that the provision of such a service is profitable; otherwise the private sector would not have become involved. An important question to pose is: will it remain so in the future? My own experience suggests that the number of beds available, particularly in the north eastern region, is barely adequate to meet the demand. For example, a couple of weeks ago I discovered that private nursing homes in my region are unable to cope with the demand and most have a waiting list. Admittedly my research was rather casual in the sense that I was simply trying to find a bed for a constituent badly in need of one. I contacted ten nursing homes, eight of which were full and the remaining two had vacancies for one and two patients respectively. That gives one some indication of the type of demand obtaining in this area.

There is an obvious need for the expansion of nursing home services. In the course of his introductory remarks the Minister pointed out that the over 65s will slowly increase up to the end of this century and thereafter more rapidly. It is my belief that the demand for nursing home accommodation will increase at a much faster rater than the demographic changes would appear to predict. I might point to a couple of reasons therefor. One is the gradual demise of the extended family in our society and the increase in the numbers of elderly people in the future with no direct family members living nearby as a consequence of emigration. These two factors must be taken into account when assessing future needs. It will be interesting to watch how the Minister develops a policy to deal with the increased demands for the care of the elderly right across the board, not just in this area. I suspect that not alone will the introduction of this Bill ensure that proper care is afforded to the dependent elderly but it will also signal the Minister's intention to rely more and more on the private sector for the delivery of the health services. Obviously we will become more aware of this as time passes.

What will happen in the short term as a result of the implementation of this Bill? Section 6 deals with regulations in relation to standards in nursing homes. From reading those regulations, and referring back to the purpose of the Bill. I suggest that quite a large cost will be borne by many of the proprietors of these private homes. The Bill would not have been necessary in the first place if there had not been some apparent deficiencies. Will the increase in cost mean that some proprietors will decide to close their homes altogether? I suspect that that will be the case.

Staffing requirements are dealt with in section 6 (2) (b) which prescribes the numbers, qualifications and availability of members of the staff. I imagine that section 6 (2) (b) will seek to improve staffing arrangements. This section, which prescribes requirements as to accommodation, including the amount of space in bedrooms and wards, the washing facilities and sanitary conveniences, will inevitably lead to increased costs for the proprietors and more than likely will lead to fewer beds being available. If there is a fairly substantial increase in the number of beds as a result of the implementation of section 6, how does the Minister propose to deal with what could turn out to be a short term crisis in this sector of the health service? Has he any contingency plans to deal with it? I notice that elsewhere in his speech the Minister referred to the category of patient I am discussing now being cared for in rest homes, and retirement homes in some cases.

When the inspectorate apply the regulations and homes are found to be inadequate, as they may well be, a further number of people will be in need of services and obviously they will not be available. I wonder if with the implementation of section 6, we are facing a period of chaos. It seems to me that we are. I expect that as a result there will be a lot of anxiety and suffering during what we might refer to as a transition period.

The implementation of section 6 should mean that the cost per bed will increase pretty dramatically in some cases. I know from my casual acquaintance with the business that the costs to the normal person are quite substantial as they stand. Because of the new staffing arrangements and the tighter accommodation prescriptions the cost per bed will probably be outside the scope of a number of people who today may be just able to afford a bed in that accommodation.

There will be an unsettled period while implementation of this Bill is brought about and new beds are being made available. Will the health boards increase the maintenance payments for qualified dependent persons in these private homes? I understand that at present this payment is around £47 per week. I assume that with the implementation of section 6 this payment will be very inadequate. Has the Minister made provision for the increased expenditure which I believe will arise in the transition period?

Our spokesperson, Deputy Yates, referred to inspections. I understand from reading this Bill that inspections will be carried out by health board personnel. I suppose there are pros and cons in that. They know the people and homes involved, and that could be a plus in some cases, but I believe the inspections would be better carried out by personnel from the Department of Health because I imagine in that case the likely variation in standards across the country would be smaller.

The Bill does not address a number of private homes. I suppose it might have been easy to include certain other types of private homes which do not deal with the particular clientele who are addressed in the Bill. For example, the Bill does not deal with the standards which private homes which look after mainly mentally ill people and alcoholics are required to provide. It is a pity the Bill did not go that far and in one fell swoop set standards for private health services which have not been covered already.

I welcome the Bill. I hope that any problems which are likely to ensue will be brought to the Minister's notice at this stage and that on the next Stage the Minister will introduce whatever amendments are necessary to put these problems right.

I too welcome the Bill and would like to very warmly congratulate the Minister, Deputy O'Hanlon, on bringing it forward. I should also like to compliment the last speaker for his magnanimity. It is true that we cut pieces off each other in politics and do not often enough recognise the positive steps which are taken. The legislation will be welcomed by all reasonable people. To date I have received a large number of submissions on the Bill from constituents who have private nursing homes in the north Wicklow area. While many of them make points and some have individual grievances with certain aspects, none have indicated an outright rejection of the Bill. Indeed among nursing home owners with whom I have discussed the Bill there has been universal welcome That is a very positive response. The feelings of progressive nursing home proprietors were exemplified by the submission I received from Mr. Bob Willis, the owner of one of Bray's largest nursing homes. In a detailed and thoughtful submission he commences by saying that the purpose of making the submission was to reflect support for the objectives of the Bill and to underline this support to the Department of Health as emanating from independent nursing homes. Several submissions that I have received have started in that way. Like the person who made that submission, I welcome the Bill.

The placing of a statutory duty on the health boards to license nursing homes and to maintain an up-to-date register of approved nursing homes is a very welcome change in the law. It means that progressive and conscientious operators need have no fear that their efforts will be undermined by the unscrupulous. That is a positive benefit flowing from the Bill. The Bill also provides the families of persons entering nursing homes with a guarantee of standards by a statutory agency, which has not existed heretofore. However, the most important reason for welcoming the Bill is that it will assure the elderly who enter private nursing homes that their position is secure and that their interests are to be defended.

Bringing all nursing homes under a common system of licensing and inspection is obviously sensible. Indeed one is amazed that a common system has not operated across the country to date. The absence of a common system and of a uniform standard is clearly something that was causing concern to nursing home patients and their families and to us as legislators. This absence is a valid basis of complaint among progressive nursing homes owners as they feel that their efforts to provide decent standards of service are being affected by other less scrupulous nursing home owners. The most important element in the Bill is the provisions that govern the standards of care in nursing homes. The best private nursing homes are careful in every sense of the word. They and their staff are as anxious as we are to deal with the needs of the elderly in a dignified, civilised and progressive manner. Some nursing homes, however, let standards slip and sadly, a minority are careless in every sense of the word. However, in the licensing and inspection powers which the Bill grants to the health board this problem is being addressed comprehensively for the first time. In a civilised society the standard of care for the aged is an issue which cannot be over-emphasised. The provisions of the Bill, focusing as they do on the standard of care afforded to the dependent person means that this is uniquely important legislation.

The provisions made for subventions are also important. This area had become clouded and confused in recent times. The question of subvention had to be rationalised and the Bill has addressed this. Changing demographic trends and the increase in the number of aged persons, changing patterns in use and availability of beds in general hospitals, curtailment of the services of the voluntary hospital sector and the expansion of the private nursing home sector have all affected demand for places in private nursing homes for the dependent elderly. Section 7 provides a general enabling power to the health boards to contribute to the maintenance of a dependent person in a private nursing home. The level of subvention will, as a number of speakers have already pointed out, be determined by the conditions of the dependent persons and by their means. Flexibility is built in to the Bill and this will enable the health boards to vary the level of subvention on the basis of the degree of care needed. If we have scarce resources, they must be channelled on the basis of need. It is clearly better and more progressive that individual need is to be the determining factor rather than the historical availability of subvented beds.

Boarding out is an area of potential controversy. The Bill enables health boards to make boarding out arrangements for frail persons who consent to such an arrangement. There is a distinction in the Bill between the needs of a frail person who does not need nursing care and a person who needs full-time nursing care. I also welcome the fact that consent is emphasised on a number of occasions in the Bill. Boarding out arrangements are at present made by some health boards under section 61, Health Act, 1970. However, this Bill makes boarding out a specific legal option available to all of the health boards. The importance of the boarding out option is that it provides a service for the frail elderly person who does not require the full service of a nursing home but who requires a level of care which he or she can no longer provide for himself. Boarding out helps the elderly person to maintain his or her independence and to stay within his own community. Clearly boarding out could be of particular assistance in rural areas. I am aware that many kindly people in Wicklow look after their frail elderly neighbours who have no immediate family. The elderly are always conscious in these cases of the strain which they place on the resources of their neighbours, to whom they are not related, and they are occasionally embarrassed that they are not in a position to pay for this care and attention. Boarding out arangements properly operated and supervised will provide a flexible adjunct to the existing services.

There is so much that is positive in the Bill that it has been broadly welcomed by the Opposition. I welcome that but I am somewhat at a loss about a number of points raised by the Labour Party spokesperson this morning. Deputy Howlin seems to have cast himself into an ever-negative frame of mind. It is not true to suggest, as he has done, that in recent times there has been no improvement in the standard or the volume of public sector care, available to the elderly. This is certainly not the case in the Eastern Health Board area. A report circulated at the last health board meeting states that in Baggot Street hospital there are now 38 long-term geriatric beds, 21 short-term beds, a fully supported day care unit for the elderly. That is a model for the direction that health boards can move towards in the future. It is characteristic of Deputy Howlin's contribution to be slightly over the top but his inference that private nursing homes have only recently become available is patent nonsense. The 340 private nursing homes dotted around the country did not spring up overnight. The majority existed for many years and it is foolish for that Deputy or anybody else to suggest otherwise.

I will now move to more specific comments. I see the Deputy has joined us.

He missed the best part.

I was with the Government Whips and I was listening on the monitor——

I will now make more specific comments on aspects of the Bill.

Specific?

Why change the habits of a lifetime?

A number of points arise from the opening section. The Irish Private Nursing Homes Association have indicated that they are not happy with the term "licence".

Tell that to the fishermen.

At first glance it might appear that this is a small point of terminology. However, a number of nursing homes in Bray who have summarised the objections have put forward very logical reasons for the objection. They feel that the term "licence" is inappropriate. They point to the reference made by Deputy Howlin. Nursing home owners feel that an alternative wording such as "registration" or "registered nursing homes" are terms which retain the positive aspects of legal control together with a connotation of permanence. While I am not pressing this issue — I do not think anybody is pressing the issue — the Minister should look at the terminology.

Other more important points were raised. The Irish Nursing Homes Association have also raised the issue of a definition of licensing authority and have suggested a licensing authority on which the private operators, through their association, together with the health boards and Department of Health, would be represented. This suggestion was made not through any desire to weaken the control mechanism provided by the licensing authority but to ensure a uniform common standard — I think the last contributor referred to that. While it is appropriate for licensing to be carried out by the health board. The nursing home operators need not be unduly concerned in this regard. It is important that the point they make about uniformly high standards across the country is an important one and should be dealt with by regulation.

Debate adjourned.
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