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Dáil Éireann debate -
Wednesday, 7 Mar 1990

Vol. 396 No. 7

Private Members' Business. - Health (Nursing Homes) Bill, 1989: Committee Stage (Resumed).

SECTION 1.

I move amendment No. 7:

In page 2, subsection (1), between lines 26 and 27, to insert the following definition: "`records' shall mean all records excluding clinical and financial records;".

This is an important amendment. I would refer the House to section 6 (2) (g). In that section in which are stated the regulations health boards may lay down in relation to having proper standards in nursing, paragraph (g) states:

Prescribe requirements as to the records to be kept in nursing homes and for the examination and copying of any such record or of extracts therefrom by officers of health boards.

In my last amendment which was not accepted, I defined officer of the health board as "designated medical practitioner" because I believe it could be of some concern as to the definition of the records, as envisaged in paragraph (g) of section 6. Therefore, I am moving an amendment that records shall mean all records, excluding clinical and financial records. It is envisaged, under paragraph (g), that these clinical records would be photocopied — it is clearly stated that they would be copied — and that they would be taken by officers of the health board.

I do not think it is appropriate that lying around in administrative offices of health boards would be the personal, clinical and medical details of elderly patients. While there is, of course, a need for a rigorous investigation in relation to the standards of care available in nursing homes and, of course, they should be available for inspection in relation to all aspects, we should put some limit in relation to copying and the taking away of clinical records. I believe that if one wishes to make a case against a particular nursing home obviously one will have to get evidence and statements from people to say that it was unsatisfactory. I do not know if it is desirable that the personal financial details of individual proprietors would be made known to everybody. I would like to see a separate procedure in the regulations set out for the Minister so that the medical and clinical records could be inspected in some discreet way if it was found to be absolutely essential.

I consider that the provisions of paragraph (g) are excessive for these types of records because it could lead to two problems; I will put it no stronger than that. I hope people understand what I am getting at. I am not trying to stifle investigations; I am not trying to stifle accountability, but I believe what are private and personal matters should be dealt with in a different way from other records about the number of patients treated, circumstances about overcrowding, circumstances about the purchasing of food, etc. Personal financial details and secret clinical records should be as they are with any doctor-patient relationship in a hospital, reserved for a very careful eye and not just for officers of the health board.

I am not sure that the amendment moved by Deputy Yates adds clarity to the section although I understand exactly what he wishes to achieve. The amendment does not actually state personal financial records. I hope it would not be implied from his amendment that the health board would not have access to the financial records of the institution itself, if that was required. There would obviously be occasions when an individual's medical history would be looked at in relation to an assessment for assistance and also the financial support they may have.

From an earlier contribution I understood that the Minister indicated that it would be improper and that he would not envisage that a non-medical person would have access to anybody's clinical or medical records. Perhaps the Minister would reaffirm that it would not be his intention to do that and that it would be inserted in the regulations subsequent to the enactment of this Bill, that only a medical practitioner would have access to anybody's clinical or medical records. The import of what Deputy Yates wants to achieve could be achieved. It is a proposal that would exclude access to information that would be proper for the health board so perhaps it is possible for the Minister to look at the intention underlying Deputy Yates' amendment and see if it is necessary to come back with a ministerial amendment on Report Stage.

We are talking about clinical records. Deputies know that in a number of homes when a person needs medical treatment they are sent into a hospital and the medical records follow them into the hospital. The unfortunate thing is that many homes will not take an old person back into the home following hospital treatment. Geriatricians are very annoyed at the fact that when they accept a person into hospital they are given the medical records of the person and when the person is fit to be returned to the home, the home refuses to take them back. If an old person is admitted to hospital for a month or two there will be a vacant bed in the home which will lead to a loss of finance for the home. Something must be done in this Bill to ensure that when a person from a nursing home has to go into hospital they have every right to go back again to a nursing home. It is very easy to dispose of the problem by saying they are being admitted to hospital. However, geriatricians will complain that they have no beds, they are getting no co-operation from the nursing homes and there will be no beds available for the more urgent cases. I ask the Minister to comment on this point. This is happening at present in some homes. Tremendous work is being carried out in most nursing homes but others abuse certain privileges.

I will deal first with the point raised by Deputy Wyse which highlights the need for an admissions policy in circumstances where the health boards are subventing the patients in private nursing homes. Obviously the issue of patients being admitted to hospitals and being referred back to the homes is appropriate to the health boards. I will take note of this issue and see what can be done about it.

I do not think it is necessary to accept the amendment put down by Deputy Yates. At present nursing homes are not required, nor is there any intention to require them, to make financial records available for inspection. Under the present regulations clinical records may only be inspected by a medical practitioner in the service of the Minister or health board or the patient's general practitioner. As Deputy Howlin pointed out, I dealt with this issue earlier when I quoted from Article 24 (d) of the Draft Nursing Home Regulations which states very clearly, and I quote:

nothing in this article authorises any person other than a medical practitioner in the service of a health board, or the patient's general practitioner to inspect any medical record relating to a patient being maintained in a nursing home,...

I am sure all Members accept the need to maintain confidentiality in relation to medical records.

Article 18 of the draft regulations deals at length with the keeping of records and the records which it is necessary to keep. Such records include the name, address, date of birth, marital status and religious denomination of the patients; the name, address and telephone number, if any, of the patient's relative or other person nominated to act on the patient's behalf as a person to be notified in the event of a change in the patient's health or circumstances; the name, address and telephone number of the patient's medical practitioner; the latest date on which the patient was admitted to the nursing home; where the patient has left the nursing home, the date on which he or she left; where the patient is admitted to hospital, the date of and reasons for the admission and the name of the hospital; and, where the patient dies in the nursing home, the date, time and the certified cause of death.

These are some of the records it will be necessary for a nursing home to keep. It will be enshrined very clearly in the regulations what is expected and who will have access to the records. I want to assure the House that there is no question of asking the nursing homes to make financial records available for inspection.

I regret that the Minister cannot accept my amendment. My amendment would have made this section watertight. However, having looked at the draft regulations I accept that there is no reference to the availability of financial records and proprietors will not have to make them available. The necessary safeguards about who will see the clinical records are included in the draft regulations as they stand. By and large, I am satisfied at the list of records which should be made available. On that basis I am happy to withdraw my amendment. I hope that during the many years when this legislation is in operation it will be recorded that the intention of this House was that these matters should be dealt with sensitively.

Amendment, by leave, withdrawn.

We now come to deal with amendment No. 8 in the name of the Minister. I observe that amendment No. 9 is cognate. I suggest, therefore, that we discuss amendments Nos. 8 and 9 together. Is that agreed? Agreed.

I move amendment No. 8:

In page 3, subsection (2) (c), line 8, to delete "or paragraph" and substitute", paragraph or subparagraph".

The parliamentary draftsman proposed these amendments in order to clarify the meaning of the section. It is not a material change. The section provides that a reference to any section, subsection or subparagraph will be construed as referring to a section, subsection or subparagraph of the Bill.

Amendment agreed to.

I move amendment No. 9:

In page 3, subsection (2) (c), line 9, to delete "or paragraph" and substitute", paragraph or subparagraph".

Amendment agreed to.
Question proposed: "That section 1, as amended, stand part of the Bill".

We spent some time discussing the inclusion of old age in the definition section of the Bill. Thanks to Deputy Fennell, I now have a copy of the Health (Homes for Incapacitated Persons) Act, 1964. Section 1, the interpretation section, of that Act is quite revealing in so far as it defines an incapacitated person as a dependent person. It defines an incapacitated person as one who is incapable of looking after himself by reason of (a) old age, (b) physical infirmity or a physical injury, defect or disease, or (c) mental infirmity or a mental handicap.

I wish to refer to the latter definition. The language used in section 1 of this Bill is identical to that used in the Act except for the definition of old age, which we have already dealt with, and mental handicap. I specifically raised this matter on Second Stage with the Minister because it was not clear from his Second Stage speech whether homes for the mentally handicapped would be included in this Bill. It is very important that such homes should be included. There is no amendment down to this effect but it is in order to discuss this matter under the section. I ask the Minister to afford the mentally handicapped the same protection we are giving to elderly people. This Bill deals with a comparable situation. We are trying to update the 1964 Act and there is no lesser reason why we should not now protect the mentally handicapped in the same way as we did in that Act.

When the Minister was replying to the Second Stage debate he said it was his intention to include the mentally handicapped in this Bill. We have had many debates in this House about the needs of the mentally handicapped, and I will not labour this point, but I ask the Minister to incorporate the mentally handicapped in the Bill on Report Stage. If he does not do this we will table an amendment.

I want to comment on the point made by Deputy Yates. We will have an opportunity to discuss this point under section 2. I understand The Workers Party put down an amendment in regard to the exclusion clause where the Minister hopes to exclude institutions for the care and maintenance of the mentally handicapped under section 2 (1) (e). We may well debate this point at that stage.

We have had an opportunity, when discussing section 1, the definition section, to think about the importance of this Bill and the need which would be applicable to many institutions and individuals. The term "old age" has been discussed at length and the Minister will look at this issue again. We can take up the point made by Deputy Yates when we are discussing section 2.

Is the section——

Will the Minister reply to my comments?

Does the Minister wish to reply to Deputy Yates's comments on section 1, as amended?

I was going to deal with it under section 2 because there is an amendment in the name of Deputy Sherlock.

Section 2 deals with nursing homes and the definition of nursing homes that would be excluded, but there are other sections that relate to dependent persons, subventions and other matters, and this section is relevant as regards the total effect of this Bill where it refers to dependent persons in a different context. I think the Minister should respond.

I do not intend to include homes for the mentally handicapped in this legislation. The position is that there are systems in place to monitor non-profit making institutions for the care and maintenance of mentally handicapped persons. I believe they are satisfactory and that there is a high standard of care provided. There are at present no private profit making homes for the mentally handicapped and if it ever became necessary to include them in the legislation, there is power to do so under section 2 (2) of this Bill and they can be included by regulations.

Question put and agreed to.
SECTION 2.

Amendment No. 10 in the names of Deputies Yates, Howlin and Sherlock. I observe that amendments Nos. 11, 13, 14, 15, 16 and 17 are related and 12 is an alternative to 11. I am suggesting therefore that we discuss amendments Nos. 10 to 17, inclusive, together by agreement.

It would probably be more efficient and more profitable if they were taken individually because there are different points to be made about each.

Yes, if you so desire.

I move amendment No.10:

In page 3, subsection (1), lines 15 and 16, to delete paragraph (a).

This section defines the scope of the Bill in terms of which nursing homes and which institutions will be affected. Section 6 defines the rigorous requirements that should be put down in terms of maintenance, care, welfare of dependent persons in these homes, staff requirements, design, maintenance, repair of accommodation, the food and all the other things that we would like to add to them. It seems that the people who are writing the rules want to exclude their own institutions from the same rigorous standards as they would impose on others. I do not think we should afford any less protection to those who happen to be in county homes, long stay geriatric homes, welfare homes, geriatric hospitals and psychiatric hospitals, and I am sure there are lots of nooks and crannies and different variations of all of those things with different voluntary and statutory bases.

This principle that we have the same standards in public care as we have in private care — and certainly no less — should be adopted. We should not be presumptuous enough to say that just because a home is run by the health board or the State it has reached these standards. As legislators we should, therefore, look for equality before the law. I would be strongly of the view that institutions caring for the elderly and dependent persons managed on behalf of the Minister by the health board should not be excluded and there is no cogent case for excluding them. In fact that would be quite unfair. I believe the same rights of complaint and everything else that people would have to ensure that standards would be enforced should be available wherever elderly persons are.

I understand that the Department of Health may not want this, and may say that this has never been done before, but it is significant that the first group to be excluded, at the top of the list, is the Minister's own institution. In my view that is wrong and I am glad other Opposition Deputies have the same view.

I support the amendment in my name. Clearly there are a few principles that have to be established. The first is that we treat elderly people in like fashion whether they are in a public or private institution. That is a fundamental principle. The fundamental object of this Bill is to bring order, regularity and enforceable standards into the running of private nursing homes, and we should lead by example. There are excellent facilities in most geriatric institutions run by the health boards and the State as there are in most privately run nursing homes. The framework we are establishing here is to enforce standards on those who might not live up to the expected norm. That is in everybody's interest. It does ourselves and the institutions of the State a disservice if we seek to exclude from the compass of this legislation the institutions that are managed and run by the Department of Health directly or by health boards.

The argument could be made that in a way this is asking people to monitor themselves in as much as the health boards will be the monitors of their own institutions. The example where we placed statutory obligations of enforcement on local authorities to monitor their own activities has stood up to that test. I am very anxious that we would not exclude institutions managed by the Minister or health boards from the provisions of this Bill. It would be a very wrong signal to give as it would indicate to the public at large that we are expecting standards from the private sector which we do not desire to enforce upon ourselves. It would be unfair to most institutions which already maintain extremely high standards. I ask the Minister to reconsider the exclusion of those institutions.

A Leas-Cheann Comhairle, the Ceann Comhairle before he left suggested taking amendments Nos. 10, 11, 13, 14, 15 and 16 together. Deputy Howlin suggested that we take them one by one. I would prefer if we could take them together because I would like to be able to go through the amendments. The same remarks can be made in regard to each amendment. I do not mind them being taken one by one if you will allow me to refer to the others during the discussion on amendment No. 10 which we are taking at the moment.

Deputy Mac Giolla, one man's poison etc. I understood from the Ceann Comhairle that he had already agreed to a request from Deputy Howlin that what had been proposed was not acceptable.

I have no objection if there is a consensus that they should be taken together. I just thought there were separate points to be made about each. If the view is that we should discuss them and then vote on them separately I totally accept that.

Usually recommendations of this kind are made because it is considered most appropriate and the best way to deal with amendments. Is it agreed that amendments Nos. 10, 11, 13, 14, 15, 16 and 17, and No. 12 is an alternative to No. 11, will be taken together? The House appreciates that, even though they will all be discussed together, only one is moved, but anywhere along the line the question can be put on any one amendment separately if the House so requires. Is that agreed? Agreed.

I thank you, Sir, and Deputy Howlin. From my point of view I find it more convenient. I agree with the points made by Deputy Yates in regard to amendment No. 10 and I feel they relate to other amendments in Deputy Sherlock's name.

The Bill is placing a statutory duty on health boards to license, register and inspect nursing homes. I think it would be expected that health boards should license, register and inspect all nursing homes, including those in their own bailiwick. Under this Bill there are exclusions some of which are very difficult to understand. An institution for the care and maintenance of mentally handicapped persons operated otherwise than for profit and to which grants are paid by the Minister or a health board is being excluded. I would like the Minister to explain why. It is only on rare occasions that a problem arises and it is necessary to be able to inspect. You can withdraw a licence if the problem arises, and one does not expect that to happen every day, every year or even every ten years. If it arises one needs to be able to take the necessary action.

Amendment No. 14 relates to premises in which children are maintained in pursuance of an arrangement with a health board. I would think a health board should not make an arrangement with any premises unless they have already been licensed and registered and are suitable to be licensed and registered as a nursing home within the meaning of the Bill. To exclude in advance premises in which children are maintained in pursuance of an arrangement with a health board allows health boards to be very careless in the arrangements they make and the premises they make the arrangements with. If within the meaning of this Bill they are not licensed, registered and subject to inspection and withholding of a licence or whatever is necessary if everything is not in order under the regulations which have been set down, if a premises is not being maintained in accordance with these regulations, the Minister must be in a position to take action under the Bill. If health boards are allowed to make arrangements for the care of children with any premises they like in their own health board area with no necessity for licensing, registering or anything else, that is excluded from the Bill. It seems meaningless. I cannot understand the purpose in excluding such premises.

Amendment No. 16 in the names of Deputies Yates and Howlin, and a similar one in the name of Deputy Sherlock, refer to the exclusion of premises in which a majority of the persons being maintained are members of a religious order or priests of any religion. Why should members of a religious order or priests not be entitled to the same care and the same responsibilities in nursing homes as everybody else? Are they allowed to be in any kind of nursing home which is not subject to licence, registration or inspection? Simply because they are members of a religious order, nobody bothers about them. I cannot understand why nursing homes which are caring for religious should be excluded from the regulations set down for all nursing homes. There is an impression here, possibly correct, that most of those would be run by the particular religious order, but that is not necessarily so. There are nursing homes for the care of elderly religious or retired priests or whatever, and these could spring up all over the place. Why should they not be subject to the same regulations as all the other such premises?

I am making similar points in regard to each of the areas because we put down the amendments to delete these exclusions. To say that because there is an arrangement with the health boards there is no need to have these premises licensed, registered, or inspected is unacceptable. Bureaucracies can create enormous problems if these places are not subject to inspection. As Deputy Yates said, they must be subject to the same regulations of licensing, registering and inspection as any other nursing homes.

On behalf of Deputy Sherlock, who is unable to be here, I am putting forward amendments Nos. 10, 11, 13, 14 and 16.

I support amendment No. 10. The Minister is suggesting that we exclude nursing homes controlled by the health boards. What is the present procedure in relation to the control of the homes in the Eastern Health Board? How does the Minister propose to have control uniformly right across the board in private and public nursing homes? That is vital. I ask the Minister to reconsider his attitude, in particular in relation to amendment No.10.

I also urge the Minister to reconsider items here under these paragraphs that are being challenged by various Members of the Opposition. I find it difficult to see justification for this. I can see that various interest groups might press to be excluded. I cannot see why we in the sovereign Parliament should concede anything to such pressures.

In relation to section 2 (1) (a), given the problem of staff embargoes in the public sector, it is entirely possible that in many cases an institution managed by or on behalf of the Government, or a health board, might be less well staffed, because of the way embargoes operate, than a private institution. I am well aware that the embargoes introduced to try to control staff have had perverse effects in many areas and, as the Taoiseach of the day who introduced the embargo system at first, I am aware of all the anomalies. I know we have had great problems in other parts of the health service because of the way the embargoes operated. It cannot be assumed that staffing would necessarily be more adequate, to take staffing as one factor which might be under consideration here in the public and private sectors. It is almost a perverse assumption, given the way the embargo was operated.

Secondly, I do not know why we should assume, because somebody's name is entered in the General Register of Medical Practitioners, that the person is capable of running an institution of that kind well and efficiently. There are many of us with particular aptitudes in life who do not have other aptitudes and the fact that somebody is a doctor does not mean he has the management capacity to run an institution efficiently, and there could well be problems of mismanagement. That assumption has no basis whatever in reality so far as I can see. I take it that this applies to an institution where people are being treated for acute ailments but I am not quite sure what is envisaged and the Minister might explain that perhaps a particular case is envisaged but whether it is for acute or other ailments the mere fact that it is under the supervision of a person whose name is entered in the General Register of Medical Practitioners does not seem to me to be adequate grounds for exclusion.

I take it that sections 2 (1) (c) and section 2 (1) (d) are covered by other Acts and therefore I understand why they are there and are not being challenged. The fact that an institution covered by section 2 (1) (e) is not operated for profit does not necessarily mean it is efficient. The opposite view is sometimes held by people who have a great belief in the profit motive. I am not challenging that one way or the other or saying that one is necessarily more efficient than the other but there could well be problems in a non-profit making institution. The fact that grants are paid by the Minister or a health board does not necessarily mean that the institution is operated efficiently. I do not see why we should discriminate against members of religious orders or priests and remove from them the protection afforded to lay people. I wonder whether it is constitutional to make such a distinction in terms of the protection of the State and I do not understand the thinking behind this paragraph. What have we got against priests or nuns? I do not see why we should pick on them in this respect. These are most curious exceptions, perhaps the Minister can explain them but I do not think he can justify them.

The Minister then adds another number of exceptions. I wonder how many interest groups have got at him. Then we come to amendment No. 15, paragraph (g) which he has not put forward yet:

...physically handicapped persons a majority of whom do not receive whole-time nursing care in the institution,

God help the minority who will not be protected. Why should they not be protected? Another institution to be excluded in paragraph (g) (ii) is an institution:

In the management of which representatives of the Minister or a health board and representatives of the persons being maintained in the institution participate with other persons.

I know cases of bodies of that kind where certainly the public authorities have alleged there are problems. I am familiar with a recent case where there was a running battle for many months. I thought that the public institution, the health board, were wrong in their judgment in that case but they insisted though they had representatives on the board and though some of the other people were representative of the people being looked after. Nonetheless there was a long campaign on the question of the management of that body, on the question of who should manage it and whether the existing manager should be retained. I thought the health board were wrong and I did my best to ensure a different outcome from the one a Deputy from another party wanted. However, the fact that the health board took a certain views in that case does not seem to me to provide a reason for exempting such bodies. It a body with that kind of representative management and health board representation on the management is one with which the health board can be unhappy why should they not be inspected? The very case I am talking of makes nonsense of the amendment that is being made. I cannot imagine on whose behalf it was introduced. The fact that a body are being paid grants does not mean they are efficient, in fact some people would say the opposite. The fact of being grant aided will not make a body efficient or guarantee that nobody will be ill-cared for and that everybody will be properly cared for.

What the Income Tax Act has to do with the Minister has yet to be explained. No doubt there is a very good reason for the provision of paragraph (g) (iv) in the amendment and I am quite willing to hear him and if there is some special income tax provisions that ensure that people are well looked after, well fed and well cared for I would like to hear about it. I should not prejudge because that is a matter which the Minister has not yet spoken about. It is a pity that the Minister has not proposed his amendment as we are talking about an amendment that has not been proposed or justified. Perhaps we should allow the Minister get in at this stage before we talk about something about which we know little and perhaps the little we know may be wrong.

On all those grounds it seems to me that the amendments are perverse. With all due respect to all concerned they represent what one could describe, not in a pejorative way, as bureaucratic thinking and vested interests seeking to be protected and trying to narrow down the provisions of the section so that everything is excluded except what is left, some kind of residue, ragtag and bobtail. Most institutions of the State are excluded, what is the Bill about? What are we at? I do not understand why the Minister should take this line. I have no hang ups about public or private care but from the point of view of caring and looking after people we are all agreed that the Minister should look again at these provisions and I hope he will.

Like all of the previous speakers, I, too, have great reservations about the exclusion of various homes and institutions. Under section 2 (1) (a) "an institution managed by or on behalf of a Minister of the Government or a health board" is excuded. Let us look for a moment at what might happen if a health board decided that a third party would be engaged to manage a home on behalf of a health board or if in turn the Minister decided to engage some third party, other than a health board to manage a home. Why would they be excluded from the provisions of the Bill which cover suitable accommodation, proper food and proper care, and all the important aspects we have covered here today, such as the provision that the person in charge of the home would have to have nursing qualifications and that there would be proper standards of cleanliness, ventilation and maintenance. Why are we excluding these institutions, and in that, members of religious orders, from the benefits of all these good provisions in section 6? If the Minister or the health board decided to have an institution managed for them there is no doubt in my mind that in times of financial restraint if the funding to the home was cut or was inadequate, staffing levels would have to be cut and there would be a very severe prospect of the standards falling to a level below the level we expect from the private nursing homes. I argue most strongly that all these amendments should be accepted by the Minister and I would be interested to hear his comments on the serious implications of the provisions he is proposing.

I concur with what all the other speakers have said. Perhaps the Minister could give his reasons for the exemptions. I would not make exceptions for any of them. I think they should all be treated in the same vein though there are no amendments down and I question seriously why they should be excluded. I have a horrible feeling that it might be because it has always been done in legislation and one gets a feeling very often that the skeleton of one Bill is lifted to form the basis of another Bill just because it was there. The Minister should be able to give us a reason under each heading for excluding these other institutions.

Let me say that there are great expectations among the general public for the Bill. There is a perception that there are abuses and problems in the growing number of nursing homes. I do not necessarily think that the perception is true, there are a great many good homes where there are very high standards but people feel that things are wrong. I do not know what they are going to say if they discover that some homes are embraced by the Bill while others are not. In order to try to ensure that we have uniform and comprehensive standards we should try to include all homes.

I would like specifically to refer to two areas which nobody else has mentioned. Deputy FitzGerald said in passing that section 2 (1) (c) was governed by the Registration of Maternity Homes Act, 1934, and that it probably did not need to be examined too carefully. Although maternity homes are no longer popular places in which to have a baby when I was having children many people went to maternity homes, many of which left a lot to be desired. We do not know what will happen in the future. It could again become the practice for women to go to maternity homes to have their babies. They should come under this updated legislation, not the 1934 Act which could not be appropriate to present gynaecological and obstetric needs. I should like to hear the Minister's views on this. We must legislate for likely trends in the future.

I now refer to the section dealing with premises in which children are maintained in pursuance of an arrangement with the health board. This service should be under the protection of this Bill. We are talking about standards, supervision and control and in this type of institution where there would be children in care there should be maximum protection.

I am somewhat baffled by the references to "for profit" or "not for profit". I do not think that matters. Regardless of whether people are running nursing homes for profit or otherwise, the same basic standards should prevail.

I do not wish to go over ground convered by previous speakers and I would basically go along with what they have been saying. I would refer briefly to two paragraphs of section 2 (1). In regard to paragraph (b) there is an amendment in my name which is identical to the amendment tabled by Deputy Yates. I can see no reason a nursing home controlled by the medical profession should be any different from another nursing home. This seems to be an extraordinary privilege or exclusion and I shall be interested to hear what the Minister has to say. I can see no reason for it.

Section 2 (1) (g) refers to "priests of any religion". There are a number of religions in this country. Possibly the Church of Ireland might be quite happy to have their ministers called priests, but I am quite sure that Methodists, Baptists, Presbyterians and others would be very offended and hurt if their ministers of religion were called priests. Surely if we are to have such a reference, the term "ministers of religion" would be more appropriate.

I am sure there are precedents for this. I have not the skills to look them up. I am sure there are many references to ministers of religion in other legislation and I wonder why the term is not used here.

I have already spoken and I will not repeat comments from others with which I substantially agree. The Minister may have cogent reasons for these exclusions but the impact of them is to gut the Bill. We are moving on to the protections to be enforced, having excluded a huge proportion of the institutions to which we would like to afford protection. It makes nonsense of later sections. I regret not having put down an amendment whereby there should be no exclusions. There is no cogent reason for excluding anybody unless they are covered by similar protections in existing legislation. Since the legislation covering maternity homes dates back to 1934 I doubt if it is as comprehensive as the legislation we are now enacting. Notwithstanding the title given to a minister of religion, I would seek to give them the same protection, under whatever title they wish to take to themselves. It is wholly improper that they should be excluded.

The Minister's new amendment No. 15 is quite sinister in that it gives a new power to the Minister to exclude new categories of institution. Basically under the Minister's amendment any institute or institution to which the Minister appointed a director or to which the health board appointed a director would be automatically excluded from the provisions of this Bill. That is quite wrong. It would give an amazing opt out facility to a health board and to the Minister. They could put somebody on the board and by agreement exempt them from the provisions of the Bill. I agree entirely with what has been said in relation to all the other categories, the physically and mentally handicapped, children and those in maternity homes who should all be afforded the comprehensive protection of this Bill. If we do not have progress on this section it will devalue all the remaining work which the Bill seeks to achieve.

I have listened to what the Deputies have said and I appreciate their concern. We will deal with each amendment in turn. The institutions managed by or on behalf of the Minister or a health board are not included in the scope of the Bill because they have already been subject to a statutory and publicly accountable system of management. The Bill is all about accountability and there is already accountability in the system. Not alone have I the authority to send an inspector into health board institutions but also they are subject to scrutiny by their own health boards, the visiting committees of health boards and by Members of the Oireachtas who are in a position to ask questions and raise issues of concern. There is in place a statutory and publicly accountable system of management. Of course, they are expected to have standards which are at least in keeping with the standards in the legislation before us.

On the question of general practitioners, Deputy FitzGerald is correct in drawing attention to the fact that the reference is to hospitals where people are being treated for acute ailments under the supervision of a person whose name is entered in the General Register of Medical Practitioners. I do not think the amendment in the names of Deputy Yates and Deputy Garland is necessary. If we accept the amendment we will have to include all acute hospitals in the legislation, places like St. Vincent's Hospital and the Mater. This is purely to exclude hospitals which are run as acute general hospitals. They may be small private hospitals.

If medical practitioners are running nursing homes, by all means they will be included in the legislation. Indeed, if they try to run a nursing home under the guise of an acute hospital the inspectors from the health board will be in a position to report them and they will very quickly be brought in under the legislation. I am told that the legislation would not be strengthened by accepting that amendment which would have the effect of including many acute voluntary hospitals which are outside its scope.

There is no amendment tabled to paragraph (c) but Deputy Fennell referred to it. Of course there is quite an adequate system of maintaining high standards under the Maternity Homes Act, 1934, and while the practices in obstetrics may have changed, the need for an updated premises and proper staffing is still enshrined in that legislation and it is not necessary to include them in this legislation.

Everybody agrees that there is a very high standard in the homes for mentally handicapped which are run by voluntary organisations. As they are all run on a voluntary basis, I felt it appropriate to exclude them but if Members of the Opposition think they should be included I will look at the matter before Report Stage.

Paragraph (f) deals with the question of homes for the care of children. Arrangements are already in place to ensure that the care of children maintained in pursuance of an arrangement with a health board is to a high standard. These arrangements will be strengthened by the Child Care Bill currently before the House. That is a more appropriate place to enshrine legislation guaranteeing the standards in homes for children.

In paragraph (g) the Bill excludes convents, monasteries and anywhere in which a religious community live and in which some of their dependent members are maintained. We see the community as the family of the members of the religious order and the difficulty is that under the legislation if you keep more than two persons who are not related you are within its scope. In a community of nuns, some are elderly and need a certain amount of help and it would be unreasonable to ask the community to register and to be subject to this legislation. It is not necessary or reasonable because you are merely referring to convents and homes for the religious in which they are part of the community whom they see as part of their family.

There is nothing about convents in the Bill.

The Bill empowers the Minister to alter, by regulation, the definition of a nursing home to include or exclude any class of home. It is considered that to provide in the Bill the power to include any class of institution within the scope of the Bill is sufficient. The possibility of excluding institutions already covered by the Bill could give rise to suspicions as to the class of homes which might be excluded. If it is necessary to exclude a class of homes in the future, exclusion will require new legislation. In other words, it is only a class of home that can be included or excluded, not a specific home.

The new section we are introducing caused concern on the Opposition Benches and I will say a word on it. The first point is that in order to qualify for inclusion, the institution must fulfil the four conditions set out in paragraph (g) (1), (2), (3) and (4). The purpose of this is to exclude homes run and managed by the Cheshire Homes Foundation from the scope of the Bill.

To what is the Minister referring?

I am speaking about amendment No. 15.

They must satisfy all four conditions?

Yes. The reason we want to include the new section is that the Cheshire Homes Foundation made an extremely reasonable case for inserting the amendment.

The important point about this is that the homes they own and manage cater for physically handicapped persons, some of whom would fall within the definition of "dependent" in the Bill but many would not. Their primary aim is to provide support to enable dependent people to live independent lives. The homes are managed to a very high standard and have a warm and caring ambience. They are funded largely by the health boards which are represented on the boards of management. The residents play an active part in managing the homes and they do not cater for highly dependent elderly people for which nursing homes cater and, give the health boards' close association in the running of the homes, it is not considered appropriate to bring the homes into the scope of the Bill. It is not possible to exclude the Cheshire Homes specifically in law as a class of institution, a specific institution or an individual cannot be included, only a class of institution can be included and that is why the amendment is in that form.

Deputy FitzGerald raised a point about the Income Tax Act, 1967. Section 3 of that Act provides for the institution to be treated as a charity for income tax purposes and the Cheshire Homes. Foundation qualifies in that regard.

I do not go with the idea that there should not be any exemptions from this Bill because its terms are quite specific as to the type of nursing care and staffing requirements involved. They deal with a particular type of dependent person. In general, very acute care in general hospitals should be exempt. The Cheshire Homes wrote to me some months ago seeking an exemption and I wrote back saying that I saw no grounds for justification for their exemptions. I subsequently visited one of their homes and, having done so, I am satisfied that many of the people there are not sufficiently elderly or dependent to require this type of thing. Some of them go to work, they come in and go out and they do not have anywhere else. Some of them are disabled but they live in a hostel environment. If you were to put in place the sort of nursing and staff ratios required under the Bill it would cause bedlam.

While there is a case for some exemptions they go too far. I will develop that argument. Religious persons should not be excluded. There was a celebrated case of a fire in St. Stephen's Green in relation to a particular religious home. I do not wish to make a direct comment on that other than to say that there are very frail and elderly people, religious sisters and so on, in some of these establishments and there should not be a total exemption. We will be dealing with this matter when the Bill is next taken. As a general principle all dependent people who require residential nursing care should be afforded the same protection whether they are in public or private care, even though there are different categories of people. Perhaps in the intervening time, before this Bill comes back to the House, the Minister would have a substantial look at section 2 and its exemptions.

Progress reported; Committee to sit again.
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